"Short-coat": 2013 William Blythe Essay Competition Winner

Short-coat

I slowly scanned the circle of our cardiology team, the ongoing dialogue about second line anti-arrhythmics sailing over my head.  Though it was only my first month as a third year student, I  understood enough of the hospital’s culture and unspoken rules to feel conspicuous.  I had never put much thought into jacket length before, but now my eyes floated from person to person observing the length and material of each white coat.

The intern next to me, his attire was a bit stained and wrinkled, the flimsy cloth obviously not meant to survive much past that first overwhelming year as a resident.  Still, the garment hung down to at least mid-thigh.  The attending physician wore one of robust white cotton, it had enviable woven buttons, and the hem clipped him at mid-calf.  Though bone white and freshly washed, the well-worn cloth had obviously survived many years; it emanated seniority and experience. 

My coat was also a pure white, but the fabric was stiff and rough with a creased fresh-out-of-the-box look.  It stopped abruptly at my waist, a length which weeks before seemed arbitrary but now embodied my awkward and benign role on the team.  Yes, medical students are folded into the clinical flow as best as possible, but during those early months in the hospital, as the entourage of attendings, fellows, residents, and interns  file from patient room to patient room, we short-coats often become the trailing caboose, continually peering over others shoulders in an attempt to glimpse patient care.

In the first week of my rotation, of the many patients admitted to our service, one man stood out.  He was a strong septuagenarian from the surrounding farmland and the much-loved patriarch of his family.   One day he was on a stool changing a light bulb when he slipped, fell, and broke his hip.  The injury triggered a heart attack, which later triggered a stroke.  When he arrived to the cardiac floor, his state was cadaveric: skin ashen and stretched over a gaunt face, his mouth draped open in a slack “O.”  Our communication with him was usually limited to simple phrases and frequently interrupted by lulls in concentration.  On bad days he wouldn’t even respond, but just stare beyond us, his consciousness drifting off.

He was in our ward for nearly my entire month with the cardiology service, and though his state waxed and waned, it never made a clear move towards improvement or decline.  I grew to know the family well as they essentially lived on the floor during his stay.  Their biggest concern was his refusal to eat which, week after week, was evidenced by his increasingly frail frame.  Frustrated, they had brought nearly every item of the cafeteria to his room only to be stonewalled.  The son had even bought his father’s favorite food, tomatoes, from a local grocery store but the man didn’t take more than a bite or so.

Eventually, we had done what we could for the man’s heart.  Thought it was time for him to move off the floor, he couldn't be discharged in his anorexic state.   At the end of the third week, our attending decided to issue an ultimatum: he eats by Monday or we order a gastrointestinal tube.  What I felt then, and what I have seen since that time, is that a g-tube is often a one-way street.   Though it is intended as a temporary measure, it can be the first step in a slow decline.  I sensed, and I think the family sensed, that if there was still a chance for him to recover, he needed to eat.

That Saturday, I was at a friend’s garden which, like all North Carolinian gardens in the summer, was bursting with vegetables – specifically, sumptuous tomatoes of unreal proportions and hue.  On a whim, I set a few of the larger, sun-warmed spheres aside and later that day biked to the hospital.  I found the family, handed them the plastic grocery bag, and with a sheepish gesture suggested that there might be an off chance a fresh-picked version of his favorite food would help.  I felt clandestine with my package, sure that this was crossing a line of professionalism.  Perhaps “Thou shalt not give foodstuffs to thy patients” was somewhere in the Hippocratic oath and I had missed the line.  I fled from the hospital, unseen and with a vague pang of guilt.

On Monday, the cardiology fellow arrived for rounds.  Sipping her coffee, she asked the resident “So, did Mr. Jones* get his PEG tube over the weekend?”  The resident looked up and said “No, apparently surgery came in and watched him finish his whole plate of food.  They said they aren’t touching him.”  The fellow, wide-eyed, sputtered in disbelief, and soon all the team members formed a procession to go see for themselves.

What we found was nothing short of remarkable.  The man, who days before had been one shade above dead, was sitting upright in bed, pink-cheeked, conversing with his wife.  He invited us in as if we were visiting at his home, cracked jokes with a surprising level of wit, and answered the confounded attending’s questions crisply.  I, as the token short-coat, found myself in the back.  Though I had to crane my head able to see beyond the wall of more senior team members, I could clearly hear the residents hypothesizing, in hushed voices, the cause of Mr. Jones’s turnaround.  “It must have been the threat of the g-tube” suggested one. “For sure” the other replied nodding in agreement “must have been the fear of the tube.” 

At that moment the man’s wife leaned over to his ear and said “there is the young man that brought you those tomatoes.”  Then his hand, weathered but confident,  lifted and stretched out; it  moved beyond the surprised attending, the coffee toting cardiac fellow, the whispering upper level, the agreeing intern, to me, the short-coated medical student.  His hand wrapped around mine firmly and drew me, through the group, to the bedside.  He folded his other hand on top of mine, looked up, and said “That…was the best tomato…of my life.”

*the name of the patient has been changed to protect his identity

 

By Matthew Wetschler