A patient is most invisible precisely where she comes to be seen. Consider the Emergency Room visit. The check-in receptionist looks at the screen. The other patients in the waiting area look at the television or Good Housekeeping. The triage nurse looks at her watch, two fingers on the wrist, at once paying close attention and making the classic gesture of impatience. The physician’s assistant looks at the vitals. A few questions, just to aim the test at the right fourth: head, torso (upper half), torso (lower half), or limb(s). Or more than one of the above, if mention is made of a slip on the ice or a fender bender.
Your name goes on the Board at the front of the Emergency Room. The Board is covered with names. Most of these patients the Emergency Department physician has not actually seen. His time, always in short supply, is best spent with people too far The patients who really need seeing are usually unaware they are being seen. gone to make eye contact: the poet (unconscious after a drinking binge), the lover (unconscious after a run-in with an ex-con ex-boyfriend), and the lunatic (unconscious after yet another fistful of goodbye-world Ambien). Or the car-versus-pedestrian head bleeds, the unhelmeted motorcyclists who have ‘kissed the pavement,’ the stroked-out elderly found after who knows how many hours of soaking in their own urine. The patients who really need seeing are usually unaware they are being seen.
Efficiency is crucial on a busy night, and medicine’s single most easily conserved resource is face time. Even in the sleepy outpatient offices of family practitioners, the patient encounter lasts roughly the duration of a haircut. In the Emergency Room, where stranger treats stranger and chitchat is not expected, a physician can bring the face time as close to zero as possible. The nurse practitioner, who takes the history, looks down at his or her clipboard, making notes. A good presentation will exclude whatever differentiates this patient from the idealized disease. Every barfight has a back story, and every adolescent suicide attempt has a small novel leading up to it, but complex narratives do not help suture a cut or pump a stomach of a Tylenol overdose. By the way, the nurse practitioner, not the doctor, will be suturing that cut – eyes cast down at the curved needle and thick black thread.
But your complaint is not so clear-cut. Fever and pain in your belly. Where is the pain? All over, or maybe it moves around, or maybe it’s more in your flank or back: Abdominal pain terrifies doctors because abdominal pain could be anything (or nothing at all). That is why the shrewd drug addicts, seeking their opiates, know that you plead dull longstanding back pain in the outpatient office and sharp new belly pain in the Emergency Room. (The exact combination is crucial: If you plead sharp new belly pain in the outpatient office, you risk being sent to the Emergency Room, and vice versa.) The pain inside you is not something that the naked eye would help diagnose anyway.
What you need is a trip to the Radiology department. The transporter stares above the elevator door until the B lights up. The scan diffracts a singular, three-dimensional I into several, two-dimensional images. The patient laid on a scanner table is more than just bare. A scan knows a body as its architect and foreman know it: Crossbeam and joint, vent ducts and plumbing, the scaffold inside the house. Nakedness is just the house before the paint. Those sketches in Andreas Vesalius, the skin banana-peeled off the latissimus dorsi – that’s just the house before the siding. A scan sees the entire circumference and everything inside that circumference. The images are called cuts or slices, but the surgeon has only an incision’s narrow aperture, or at best the pinhole of laparoscopy. The surgeon peeks. The scan sees through.
So who sees the scan? It’s past midnight. Those pixie-dust pixels are packed down into a packet of information. And that’s when you – Med. Rec. No. 003249352, DOB 2/4/61 – travel. To Australia or New Zealand, The pain inside you is not something that the naked eye would help diagnose anyway. maybe. Or Switzerland, or Israel. Somewhere there’s daylight, not that a radiological sweatshop-worker ever sees daylight. These middle-of-the-night studies are sent to chronologically offset countries, where hospitals get their reads on the cheap. Teleradiology is not always a case of a hospital saving itself money, though. Many hospitals contract with a group of radiologists, who read the studies performed on the hospital’s machines. This radiology group, in turn, contracts with the teleradiology company – surely the only instance of skilled labourers outsourcing their own work overseas.
So the Board-certified professional, who would be reading your scan during the daylight hours, is currently in his bed, perhaps with a sleep mask over his eyes. Somewhere far, far away, in a dark dungeon, in another time zone, a rushed radiologist double-clicks your name. The preliminary rigmarole of who you are and what exam this is starts coming out of his mouth before the screen’s pale rectangles ghost his glasses.
The doctor will see you now. A clock icon pops up and begins ticking in the corner of the screen. He’s built for speed. More studies interpreted means more money earned. Radiologist black humor calls this system ‘eat-what-you-kill’. Above all, do no harm – but ‘kill’ as many as you can. He sees a single horn sticking off the bent slug that is your colon. It’s too thick, it’s blurry: Appendicitis. Your surgical emergency makes him feel relieved, maybe even a little happy. He’s found the answer. Every other organ gets its own roll-through now. One must be methodical. It’s not the appendicitis he finds, it’s the cancer he misses that will get him sued. He’s in a cubicle in Zurich, true, but litigation is imperialist; it will cross oceans and borders in search of profit. At some level, though, each roll-through is perfunctory, impatient. There are other cases to be read. Can’t waste time.
The doctor whose name is on the order – the Emergency Room doctor, who never actually saw you – gets the phone call just as he’s walking out of the trauma bay. Mrs. Who? Um, let me see. (He’s checking a board at the front: of course, bed 17.) Go ahead. Really? Any signs of perforation? Okay. Thanks for your help.
The next step is putting in a page to the surgeon on call. The last step is visiting the room. He introduces himself and delivers the diagnosis. At this point, if he gets curious, he may press on the belly where it hurts, or press on the belly on the opposite side and withdraw his hand quickly and see if that hurts, and maybe even have you flex your right hip and rotate it internally – this is the obturator sign, which he read about in medical school. And he may think: Yup, classic. Or he may think: Who would have guessed. Barely tender at all.
He’s not to blame. He’s been surprised enough times by the scan; he knows better than to trust the body. The laying-on of hands is not faith healing, but it is faith diagnosis. Because histories are vague, because pain speaks in riddles (right shoulder can mean right shoulder, but it can also mean gallbladder), because diseases are locked-room mysteries. Because some seek pain relief and some seek pain medication. Because he will never find if he never looks, and he can look, really look, no other way but this.
The surgeon, having hung up the phone, sits up in bed at last, groggy and annoyed. He can foresee the coming operation from the diagnosis alone. He will probably do the operation laparoscopically, which involves puncturing the abdomen with tubes and distending it with air. One tube will be a sheath for a mechanical scalpel or a clamp, whichever he might need. Another tube will have a small camera and light at the end of it. A drape will cover Every barfight has a back story, and every adolescent suicide attempt has a small novel leading up to it, but complex narratives do not help suture a cut or pump a stomach of a Tylenol overdose. everything but the patient’s sterilized abdomen. The surgeon, in order to see what he is doing, will stare away from the patient – at the real time screen connected to his camera. He will take some photographs of his own for documentation. On the other side of the drape, the anesthesiologist – or, more likely, a nurse anesthetist – will stand very close to the patient’s face. But the patient will be unconscious, and the nurse anesthetist will be looking at the monitors to his or her left, the ones that show heart rate, respiration rate, and oxygen saturation. If the patient starts moving at all during the procedure, the surgeon will look at the nurse anesthetist; the nurse anesthetist will nod and push the plunger on a syringe of milky-looking paralytic or opiate. Then the nurse anesthetist will look at the surgeon, who will nod and look at his screens again. The two professionals aren’t really looking at each other, either. Their eyes meet through fanlike plastic eye shields and glasses, while their noses and mouths are covered with sterile masks.
2.40 a.m., by the way, was the worst time your surgeon could get called in. He hasn’t slept much, and by the time he gets into the hospital and takes out your appendix, he will have an hour and a half before he has to round on his in-house patients. It isn’t enough time to drive back home and get some sleep, and in any case he has just done the surgery on two cups of black coffee. The doctor’s lounge is a limbo between night and day. The morning’s danishes and muffins haven’t been delivered yet. A glazed half-donut from yesterday’s spread, one edge flecked with a bygone neighbor’s sprinkles, would be as stiff as a baguette. Saltines will have to suffice. All he can do is answer emails and look out resentfully as the window brightens. And get another coffee. Some time later, on his way to the floors, he strolls past your bed in the recovery bay. You are as morphine-groggy as he is caffeine-wired. You do not recognize him; he was scrubbing in while you were going under. He doesn’t recognize you, either. He knows you are the right person because he sees his name on your chart. In a way, it is a first encounter. ?
Photo by cdsessums.
You can also see Amit Majmudar at the following event:
Narrative Medicine Rounds: The Granta Medicine Launch
3 October, 5 p.m., Faculty Club of Columbia University Medical Center, 630 W. 168th Street, 4th Floor, New York, NY 10032. Free and open to the public
Granta assistant editor Patrick Ryan and Medicine contributors Drs Ike Anya and Amit Majmudar join the Columbia University Narrative Medicine program to explore fiction and memoir about the practice of medicine, in particular the idea of illness narratives, the cultural beliefs regarding mental health and the experiences of a new doctor in rural Nigeria.