Anecdotally Speaking

It was a quintessential moment, fitting for a rural medical practice. I was on my hands and knees in the dark cramped kitchen of a patient's home. The patient was sprawled across the floor in front of me. CPR was in progress.

I looked down at her face. It was devoid of even a vestige of color. Thin electric wires fastened to her chest made their way to an automatic defibrillator. A disembodied robotic voice from the device intoned, "Continue CPR." I prepared to provide her with an airway.

Moments before I was in my clinic seeing routine patients when my typically busy Friday morning was interrupted by the urgent call, "Code blue, patient down." I answered the call.

It wasn't far; she lived only a few blocks from the clinic. But then, in a small town, everyone lives only a few blocks from the clinic. I arrived at her house with the airway equipment in less than a minute.

While she was being ventilated and chest compressions were being delivered, I calmly prepared for what I needed. I checked the laryngoscope, inserted the batteries, attached the curved blade and checked the light bulb. Fourteen years ago, I was an ER doctor and I did this all the time. I was very good at it and fancy that I still am, even though I don't do it that much anymore.

I selected an ET tube, inserted the stylet, adjusted the stylet and shaped the curve of the ET tube just right, attached a ten cc syringe, inflated the balloon, checked it and then I was all set; I was ready.

I gently extended her head and inserted the blade of the laryngoscope along the side of her tongue, pushing the tongue out of the way. I was nearly laying flat on the floor, my head lowered down as low as I could go, to be at the best angle to see into the larynx.

Redundant folds of oral and pharyngeal structures obscured my view. I pulled up on the scope with my left hand and angled it to try to expose even just the smallest glimpse of the arytenoids or the vocal cords. I craned my neck. It was an awkward angle.

My bifocals couldn't quite bring into focus the minute area I needed to see, that particular teensy tiny little spot just beyond the tip of the epiglottis that I had to visualize in order to place the ET tube properly. I had to see it. I repositioned the blade and probed with the tip of the ET tube. I jiggled my glasses up and down.

For a flash of a moment it crossed my mind that maybe I wouldn't be able to do it. That it would be just too hard for me, that it had been too long since I had done this sort of thing and my eyesight was not good enough anymore. As I struggled within the diminutive space of my patient's gullet, stretched out as I was across the floor, it flickered through my mind for only a brief half of an instant that I should let the other doctor have a go.

Then I recalled that I am good at this. Really good. I used to do this all the time. I worked once in a busy ER full-time. I intubated people in code situations nearly every day. I am the best person for the job, I reminded myself. This patient needs me and by golly I am not giving up, I am doing what it takes to get this done.

So I pulled a little harder, angled a little bit more, got down a little closer to the floor, then I slid the tip of the ET tube up under the epiglottis and directed it anterior into the trachea. I removed the laryngoscope, inflated the balloon, attached the amboo bag, gave some breaths, watched the chest rise, fall and listened for breath sounds. It was a successful intubation.

Later on, ensconced again in my ordinary busy Friday clinic, I was still feeling warm inside from the glow of accomplishing something truly remarkable. I imagined that it might be like the feeling one might get from catching a game-winning touchdown pass or from winning a $10,000 Lottery Prize.

I wanted to share the feeling, so I said to my staff, to no one in particular, "You know, intubating somebody is always tricky, but it really is something doing it when you're in a cramped dark space laying flat on the floor."

No one in particular, replied, "Huh, huh, that's nice."

Hmmm, what do I expect? Anyway, I think I'll make an appointment to get my eyes checked. Maybe they can do something about that.

He was bigger-than-life and big in true life with a loud Texas drawl that boomed in the distance before you even saw him. Ruddy, barrel-chested, thin greasy hair plastered carelessly across a mottled scalp, his face was adorned with a toothy grin spread perpetually wide from one haggard ear to the other.

His cylindrical girth was festooned with a long white lab coat embroidered with his name and title, and I dare say no one ever saw him bedecked in anything else. He was an icon at our institution, as close to god as anyone could be. He was Chief of Pediatrics of Children's Hospital, specialized as a Pediatric Pulmonologist. He was world famous as an authority on Cystic Fibrosis, making the hospital a foremost treatment facility for the disease.

He was an imposing figure, no he was an intimidating figure, no he was simply terrifying, at least from the perspective of a fledgling third year medical student. That is what I was when I encountered this paragon of a legend many moons ago.

I heard stories about him; everybody talked. I heard that he was brilliant and that he was awful, but I couldn't really tell in the end what to expect from him. Then, I didn't know what to expect from anything. I was fresh from two years in lecture halls, gross anatomy dissection labs, mountains of thick textbooks and all with never a patient in sight. Then finally, I was thrust onto the wards of the Pediatric Hospital and I didn't have the slightest clue as to what came next. I was overwhelmed.

It was the first assignment of my Pediatric rotation. I had morning rounds with the famous terrifying Pediatric Chief. Fortunately, I thought to myself, with some degree of comfort, the group making rounds that morning was big enough that I could fall back on the time tested strategy of making myself look real small, become invisible, blend in, disappear and survive by not being noticed.

The grand Pooh-Bah entered, his white coat flying, big belt buckle flashing, cowboy boots clomping, he swooped down on our ensemble, a huddled mass of unsuspecting learners waiting for his arrival. He wasted no time as he launched into a soliloquy, shooting questions right and left, attacking here, zinging there. There was no hiding; no one was safe, so much for my strategy. He was fast, loud; eyes darted everywhere and missed nothing. This was his turf, he was king and he relished asserting it. In a dervish, we were off, bed-by-bed, patient-by-patient, on "lightning" rounds.

I was a novice student, as green as they came, my first time in a hospital. At that stage of things I was prepared for doing little more than just tagging along. We came to the room of a mother tenderly holding a small, thin, almost emaciated child in her arms. She gently rocked him as the room filled from the onslaught of our Chief-following troupe. We crowded in until we surrounded the tiny patient and his mother. No one knew what the diagnosis was; we waited to hear the presentation.

The Chief boomed out, "Where's a student? You there!" He pointed directly at me and my eyes must have widened in response, I know my heart quickened. "Kiss that baby!" he commanded.

"Kiss the baby?" Nonplused, incredulous, I froze; I didn't move a muscle. "Am I missing something here? He can't really mean it, can he? 'Kiss the baby?' What part of Marcus Welby did I miss? Do doctors examine patients by kissing them? Is he making fun of me? Is this a joke? Am I going mad? Am I missing something here!"

During the brief moments that I hesitated, I noticed that no one in the group made a sound. This wasn't turning out to be a joke. The Chief persisted, this time more earnestly, "Come on, kiss the baby!" He was motioning me on. His imperative was not in my imagination.

I looked around. Everyone stared back at me. There were no smiles; no offers of any help. I looked at the mother. She looked like a normal everyday kind of mother. I looked at the baby. Nothing special there, just sleeping away. I looked back at the Chief. He didn't look happy. I shook my head. This just couldn't be right. I didn't want to kiss the baby. Right then, I wished that I was on another planet. I wished that a hole would open up in the floor and would just swallow me up. I didn't know what was going on and I didn't know what to do.

The Chief's face turned a scary red color. He jumped out, grabbed my arm, pulled me forward toward the patient and continued to insist that I "kiss the baby, kiss the baby!" Wanting to just end the disaster, I leaned over and quickly planted a peck on the child's arm, then returned to my place with the rest of the group. Seemingly satisfied, the Chief then turned to me triumphantly and asked, "Well, what did he taste like?"

"What did he taste like!!!? How the heck do I know what he tasted like!!? I didn't lickthe child!! What did he taste like!!? Is this guy stark raving mad!!? Does he think I French kissed the stupid baby's arm!!? What did he taste like!? Is this guy a moron!?"

Of coarse I didn't actually say any of this, instead, I just mumbled, "I don't know." With that response, thank God, in exasperation, he finally lost patience with me, gave up and moved on. It turns out that he never spoke another word to me again. Fine with me.

The point he was trying to make was that patients with Cystic Fibrosis have a genetic defect that prevents them from being able to keep salt out of their perspiration. Therefore, patients that have Cystic Fibrosis have salty tasting skin. It is so salty in fact, that it is virtually diagnostic for the disease.

There was a time once when physicians no doubt made the diagnosis of Cystic Fibrosis with their own tongues, but in our day, there is a lab test for measuring the amount of salt on a persons skin. Doctors do not have to go around licking their patients in order to make a diagnosis; we can save our tongues for other uses.

So, out of my fear and naiveté did I miss the chance of a lifetime to experience a great clinical teaching moment by not licking the child and actually tasting the salty skin of a Cystic Fibrosis patient?

Or, did my fear and naiveté lead me into being intimidated and browbeaten by a bully of a man who was ultimately just a poor teacher?

Something I do know. People like him do not scare me anymore and I don't let things like that day on rounds happen to me anymore.

I don't know where that unfortunate man is today, but I have to say, he sure was one strange cookie, ho boy. Sometimes I wonder -- if he had been a Pediatric Endocrinologist and if the patient had been a diabetic -- would I have been required to taste the patient's urine for sugar? Would I have done it? It boggles the mind.