Tools of the trade.

I grasped the list of patients, fingering the crispness of the sheet that represented my first day of service on the medical wards. I knew that the sheet would soon be crumpled and covered with scrawl, as I scurried about, meeting 36 patients, 2 residents, 4 interns, and 6 medical students. But for now, the paper felt cool, controlled, and reliable in my grip. I was ashamed to admit it, but I was perversely thankful for the numerous comatose patients on my service, because they made rounds faster and left me more time to concentrate on the active GI bleeders, the patients in DKA, the ones with gram-negative septicemia, and the ones who spoke English. Mrs. Millstein was one such comatose patient, an elderly woman with Alzheimer’s disease who had been sent from her nursing home in Brooklyn after falling and hitting her head. An overflowing hospital census and pure bad luck conspired to land Mrs. Millstein on 7-East, galaxies away, for all practical purposes, from the medical wards on the 16th and 17th floors. The combination of her flat-line mental status and her location in the hinterlands of the hospital ensured that my visits would be brief and infrequent. The previous attending told me that he had spoken with the patient’s sister in Florida, the social worker from the nursing home, and the patient’s rabbi. All had assured him that Mrs. Millstein would not want any aggressive measures. A DNR order had been signed, and the plan was to place a permanent feeding tube and then return the patient to her nursing home. I poked my head into Mrs. Millstein’s room on that first day of service. I saw a white-haired elderly lady, either sleeping or unconscious, but clearly comfortable. She was breathing well and her vital signs were stable. The pen was already in my hand as I stood in the doorway, and I jotted the briefest of notes in the chart. I nodded to myself, checked off the box on my now slightly rumpled list of patients, and continued with my rounds. I had no plans to call the sister — or to do any additional work for this patient — since the previous attending had settled the main issues. But then the question arose of whether Mrs. Millstein would consider the planned permanent feeding tube to be too invasive, and this decision would require consultation with the family. So I dialed the number, and a heavily Eastern European accented voice met my ears. “Yes, I am Goldie. I am her sister.” My fingers leafed through a medical journal as I explained to Goldie that I was taking care of her sister, that I was the new doctor on the service. She told me that Dora would never want any painful or invasive procedures. We agreed that a permanent feeding tube would not be necessary, that the temporary tube was OK, given Mrs. Millstein’s comatose state and probably abbreviated life expectancy, and that the patient would not have any IVs inserted or blood drawn. The transfer process moved along. Papers were signed and stamped. Transportation services were arranged. Necessary authorizations were obtained. On the day of transfer, as I readied myself to cross one more patient off my now well-worn list, the social worker noted the last set of vital signs. There was a fever. The great machinations of interhospital transfer ground to a halt: nobody, it seemed, could be transferred anywhere, anytime, at any stage of illness with a core body temperature other than 98.7°. Despite my protestations that the patient was already receiving oral antibiotics, that she would not undergo blood cultures or be given IV antibiotics, that she had a DNR order, that the medical team would not do anything about this fever, that in fact it was actually expected that this patient would have a fever, the social worker’s rule was ironclad. I would not be able to cross Mrs. Millstein off my list. It was already quite late in the day, but I decided to call Goldie. I assumed that we could have a quick conversation and that she would agree with my judgment that her sister could indeed return to her nursing home, despite the fluctuations of her body temperature. I glanced at my watch as I dialed her number. Goldie sounded delighted to hear from me. While I packed my stethoscope and crumpled patient list in my bag to leave for the evening, she asked me if Dora looked comfortable. I said yes. “Dora had such a hard life,” Goldie said. “I am much younger, and she was like a mother to me.” In the casual voice of someone recounting her afternoon shopping, she added, “We went through the camps together, you know. She took care of me after we lost our parents. She is the reason I survived.” My hands abruptly ceased their activity and drew together with interlocked fingers, awkwardly making their way down into my lap. Goldie and I proceeded to talk for the better part of an hour. Goldie Tools of the Trade