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Risking Medical Decisions on Loveby Carol Cassella
I read the concise history and physical, dictated by his surgeon: "This is a 51-year-old previously healthy male, presenting..." Then, I notice the two capital letters stamped after his name on the rectangular yellow sticker at the bottom of each page. M.D. Doctor. He is a doctor. Like me. And my heart rate notches up.
He is a surgeon. He works here, in my hospital. I have operated with him. I have been the anesthesiologist on one side of the sterile blue drape that "separates the blood from the brains," as the inside joke goes, focused on keeping our mutual patient unconscious and stable while he stood on the other side, neatly snipping out an appendix. In that operating room, we had shared one common goal: to make the most educated and objective decisions possible as the course of surgery evolved.
But now, we are in quite different roles. Now he is the patient, and I am the randomly assigned anesthesiologist. His task is to overcome fear, tolerate the pain of surgery, and be cured of a small tumor growing inside his colon. My task is to treat him exactly the same as any stranger; to avoid the skewed VIP touch that could induce me to cut uncomfortable corners, offer him cushier care that might not be as safe. I have to forget that he is of my own league, and that he, like me, fully understands all the precarious things that could cause this operation to go awry. He won't generate any self-comforting illusion that I am infallible.
My hands begin to perspire, and the synthetic gloves I'm slipping on to start his IV are no longer slipping.
When we take care of our own, we try too hard to be perfect, to be inclusive and accommodating, even when our medical mind knows the choice may not be the best. In a routine workday, when all my patients are strangers unique to me in physique as well as face my experience takes control. There will be no glitch in the matrix while I hastily rewrite what my educated instincts, the fruit of thousands of anesthetics, tell my hands to do. Instead of a comfortable and familiar marriage, we are now on a first date.
It would be lovely if there were an internal wall I could voluntarily slap up between my doctor-self and all the other caretaking roles I play in my life. It is so inconvenient, at times, to be a wife, a mother, a daughter, or even a colleague.
There are particular moments, looking back on my medical training, when I can spot the emergence of my medical persona, tenderly poking through like a brand new grown-up tooth: the day I used "bifurcation" instead of "Y" to describe two roads diverging; the first time a nurse asked me to pronounce a death and I wondered what on earth made her think I was any more capable than she; the first time an airline passenger fainted and I was on my feet before anyone asked if a medic was aboard; the first time I wrote "MD" behind my last name and did not think it counterfeit; the first time I was addressed as "Doctor" and did not blush.
The transformation is now complete; I have forgotten how to be medically naïve, how to stay politely quiet about the discolored mole or odd lump. But I am still a wife and mother and daughter and friend, and I cannot be the best doctor to the people I love, because the most precise medicine is cut with an objective scalpel, and love is rarely objective.
The calls from parents or former roommates or boyfriends come randomly, perhaps in the middle of a lovely summer day, catching me in sweaty shorts with a wet dog hauled out of the lake and my child crying for another cookie: "there's a new lump but it could just be scar tissue"; "the surgeon says he should look with a laparoscope before trying to take the tumor out"; "she said there are some interesting experimental treatments in the pipeline." I hear the camouflaged truth their doctor isn't ready to detail.
I try to use the same comforting words I would say to a patient. I try to mimic the lulling tones of the airline pilot who announces that the landing gear seems a little sticky, so we're going to follow a few special procedures, just to be on the safe side. How would his voice change if the first-class section held his wife and four children?
My son, my sweet son, had to have his tonsils out when he was four. I chose one close friend to be his surgeon and another to be his anesthesiologist. They had both operated on me the prior year, and I'd not had a flicker of fear. But on the day of the tonsillectomy, I sat in the waiting room, shredding Kleenex in my sweaty palms, asking (with a red face) if the anesthesiologist could please be sure all the emergency drugs were ready to go. Was the defibrillator charged? The oxygen cylinder full? He took it well and stayed my friend. A year later, I took care of his own daughter, which he requested either in empathy or to pay me back I may never know. I had to answer the same questions for him.
Last spring, it was my mother who called. She had the flu, and her doctor put her on Tylenol and amantidine. His nurse reassured my father that it was going around, "But be sure to call Monday if she's not better." I moved into the automatic questions: "Are you coughing? Does your chest hurt? How high is your fever? Are you short of breath?" I called every day. She was no better, but no worse, either. I was flying in for a visit in only four days, so they would wait, despite my advice. Her doctor never called her back.
At last I arrived and walked into my mother's bedroom, took one look, and hauled her to the nearest emergency room, where she was admitted with pneumococcal pneumonia and sepsis. If my parents had waited another two days for their doctor-daughter, my mother would likely have died.
The medical staff was especially conciliatory after they learned I was a physician. They gave her an injection of Demerol in an effort to make her comfortable while she waited for the transport team. As a special courtesy, they shut off the annoying, beeping monitor, and closed the curtains around her cubicle for privacy. My father was relieved to see her finally drift into a painless sleep. I was alarmed to see her face go gray as the Demerol suppressed her breath and her blood oxygen plummeted.
If I were not a doctor, I am sure my parents would have gone to the hospital sooner, before her entire right lung was consumed by infection. If I were not a doctor, I doubt the aid would have shut off the oxygen monitor simply to protect my mother's peace and quiet. But, if I were not a doctor and had not scrambled to put an oxygen mask on her face, the fifteen silent minutes after her Demerol shot could have been fatal.
I wade into the pre-operative interview with my blue man, a surgeon praised for his technique but most famous for his sense of humor. I take his medical history, hoping I won't need to ask anything he would prefer not to answer. He is healthy, and his risk is not high, but still we have to have the conversation about objectivity and the sticky mix of operating on our colleagues.
We keep his sleeping body covered when possible, conscientiously ignore his private parts. His surgeon makes no comments about habits or physique that make this job tougher. It all goes as smoothly as we could wish for any anonymous patient. In celebration, just before I wake him from his deep and helpless anesthetic sleep, the circulating nurse pulls a small bottle from her pocket, and we paint all 10 of his toenails hot pink. At least he will know we consider him special.
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Carol Cassella practices anesthesiology in Seattle and is a freelance medical writer specializing in global health advocacy for the developing world. She is a former student of David Guterson and graduated with a degree in English literature from Duke University. She is the mother of two sets of twins, 15 months apart, and is working on her next novel.