“Aint no need to worry what the night is gonna bring, it’ll be all over in the mornin’…The soundtrack that is constantly playing in my head decided to soothe me with Anita Baker joining the Winans. I was able to sleep through the night without the interruption of my ringtone signaling a call from the Transfer Center. Our own Emergency Department had been equally kind to my sleep hygiene.
As an attending, I do not have to go to morning rounds every day anymore, but when I have patients for whom I am the surgeon, it is the least I can do to show my face and remind them that my care doesn’t end after we close the incisions. Jamie is somewhat uncomfortable, but doing relatively well. The overall report of pain, headache, vision, and general well-being is a notable improvement from the status upon arrival. Max is in the ICU, improved and awaiting transfer. We often find that transferring a patient out to another institution is decidedly more knotty than receiving someone. So, we expect a protracted process.
Sunday’s exposure of the fault in our stars began with a phone call, just like Saturday. Another erstwhile colleague in Emergency Medicine wants to transfer a patient to our institution for a “higher level of care.” This time, we are actually just a few blocks away, which feels, oddly, like a win. I try to just focus on the work, but I cannot help but wonder how and why so many Emergency Departments in a 30 mile radius choose us to call first? I would love to believe it is because the reputations of the physicians at our institution is a significant draw. I fear that that the reason is less complementary, however. Empty still does carry the same meaning as available when it comes to open beds in a healthcare facility….
“Pat” has been having trouble swallowing for “a few weeks.” Whenever there is a foundational story and symptoms really aren’t new, natural inquiry wants to know what happened to create a change that made you go to an Emergency Department. In this case, the mild trouble in getting liquids to go down captured solid foods in its web of increased work to accomplish once effortless functions. Daily variations in swallowing had been ignored or denied. The most significant change, however, was the result of how close the swallowing tube is to the breathing tube. The problems we won’t face sometimes hunt us down. The essential function of breathing in air was now a struggle for Pat. The hunger for air can only be denied as long as one can hold their breath. So, this symptom carries Pat to the nearest hospital.
The very pleasant physician on the phone tells me that they already decided that Pat needed a CAT scan to try to figure out what was going on. There a “bump” on the front of the throat and they were rightly concerned about the trouble breathing. The CT scan shows a mass in the front of the neck that appears to be fluid-filled. The airway also appears to be pretty narrow. Can we transfer? The detailed narrative was a build up to the most important question. We accept.
The patient arrives in our Emergency Department and is stable, but there is some obvious work to take in each breath. The nostrils flare a bit, the rise of chest is heavy, not second nature. The collective powers of observation between me and the two residents on call suggest that the situation is urgent, but not yet emergent. Let’s get a little more information. We have a scope, which is sort of like a fat piece of spaghetti with a light at the end, that is small enough and flexible enough to let us peer inside the human body. We can try to take a look and see why Pat can’t swallow and now can’t breathe. Our hopes of gaining understanding are quickly dashed. Nothing looks recognizable. We don’t see the vocal cords—which are the gateway into the windpipe—and we don’t see much space at all. In fact, we don’t see much at all that resembles what we’re looking for. Whatever this mass is, it has encroached upon the expected anatomy in a way that curls lips, raises eyebrows, and adds stress lines to the face.
The “bump” on the front of the neck looks more like a golf ball and seems to be filled with fluid. I feel like we can move it around some, so I think it is a cyst. Maybe the fluid is infected and this is an abscess. I am not sure about the exact nature, but I am positive this is a barrier between me and the windpipe and I have to think about how to get around it. We plan to go straight to the operating room and establish a surgical airway. So many of the obstacles that now lay behind me stream into consciousness to build me up and encourage me. Your 9th grade guidance counselor told you that you weren’t college material. Look at what happened. Some of your friends told you that getting into Yale College was a fluke, but you finished Yale School of Medicine. Anyone who has ever been plagued by imposter syndrome understands this roll call of slain dragons. I have pushed back that annoying voice fed by the teachings of minority inferiority and I have reclaimed so truths. The residents working with me are compassionate and capable. So am I. We’re ready to do this!
We can tell from the scans that the breathing tube looks pretty normal below the mass. So, we need to make an incision in the front of the neck, get down to the windpipe and open the airway so we can bypass all the trouble we saw with our scope and on the radiology images. Having been cheated in our attempts to see the voicebox, we have seen the roadblocks and we know the anesthesiologist won’t be able to put in a breathing tube in the standard way through the mouth. We have no choice but to keep the patient awake and breathing while we clear a path to let the patient fully inhale and exhale, and not just in the metaphorical sense. Human beings like oxygen and a person who is awake and breathing will do everything they can to stay that way. We are going to take full advantage of this natural law planning to make sure Pat won’t keep working to get air in.
One of the great enigmas of practicing medicine is how rapidly the initial encounter with a patient can progress from “hello, what can I do to help?,” to an urgent operation. “We need to go to the operating room and make a cut on your throat to place a tube in your airway. We also need to do this with you awake. We will give you some medicines to take away pain and try to help keep you calm, but you will somewhat aware of what is happening while we do it.” Those words could be received as paralyzing coming from a most trusted, longtime confidant. How oddly and clumsily they must fall on one’s ears coming from someone you met 6 minutes ago. Smoothing the awkwardness, however cannot eclipse the gravity of the situation, nor do we have generous time for pleasantries. We proceed to the operating room trying to build some manner of trust in the elevator ride, making the most of each second.
We enter the operative theatre once again and it is welcomingly familiar to us. We are comfortable on this stage, the characters are known and the props rest in our hands with a sense of knowing. Some of the actors have changes—even on call, there is a first team and a back-up team so there are personnel guarantees.
For our patient, the experience is entirely new and, as an extension of this fact, somewhat threatening. The lights are bright! The room is a little chilly. More often than not, it bears no resemblance to somewhere you’ve been before. We maintain an awareness of this dilemma and do all we can to encourage calm and focus in a setting that can feel disjointed and chaotic. The room is filled with total strangers. The tender hearts are genuine, but because we have no sustained relationship with Pat, it might feel perfunctory. Still, we must continue.
As promised, we start injecting some medicine to make the area numb. “A little pinch, then some stinging,” we explain as we work. “Keep taking deep breaths and blow that little sting away.” Aware that time is not fully on our side, the entire OR team is aware of how scary this must all be for the person on the table. So, we practice patience. We give the medicines time to work while we fix our gaze on Pat. Verbal communication is fill with reassuring words. Even in a COVID-19 world, human touch brings comfort.
The three surgeons transfer all of our good thoughts and positive vibes to a steel scalpel that divides the skin exposing what lies beneath. A frequent, if fleeting thought visits any surgeon whose mind is open. Despite all the importance society can place on the hue of skin, one it is breached, we are the same beneath. The priority assigned to the peel so often keeps people from enjoying the fruit. The revelation, of course, calls into question how racism could ever become so prevalent in medicine.
With kindness and concern, we initiate the journey to make a new entryway for life-giving oxygen. Pat is amazingly cooperative and we are able to maintain some serenity with deep breathing and self-soothing (for everyone in the room). Like many excursions—including Pat’s day—things often veer off the path and the lump in the neck we saw before shifts our course. As fluid slowly creeps into our sight, we know the fluid filled sac in the front of the neck is no longer contained. This is actually a good thing because we can suck out the fluid and the golf ball in our path is now flat. It is easier to see and easier to feel. Our senses are how we experience the world and the surgeon’s world relies on the unique information gathered sight, touch and sometimes, olfaction.
When anatomy is distorted, the goal shifts and we aim to make things look like they are supposed to look rather and try to recapitulate normal. Carefully and methodically, we move structures that were pushed aside by the mass back to the middle. Then, we can follow them down to the next layer of tissue as we approach our destination. We move with alacrity and precision all the while imbuing the atmosphere with as much confident serenity as possible. Pat is awake, and understandably more nervous as we move closer to the airway. Although our purpose is to be helpful, the body can perceive us as a threat. Humans have protective reflexes and approaching the windpipe with a scalpel should raise a hair or tow. We explain our next moves and place a hand on Pat’s should to offer some reassurance. We then make our cut into the trachea and place a tube in the windpipe that gives Pat significant relief. We exhale! Collectively, we ALL exhale!!
We had turned on some music to help keep the room the calm. Now that Pat’s breathing was stable, I could actually hear a rhythm. The melodies emerged from the recesses and enhanced a brief celebration. Then, stark reality forces us to attention. We need to collect some tissue for a biopsy. For all intents and purposes, the “thing” interfering with swallowing and breathing is cancer until proven otherwise. It is always arduous to find proof of the things we already know, but don’t want to believe. So, we prove that this is cancer to prevent ourselves from accepting all the alternatives we create that are easier to digest. We retrieve several pieces of tissue for reassurance and to combat any future doubts. We make sure the plastic tube is secure and tidy things up. Pat’s situation is better than it was, but we still have a long way to go and many questions to answer (or difficult answers to accept).
We pick up the phone to reach Pat’s family learn more about the sequence of events that lead to our introductions during an emergency operation as well. Pat’s close relative informs us that Pat has been having trouble swallowing for about a year and it has slowly been getting worse. People had encouraged Pat to go get it checked out, but Pat doesn’t have insurance. Pat also works part time without benefits and was/is afraid of missing work and unpaid bills. Pat actually went to work the day of the ED visit, compelled to protect a paycheck and compelled by the fear of what happens to people who are impoverished in a country of great wealth. They took a break early in the shift to try to ease the shortness of breath. Pat actually agonized over making the decision to leave work and seek medical attention and only left the job when the work of breathing became stifling.
We collectively experienced a circumstance in which having trouble breathing was balanced against the need to participate in our modified, crony-, corporate-capitalist economy in order to secure basic goods, services, and shelter. The need to make money for survival eclipses the basic instinct for survival. THIS is bad!
When Adam Smith provided a framework for what would later be called capitalism, he valued the worker and the work. The ability to provide a service was honored and the providers were important, not just cogs in the wheel. Adam Smith did not envision that one day, when supplied with patients who need service, healthcare facilities would demand that these under-resourced people with illness be transferred elsewhere. The working poor remain some of the most undervalued, vulnerable people in the experiment that is America.
Caring for these three life forces was complicated. I am grateful for my training and it readily came to mind that essentially all training hospitals are funded through Medicare/Medicaid coffers. So, in a very real sense, every trained physician owes some of their clinical acumen, expertise and finesse to the very patients who get displaced and shunned in our modern healthcare system.
In each case, there is a gnawing sense that had something been done with more alacrity, the outcomes could have been improved. We wonder why Jamie didn’t go back to the doctor a little earlier. We wonder is Max could have avoided a catastrophe. We secretly judge Pat for choosing between a rock and a hard place. We spend far less time questioning the system.
Much of the research about healthcare disparities confuses access with invitation. There is an assumption that if a clinic is close by, individuals will go there seeking care. If proximity isn’t reinforced with making people feel like they belong and that their presence is cherished, then the location won’t be enough. The care is essential in healthcare. We also talk about health insurance by asking the wrong questions. Universal coverage is the buzz phrase when we really need universal acceptance. In 1882, Emma Lazarus penned the ultimate invitation in The New Colossus which concludes, “Send these, the homeless, tempest-tost to me, I lift my lamp beside the golden door!” The ‘Mother of Exiles,’ also known at the Statue of Liberty, was not about proximity. There was deliberate invitation and welcome.
Part of the idea of a safeguard healthcare facility is to create a space for those less likely to be accepted. The idea that healthcare should be a lucrative enterprise pits the entire system against some of the very people who need care the most. Poverty keeps asking questions and our answers are void of alacrity. We keep wondering if we can change the outcomes, but we aren’t willing to try to avoid the catastrophe.
Superman and the Wonder Twins will rest. We will reflect. We will decompress. We will critique our actions and we will strive to keep being better, all the while realizing how blessed we are to be in our positions. Something needs to be fixed. We know something is wrong. Three lives hung in the balance and we were able to achieve somewhat favorable outcomes. Still, Jamie, Max, and Pat haven’t received a hospital bill yet. There are obstacles in planning for discharge we haven’t even discovered yet. The acute care results are only as good as the ability to sustain day-to-day health maintenance and appropriate follow-up. Why do we need to guard against people being denied access to healthcare? Why isn’t this more of a guarantee? Why do we spend resources on acute care but neglect preventive measures? Why do we wait for sickness before acting, but call it HEALTHcare? We know this is bad. We know poverty is the underlying condition. The problems we won’t face sometimes hunt us down. This is bad.