My father was a Captain in the Navy. He was also a pediatrician. My goal to be a doctor formed way before I had a clue what that meant. There was nothing in my father’s lifestyle that would tell me what to expect. I rarely saw him in a white coat; he left for work in a khaki navy uniform. I don’t recall him being on call or telling us about his interesting cases at the dinner table, as was the custom at mine. By the time I had a conscious mind for such details, he was mostly an administrator and he wisely held the interesting stories from that work from us. Occasionally, there would be stories from his past. When I was very young, perhaps seven years old, I overheard him speaking to my mother about the Christmas season and how it reminded him of Christmases he had had when in training and his early years as a doctor. I remember a word: Leukemia. It seemed that the dark cloud of his luck or karma or whatever conspired to earn him memories on at least a couple of Christmases when he would admit child to the hospital with a new diagnosis of Leukemia, which in the 1930’s and 1940’s was a death sentence. Without understanding the words, I understood the gravity of what he was communicating.
My life and family present a different picture. My uniform was slacks and a button down shirt with tie—no white coat. When I came home from work, dinner conversation was filled with events of my day. My children learned medicine by osmosis to the point that Darby, in elementary school, when called by the OB nurse to let me know there was someone in labor, would ask, “Is she a primip or a multip,” as to sort out if I would have time for dinner when I got the message. One of my sadder cases would find Amber calling as a 5 year old to talk to “baby Brook” who had microcephaly and uncontrolled seizures. Amber felt the need to say hello by phone and the pediatric nurses accommodated her. When Darby was dating in high school, her boyfriend Evin after a few dinners with us paused, and asked, “Are we going to talk about vaginas tonight?”
I in turn, would find Christmas as an unusual holiday with interesting but mostly bad cases to remind me that despite the holiday and despite the hope the season represents, disease does not recognize or celebrate the date. In a sense, these medical patients all offered me a gift—in each case, I learned something about myself and improved my ability to sort and come to conclusions accurately. The price was sometimes heavy. I have worried that my working Christmas Eve and Christmas would somehow diminish it for the kids. No worries, they had great Christmases and one Christmas Eve, when it was on a weekend and I was not working, the girls asked, “Is Dad coming to the movie with us,” when the tone suggested they had a ritual for this date and my presence was somehow, imposing on it.
My first Christmas in private practice (Salinas, California) found me taking a phone call around 6 PM. My partner’s patient who was due to deliver any day was put through by the answering service in a panic. She sounded hysterical — which is to say, she had a high pitched panicked voice, spoke rapidly, almost squeezing the words out, and I could not understand what her concern was. Given that she was due to deliver a baby, I asked her to come right in. The nurse who called when she arrived was in a panic as she related the following: the patient had an elevated blood pressure and seemed to be in labor, but, there was no fetal heartbeat. I felt a sense of disbelief—that I could go in and somehow discover an error and…….but the OB staff was solid. There was not going to be a miracle here. On arriving the woman was now calmer but indeed, I could not hear a heartbeat with an ultrasound or with a normal OB stethoscope. I applied an electronic lead to the fetal scalp as labor was progressing. I got a heartbeat!!!!—— but it was slow and I quickly sorted that I had attached the lead to the cervix and so, was getting the mother’s signal. In 1981 there was no OB ultrasound available on Christmas night. I was sad and resigned; I chose my words carefully but was clear—the baby had passed and we had a delivery underway. She delivered quickly— by 10 PM. There was no malformation, no obvious cause for the death. I followed as best I could what I understood the next steps to be with her emotional needs in mind: we washed the baby, had the mother hold her, and were as sympathetic and helpful as we could be. We were in the county hospital and there were no private beds on the delivery wing. After the birth, women stayed in a large common ward and it occurred to me that that would be pretty depressing for this patient as well as the mothers sharing that room (while admiring and nursing their newborns), so I arranged for her to stay the night in a surgical bed on the surgical floor. Her blood pressure was only moderately elevated when she was transferred there and she appeared to be medically stable. I went home, kissed my daughter and wife, counted my blessings, and went to bed, mind racing at what I had witnessed. The death of that baby effectively put blinders on me that night. At midnight, I got a call from a departing LPN who had participated in the delivery. She felt the need and wanted to provide a brief touch and care before going home. She was grim on the phone.
“The surgical nurses have not been following her closely enough. She has bled a lot and her vital signs are not good.”
I came right in and sorted out that she had DIC (disseminated intravascular coagulation) a dreaded effect of pre-eclampsia—which I had not recognized. Her blood pressure, though not dramatically elevated and a repeat urine test confirmed the likelihood of pre-eclampsia. Her blood tests supported the problem with clotting. She was moved to the ICU and started on IV fluids. She was typed and crossed for blood transfusions. I called local OB-GYN’s for advice and with some luck, a possible transfer.
“That’s a bad case you have there….” Was the most I could get. No one wanted to jump into this problem mid-stream and the outcome was likely to a bad one. I called UC San Francisco. They gave advice for care but thought a transfer too risky. The bottom line was that we had to stop her uterine bleeding and we had to correct what we could in her blood to reverse the problem with her inability to further clot blood. We—I— had to keep her from bleeding to death. I stayed in the ICU that night and at 6:00 AM was handed a lab slip telling me that despite four units of blood, she was still dangerously anemic. I had alternated with her husband massaging her uterus abdominally to help keep it contracted (this prevented bleeding) as the IV continue to supply Pitocin (uterine contracting medication), fluid, and blood. Her blood pressure was very very low. She was in a hospital bed with her head down about ten degrees. As I walked into the room, she asked, “why am I so dizzy?”
I was sure she was going to be my first maternal death. I was scared and I was exhausted. My partner (her doctor) came at 8:00 AM to take over.
She survived. I heard her voice (I will never forget that voice) at her six week post-partum check up and came out to see her. I did not recognize her. Having never met her before, I had not realized how swollen her face was from the pre eclampsia that night of the delivery. Before me was a somber but very thin woman who looked nothing like the woman I thought was going to die.
The experience left me sad and vulnerable. There was so much I did not know and yet the responsibility was mine. Children die on Christmas, just as my father had suggested. It was with some joy that after moving to Olympia, she took pains to send us a card to let us know her second pregnancy was successful and without complications.
Our third Christmas in Olympia found me on call for Group Health and the number of patients potentially accessing care at the hospital was 45,000 people. We had a wonderful morning with presents and clear but cold weather when around 11:00 AM, the phone rang.
I had the Emergency Room calling to let me know there were two people needing admission.
The first was a pediatric case: a twelve year old boy who was stable but who had a platelet count of only 2,000—-a critical value (normal counts are between 150,000 and 450,000. I thought, “Here we go again; he could bleed to death.” This would prove to be the lowest platelet count I encountered in my medical career. I approached this kid academically as he was stable, and a few phone calls found that his likely diagnosis was Idiopathic Thrombocytopenia—an interesting condition that I had seen once or twice and with much less dramatic lab results. So I learned something that perhaps I had read about but did not know until the consultant suggested I order it: an infusion of immune globulin. I arranged for this and for his pediatrician to come in the next morning to assume care. Now that was an interesting case—I learned something new—-and there was no real concern about death or dying on Christmas in his case.
The second patient that morning was a thirty-seven year old man with a facial skin infection, fever, and white blood cell count of over 100,000. The profile of white cells and that number made the diagnosis very clear: he had an acute leukemia and a bacterial infection in his face. I made some calls and got the basic treatments underway: serial labs, IV fluids, treatment for the fever, blood cultures and initiated antibiotics. It was an experienced and unrelated internist who hearing of this case took me aside and suggested that he had a very good chance of dying regardless of therapy—but the therapy he needed could only be given in a tertiary care center ie Seattle. What a blessing! I was dogmatically working through a mental exercise of care having been trained where there were few outlets for transfers, and he put the idea in my head that I had but to call and arrange a transfer. I made the call and got feedback from the doctor taking the call: the transfer was wise and necessary— that the care and treatment options were complicated and yes, he really needed to be in Seattle ASAP. As it turned out, he did not do so well; he responded the treatment but died later that spring. Some diseases progress no matter where you are.
The last clinical Christmas of note was one that I shared with Amber who now as an ARNP had her own primary care practice in Olympia. Again, we had opened presents and enjoyed breakfast on Christmas morning. The call I got was near noon—the first of the day. An old woman on an Alzheimer’s unit next door to the hospital had fallen. She had head trauma with a forehead laceration and a dislocated little finger. I was asked to bless a transfer by ambulance to the hospital ER. Her vital signs were good and she was in no distress. Her fall was witnessed and she had not lost consciousness. I asked them to not transfer and that I would come to her to manage the problems. I asked Amber, now a teenager, if she would join me in evaluating the patient. She came along as I got a laceration pack and local anesthetic from the clinic. This woman, though demented, was very sweet and pleasant. She absolutely loved that there was a young woman to speak with. I reviewed her chart and expected abilities as they related to walking and talking. She seemed fine. She indeed had a dislocated little finger and a small simple laceration over an eyelid. No other new problems could be found with the examination.
I had an insecurity: I was terrible when confronted with orthopedic conditions that others found simple. I had failed to reduce dislocated fingers at least two or three times prior to this from timidity and a lack of knowledge regarding where force had to be applied. In fact, broken bones making noise and vibration as they grate against each other is one of the few things that make me light headed and nauseated. I worked through what I thought I needed to do and with Amber looking on, applied traction and pushed the base of the affected bone. I was as surprised as the patient when with a slipping sensation, the finger resumed its normal shape. She gave out a yelp and then looked at me with appreciation as she wiggled the finger without pain. Her memory might not be good but now we had a bond. She relaxed and followed direction as we applied the anesthetic and I sutured up the forehead laceration. I suggested to Amber she could try this if she wanted, but her judgement was better than mine— she declined. She has made up for that over time as I have watched he repair lacerations in her practice and she does them very very well. I like to think this brief Christmas experience—one that ended well—was one that helped motivate her to achieve her goal, which like me involves providing medical care—even on Christmas.
In my first Christmas season in Olympia, I was on call and saw patients in clinic until 7:30 PM. A nurse from our OB clinic brought her two year old daughter in for a fever and illness. On examination, she was pale. Her story and examination suggested infection. The laboratory came back and I was reminded of my father’s story. She had a very elevated white blood cell count and was anemic with low platelets as well. My first thought looking at her was that this was probably a leukemia. I called the hematologist in Seattle and relayed the story, exam, and lab. He agreed with a very somber voice, that she would be well served by driving up that very night for further evaluation. The night was crystal-clear and well below freezing. I was shaken and it showed as I had to tell her mother, an RN with experience, that I suspected leukemia and wanted her to drive her daughter to the Seattle hospital that very night. I had a six month old child as well as Amber, then six years old. I could be very empathetic and yet could not really conceive of what this next week would hold for the mother, much less this child. A week later, I saw on the schedule that they were back; it turned out that she did not have leukemia after all, but rather, hereditary spherocytosis —which was treated with a splenectomy (a surgery to remove the spleen—which does not cure spherocytosis but does prevent some of the complications she suffered from). Her eyes were alert and she was healing well. I could reassure the mother that the wound was healing well and we parted, both of us feeling like we had beat the reaper. Interesting cases like this tended to gravitate to specialists and with time I lost this child to follow up with pediatricians. Years later, at a rest stop in Yelm High School, while riding on the Seattle to Portland bicycle event, I purchased some snacks from a High School vending table and the teen ager taking my money started up a conversation with me. She turned out to be the little girl who I thought would die that Christmas. She was healthy, as was her mother with a full life before her. I remember wishing I could relate this story to my father who never knew I went to medical school or had a career so similar and yet much different than his.
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