Getting There

Here’s a new Chapter excerpt called Getting There – happy summer everyone!

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We are standing on the threshold of both heaven and hell, dancing nervously between the gates of one and the ante room of the other.

-Yuval Harari, Sapiens

The nausea was so overwhelming it nearly sent me to the ground.  I’d spent 31 years in training (if you count preschool) preparing for this day, my first day as an attending physician running my own service, my own way.

Sure, by that point I’d been a doctor for six years and had made thousands of in-the-moment decisions that were only later validated by my supervising attending.  But this time there was no supervisor – I was the attending, the end of the line, and the final call on each decision was entirely my own.  Like a trapeze artist swinging without a net for the first time, the magnitude of that responsibility hit me in the gut like a hot iron and sent my stomach reeling through loops that put the meanest Six Flags attractions to shame.  That responsibility was why I went into medicine in the first place, and the full weight of it now finally rested on my shoulders.

Truth be told, the arc of my life had bent towards healthcare since I was in Stride Rites.  When I was five my family lived in a small Long Island town about an hour outside of New York City.  My father had torn the place down to the studs and rebuilt it for my mother before moving in.  The house soon became a bustling home, backyard replete with swing-set, batting tee, Slip-N-Slide, and a variety of bushes that had grown into what seemed to me like giant redwoods.

We were in the middle of my sister’s second birthday party, and I was outside with her playing near the bushes.  Summertime was in full swing, and the enormous bushes were covered from top to bottom with small red berries.  The kind that look just like candy to two year-olds.

I was watching her walk towards the back stoop, a firstborn son genetically incapable of not serving as guardian and protector of all in my keep, when in an instant her tiny hand darted towards the berries and she shoved a handful in her mouth.  They must have been bitter because I remember her making a terrible face, spitting them out, and then toddling off towards the Slip-N-Slide.

Alarmed I took off into the house, heart pounding and hands spinning over my head like the lights on an old police car screaming “EMERGENCY! EMERGENCY!” at the top of my lungs.  I relayed the story, crushed that I couldn’t stop her from eating the berries and utterly convinced that I was going to lose my first patient before I’d even graduated from kindergarten.  A quick (and reassuring) call to poison control and all was returned to normal.  Except for the helpless bushes, as my father slipped silently away from the party to promptly turn them into wood chips.

My mother practiced nursing before my siblings and I were born, and I grew up marveling at how much she knew about medicine.  She always had an answer, a treatment, a reassurance for whatever was ailing anyone in the family, and I wanted to know just as much.  By elementary school other kids were coming to me for medical advice about bug bites and scrapes.

One day on the playground a boy bloodied his knee playing kickball and a flotilla of children came running my way.  He had a small laceration just beneath his knee cap that was indeed bleeding but would clearly stop on its own.  I vividly remember thinking to myself “Well, touching blood with my bare hands is risky but I really need to treat my patient.”  I wiped away his blood, told everyone he’d be fine, and they went back to playing.

Recess ended and I walked to the school nurse’s office, ready to face whatever horrors awaited me for touching blood without wearing the appropriate personal protective equipment.  Pale and trembling I told her what happened and that I was ready now for the gigantic needle I was convinced she needed to use to test me for AIDS.  She instead gave me a popsicle, reminded me that I didn’t have a license to practice either nursing or medicine in the state of New York, and sent me back to class.

Even at 8 years-old the strains of the American Medical Association’s 1847 Code of Ethics rang true, which says a physician must be:

“ever ready to obey the calls of the sick… because there is no tribunal other than his own conscience, to adjudge penalties for carelessness or neglect.”

It turns out that the actual practice of real medicine is rather different from what most people think.  Centuries of folklore have given us a picture of the good doctor, sitting in a dark, wood-paneled library surrounded by stack upon stack of textbooks.  The air is heavy, and you can practically feel the weight of ancient wisdom as the ghosts of Osler, Galen, and Hippocrates hover over his tense shoulders. His white coat is rumpled, glasses askew, and you can just make out his furrowed brow beneath the amber light of his table lamp as he desperately tries to connect the dots.

We watch for a moment as he moves from book to book, the gears in his mind spinning faster and faster until something finally catches his eye.  It’s a line from the 19th century Latin translation of the Ancient Egyptian Ebers Papyrus and it sends him headlong again into the stacks. Thousand-page tomes by Sabiston, Harrison, and Schwartz crash thunderously to the floor until he finally emerges with a copy of Nelson’s Textbook of Pediatrics.  Rifling through the pages he stops on page 1,754, scans the minuscule print, pounds his fist against the heavy wooden desk so hard it startles the medical students hunched in their nearby cubbyholes, and exclaims “Of course!”

He grabs the book and streaks down the library’s Gothic corridors, his white coat a blur as he enters the hospital’s main doors and re-enters its cold, sterile embrace. Taking the stairs two at a time he climbs five flights up to the pediatric ward.  Stopping only briefly at the pharmacy he sprints to his patient’s room, locks eyes with the young girl’s parents and says with both relief and triumph in his face “We’ve got it.”

He starts an intravenous line in her tiny arm, spikes the clear glass bottle of medication, opens the clamp and the mysterious drug begins flowing into her bloodstream.  Within a matter of seconds her eyelids flutter, she begins to stir, her mouth twists into weak smile and she opens her eyes for the first time in days.  Her parents rejoice while the good doctor slumps into an uncomfortable rocking chair, the weight of one life lifted from his shoulders while other lives wait in line to climb on.

Medicine is practiced like this in exactly two places: 19th century British paintings and prime-time television dramas.

My real life as a physician has never been that simple – while there have been periodic “eureka” moments, I can’t count the number of times I’ve fallen asleep on hard call-room mattresses thinking about a particularly challenging patient and woken up still thinking, struggling to find the one unifying diagnosis that would perfectly connect all the dots.

Real medicine is messier than it looks in paintings or on television, diagnoses are rarely perfectly cut and dried, and with the possible exception of doctors old enough to have actually used glass bottles and metal IV catheters in their training you should almost never allow a doctor to start your IV.  We’re just not as good at it as nurses are, a fact my wife (an oncology nurse who has in fact successfully gotten blood from a stone) finds reason to remind me about on a nearly daily basis.

MORE TO COME THIS WINTER!