Second Opinions: 8 Clinical Dramas Intuition Decision Making Front Lines mednby Jerome Groopman
Anxious about the prognosis, lost in a blur of technical jargon, and fatigued from worry or pain, people who are ill are easily overwhelmed by treatment choices. Told through eight gripping clinical dramas, Second Opinions reveals the forces at play in making critical medical/b>
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A unique insider's view of today's complex and often contentious world of medicine
Anxious about the prognosis, lost in a blur of technical jargon, and fatigued from worry or pain, people who are ill are easily overwhelmed by treatment choices. Told through eight gripping clinical dramas, Second Opinions reveals the forces at play in making critical medical decisions. Dr. Jerome Groopman illuminates the world of medicine where knowledge is imperfect, no therapy is without risks, and no outcome is fully predictable. He portrays moments of astute diagnosis and misguided perception, of lifesaving triumphs and shattering failures.
These real-life lessons prepare us to navigate the uncertain terrain of illness, and enable us to balance intuition and information, and thereby make the best possible decisions about our health and future.
- Penguin Publishing Group
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- 5.00(w) x 7.80(h) x 0.60(d)
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- 18 Years
Read an Excerpt
Our Firstborn Son
* * *
On the morning of July 4, 1983, Steven, our first child and then nine months old, was crying bitterly and refusing to nurse. Usually good-tempered and not prone to colic, he seemed inconsolable. Something was wrong.
It was the last leg of our journey back to Boston after three years working at the University of California. We had flown nonstop from Los Angeles to New York the prior evening and then driven to Pam's parents' house in Connecticut to spend the night. Steve had missed his regular nap on the flight and was too cranky to rest in the car.
We were first-time parents, and as physicians, Pam and I vowed when Steve arrived that we would not diagnose or treat our own children. It was not only the concern that our clinical judgment would be clouded by parental emotion. We were also relatively ignorant about pediatrics. Our knowledge of infant health and disease came from a brief introductory course during the third year of medical school. And living in California, far from our families, we had no one to mentor us in the common sense of baby care. So we studiously read how-to books by popular pediatrician writers and checked Steve's milestones in growth and development against their charts. He had been a healthy infant.
It had been an animated homecoming that hot July evening in Connecticut. Steve was my in-laws' first grandchild, and they were delighted that we had returned. We had talked together around the kitchen table late into the night, shamelessly eatingHäagen-Dazs and homemade cookies.
Pam and I assumed Steve would sleep late the next morning, given the three-hour time difference and his missed nap. But the night-table clock read just 5:12 when we heard his plaintive cries.
"You check him," Pam muttered as she fixed the blanket over her head like a cowl in a determined effort to return to sleep. We attended to our son pretty much according to our biological clocks. I am a morning person, Pam a night owl. Before 3 A.M., she gets up; after that, it's my turn.
"Did he nurse last night?" I asked, wondering if Steve was hungry.
"Not much. He started, and then stopped, so I just put him down to sleep."
I navigated through the clutter of luggage, laundry, and shoes on the bedroom floor to Steve's Portacrib. I noticed he was lying on his side rather than in his usual position on his back. His broad silky crown was pressed into the crib's foam bumpers, obscuring his face.
"Hey, it's too early to get up, Zalman Leyb," I said, using his Yiddish name he was given in conjunction with his English one. In the Ashkenazi tradition, children carry the Hebrew or Yiddish names of deceased relatives, to perpetuate their memory. Zalman was my father's name and is the equivalent of Solomon. Leyb was Pam's grandfather's name and means "heart" in Hebrew and "lion" in Russian-Yiddish. We had chosen these names not only as a bridge to the past but as a hope for the future that our firstborn son would be blessed with a heart of wisdom, courage, and compassion.
A sharp sulfurous odor assaulted my nostrils. It rose from a heavy black stream that was lazily meandering down Steve's fleshy thighs.
"Must be a whopper," I said. I held my breath and quickly unhitched the adhesive waistband of his Huggies. On Steve's bottom was a wide swath of mucoid diarrhea. I noticed speckles of maroon dotting a tarry gelatinous stool.
"His poop is strange," I called to Pam.
Pam threw the blanket from her head and unsteadily made her way to the crib. I offered the open diaper for her inspection. Her brow tensed and cheeks stiffened.
"It looks like melena," she said gravely.
Melena is the medical term for blood in the stool. Blood, when it is digested in the intestines, gives stool a distinctive tarry appearance and pungent odor.
"And he feels a little warm to me."
I placed my palm next to Pam's on Steve's flushed forehead. Not more than a 101, I estimated.
Pam stood next to the crib, warily observing the baby.
"I'll clean him," I said.
I volunteered for such chores, knowing that my father never once, according to family lore, changed a diaper or gave a bottle. I aimed to be the modern husband-partner. But my initiative at that moment was different: I wanted to be occupied in a menial task that suspended thinking. Melena indicated internal bleeding, and although it could be caused by gastritis, it also might be the first sign of something more serious, like a tumor.
As I wiped away the viscous stool, an angry rash emerged. I liberally sprinkled Desenex powder over Steve's crimson buttocks and then snugly enclosed him in a new diaper.
"Let's see if he's hungry," Pam suggested, deftly lifting Steve from the crib and holding him securely across her chest. She began to coo softly and to stroke his back. Steve faced me, and I noted again how he had inherited Pam's unusual eyes, the left one sea green, the right one lapis blue.
Pam settled into a large wicker rocker set near the bed and unsnapped her nursing bra. Her swollen breast was directed to Steve's thin closed mouth. Pam lightly stroked his dry lips with her offering. Beads of ivory milk coalesced into a halo around her areola. Steve responded quickly, sucking greedily, but after less than a minute tensed his cheeks, whimpered, and released the nipple. The milk streamed down his chin.
"What's the matter, sweetness?" Pam asked gently.
Steve emitted a harsh grunt and then flexed his legs toward his belly. He repeated this brusque motion several times, breathing noisily.
"Here, let's try again."
But to no avail. Each attempt to nurse was met with aborted gulps followed by sharp jerking of his legs.
We laid Steve on his back in the crib, but he fussed until he turned himself on his side with his knees wedged toward his belly.
Pam balanced on her toes next to the crib, her hands whitening in clenched fists as she stared down at the baby. She was poised like a lion that had picked up the scent of danger and was ready to defend her young.
"Where do we find a pediatrician on July Fourth?" she tensely asked.
It was not obvious, and we began to think out loud. We first would look for neighbors with children and ask them to call their doctor. The doctor might be away, or reluctant to respond since we were not his patients. We'd then be forced to go to a hospital emergency room. Norwalk and Bridgeport were equidistant from Pam's parents. Emergency rooms are notoriously busy on holiday weekends. Despite our suspicion of melena, Steve was not frankly bleeding, and would not be judged an urgent case. We likely would sit for hours, triaged to the back of a queue of people in greater need, with heart attack, trauma, sepsis. There also would be a single primary care doctor covering such a local ER, without a pediatrician in attendance. Yale-New Haven Hospital, a larger teaching institution, would have a pediatric intern on site, but it was nearly two hours away. And we both knew the inside joke among physicians: Never get sick in July. The new interns begin then. Some few days ago they were bewildered students, but on the first of that month they are instantly transformed into decision-making doctors by donning a white coat with the monogram MD.
Pam always stocked liquid Tylenol in Steve's travel bag. A dropperful would do no harm, we agreed. Lowering his fever might improve his disposition and facilitate his nursing. The Tylenol at first stayed down, but as we lay Steve back in the crib, he grimaced, abruptly drew his knees to his chest, and vomited. The cherry color of the medicine grew into a sickly brown as it diffused in a pool of bile on the sheet.
* * *
The Clarks, young neighbors who had purchased their home through my mother-in-law's real estate agency, called their pediatrician, Dr. John Burgess, at home. We explained our dilemma to him, and without a hint of hesitation, he instructed us to meet him at his office in fifteen minutes.
Steve had become calmer after vomiting, and the brusque flexing of his legs ceased. We easily found a parking spot on the tree-lined street in front of the town's medical building. Dr. Burgess was waiting at the entrance and greeted us with a polite smile. He was a trim man in his early sixties, with short-cropped white hair and half-glasses that rested low on his nose. Despite the steamy summer heat and the holiday, Dr. Burgess wore a starched button-down blue shirt, paisley bow tie, and knee-length white coat with his name embroidered in blue script over the left breast pocket. His crisp professional appearance reassured me. In Los Angeles, I was disturbed by the indifferent attire of many of the younger doctors: the unkempt hair, running shoes, and jeans bordered on sloppiness and did not indicate to the patient the sense of order and attention to detail essential to diagnosis and treatment.
Steve submitted docilely to the pediatrician's experienced prodding and auscultation. After a few minutes, Dr. Burgess nodded to us that his exam was finished. Pam picked up Steve and dressed him in a fresh diaper and clothes.
"Just an intestinal virus," Dr. Burgess announced with confidence. "Keep up the Tylenol--"
"But it had the look and smell of melena," Pam interjected.
"It wasn't," Dr. Burgess quickly retorted, his eyes holding Pam's. "I was once an overanxious doctor-parent, too." He paused and his face softened with a knowing grin. "My brood is grown up and long out of the house. But you never stop worrying about children. And a little knowledge is a dangerous thing. He'll be himself in a day or two. You have a basically healthy baby."
A wave of warm relief slowly passed over me. I looked to Pam. She maintained a stony silence.
"Like I started to say, continue the Tylenol if he feels feverish, every four to six hours, for the rest of the day. And just let the diarrhea flow. Nature knows how to get rid of the bad humors. Keep him hydrated today with warm sugar water from a bottle. It goes down easier than breast milk with an intestinal virus. You can try to nurse him again tonight. And don't bundle him up on the ride back to Boston. It's going to reach into the nineties today. You'll overheat him." Dr. Burgess smiled again, removed his white coat, and donned a blue-striped seersucker sports jacket. He escorted us out to the front door.
"Sorry to have bothered you on the holiday," I repeated as I shook Dr. Burgess's hand good-bye.
"My pleasure to assist."
I was filled with that profound gratitude of the patient for the doctor, for not only selflessly attending to a loved one but also for taking away my fear. I carry a special affection and admiration for pediatricians, realizing early in my training that I could not be one. It was too emotionally wrenching for me to attend to very sick children. During my brief medical school tour through the pediatric wards, I cared for children with ultimately fatal problems, like cystic fibrosis and leukemia and malformed hearts, and ended each day profoundly upset, pained that such young and delicate innocents were suffering. These feelings overran my thoughts on rounds, and I couldn't focus on the clinical issues of the cases being presented.
Since Steve's birth, I had tried to subsume much of the anxiety that comes with parenting in general and my past exposure to seriously ill children in particular. I am not a hypochondriac, but as a specialist dealing daily with life-threatening blood diseases and cancers, I found myself imagining these maladies striking my son. Similarly morbid thoughts seized my mind at unexpected moments. That first year of Steven's life, at the Passover seder, the ritual recitation of the Exodus from Egypt, I had shuddered when Pharaoh orders all male Hebrew children thrown into the Nile. I was especially gripped by the Tenth Plague, when the Angel of Death passes over all the firstborn of Egypt, man and beast, and kills them in retribution. These were chilling illustrations of the shattering power of the loss of a child. Only the Tenth Plague could break the obdurate Pharaoh, all his authority and possessions made meaningless in its wake.
Dr. Burgess's words reminded me how easy it was, with a little knowledge, to allow my fears to race ahead of rational thinking. As a first-time father with a "basically healthy baby," I remarked to myself, Better to be a layman, in the bliss of ignorance, than a neurotic doctor.
"It's already one o'clock," I said to Pam as we exited the medical office building. "Let's pack and try to get up to Boston before dark."
Pam looked hard into my eyes. "I hope he's right."
* * *
Before we left Pam's parents, Steve kept down the full six-ounce bottle of sugar water recommended by Dr. Burgess. The July sun was high in the sky, and the rental car had no air-conditioning. We drove with all windows open. The warm breeze seemed to soothe Steve. Traffic was light and we enjoyed a steady cruising speed on the Merritt Parkway. Most people had left early for beaches or parks to escape the heat and claim a good vantage for the evening fireworks sponsored by the local towns. By the time we approached the exit to Interstate 91 North, Pam had fallen asleep in the back beside Steve. He sat awake, docile in his car seat.
I relaxed and began to think of our new life back in Boston. It was a career risk to return. We had just begun to establish ourselves at UCLA. I had succeeded in setting up my own laboratory, secured a five-year grant to study blood cell development, hired an adept technician, and was publishing scientific papers. The dean of the UCLA Medical School had prevailed upon me not to leave. The ticket to success in academia was to investigate a problem "an inch wide and a mile deep." AIDS seemed to be such a problem. It had just appeared, the first cases reported by our group in Los Angeles and colleagues in New York. This was an unparalleled opportunity: rarely in a doctor's career does he have the chance to describe the manifestations of an entirely new disease, contribute to identifying its cause, and work to create effective therapies. There is no AIDS in Boston, the dean had said; you have funding, lab space, and a growing reputation. You're throwing away a golden chance to make your career on this new rare syndrome.
But I always had a contrarian streak. When I was a youngster, my father gave me the nickname "Upside-Down Jerry," because I stubbornly insisted on trying to do things against given directions. Authority was heeded only if it seemed sensible, not because it was authority per se. Now a group was moving from the Massachusetts General Hospital, where both Pam and I had trained, to create a new department of medicine at a small neighboring institution, the Deaconess. The Deaconess was excellent in clinical care but lacked the research depth that marked the other Harvard teaching hospitals. I could build a new research enterprise in blood diseases, cancer, and immunology from the ground up. Risk and change energized me.
Pam had wanted a change, too, in the form of a flexible year with the new baby. She had been on track since college, engaged full-time in her work. Now she planned to break away from that path. She had taken a part-time job, teaching interns and residents at the Waltham Hospital, a community-based center associated with Harvard's Brigham Hospital. With the position came the perk of a free house in that blue-collar town some fifteen miles west of Boston. A few months earlier, when we came to Waltham to finalize our arrangements, we had inspected the two-bedroom prefab with its single bathroom and backyard abutting the parking lot of the McNamara Concrete Company. From the kitchen window you saw scores of steel gray concrete mixers standing like soldiers in formation. In California, our home was on a cliff overlooking the Pacific Ocean with a view of Catalina. "Are you sure you are ready for this?" Pam had pointedly asked. I had paused, and then said I was ready for anything.
Shortly after we connected to Interstate 84 in eastern Connecticut, Steve began to fidget and whimper. Pam snapped awake at the sound of his cries. The car radio said the temperature was 93 and the humidity 87 percent. Pam felt his cheek. He was warm and likely thirsty. We stopped at the next highway rest area and settled under the speckled shade of a motionless willow. Pam sat cross-legged and cradled Steve, speaking to him encouragingly. But he continued to fuss and would not take any sugar water from the bottle. I slid my index finger into the bottom of the new diaper he was given after Dr. Burgess's examination. It was completely dry.
"He hasn't peed at all."
Pam's face tensed and her eyes focused on Steve's squirming legs.
"Let's sponge him with some cool water from the fountain and get to Boston," I suggested.
Pam silently indicated her assent.
We drove quickly up Interstate 84 to the Massachusetts Turnpike and headed east. I knew the exits on the route to Boston by heart: Palmer, Auburn, Worcester, Framingham. As we passed each, I noted the mileage on the odometer and estimated the distance to the next one. Pam again tried to coax Steve with the bottle of sugar water but without success. It was too early to give him more Tylenol, and in line with Dr. Burgess's instructions, she did not try breastfeeding.
As we passed Framingham, the penultimate exit, Steve tried to flex his legs upward but was restrained by the straps of the car seat. Each aborted attempt ended in a piercing cry, like a kitten stepped on by a heavy boot. Pam tried to comfort him, stroking his pale and dry forehead.
I began to sing "Humpty Dumpty," which we played from a music box for Steve at bedtime, hoping the familiar hypnotic rhythm would be soothing. But my voice wavered as the meaning of the words took on a dark resonance:
Humpty Dumpty sat on a wall, Humpty Dumpty had a great fall; All the king's horses And all the king's men Couldn't put Humpty Dumpty together again.
I stopped and tried to think of another song we sang. "Jack and Jill" ended in a broken crown and tumbling down a hill. "Rock-a- Bye-Baby" climaxed in a free fall of cradle and child. I remained silent.
"Try 'Hot Cross Buns,'" Pam offered.
I tried to remember the verses, but the song became dispersed in the waves of fear breaking in my mind. It was melena. Steve is bleeding internally. From an intestinal tumor.
My hands became unsteady and I worried I'd miss the turn off the Mass Pike onto the twisting surface roads into Waltham. I calmed myself by repeating Dr. Burgess's injunction, to try not to be a physician-parent with limited knowledge who easily panicked.
"We'll settle in at the house, cool him down in the bath, and then see how he is," I said, talking as much to myself as to Pam.
We pulled into the driveway at dusk, the last tired rays of the summer sun casting a pall over the small house. Our new neighbors were in their front yard, drinking cans of soda and beer next to a smoldering barbecue. I stopped to wave to them and then began unloading our bags. Pam freed Steve from the car seat and quickly carried him into the house.
The bags felt extraordinarily heavy, and I realized I was exhausted. I had slept less than four hours the night before, and except for the respite following the visit to Dr. Burgess, had been in a sustained state of anxiety since. My infant son was in escalating pain. If this were an intestinal virus, as Dr. Burgess asserted, it was wreaking havoc inside his tiny abdomen.
I looked to Pam for reassurance. I admired her as a highly competent physician whose attention to detail and clinical judgment were formidable. At the hospital, she functioned in a deliberate manner, coolheaded and in control, even in the most harrowing emergencies. But her reassuring mien was gone. Her eyes had a furtive look and her voice was unsteady when she asked if everything had been unloaded from the car.
"Let's give it an hour or two," I said as I glanced at my watch and noted it was just after eight. "Maybe if he's out of that hot box of a car and in your arms he'll relax and take the sugar water again."
Pam warily agreed as she searched for a kettle in the kitchen cabinets to warm the water. I busied myself upstairs in the bedroom by putting away clothes.
I followed the order I'd used since first leaving home for college: socks and underwear in the upper drawer; T-shirts and shorts below; with heavier items, jeans and folded dress shirts, at the bottom. Then I arranged my pens as I liked them on the night table. These set, I began to organize my books on the shelf, the upper shelf for medical texts, the lower for literature. As I put away my belongings, I strained to hear noises from downstairs, and when no cries were apparent, told myself that in the more comfortable setting of the house Steve would settle down. The stomach bug would run its course, as Dr. Burgess had said. Steve was a basically healthy baby.
"Jer, come down! Come down!"
I dropped a pile of books and bolted from the bedroom. I took the steps two at a time, the rickety banister barely supporting my weight. Pam was kneeling on the beige carpet. Steve was on his back next to her, his face ashen and his breathing forced in short gasps. He was desperately flexing his knees to his chest, his arms flailing at his sides. He looked like a wounded beetle in the throes of dying.
"Let's take him to Children's Hospital--now!"
I responded to Pam's command by grabbing the ring of keys I had left on the table in the foyer. Pam struggled to hold Steve securely as we ran to the car.
I retraced our route back down Highland Street to the Mass Pike. On the highway, I forced myself to keep a steady 55; this was no time to be stopped by a cop or lose control and hit another car. Pam sat with Steve pressed to her chest. He was having spasms of pain every few minutes. As each came on, he would again draw up his knees and shriek. Pam stroked his back, softly repeating, "It's okay, it's okay."
I again focused on landmarks to mark our progress: the Newton Centre sign indicating we were halfway there, then the Allston-Cambridge toll, the reverse curve of Storrow Drive at Boston University, the Fenway overpass at Kenmore Square, and finally Longwood Avenue, the heart of the Harvard Medical area. The car clock read 8:22 when we left Waltham. It took twenty-one minutes to arrive at the Children's Hospital.
I spied three empty parking spots near the hospital entrance and pulled into one, wondering if it was a sign that the ER was not busy.
We hurried through the sliding automatic doors and then halted in the ER waiting room. It was a tumultuous scene. Every chair was taken. Many parents stood with squirming infants in their arms. Toddlers were sprawled on the floor.
The waiting room, with all its chaos, was unexpectedly comforting. We were finally in a hospital, and not just any hospital but Boston Children's, one of the premier pediatric institutions in the world. And I knew the place well. I had worked for a year at Children's in a research laboratory in the department of a prominent hematologist, Dr. David Nathan. A burly, avuncular man, David relished the role of "godfather" to several generations of hematologists whom he trained at Children's and then placed in academic positions throughout the country. When Pam would work nights as a resident at Massachusetts General Hospital, I would conduct experiments late into the evening. I often went for a midnight snack in the hospital cafeteria before taking the last trolley home. The route from my lab to the cafeteria required passing through the ER waiting room.
I located the triage desk and moved toward it with a determined stride. Pam, gripping Steve, followed in my wake.
The triage nurse was a wizened, plump woman whose name badge read "McArdle," with no first name. She quickly surveyed us with her trained eyes, flipped the intake pad to a fresh page, and briskly obtained the essential information: names, address, home phone, employment, presenting problem. I couldn't remember the phone number at the new house and fumbled through my wallet for my insurance card until I realized it was for the UCLA clinics.
"We'll deal with that later," McArdle said as she put the pad aside and directed us to the swinging doors behind her that led to the ER proper.
"First door on your right. You'll be seen shortly."
The room was a thin rectangle that accommodated two chrome chairs with black vinyl seats, a short examining table, and a row of instruments on the wall: blood pressure cuff, ophthalmoscope, otoscope, suction apparatus. I sat on the chair next to the examining table, noting how unyielding it was. A painful knot grew in my lower back. I shifted in the chair and tried to ignore it. Pam would not sit but paced the room clutching Steve to her chest.
After a few minutes, an ER doctor walked in. He plucked McArdle's triage form from a Lucite box on the open door. In his late twenties, he was strong featured and wore the V-neck blue scrub shirt of a surgeon. Tufts of wiry brown chest hair formed a nest upon which his stethoscope rested. The stubble on his cheeks suggested he hadn't shaved that day. I saw his hospital badge and read, "Scott Warren, MD."
"Dr. Warren, I'm Dr. Jerry Groopman, and this is my wife, Dr. Pam Hartzband," I said in as welcoming and deferential a tone as I could muster.
"Uh-huh," he responded, not picking his head up from the telegraphed notes on the sheet. After fully reading the form, he introduced himself.
"I'm the surgical moonlighter, a PGY3 covering the ER."
I took some comfort from this, that he was in his third postgraduate year of surgical training. Abdominal pain is properly first triaged to surgeons in the ER.
I was tempted to ask him if there was a senior attending surgeon available, but refrained. I had been a resident and now was a teacher of residents. Patients and families who immediately challenge a resident's authority by demanding the attending doctor may alienate someone who can be an important ally. Senior residents at major university hospitals often are the best and the brightest in medicine--young, enthusiastic, hardworking, fresh from the latest teaching. True, they lack seasoned experience, but they also are more hands-on, and often perform better in the ER than older staff, because they work there day in and day out. Of more concern was that some residents become perverse when they encounter patients who are difficult or noncompliant. At Mass General during my training, such patients were given a denigrating acronym by the interns and residents: GOMER, for "get out of my emergency room." The vitriol embodied in the term sometimes impaired sound judgment or led to neglect of serious complaints. Dr. Warren was the most important person in our universe at that moment, and I was eager to win him to our side.
"Are you any relation to Chip Warren of the distinguished Warren medical family? Chip was in Pam's class at Harvard Medical School and one of my students when I was a junior resident at the Mass General."
This was not idle social conversation. My words were meant to say: We are both doctors, Harvard trained. Our past is like your present. We may even know people you know. Please treat our son with special care and concern.
"No, no relation. A lot of attendings ask if I'm part of the Warren dynasty. But I'm not. Now, when did your son first seem sick?"
He directed the question to Pam, who responded with a chronicle of the events of the last thirty-six hours. It was Pam at her best, the organized thinker with flawless recall for detail. She began by stating that Steve had been previously healthy, the product of a normal delivery who had achieved all his developmental milestones. She then described the missed nap on the flight from L.A., his cranky awakening the next morning, and emphasized the color, viscosity, and odor of the morning stool that she thought was melena. Her recounting of Dr. Burgess's evaluation and contrary opinion was objective, without editorial comment. Pam then summarized Steve's temporary respite after the Tylenol and sugar water, his renewed whimpering on the trip up, the stop at the highway rest area in Connecticut, his dry diaper and refusal to drink, which meant that he was without any liquid or nourishment for the past eight hours. She ended with his gasping breathing punctuated by shrill cries during the spasms of pain that brought us to the ER. I sat silently, ready to comment on an omitted event or observation, but the clinical history was complete.
"Has his diaper been dry? How many hours since he last had fluids?" Dr. Warren asked.
I saw Pam's face register first uncertainty and then concern. A sick taste welled in my mouth. I locked on to Pam's eyes and spoke without words: You already told him that; he's not listening carefully; he wasn't paying close attention.
"What d'you got in here, Scott? What is it? A good case?"
I looked at the door and a grinning pie-faced young doctor stood under the lintel. Also wearing a blue surgical scrub shirt, the hip pocket of his short white coat bulged with the Washington Manual, a primer that interns carry to reference diagnoses and treatments on the run.
I met the intern's gleeful eyes with mine. I felt my hands tremble, my jaw tighten, my chest heave. A thunderous rage rose up from the deepest recesses of my being.
"Who the hell are you?" I bellowed. "Who the hell are you? My son is not a 'good case'! My son is not an 'it'!"
I felt I might kill the intern, literally grab his neck and snap his spine with the force that was exploding in my limbs. In my mind's eye, I saw myself pounding his flopping head against the pale green wall of the ER exam room.
The intern looked at me in shock and then turned perplexed to Dr. Warren.
"Get out of the room! Now! Now!" I yelled.
Dr. Warren nodded to indicate that his intern should leave.
I stood paralyzed for a long moment and then retreated to the corner of the room, lowering myself onto the chrome chair. My blood was coursing in forceful pulses through my head, my breathing still sharp and fast. I willed my fists to release, my arms to rest at my sides. I reached for the handkerchief in my pocket and wiped the lines of sweat collecting at my brow.
"I'm sorry," I finally said, my eyes fixed on the floor before me. "I know that is how we doctors sometimes talk about patients. But he's our child." I raised my head to speak directly to Dr. Warren. "We're just scared out of our minds."
Dr. Warren nodded to accept my apology and then politely asked if he could examine the baby.
Pam and I hovered close by, observing the resident's every move. Steve had tired, his efforts in drawing his legs to his chest less forceful than earlier in the evening. I glanced at the large Seth Thomas clock on the wall. Its numbers were in bold black, and it had a silent, sweeping red second hand. It was already 9:35.
Dr. Warren worked silently, lingering with his stethoscope over each quadrant of Steve's belly. Finally, he seemed satisfied with what he heard and slung the stethoscope around his shoulders like a mantle. Pam reached over and gathered Steve back in her arms.
"Rushes of bowel sounds, then quiet. Very classic."
"Intussusception?" Pam asked, quicker than I to translate the physical findings into a diagnosis.
Dr. Warren said yes.
Intussusception is a telescoping of one segment of bowel into another, resulting in acute intestinal blockage. In infants, it often occurs without apparent cause, but can also be due to a viral infection or a tumor growing in the intestine. One segment of bowel becomes abnormally heavy as the tumor grows in it or viral infection inflames it. This weighted area acts as a so-called leading point. Waves of peristalsis, the rhythmic muscular contractions that move food and stool down the intestine, push forward and meet the resistance of this weighted segment. This causes the preceding piece of intestine to telescope over the heavy segment and swallow its partner in a strangling gulp. Each peristaltic wave triggers searing pain as the lighter piece of bowel further engulfs its heavy partner and stretches the delicate intestinal nerves like subjects of torture on an inquisitor's rack. This explained the excruciating spasms of pain Steve had suffered over the last day. The blockage accounted for his bilious vomiting.
"We'll get some blood tests and then do a barium enema."
Dr. Warren explained the barium enema would confirm the diagnosis and possibly open the obstruction. The air pressure from the rectum through the enema was often enough to push back the telescoped piece of bowel. Neither Pam nor I was expert enough to know if this was the right first approach, but it seemed logical. We surrendered Steve to Dr. Warren, who transported him on a stretcher for his blood tests and then to X ray.
We walked up the flight of stairs to the empty reception area of the Radiology Department and sat in its first row of chairs. I grasped Pam's thin, moist hand and offered hollow reassurances: "It will all turn out fine.... We're at Children's, he's in good hands." She replied with a wan smile.
We both knew that we could not know--no one knew--how it would turn out, whether Steve would quickly recover with the simple maneuver of the barium enema, the blockage due to a virus that had inflamed his bowel, with this nightmare easily ended, or whether he required surgery, where some serious pathology would be revealed, a hidden tumor, incurable, our nightmare just beginning.
I closed my eyes to pray but couldn't focus my thoughts. A chill passed through my body.
The world seemed to become motionless and without sound, as if I had passed into a frozen vacuum.
Is this the prelude to death, my son a part of me, my soul sensing the eternal stillness of the dimension he is entering?
I felt the chill penetrate deeper into my bones.
The chill is the icy breath of the Angel of Death, searching for my firstborn son. Did I forget to paint lamb's blood above our door when we left Los Angeles?
I began to speak to myself, firmly and deliberately.
Gain control of your thoughts. This is a medical emergency in Boston, not the Exodus from Egypt. There are no signs and wonders. Steven is not being punished in retribution for his father's sins, the times you were inconsiderate, ungenerous, arrogant, the occasions you turned to the idols of power, money, fame.
God, please restore my son. If you do, I will ...
What? Attend synagogue daily for a year? Give more to charity? Strictly observe the Sabbath?
Prayer is not bartering with God.
Then how do I pray for my son's life?
Like you prayed for your father's life. In an eerily similar moment, in that small, ill-equipped, understaffed community hospital in Queens, New York, waiting to see if he would survive. Then, too, time felt halted and the motion of the present seemed to pause as the future was determined.
Please, God, save my beloved father.
But he had died, gasping for air before my eyes. My prayers had not been answered then.
"Dr. Groopman?" The radiology resident was standing before me.
"It is an intussusception. But the enema did not open it. Sorry." The resident paused. "And good luck."
For a moment I was confused. Where was Steve? Who was attending to him? I slowed my growing panic and then realized that, according to standard hospital procedure, he was being returned in the special patient transport elevator to the ER, with a nurse accompanying him, and we would meet him there.
Pam and I walked hand in hand down the hospital corridor. The reflected fluorescent light cast a ghostly aura on her face. Her usually strong features, the high prominent cheekbones, piercing eyes, and calm smile, were bleached away. I again felt deeply exhausted. For a moment I feared I would collapse. I forced myself to stand erect and appear strong as I walked with her down the stairs to the ER.
"See how the dilated loops of bowel stop right here?" Dr. Warren said as he held the X-ray films up to the ceiling light.
I saw what looked like a child's unfinished chalk sketch of balloons. Their tense white upper borders stretched up against a black background. But they had no bottoms, their lower halves lost in a sea of gray.
"You can follow the loops to the air-fluid levels," Dr. Warren added, pointing on the X ray to where the balloons disappeared into the gray puddle of liquid and stool that had accumulated from the blockage.
"You know it didn't open after the enema," he continued.
I felt my eyes tighten.
"And we just got the blood work back. His white count is up--29,000--with a left shift."
I didn't know if that was typical for an intussusception, but an elevated white blood cell count and "left shift," meaning the appearance in the bloodstream of immature white cells, were often a harbinger of major infection or tissue damage.
"He seems very tenuous," Pam said. "I guess you're going to operate to relieve the obstruction."
"In my clinical experience," Dr. Warren stated with calm gravity, "we can safely observe your son overnight. It's premature to operate. And it's already past midnight."
I glanced quickly at the Seth Thomas clock: 12:17.
"I'll sign him over to the morning shift at six. They'll reassess him then. Meanwhile, he'll be kept hydrated with intravenous fluids. You can stay in the room with him. There's coffee in a pot by the nurses' station in the back. We usually don't offer coffee, but since you're doctors, feel free to get some."
Dr. Warren looked at his clipboard.
"I've got another two kids to see down here and then I'm going to get a few hours of sleep--if I'm lucky."
Dr. Warren left with a conspiratorial smile, which I interpreted to mean that Pam and I both understood how precious sleep was for an ER resident and how lucky he would be to get even two or three uninterrupted hours.
Pam and I looked down on our child. An intravenous line was tapped at his wrist, a salt-and-sugar solution slowly dripping in. I counted the drops against the movement of the sweeping second hand of the clock and then stopped. I knew what infusion rate should be set for an adult who had not been eating or drinking for more than a day and who was "third spacing," in medical jargon meaning accumulating excess fluid in the third space of his abdomen. Had Dr. Warren set the rate correctly for a child of Steve's age and weight and condition?
I thought back to my nights as an intern and resident at Mass General. Sleep-deprived, inexperienced, constantly called to attend to several sick patients at once, I was terrified I would make a mistake. There were so many pressured moments when I worried I would miss a clue in a patient's history, overlook an important physical finding, misinterpret a laboratory test. Like the other trainees, I tried desperately to hide my fear by assuming the calm affect of an experienced physician in front of the patients and their families. We were supposed to be supervised by the chief resident, but the oversight was intentionally light-handed and uneven. You were a baby chick who had been pushed from the nest and had to learn to fly on your own. It was the way doctors had been trained for generations. And there was a macho pride in refraining from asking for backup. It was a coup for an intern or junior resident, bleary-eyed and sleepless, to greet the chief resident in the morning having "held the fort" without asking for assistance.
In crises, I learned that my saviors were the nurses. They had seen generations of interns and residents come and go and were conversant with every detail of the patient's condition. They also were acutely aware of the interns' and residents' inexperience and the risk of error. Many were from working-class backgrounds, the first in their large families to complete a degree, and under different social and economic circumstances would have been likely to become doctors. Although you were the physician and they the nurses, you quickly learned to read the lightly veiled instructions within their queries and suggestions: "Doctor, shouldn't that blood transfusion be given more slowly for a thin elderly woman?" "We usually premedicate with antihistamines and steroids at higher doses than the ones you ordered before giving that antibiotic." "Hold the neck back a little more as you push down the tube into the trachea or else it may go into the esophagus." But there was no nurse to turn to, except McArdle, and she was in triage, no longer responsible for Steve's case.
"He looks so sick," Pam said softly. He did. Steve's skin was mottled, his eyes glazed and hardly moving. Only occasionally did he draw his stubby legs toward his chest, but weakly.
"And he seems to have more fever. Here, feel his head."
Pam's soft hand guided mine to Steve's crown. He was hotter than before, although he had been given Tylenol before the barium enema.
A sense of dread grew within me. Steve was deteriorating. The conclusion about Dr. Warren that I had read in Pam's eyes echoed loudly in my mind: He's not listening carefully; he wasn't paying close attention. Now Dr. Warren had asserted that, "in my experience," Steve could safely be observed overnight. And after two other children were seen, he hoped to get some sleep.
"I don't trust him," Pam stated firmly. "It doesn't feel safe to wait."
I nodded silently in agreement. But what could we do? If we insisted on going to the operating room, it would be Dr. Warren wielding the scalpel along with his nameless intern who had been looking for a good case.
I felt off balance and reached out to clutch Pam's hand, using her as ballast to gain equilibrium. For a long, terrifying moment my mind was blank. I then forced myself to think. Pam had trained at Harvard Medical School. She had rotated through the Children's Hospital. But she was only a student then, and that was many years ago. She had no personal contacts. I had worked only in a basic science lab, as a researcher, not in the hospital ...
"David Nathan?" I blurted before my thought was finished.
Pam looked uncertainly at me.
I had bumped into David bicycling with his wife, Jean, along Memorial Drive a few days before we left for California. He had wished me luck in my new job at UCLA, and I had thanked him for the basic science training I got in his department. I knew he lived in Cambridge but also recalled that he was an avid sailor. He spent most summer weekends on his boat moored in Nantucket Harbor.
It was a long shot but the only one we had. I had three quarters in my pocket, the change from the Allston-Cambridge toll on the Mass Pike.
"In Cambridge. N-A-T-H-A-N, David and Jean. Don't know the address," I told the operator from the pay phone in the ER waiting room. I cupped my hand over my exposed ear, muffling the sounds of the crying children and frazzled parents camped out around me. Most doctors, for reasons of privacy, don't list their home numbers, only their office numbers.
Thank God, I said to myself.
I wrote the number on a scrap of paper towel I had taken from the ER room. Please be home.
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Meet the Author
Jerome Groopman, M.D. is the Recanati Professor of Immunology at Harvard Medical School, Chief of Experimental Medicine at Beth Israel Deaconess Medical Center, and one of the world's leading researchers in cancer and AIDS. He and his work have been featured in The New York Times, The Wall Street Journal, and Time magazine, as well as in numerous scientific journals. He lives with his family in Brookline, Massachusetts.
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This is a must read for anyone who has ever had to deal with a medical mystery or serious illness for themselves or a loved one. Gripping and entertaining, this is not a slow, tedious read, and actually teaches you something about being a patient, or a doctor.