She was eighty-four but didn't look a day over sixty-seven. She had curly grey hair and wrinkly cheeks—she must have been edentulous. I watched apprehensively as the nurse filled a paper cup with malodorous, thick, fizzy white fluid: it looked ghastly. The resident asked the patient to gulp down the barium and then stand still against what looked like a freezing cold plank. The patient squeezed her eyes shut and did as she was instructed. As I watched her, I wondered what I would do if I needed a barium study one day: is life (as beautiful as it is) worth drinking that awful concoction, I mused, scrunching my nose in disgust.
Her name was Mrs. Shifflet and because of her recent onset of early satiety, her doctor ordered a barium swallow with small bowel follow-through. I heard the clicks and clacks of the equipment as the resident captured the flow of the radioactive material oozing down her digestive tract. Unable to stay focused on her upper gastrointestinal anatomy, I continued to ponder: had I been in her position, would I go ahead with this study? While the resident worked diligently to complete the task at hand, Mrs. Shifflet said that she was going to be sick. "That’s OK," he assured her, then added, "we need to get some more pictures." I knew he meant well. She continued to brave her nausea. She even drank another cup of the barium when he asked her to do so.
After he was finished with the first part of the study, the resident offered Mrs. Shifflet the opportunity to sit down and rest before moving on (and drinking her third cup of barium). She answered, "I think I am going to be sick." We all watched as she shuffled over to the chair, sat down, and dropped her head in discomfort. I noticed her shoulders begin to rise and knew what was going to follow. "There must be basins within my reach," I thought. "This must make patients sick all the time." I opened the cabinet over the sink and was relieved to find row after row of blue plastic tubs. I grabbed one, swiveled around and held it under her chin. With my other hand, I rubbed her back as milky emesis poured out of her mouth. I kept moving closer and closer to her. I wanted to hug her. A dear friend once told me that vomiting always made him feel lonely: I hoped she didn't feel lonely. I got down on my knees and continued to rub her back. She stared at the chunks of food floating in the rejected barium. I could tell they were concerning her, so I reached for a clean basin and switched them just as she got sick again.
As she continued to vomit, I couldn't help but remember …
•
"See one, do one, teach one," he said with a wink as we walked to the room. J.P. was a great intern—he had a sense of humor, he cared about the patients, and he cared about my education. He had asked me to come watch him place an NG tube. Although Mr. Shiflett wasn't "my" patient, this was a great learning opportunity, as I had never seen one placed. To be honest, I didn't even know what "NG" stood for, although I didn't mention that to J.P.
Mr. Shiflett was very sick, but we still didn't understand why … or maybe "we" did. At that point, there was A LOT that I didn't understand. Fresh out of the lecture hall, I was still getting used to things—learning how to comprehend clinical language and abbreviations, learning how to "pre-round" on my patients, learning how to follow patient presentations on rounds (let alone, present them myself), learning how to access patient information from the very user-unfriendly computer system, and learning simply how to be with patients.
As we entered the room, the smell hit me like a ton of bricks. It didn't just smell bad—the room's air felt almost intolerable on my skin. J.P. didn't seem to notice. He quickly approached Mr. Shiflett, an obese man with green skin and the look of discomfort on his face. J.P. explained that we needed to get a tube down to his stomach in order to help him feel better. He continued, "Farnaz, our student here, is going to place the tube down your nose, but, don't worry, I am going to be helping her.” Not noticing my total state of shock (he had changed the plan without any warning), he handed me the plastic tubing. In spite of my trepidation, I began to advance the tube up Mr. Shiflett's right nostril just as J.P. instructed. I did everything I could not to look scared, but I am sure my fear was as obvious as Mr. Shiflett's discomfort.
As I attempted to advance the tube from his nose to his stomach, Mr. Shiflett suddenly began vomiting. Before I even knew what was happening, I dropped the tube in his lap, collected my hands into a neat bundle, and jumped away from the bed. I had managed to sprint to the door within seconds. With eyes wide, I watched as J.P. quickly grabbed a plastic basin and held it for Mr. Shiflett. I wanted to move closer, but I couldn't will my legs to start walking. It was the first time I had ever been with a patient while he/she vomited. Standing back was all I could do not to throw up myself. To my bewilderment, J.P. convinced Mr. Shiflett that the wisest course of action was to attempt to place the NG tube now, rather than later. After several attempts, each marked by a great deal of gagging and retching, he succeeded. He connected the free end of the tube to suction and, within seconds, dark brown liquid poured out of the tube into a plastic canister.
"See the coffee-ground color, Farnaz?" J.P. asked. I spouted out a differential for coffee-ground emesis as we walked away. I don't remember anything else about Mr. Shiflett. Not a thing. But I will never forget what it was like to be there in his room: paralyzed, uncomfortable, and disappointed in my limitations and in myself.
•
… Mrs. Shifflet stopped vomiting and was back on the table. After the study was complete, I said good-bye and walked out of the room with a great sense of pride, which quickly turned to surprise, then disappointment. Why was I so "proud" of something as insignificant as holding a plastic basin for someone? "Two months away from graduating from medical school and this makes you proud?" I asked myself. After days of reflecting on this, it occurred to me that when I entered medical school in the fall of 1999, my perception of medical education was a bit inaccurate. I believed that medical education was all about (what I now call) bedside manner. I sought to develop the ability to be with patients, to hold them and comfort them, to make them feel loved and cared for. I didn't care so much about pharmacology and physiology when I commenced my medical studies, but I have, ironically enough, come to worship them as the very tools I need to maintain life and to prevent and alleviate pain. As my eyes had opened to the role of science in medicine, I had briefly forgotten, perhaps, about the human role and the importance of learning the "untestable" skills. What I had done for Mrs. Shifflet—holding the basin, rubbing her back, acknowledging her hard work in being a compliant patient, and just being with her in her discomfort—was "untestable" and yet it was, perhaps, at the very heart of doctoring. I learned all this from J.P., even at a time when I felt most vulnerable and most disappointed as a young clinician. Even if it represented only a baby-step, holding the basin for Mrs. Shifflet was one of my proudest moments.
...... . ...... . ...... . ......
Reprinted from Veritas, Volume 16, Spring 2004, with permission of the
Center for Humanism in Medicine.
© 2004 The Rector and Board of Visitors of the University of Virginia
Author Farnaz Milani Gazoni, M.D., graduated from the University of Virginia School of Medicine in 2004
and is now completing a residency in Anesthesiology at UVa.