DR. ROBERT H. NELSON, M.D., CONTRIBUTED THE NEXT TWO STORIES

Dr. Robert H. Nelson, M.D., is a Family Physician. He practiced for twenty-two years in Hastings, Minnesota, before joining the staff of the Mayo Clinic in Rochester, where he currently works with a research team studying type two diabetes. Let me introduce you to Dr. Nelson, using his own words as he describes incidents from his practice:

Bad Doc, Good Doc

Many of the decisions made by a doctor impact a patient’s daily life. Having to advise an elderly person to cease driving an automobile qualifies. Most people resent losing driving privileges. Agnes was such a person. She was in early stages of Alzheimer’s disease, but still able to live alone with the assistance of family members.

One day a sister escorted Agnes to my office. Agnes was cheerful but had no idea why she had been brought to see me. Her sister took me aside and told me that several days earlier, Agnes had driven to the grocery store and become lost on her way home. Fortunately, she had found her sister’s home before any tragedies occurred. Her sister did not want her to drive anymore, but lacked the courage to tell her so. She asked if I would do it for her.

As I conversed with Agnes, it was evident that her dementia was progressing. Tragically, Alzheimer’s assaults not only memory. Poor judgment, loss of abstract thinking, inability to problem-solve, even to perform tasks of daily living result. It can rob people of social inhibitions. Agnes, sweet and proper, even prim, hovered on the brink of disintegration of her personality.

I asked Agnes about her trip to the grocery. She had only vague recollections of the event and downplayed its significance. I explained to her that this episode was a sign of disease progression. I told her she could no longer drive a car. She erupted into a tirade, using language that a hack Hollywood writer would hesitate to use. She accused me of greed, incompetence and lack of caring. Her sister huddled into the corner of her chair in an agony of embarrassment. Agnes threatened to kill herself if I “took away her license.” Her death would be my fault.

Eventually I calmed her enough that she was no longer shouting, but her voice and glare bore icicles when she stomped from my office.

Six weeks later, I again found Agnes’s name on my appointment schedule. I approached the exam-room door with apprehension. I put on what I hoped was my most disarming smile and walked into the room. Agnes greeted me cordially. She was in a chatty mood and skipped through a series of topics.

Eventually, I steered the conversation to how she was coping now that she no longer had a car. She brushed my attempt aside as though it was an inconsequential matter. As the visit terminated, she squeezed my hand between both of hers and smiled broadly.

“Thank you, Doctor. You’re such a nice man, not at all like that other guy. He wouldn’t let me drive!”

Sirens in the Night

It seems so long ago that I sat in an auditorium, waiting to receive the diploma decreeing that I had become a medical doctor. There was one more lecture to hear, that called the commencement address. I do not recall the name of the physician-poet who delivered it, but I haven’t forgotten its message. He spoke eloquently of the life changes that happen when one becomes a doctor. Never again, he said, would we experience the world in quite the same way. Daily events would take on new meaning. The example, upon which he built his talk, was the sound of a siren in the night. How true his words were! To this day, I cannot hear a siren in the distance and darkness without feeling a knot in my stomach. What does the sound foretell? Someone gravely injured, fighting for life? Some other catastrophe in a person’s life? Even, a false alarm?

I recalled those words and thoughts recently when I happened across a popular prime time television program known for its use of gruesome imagery. I could not watch. Events on the screen were too close to those in an emergency room. The next day, as I took a stroll around my neighborhood, I was moved to reflect on some of the more dramatic moments of my career. Some were brief. In most cases, I do not recall names. Yet, they etched indelible marks on my memory, on who I am as a physician. As a person.

—————

Call him Charlie. He was a fifteen-month-old toddler who had only recently learned to take his first faltering steps. I never saw him alive. I had to piece together details of the accident that had claimed him.

His father was backing a car out of the garage so he could take his young family on a picnic. Charlie’s mother was packing food. Each had assumed the other was keeping an eye on their only son.

When I arrived at the emergency room, I found the staff working on the boy with every tool at their disposal. A tube had been inserted into his windpipe to allow the anesthetist to breathe for him. Another had been inserted into his stomach to remove any air that might have been blown down his esophagus. An intravenous line had been inserted into each arm. Fluids poured into him to raise blood pressure. An intern expertly administered cardiopulmonary resuscitation (CPR). The emergency room chief resident studied the latest lab results and a cardiogram.

Somehow, in the rush to perform all the duties they had been trained to do, nobody seemed actually to have stepped back to look at Charlie. His head was terribly misshapen. A gray mushy substance oozed from his right ear. Brain substance! In effect, the ER staff was earnestly trying to resuscitate a corpse.

As the attending physician in charge of the case, it fell onto my shoulders to call an end to attempts at revival. My next duty was to go to the small private room where terrified family members waited and inform Charlie’s parents that the boy was dead. I did my best to give them something that was not mine to give, consolation.

Charlie’s father stared blankly ahead, hearing little or nothing when I introduced myself. Over and over he repeated, “I didn’t know he was there. I didn’t know...”

Charlie’s mother watched my face tearfully, obviously searching for any sign of good news. As gently as I could, I told them. I sat for a while in a vain attempt to comfort—until I was summoned for another case.

Another case.

Is it possible to become “case-hardened?”

If it were so, a protective shield, a Teflon-like coat to let a doctor go home and sleep of a night, where is it to be found? The scent of newly shed blood, the sweat of anguished personnel who must watch a life seep away, grief’s nearly palpable aura: why do the miasmas of any emergency room not stay chastely confined within hospital walls?

—————

Mr. Olson was driving through our community when he passed out and slammed his car into a telephone pole. When I arrived in the emergency room, the ER physician had stabilized him as best he could, but the man’s heart rate remained ominously fast and his blood pressure was unacceptably low.

Staff members and I quickly reviewed the extent of his known injuries and those treatments begun. Everything seemed to have been done correctly, yet Mr. Olson had not responded to the efforts. Clearly, we were missing something. Then, I was hit by an idea. We had assumed that the high pulse rate and low blood pressure had been caused by the accident. What if the reverse was true?

Injuries cause shock, characterized by low blood pressure. Reflexes try to correct the situation by delivering more blood to circulation via a speeded-up pulse. What if the accident had been caused by a medical condition we call tachycardia, a rapid heart rate that causes the blood pressure to fall? I reviewed his electrocardiogram (EKG) and saw that my new diagnosis was plausible. I called for appropriate treatment, in this case a low level electrical shock to the chest to interrupt the aberrant impulses dominating his heart.

His heart slowed immediately to a normal rate, and his blood pressure returned to normal. We had done it, a life saved.

I transferred Mr. Olson to the intensive care unit (ICU). I talked with the ER staff for a few minutes, then went to the ICU to finish an admitting examination and to write orders.

Mr. Olson’s blood pressure had again fallen. Once more, it seemed that we were missing something. I realized that his abdomen had swollen until it resembled that of a woman eight months pregnant. This finding had appeared since leaving the emergency room and could mean only one thing. Mr. Olson had received internal injuries and was either bleeding into his abdomen, or he was filling up with air from a ruptured intestine.

I summoned our community surgeon. He arrived within minutes and agreed with my diagnosis. Since this was in the days prior to high-tech, noninvasive tests such as CT scans and MRI, we prepared for exploratory surgery.

Thirty minutes later, we were in the operating room, ready to begin. Transfusions had restored normal blood pressure, and we felt confident that we could save him.

Within minutes, our confidence was shattered. As soon as we opened his belly, we saw that there was not a localized, single injury. Blood oozed from all directions. A quick look at the liver revealed the reason.

Mr. Olson had advanced cirrhosis of the liver. A cirrhotic liver cannot make essential blood-clotting factors. We knew we could transfuse necessary clotting factors and keep him alive if we could just identify a main source of blood loss and stop the bleeding. What we could not do was pour in enough clotting factors to stop the generalized oozing from every surface in view. Nevertheless, we tried. Fresh-frozen plasma. Platelet transfusions.

We were losing.

After a length of time that seemed like hours, even days, the surgeon and I looked at each other and nodded. It was time to stop. We bowed our heads and watched Mr. Olson die.

—————

These are representative of the memories that flashed through my mind while I took that walk. I recalled each with such a sense of sadness. I also knew that my commencement-day poet had been right. I was changed. For me, violence, brutality, suffering and death became too much a part of real life. They could never be a source of prime time entertainment.

• • •