One day in March of 2010, while plugging away at my computer in the living room (my infinite past-time), my younger brother was making his usual grumping sounds in the kitchen while struggling to make his morning eggs “Southwestern Style”. We haven’t always been the best of brothers, if that ever exists between siblings. Frankly speaking, most of the time we just tolerate each other. The biggest problem we have, as brothers mind you, seems we both have the unwavering ability to always know the right thing to do at the same time-from opposite directions. Again, we’re brothers, and I’m the oldest, he’s the youngster who is well, clueless. I’m always right, of course. He’s as strong willed as I am which prompted him to punch me in the mouth about 2 months earlier after I yelled at him at the drive through at McDonald’s to make up his mind over the important issue of French fries or no French fries. In no uncertain terms, he found out he was not human in addition to being the ultimate asshole (amongst other things). After that, the asshole and I dared not to come into the same room together for the next two weeks. Then we became brothers again. So that’s the starting point. Looking over at him, he appeared to be in his usual surly “I’ve been awake for an hour, so don’t fuck with me” mood. I needed my fourth cup of morning brew after reading and typing for 4 hours so I walked over to the kitchen which required walking within the 6 feet of the personal space of the my brother the asshole. So, to cheer him out of his surly mood, I happily bounced into the kitchen and played Frazier vs. Ali with him. Coming from the opposite direction as usual in his perceptions of the moment, he interpreted it, incorrectly of course, as an aggressive move on my part. For the next two minutes we began the brotherly ritual of slamming bodies until one of us ended up on the floor. Him. Thinking quickly, and realizing my brother had again mutated to an inhuman asshole, it seemed to be the best thing at the moment to hit him as hard as I could on the arm. ‘Good”, I thought, “Now, if it hurts a little, that asshole won’t do that again”. We both parted and the evil one limped to his room and me to my impatient computer. After most physical squirmishes like that I’m a little shaky ad this time was no different. Realizing I never did get that cup of coffee, I tried to get out of the chair. It hurt. My back. It’s hurt before but not like this. From the back of my neck to the right side of my lower back was a never ending vise-like spasm that dared me to take another step. I sat back down. Its things like that that break you out of the denial that not only are you 55, but you are really 55. Being a retired physician, a spine surgeon, I quickly began the home front inventory of the critical signs and symptoms. “Let’s check, “thinking “there’s no numbness or paresthesias and no weakness. Good. My shorts aren’t soiled-that’s a good thing. And it hurts when I move and gets better when I don’t move. It’s a simple back strain and 90% of everyone with this problem spontaneously improve within 4 weeks regardless of the intervention, yaddi yaddah. Ice, Motrin, rest and since I’m an indestructible 55 year old it’ll be gone in 2 days”. March 3 My latest work adventure is teaching. Two weeks before this began I was hired on as instructor at a local College. Prior to that I had joined the unhappy ranks of the nearly permanently unemployed and remained so for 14 months. It’s good to be paid. The students are great and have that youthful lust for knowledge. So it became my mission to be the beat instructor they had. The night before my Wednesday classes was a fitful sleepless unrest of never ending pain, night sweats and nausea. That’s not the typical pattern of a simple back strain. That was always a red flag to me when patients came in complaining of back pain and unfortunately for most of them it wasn’t a simple problem. Infection, occult fracture, cancer and other bad stuff act like that. Stress from excessive worry over a presumed bad problem (cancer, infection) can also do this. Needless to say, it was extremely difficult to be the energetic engaging professor. However, it seemed to be a relatively simple adjustment in school to have the students work mostly in the lab while I did the chair side instruction and write. The lab work was a simple hematology blood smear and differential. We do have a bottle of fake blood in the lab so I tried that first. I hadn’t actually done a smear much less stain t for over 20 years but the technique was on the insert. As learned instructors we can get away with it. When I looked at the fake blood under the scope, all the cells had fragmented so it was totally useless. The students were practicing venipuncture so it looked like the next best choice was my own finger. I located the pin-prick “device”, the alcohol, the swabs, and the slides to do my own finger stick on the back table. It seemed to be a good idea to do at least 5 of my own so it at least looked like I was an expert hemo-prof. After the QuikI WrightsStain sat for a while (how long was it supposed to be?), I rinsed the colorful blue dye off the slide with tap water (the directions said deionized water but we didn’t have any) onto my now purple fingertips. After blotting the slides looked about right and there was the imaginary feathered edge at the edge of the smear which suggested I had lucked out. The next step in the presentation was to set up 5 microscopes centered on each cellular element for the students to identify. Under the first microscope I couldn’t find any neutrophils and only a couple of lymphocytes and 1 monocyte. These should be readily seen if you did the staining correctly. Granted the stain was somewhat on the light side but it was obviously abnormal to my well trained eye. There really should be a rule at the schools that instructors should never analyze their own blood. Especially if they hadn’t done one in 25 years. The rest of the slides didn’t look any different (cancer, infection) so it was correctly assumed the staining technique left a little to be desired. So the next best thing to do was to obtain one of the relatively available students to volunteer (the control slide). Since they get a grade for participation and I’m the one that assigns the grade, this was easy to accomplish. As luck would have it, when I looked under the microscope there were plenty of the right cells to identify. Good for the student. So, if the student’s blood looked normal and mine looked like something out of my Emerging African Diseases book, it seemed to be the logical assumption was that there might be something else going on besides the back strain. At the break I went out to smoke another cigarette while running the differential diagnosis of leukopenia and atypical back pain in my head (cancer, infection). March 5 After 2 more nights of severe pain I had resolved to ask for help from a real doctor. As physicians, we don’t like to do that especially if you say, “Back pain”, when they ask for your chief complaint. The short list on the differential for this problem if you didn’t know, especially on a Friday, is drug seeking behavior, drugs again, and “oh crap, not another druggie”. So remember the first thing out of your mouth when they ask you, “What can I do for you?” is not ask for pain medicine. You will leave with a new prescription of extra-strength Tylenol, no work-up and a follow up appointment in three months or a quick referral to a specialist that hates drug-seeking back pain patients even more than the physician you just saw. That’s true because I had been the guy they sent the druggie referral to. One of the bad things about that was that most of the time, they weren’t druggies and did have something bad (cancer, infection) that was mostly ignored for 2-3 months. But that’s another story and here I was in the druggie infested Urgent Care Center with the chief complaint of back pain. Outside the hospital was the local Public Health Department that offers a lot of free screening tests for a variety of “Personal Activity” Related Diseases. This was Friday and they had a morning free HIV Testing clinic. Granted I was a little low on the infection differential but, seeing as how I was a single guy with a job that paid, this might be a reasonable thing to do especially if it was negative. I could put the results it in my wallet as a sort of social business card. So after a while and after my HIV result came back negative (which I neatly folded and put in my wallet), we talked about my abnormal blood smear and what my options were to narrow down my differential diagnosis (cancer, infection). So back to the Urgent Care Center I went with one less etiology of my leukopenia to worry about. The hospital was a County Hospital, and for those of you who don’t know, it is frequented by patients that won’t usually appear in the waiting rooms of room more upscale physician’s office. It isn’t that they can’t. Contrary to the public opinion rumor mill, most physicians do see it as their duty to provide care to the unfortunate members of our society even outside the university setting. Many of these patients think they don’t have a choice but to go to the County Hospital. That is simply not true. However, that being said, it is also true that the physicians who do work at the County Hospital want to be there. The patients who go to the County Hospitals are usually a diagnostic challenge and often times have a disease process that you won’t find anywhere else. The waiting room reminds me of the song Alice’s Restaurant” where Arlo Guthrie is arrested and put in the same cell as the “meanest, nastiest” people you can imagine. When Arlo says, “Litterin,” as a response to, “What’re in for, boy?” they all move away. He then says, “And creatin’ a nuisance!” and they all move back and have a great time. The waiting room is like that. The concept of “privileged medical information” does not apply in County Hospital waiting rooms. Sharing of everyone’s medical problem and airborne infectious diseases readily occur here. That’s the trade off-great pathology (for the doc’s) and treatment for a lowered cost to the patient. That is except for the unspecified time where you will be an intimate part of the system. It was actually a very slow morning. I brought all my students homework with me to grade (always allow 4 hours) expecting to wait at least an hour just check in. 10 minutes after I arrived they called my name and handed me the paper work (one page in English with Spanish subtitles). Just for fun, on the line that said “Occupation”, I wrote, “teacher”. After the paper work was completed 10 minutes later, the clerk handed me off to the triage area. The triage area is the make-it-or-break-it room. It is usually staffed by a few overworked and burned out nurses that have as their duty to tell you that patients “are seen in the order of severity”. Most of them are used to be lied to, like attorneys, and so will take what you tell them with a grain of salt (like attorneys). Therefore, one wrong statement may put you at the 7 hour wait list before you’re ever seen. “Back Pain Druggies” go on this list and probably after the section that reads, “Reserved for Patients Possibly Arriving in the Next 2 Hours with a Potentially Worse Unknown Problem”. With that in mind, and feeling a bit creative, when the tired and burned out triage nurse with the AA button on his collar asked me, “What do you need to be seen for today?”, I said “weight loss, fever chills, night sweats, and by the way the other day…” and told him about the leukopenia on the blood smear. He then appeared curious so I told him I taught pathology and hematology, about the students, what they were learning, and etc. “Anything else before the doctor sees you?” he asked. “Oh, yeah. I’m so tired I almost forgot. The past several nights my back pain has been so severe I haven’t been able to sleep. I’ve had back pain in the past and it’s never been like this. It seems different somehow. I can’t help wondering if it’s all related”, I said as if my back pain was an unintentional oversight. He then took me to a room with a number on it to see the physician, back pain and all. The time from initial check to seeing the physician was 30 minutes. Dr. Vijay was great. I decided that now that I was behind the Impenetrable Curtain of Triage I would tell him as it was. When Dr. Vijay asked, “How can I help you?” I told him, that I really couldn’t take the back pain anymore, couldn’t sleep, was tired, nauseated, and then told him about the blood smear with the possible leukopenia vs. poor staining technique. It was in basically the opposite order in which I told the triage nurse. I admitted I was a retired physician and why I was so concerned about the symptoms. The leukopenia was the surprise of the week and we both thought it best not to trust my staining technique and have the lab do a real one by people who have done more than one in 25 years. After that he would send me to radiology for the spine x-rays while the lab work was being processed. The lab tech came in with a vacutainer, several blood collection tubes and a butterfly needle with a silicon tube extension. She’d been working at the County Hospital for 3 years she said, but was clearly nervous as she had graduated from the school where I currently am teaching. She had attached the vacutainer to the silicon tube end of the butterfly needle apparatus which she held in her right hand. She held the collection tubes in her left hand. So when she started to insert the needle into the vein in my left arm, I wondered how she was going to hold the needle in place against the skin, hold the vacutainer, and then somehow insert and remove sequentially the collection tubes she held in her left hand. You can do that if you’re drawing blood with a syringe and butterfly but you really do need three hands they way she was intending to do it. She seemed a bit perplexed as well so I offered to hold the vacutainer while she held the needle in place in my arm with her right hand and did the collection tube transfers with her left. That worked great and she smiled. Never miss a moment to teach especially when your own blood is involved. Dr. Vijay’s nurse came in soon after and gave me the slip to radiology and tried to explain how to get there via the usual maze like layout of the hospital. It would have been better if they gave everyone a GPS to get there but we do need to draw the line somewhere in regards to cost of healthcare. I wouldn’t use it even if she gave it to me (I don’t ask for directions of course being a male) and even if she did offer a GPS, I’d get lost. There’s always an adventure somewhere in everyday life and I needed the distraction anyway. Surprisingly, the Radiology Department was easy to find since there were signs that said “Radiology” and had an arrow pointing in the right direction. They were slow, too, so within 10 minutes the Radiology Technician called two of us to follow him. 3 hallways later we were at our destination. The lady with us seemed quite ill, but he told her to have a seat on the bench and asked me to go into the first room. I never gave him the “retired physician” line so being curious I said, “She looks a lot sicker than me, why don’t you go ahead and bring her in first”. He said he couldn’t because my order was “STAT” (Same Test, Arbitrary Timing) and hers wasn’t. I apologized to the woman and went in. The tech was good even though he did ask me what was my problem that we were getting so many x-rays. So I said, “Back pain”, and he turned away. Sometimes it’s funny to watch the way people react to you when you say those two words in a hospital. I think the longest sentence he said to me was, “Open your mouth wide”; “When?” “When I tell you”. “OK”. Most of the time it was, “Stand there”, and, “Sit there”, and then finally. “We’re done”. Knowing the answer, I asked, “Mind if I see the films?” “Ask the doctor”. “OK, thanks”, and I went back to the Urgent Care Center. It had been three hours since I had left the house on today’s journey and surprisingly my stomach wanted to be fed. Next to the entrance to the Cardiothoracic Wing in the main hallway of the hospital was a McDonald’s. It was quite busy with patients and their families, hospital staff and administrators. One patient had an O2 nasal canula cresting the top of his head with the tube attached to the oxygen canister he was pulling behind. The menu didn’t serve McLowInFat nor did it give you the option to ‘Supersize” it. They did have a double cheeseburger (my favorite) for 99 cents. I paid, ate it in five minutes and headed down the hall. The lab tests and the x-ray reports weren’t about to be ready yet so, like most patients waiting for their test results (cancer, infection) I went towards the exit to smoke my 5th cigarette of the day. Waiting without thinking is impossible. I thought about a teacher I had in medical school during my senior rotation who told us that being detached from the emotions of the patients did not make you more objective or more effective as a physician. I was going to be a surgeon so I had to ask him how you could do that and be a surgeon. The concept of “I feel your pain because I’m the one that will inflict it upon you with my knife” just didn’t work for me using that concept. What he was saying was absolutely correct. Judgment requires empathy to be effective, objectivity does not. Judgment without empathy is destined for failure. It’s depressing to think how many times you hear about health care providers having this revelation only after a serious personal illness. As I walked down the hall to go outside, many patients had begun to congregate at the main entrance. Most looked old, probably much older than they really were, ravaged from within by some unseen and unknown scavenger. Many walked alone as I did in silent refection. There was a woman, probably in her mid-70’s in a front-back hospital gown sitting on the cushioned bench with her back against the brick wall. Her face was a desaturated and pale flesh color, wrinkled not only from age but like the faces I remembered in Hawaii that had demonstrated the effects of years under the harsh equatorial sun. By her left side on the cushion where she sat, her left hand cradled a small clay pot that was wrapped in fluorescent green paper. The stem was green, and the slender crescent leaves that extended from its stalk were a mix of pink swirl against a silken white base. At the top of the plant was a scarlet flowering bulb. I must have been staring at it for a while because she looked over at me. At that moment there seemed to be an understanding between us, as if whatever problem we had separately was connected in some spiritual fashion. It was me that pulled away first and walked away with that image of her and her flower firmly embedded in my mind. I went outside. And took another breath.
Reflections on a personal experience by Allie Foxe