It’s okay, Doc. If you’ve seen one, you’ve seen ‘em all!
Why does everyone always make that same joke? I always wonder if it’s meant to comfort me or the joker. If I’ve seen a thousand, does that mean I might be less interested? Don’t they want me to be interested? They came to me for advice, after all. Presumably it is meant to de-sexualize nudity. Like if I’ve seen it all, it probably doesn’t turn me on anymore. That is the most depressing thought possible. One of the popular complaints about doctors is that we have a hard time seeing the patient as a person, that we don’t relate on an individual human level. And yet, when faced with that uncomfortable interchange where clothing becomes an issue, the person at the point of revelation objectifies herself to remove any sensual element, to ease the momentary conflict that represents both a glimpse of a power imbalance and a fleeting vulnerability. Sometimes, though, it’s the physician who is assailable.
In medical school, we had to practice the heart and lung exam on each other. The class was divided into genders (as far as they knew); our instructor was this crusty old French Canadian, whom I had really admired up until then. She felt that it was necessary that we take off our shirts and get into gowns for this exercise, and there was nowhere to change. While I was wishing that I had shaved my armpits, she chose one of us (who happened to be the most reserved and modest, and later became a dermatologist, perhaps due to this very experience), and sat her on a desk to use as a model for the exam, which I guess is the way they do it in Montreal. As the instructor went for the location of the mitral valve with her stethoscope, she flung wide the future dermatologist’s gown, and left her sitting there for a long, painfully embarrassing time while we all tried to focus on her chest and memorize the four locations to listen for murmurs: A-P-T-M (aortic, pulmonic, tricuspid, mitral) the mnemonic for which is All Physicians Take Money, the only one I can think of that involves currency. More typically, mnemonics for memorization in anatomy are weirdly sexualized. The bones of the wrist can be remembered by Some Lovers Try Positions That They Cannot Handle (scaphoid, lunate, triquetrum, pisiform, trapezium, trapezoid, capitate, hamate) The structures that pass through the superior orbital fissure: Lazy French Tarts Lie Naked in Anticipation of Sex. The twelve cranial nerves: Oh, Oh, Oh, To Touch And Feel a Valley Girl’s Vagina And Heiny. I imagine that it goes without saying that the rest of them are also misogynistic and um, grammatically painful.
The cardiopulmonary lesson was relaxing compared to the Pelvic Exam Module. During this path to a bleeding ulcer, one reads a book about how to do the exam, watches a video, and inspects a model to review the anatomy. Then there is a “simulated patient” who is a woman trained (and paid) to be the recipient of pelvic exams by bumbling medical students and to provide them with “feedback” in order to hopefully polish things up a bit before they are wielding a speculum amongst the masses. The idea is to role-play, to pretend that I am a real doctor (ha!) and that she is a real patient. Part of the requirement is to recite out loud all the steps so that the preceptor, (a fifty-something guy sitting on a metal chair in the corner scribbling on a legal pad) will know that I have memorized the exam and have some clue what I am doing. This is a damn sight harder than it sounds. Faced (literally) with the actual lady, and her actual, you know, pelvis, aware of the guy in the corner, and having to say out loud things like, “I’m going to separate your labia now,” it is very difficult to remember to palpate the ovary and inspect the cervix. When it is blessedly over, she is supposed to gently explain all the things you could have done better. In my case, it was even worse. She sat up and smoothed the sheet with her hand. I noticed her wedding band, but thankfully I have no memory of her face. Her shiny pink cervix, yes; but the color of her eyes, her age, and her hairstyle have all vanished. As the guy in the corner and I both waited, his pen poised above the paper, eyes on the clock, the back of my neck wet and clammy, she said (I swear to God), “That was very nice. Have you done this before?” She paused, sweetly, expecting an answer, but there was no way I could possibly form a useful sentence (Like what? Yes, but it’s not usually so brightly lighted? Yes, but usually after dinner and wine? No, but I already know where everything is?), so I just said no, and smiled sheepishly.
Since it was my first day as a real doctor, and my first day on call, I decided I should stop in to introduce myself (I subsequently discontinued this practice), and peeked my head in the door of her clean dark room. I explained who I was, and that I’d be on call overnight, if she had any kind of acute medical problems. I told her I’d read her chart and was familiar with her history. I had on my brand new white coat, which was so crispy that it made a distracting noise when I flexed my shoulder. It had my name embroidered in blue right above the pocket. I had some concerns that I had not turned my pager up loud enough and that perhaps I would not hear it if it went off. I remembered that I had not found out where the call rooms were, and wondered how I would go about finding them. I smiled warmly and asked her if there was anything I could do for her right now. She turned her swollen face away from the blue light of the TV and looked me right in the eye and said,
Fuck you.
I was somewhat taken aback. Certainly it is not the first time anyone ever told me such a thing; I’m quite used to it, in many ways. But I confess that it’s the first time I had heard it from a 13 year old patient. Why so crabby, I wondered, fingering my brand new reflex hammer, cool and reassuring in my pocket, scratching against several little spiral-bound books which would hopefully tell me what to do in case of any, you know, emergency. I was most assuredly hoping for the absence of any such event on my first night as an actual physician, and so had been disturbed during lunch to hear the Chief Resident explain the process for doing a lumbar puncture on a newborn in the middle of the night. A spinal tap on a newborn; I had somehow made it through medical school without ever successfully getting clear spinal fluid out of anybody, let alone a tiny baby. Blood, sure. Fat, bits of flesh, little hunks of bone, of course. But actual clear CSF? Not yet.
The perfect tap is supposed to be pure-sterile, devoid of even one single red blood cell. It’s called a “Champagne Tap,” both because it is sparkly clean, and because when you are the tapper of such a success, your supervisor is required by tradition to buy you a bottle of Champagne. Of course, most medical students and residents cannot afford even a little Moet, and so it ends up being just domestic sparkling wine, but it’s better than nothing. Lumbar puncture is not as easy as it sounds, at least not at first, and the first few I did were more like Merlot than Champagne.
There are actually many steps involved. The most pressing thing to do is to explain the process to the parents without unduly frightening them. Then you have to take their very cute, warm, cozy baby and lay him on his side on a table with nothing on but a diaper. Then the holder, usually a nurse, takes his arms and legs and draws him into an arc. You open up a sterile tray filled with a very long steel needle with which to puncture his back and a lot of clear plastic things to drain his oily spinal fluid into ( if you get any spinal fluid! Ha ha!) You put on gloves and a mask (mostly to absorb the sweat running off your forehead), and find a sweet spot between his vertebrae where you think the wellspring of liquor might reside. You take a scrubby swab of Betadine and draw ever-increasing circles on his back over your chosen hole-to-be, moving very slowly in hopes that someone will walk in the door and announce that the tap is not needed. When no one comes, and with his mother watching, you draw the stainless steel needle out of its opaque sleeve (no one likes to look at the bare bevel before it’s needed; it’s hooded like an executioner) and aim it at the soft little back.
The sensation of the needle piercing the epidermis is tiny, like the feet of a fly on the back of your hand, but instantaneously you encounter the tight ligaments; supraspinous, interspinous, ligamentum flavum. The resistance here is intimidating, but there is no where to go but forward. You increase the pressure, tentatively at first, and when nothing happens, a little more. Working your way through the fibrous barrier is the worst part, pushing, adjusting, angling; but finally the needle pops through the dura, a bizarre giving-way like cracking an egg that signals you wait for the fluid. You remove the stylet that occupies the interior of the needle, and if your aim was good, a tiny glistening drop of transparent liquid gathers at the hub of the needle. The surface tension causes the first drip to quiver at the edge, rolling off slowly as if it’s reluctant to leave.
Because I have the equivalent of a six-figure mortgage on my brain, I moonlight in urgent care to pay Sallie Mae some of the money I owe her. Urgent care in no way resembles the holistic evidence-based care using a family-centered model I was taught in residency. It is instead a combination of negotiation, exasperation, disinfection, and explanation. The explanation typically involves explaining germ theory to people who watch way too much teevee.
Just the other night, I saw four kids in the same family who were febrile, coughing, aching, stuffy headed, and not-resting. When I explained to their mother that they all had influenza A, she looked at me incredulously and asked, “Is that contagious?”
“It is indeed,” I said, signing the billing sheet.
“They’ll be contagious for a few more days most likely. Be sure you wash your hands a lot, and hopefully you won’t get it, too,” I said cheerfully, knowing that she probably would not be feeling so great tomorrow.
As I was washing my hands for the six hundredth time, I thought, is it contagious? Is she serious? In 1918 Influenza killed more people than World War I (like maybe 100 million), so um, yeah, it’s contagious, lady. In fact, it’s incredibly fucking contagious. That’s why they make a vaccine. You know, the one you can get at the health clinic, Walgreen’s, McDonald’s, oh I don’t know, anywhere? That’s why governments around the world are spending billions of dollars to avoid an epidemic, and why I have at least forty more opportunities to get barfed on tonight.
Then she wanted to know what I could give them to make it go away, and I explained clearly that what she needed was a 500 count bottle of ibuprofen, seventeen gallons of Gatorade, and a Spongebob marathon. She asked if they need antibiotics. I said nope—it won’t help, because influenza is a virus, and antibiotics can’t kill it because they only work on bacteria, but that if the kids stayed hydrated, they’d likely be fine. She said her regular doctor always gives them the pink medicine and they get better right away. I explained the difference between viruses and bacteria again, and she started to get agitated. I explained how giving unnecessary antibiotics can cause problems not only for her children, but also for others. She stormed out the door, and I understood why her regular doctor might behave as he does.
Since we’re talking about antibiotics, if I were President, my first executive order would be to decriminalize common pink eye. I cannot imagine how much money, time, and other tangible resources are squandered diagnosing, treating and quarantining pink eye for no good reason. It’s ridiculous. The vast majority of plain old red eye in kids over one month old is caused by either adenovirus or allergies. Adenovirus is relatively harmless (in the eye, anyway), and more importantly, there is nothing anyone can do to make it go away faster. Is it contagious? Sure, just like every other kid-germ. But it doesn’t matter if it’s contagious if it’s mostly harmless. So why does daycare kick your kid out when his eye is a little pink? Beats me. Why does your doctor give you drops for your kid’s pink eye? To get him back into daycare. Why do they even make drops if they don’t shorten the course of most conjunctivitis? Money, brothers and sisters, money. There is a smaller percentage of cases caused by common bacteria which can and should be treated, but those are easily relieved by an antibiotic that costs about two dollars. And yet, if you open any magazine targeted at moms or pediatricians you see some big, goopy red eye staring back at you in an ad for some kind of concoction that will cost seventy-five dollars and further contribute to antibiotic resistance, because it has a broad spectrum and should be reserved for germs that are resistant to more common drugs. Ponder that, next time you’re pinning your screaming toddler to the sofa twice a day, dripping chilly medicine all over his face in hopes that some runs into his eye.
And since we’re talking about germs, let me just be clear–weather does not make you sick. I don’t care if your baby was teleported instantaneously from the Amazon basin to the polar ice cap without his hat, his nose is congested because some other germy kid at day care wiped her nose on him, not because his dad left the hat in the car. And by the way, a good bit of nose congestion is from secondhand smoke exposure. I know–you “smoke outside.” So does everybody else.
And since we’re talking about noses, the color of your child’s snot is in no way related to the severity of her illness. In fact, if you begin to describe the color in detail, or worse yet, try to show it to me, I will stop listening immediately. I have seen every texture, color, and matter stage of nose drainage that exists, and while I am sure your child is very, very special, there is no reason to save the Kleenex for me. Also, if you tell the triage nurse that your child’s (insert common symptom) is “severe”, it in no way catapults you to the head of the line, unless the symptom is “bleeding.”
Let’s consider an example: ear pulling. Even, God forbid, severe ear pulling. Children between the ages of four months and two years sometimes pull on their ears just because they stick out from their heads, not to signal you to drive them to the emergency department in the middle of the night. In fact, for the most part, any complaint that has been present less than twenty-four hours is not a reason to seek immediate medical attention. Pediatric exceptions to this rule are: turning a color based in blue or yellow, not waking up, acute testicular pain, fever in newborns, sudden neurologic changes, and rashes that look like bruises. Also large lacerations. Not, I repeat, not insect bites. Unless you initially doubted that it was a mosquito bite, and so rubbed it with Sea Breeze, and then when it looked worse, slathered it in hydrocortisone, and when it became open and oozing, you doused it in rubbing alcohol, and so now it is a chemical burn. I understand that it seems unlikely to have been a mosquito, since you did not see a mosquito, but I have to tell you that they are very small. It’s part of their survival strategy; if they were the size of a banana, we’d see them coming.
And since we’re talking about lacerations (we were, weren’t we?), if your child has a cut that I have to sew, yes, it will scar. That is the way our skin heals. I did not invent it, and there isn’t much I can do to change it. If you wanted her to be on “America’s Next Top Model”, you should not have purchased the bunk beds from IKEA.
And while I’m at it, let me just tell you that when I feel a clump of tight, matted cervical lymph nodes on your beautiful, smart, funny, brown-eyed 6 year old who likes to play soccer, and is sitting on my exam table in his Spiderman pajamas, and you tell me that he’s had a fever for several days, and some intermittent leg pain, and yesterday he didn’t eat his string cheese even though he loves string cheese, I will suddenly pay extremely close attention to every single thing on his body, and every sound of his heart and lungs, and when I go slowly looking for other lymph nodes in other areas, I know we will need to stick a cold steel needle into his skinny little arm, and when I see the results of his white blood cell count, I will know that it is far from the last needle he or you will ever see. I’ll sit down and tell you that there are some abnormalities in his laboratory studies, and that no one will know all the answers for a few days, and that you should probably try to find a babysitter for his sister and call in sick to work because it would be best if he stayed in the hospital for a few days so that we can do some more tests. I’ll hand you the box of tissues and say I’m sorry eight thousand times, and very carefully not think about my own son sleeping safe in his bed at home. Later, while I’m driving in the dark, I’ll be thinking of your family, and the ruined soccer season, and the bone marrow biopsies, and how the other kids in second grade will soon shave their heads in solidarity. In a few months, I will stop in the cafeteria and say hello while you’re pushing his IV pole through the hot dog line, and you’ll say thanks for being so nice, and that things are going as well as can be expected. He’ll still have big brown eyes, and the Spiderman pajamas, but his childhood will be over, as will what was left of your sense of security.