Finding Your Voice

A friend, who is a new medical resident, confided that she was frustrated on her latest hospital rotation because one of the attending physicians made it a sport of intimidating anyone within spitting-while-yelling-at-you distance.  She confessed that her fear was probably interfering with the care that she providing.  Hoping to encourage her to choose caring for her patients even if it meant suffering at the hands of an insufferable attending physician, I told her the following story.  I learned the very hard way that we all have to avoid the “mute button” when that little voice inside yells at us to do so….

After placing my order at Cosi’s and collecting my hummus and vegetable sandwich, I set my sights on joining the queue that would ultimately separate me from the $6.97 of paper and coins in my right pocket.  As I worked my way through the lunch-time masses, I excused myself to pass an elderly woman.  When she turned and smiled, the air in my lungs was vacuumed out by the sight of a ghost.  The words that leaked from my mouth must have left this grandmotherly figure thinking that English was not my native language.  Unable to comprehend her presence, I moved past her and joined the cash register line where I could assess her without further risk that someone would telephone the police about my behavior.

I have often heard that everyone has a twin.  Beyond feeling bad for the guy running around looking like me, I have not given that idea great thought.  But then again, the only plausible explanation for the presence of the wrinkled, gray-haired woman slumping on her cane four feet away from me was this concept.  After all, her “twin” is dead, and the memory of that death haunts me many months later because I think that I may have contributed to it with my silence.

On what was a perfect spring afternoon, I noted how the sun had coaxed smiles onto most of the faces that paraded by me and that many people were humming, singing or whistling.  Winter, I was starting to believe, was a memory (for now).  Arriving at the hospital, I donned my white coat and was quickly given a job to do.  Coming out of Room 13 a few minutes later with a patient’s history bouncing in my mind, I was startled when someone grabbed my arm.  Before I could say anything, a man in his 50’s jumped from his chair and assured, “Mom, it’s ok.  We can’t bother this doctor right now.  They’ll get to us soon.” 

In part because warm weather brings more accidents, more fights, more drunks and generally just more emergency business, the ED was littered with stretchers that lined the hallways as overflow for the filled rooms.  Knowing that the resident physician with whom I was working was not in a rush to hear my presentation on the “belly pain” in Room 13, I turned and found a scared old woman attached to the hand on my white coat sleeve.  This octogenarian, and mother of the man now standing next to her, was uncomfortably resting on a full backboard.  Her head and neck movement was restrained by a hard yellow collar.  Her sad eyes reminded me of that confused look my dog has anytime the veterinarian requires him to wear a protective plastic “collar” around his neck.

Gently plying her surprisingly strong fingers from my arm, I took her hand in mind and asked if there was something I could do.  Ms. W. complained about pain and was a little difficult to understand.  I smoothed her hair and told her that I would let her doctor know that she was uncomfortable.  Her son thanked me (for nothing) and told me that his mom was waiting for a CT scan after falling down a flight of stairs.  Confirming that the son did not want a ginger ale or graham crackers (there was a limited selection at my disposal), I set out to find those in charge of Ms. W.’s care.  I found the resident physician charged with ensuring that Ms. W. left the ED better than when she arrived, updated her on Ms. W.’s pain and apparent delirium.  Dismissing me with both words and a look – the look of “thanks, medical student for wasting my time” – she said she would check on Ms. W. when she had a chance.

Taking an arterial blood gas (“ABG”) in Room 17 and then observing the attempted – and failed – resuscitation of a 47-year-old man who had “been down” for 40 minutes upon arrival at the hospital because the condoms of heroine he was transporting as a “drug mule” in his intestines had ruptured had kept me out of the hallway where Ms. W. was housed.  When I caught a “break” (a very relative term for the incredibly hard-working doctors, nurses and staff in an emergency department), I tracked down Ms. W. and was disappointed to find that she was in her original location.  Her son remained pleasant, and I was struck by how calm he was and how irate I would have been if my mom was immobilized in an uncomfortable position, place and state.  Ms. W. seemed more confused and remained in pain.  She didn’t look well but I wasn’t sure that she looked worse.  Again, I spoke to her, smoothed her hair and held her hand while her son grinned pleasantly.

I sought out Ms. W.’s resident and found her in the middle of presenting to one of the attending physicians.  I waited.  I made my presence known.  We made eye contact and she glanced away, even turning her back a bit to make it clear that my opinion was not needed at that moment.  While thinking about how to proceed, a previously unannounced (often the case when someone is thrown out of a moving vehicle by “friends” at the ED’s front door) trauma boomed through the overhead speakers and I headed toward the red pod to meet my assigned boss for the night.

After watching the emergency physicians stabilize the 17-year-old boy with multiple gunshot wounds and the trauma surgical team wheel him out of the ED, I returned to the nurse’s station that had been my home base all night.  Over my shoulder, I noticed that Ms. W.’s son was stretching in the corridor.  I risked his ire and went to check on his mom.  He remained calm and pleasant.  He informed me that his mother had been to the CT machine and they were waiting for news.  His mom had settled down but remained in pain and confused.  I apologized (on behalf of whom, I do not know) for the delay and joined him in hoping that answers would come soon.  He asked me about the photo dangling on the pocket of my white coat and, consequently, we talked briefly about my daughter.

Moments later, a gurney – the gurney she had been on for literally hours – carrying Ms. W. flew around the corner with a flurry of people in tow.  She was brought into one of the trauma rooms, CPR was initiated and a nurse gave an update that she had found Ms. W. unresponsive in the hallway.  Questions about the failure of having her on a monitor were pressed to the corner of the room while the team worked aggressively to revive her with medications, joules of energy and simple hope.  Her gown had fallen to the side, exposing Ms. W.’s naked body to the indecency of the cold, trauma room.  An attending asked about advanced directives.  The resident physician – the one who had ignored my earlier communications and who had accepted responsibility for Ms. W. – calmly started to leave the room indicating that she would speak to the family. 

Ms. W.’s son, who was now joined by two other brothers, remained a giant among gentlemen.  He quickly convened a family summit and within seconds concluded that the efforts being made in the trauma room were not what his mom wanted.  With that decision, the resident carried the news back to the team working aggressively to revive Ms. W.  Everyone stopped.  The attending physician ordered that Ms. W. be covered appropriately, that tubes be removed, and that everyone in the room leave immediately to make room for the family.  As I left, I diverted my gaze away from the son, holding each tile of the floor with my eyes.

Ten, maybe 15 minutes later, I passed Ms. W.’s son and his brothers in the hallway.  Unsure, I nodded.  He stopped.  Gripped my hand with both of his and thanked me for caring so much about his mother and taking such great care of her.  Though we had discussed my status as a medical student, he introduced me to his brothers as “the Dr. who checked on Mom all night.”  I had done nothing but show him that someone was paying attention, even though I had failed to exercise the limited power that I had.  I had not questioned why an 89-year-old woman was in an unmonitored bed after a substantial fall.  I had failed to push the resident to pay Ms. W. the attention that she needed and deserved.  And most concerning, I did not seek out the attending – the resident’s supervisor – to share my concerns.  If I had found my voice, I had to wonder, would Ms. W. had lived through that night?

On the ride home that early morning, I turned right off of one of the city’s still sleeping streets and spotted flickering red ambulance lights that helped dilute the darkness of a new day.  I apologized silently to Ms. W. and her sons.  The exhaustion of the past 12 hours, the dehydration and hunger of the extended shift, and the sorrow of her death caused a quiet, reflexive promise to escape my lips: “I will find my voice next time.”

It is not always easy but, I hope that you’ll remember that people like Ms. W. are counting on all of us to find our respective voices when it matters.