Pushing and Pulling

Medical training consists of years of daily pushing and pulling. As a medical student, or during residency, you are constantly pulling in senior residents for consultations to provide desperately needed guidance ensuring that you don’t hurt anyone; or else you’re pushing away those same senior residents when you finally feel, It’s okay, I got this.

If you ask for help too early, you’ll meet with stern and frustrated rebukes: “I’m busy! Why are you calling me? You should be able to manage this by now!”

But if you call too late, it’s: “Why didn’t you call me? What the hell were you thinking? You coulda killed him!”

So it can be a bit tense.

In the early Eighties, I was the latest in a constant stream of terrified medical students doing their first rotation on Surgery 1 (general-surgery inpatients) at a large university teaching hospital. I was very inexperienced and needed to do a lot of pulling.

Under these circumstances it is wise to stick very close to your supervising resident, but on this unusually quiet afternoon, I had drifted away from the safety of the herd and was just hanging out on the ward, alone and vulnerable.

I looked a lot like a doctor, so it was not surprising that a nurse who’d noticed “a little bit of a problem with the man in room 12” felt comfortable discharging her duty by telling me about it. Her charting would read: “Doctor notified.”

Thankfully, this “bit of a problem” seemed to be something I could handle. Mr. Grove was a man in his fifties, recovering nicely from abdominal surgery performed a few days earlier. A routine check of his vital signs revealed that, for unclear reasons, he was breathing fast. The nurse didn’t seem very worried, and when I went to see Mr. Grove, I was reassured to discover that he wasn’t worried either.

He was lying on his side in bed and breathing a bit faster than normal, but everything else was fine. His other vital signs were normal, he wasn’t complaining about being short of breath or in pain, and my unfocused, needlessly elaborate physical examination was unremarkable.

I distinctly remember just staring at Mr. Grove and thinking that everything was perfectly normal, except his breathing rate. He didn’t seem sick; it didn’t seem to fit. If I concluded that the breathing was a problem, then I’d need to attempt a differential diagnosis before notifying my resident, probably start several complex investigations that I didn’t really understand very well, and generally get everyone upset. If, on the other hand, I concluded that the breathing was not a problem (and after all, neither the nurse nor the patient seemed to be concerned), then I could ignore all of this, and everyone could go about their quiet, pleasant afternoon.

I was conflicted—pushing and pulling at the same time.

I decided to go off in a corner and think this through like a real doctor (after all, that was the whole point, and I was wearing a white coat).

I continued trying to convince myself that I hadn’t seen what I just saw: He couldn’t be breathing fast, because it just doesn’t fit with everything else….

Finally I concluded that this was a minor and likely transient issue that didn’t require further action on my part, but perhaps warranted notifying my supervisor, just to be safe.

I paged the surgical resident, Rick, and gave him a very brief report over the phone–carefully packaged with phrases and nuances chosen to convey the impression that all was well. I don’t recall the words I used…only my growing angst because I needed Rick to agree with my opinion; after all, I had chosen to do nothing.

He seemed reassured and replied, “Okay…Hey, it’s coffee time anyway; meet me at the café in twenty minutes, and we can talk about it.”

Great! I thought. I mostly pushed, and then pulled a little–and nobody yelled at me. I didn’t get someone else’s body fluids on my clothes, and now I get to go for coffee. That was easy.

The café was a tiny but great place run by the hospital auxiliary, and in no way like the huge, industrial hospital cafeteria. An oasis of hand-painted flowers on yellow walls embracing four small tables, the café was tucked away in a sunny, quiet corner of the administrative wing. It always smelled like muffins. Its soothing ambiance instantly carried you a million miles away. The only hospital-like remnant was a tiny, solitary speaker in the ceiling—a metastatic nodule from the ever-present hospital-wide paging system; it seemed garbled and apologetic whenever it tried to penetrate the serenity.

After about an hour, Rick and I finally met up and sat at the only remaining table. We shared a bit of small talk, savoring the moment before eventually getting around to discussing the case.

A dog barks, a cat meows and a cow goes moo. We learn this as toddlers, and it helps entrench the developmental skill of pattern recognition that then helps us to understand far more complex issues as adults: Healthy people generally look healthy, sick people are supposed to look sick, and tiny speakers in the ceiling of a quiet, cozy café should only play soft jazz. When these things don’t happen—when the comfortable pattern is broken—the unsettling effect can linger in the memory for years.

And so it was when that lone speaker in the ceiling began squeaking out words that are usually shouted above screeching alarms:

“…. Code Blue. Surgery 1. Room 12.”

Simultaneously, our pagers went off.

Turns out that I shouldn’t have pushed; I should’ve just pulled.

Forty years later, I still don’t remember going to the code. I don’t remember if Mr. Grove died that day, if the team held the standard Morbidity and Mortality review, or if my inaction was exposed. But all of that probably happened.

What I do remember is Mr. Grove. I remember his short hair, once likely a vibrant coal-black but now mostly grey. I remember him lying quietly on his side, his thin body comfortably tucked beneath blue and white hospital blankets after I’d examined him, and his trusting eyes silently waiting for me to let him know if anything was wrong.

And I remember the soul-crushing guilt when the day was over.

Doctors almost never talk about it, but we all have a Mr. Grove…and, after decades of practice and tens of thousands of patients, likely more than one. Patients who ultimately made us better doctors. Patients we will always remember. Patients who remind us that we are only human; that all we can do is our best with what we know, and who we are.

Too often, that’s just not enough.