November 12, 2002

The first time I see Mr. Rawlins is in the operating room. He is already asleep. You can tell that he used to be a big man, but he is sick, and there is a pruned thinness in his limbs. He has advanced stage IV lung cancer, and his right lung is bound in a tight capsule of inflamed tissue. He can’t breathe and we are going in to free his lung up to make him more comfortable. The procedure, in its sanitized way, is called a “right video-assisted thoracoscopic decortication”, which means that we make 3 small incisions in Mr. Rawlins’s side, inserting a small fiberoptic camera in one, long, tweezer like instruments through the others, and clean up the mess. The attending surgeon I’m working with is a virtuoso at this sort of thing.

Mr. Rawlins’s right chest is filled with bloody fluid and debris. I “drive” the camera as the attending and cardiothoracic resident clear it out, and dexterously strip off the suffocating binding cancer has wrapped around his lung. And we’re out again.

Later, in his room, his daughter is sitting on his right next to a window that looks out onto the concrete span of the parking garage.
“How are you feeling Mr. Rawlins?” He opens his eyes. Their blue is a startling contrast to his pallid skin and tousled white hair.
“Tell him how you’re doing Daddy,”
“All right,” he looks surprised and closes his eyes.
“Can you cough for me, Mr. Rawlins?” I have to check for an air leak. As I inspect his chest tubes, I describe to her what we saw in the operating room. She wants to know. People like to know more, even if the attending has already spoken to them. It’s comforting for family that other people know what’s going on.

I’ve just come back to clinical life. After several years pursuing a doctorate in a basic science lab, it’s back to patients and the daily deluge of morning labs, CT scans, and chest X-rays. Returning for my last year of medical school is a shuddering culture shock. I’m older than most of my residents. A third of the drugs they use are new to me, and there’s an urgency on the wards that my former laboratory flasks of tissue culture cells just didn’t demand on a daily basis. On the other hand, where our goal in lab was to generate knowledge novel enough to merit publication, the sort of knowledge required of me as a medical student, intern, or junior resident is textbook knowledge and clinical “pearls” shamanistically memorized and regurgitated by generations of trainees. I’ve shifted gears, but my clutch work is not perfect, and I can hear the gnashing of the synchros.

A short, polyester blend white coat reminiscent of a ice cream delivery man’s marks me as belonging on the bottom rungs of a long ladder of clinical training. The Rawlins family doesn’t care though, they’ve gotten used to my waking them up at 4:00 every morning, and stopping by every afternoon. Mister Rawlins happily complies when I ask him to cough for me. We talk about his golf scores—he’s a scratch golfer—and his other daughter, the older one, tells me about the farms and hiking trails they have around their place in Virginia. I’m supposed to come up and visit them sometime.

One afternoon, I find the medical intern on the floor drawing a blood gas out of Mr. Rawlins’s wrist. The intern is cross-coverage, but it’s clear that Mr. Rawlins is more disoriented, and less responsive to people. They transfer him to the intensive care unit that night. Over the next weeks he is cheerful when I can wake him, but more confused.
“Do you know where you are, Mr. Rawlins?” We have to ask silly questions like this because they become less straightforward the sicker the patients get. He doesn’t remember.
“What’s your favorite hospital?” No one should have a favorite hospital.
“Duke,” he says and smiles brightly.

He’s fading. Soon he’s transferred back to a regular room. There are dozens of get well cards taped to the walls. They’ve taken away the heart monitor. They’ve stopped drawing labs. He now has to wear an oxygen rebreather mask and his chest retracts as he gasps for air. The older daughter is distraught. More family are in town.

One evening, in a spare moment, I go upstairs to check on him. The room is dark and empty. There’s a gauze wrapper on the floor. Up front, a nurse tells me that he’s gone.
The wards are acquiring their evening hush. The elevator whispers open, it’s empty and I enter slowly. Still in my hand are the stapled index cards on which I’ve recorded Mr. Rawlins’s vitals, labs, and medications for the last few weeks on the service. I slip his cards into the inside coat pocket where I keep “retired” index cards. There’s a momentary loss of gravity as the elevator accelerates downwards.
It’s bad and good to be back.

Posted by erich at November 12, 2002 11:52 AM
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