Designated Driver

Designated driver

Residency is a mystery to the vast public. It is a constant flip switch climb. Each
month the rotation resets and the learning curve starts again in another aspect of
the art. It’s an infuriating back slide but sometimes a reprieve. A fresh rotation
can help walk away from drudgery or sometimes too much attachment while still
helpless in training.

Gastroenterology rotation.

She was 87 years old. Her name was Alice. Some decades ago she had a total
colectomy. This lead to dumping syndrome. Every meal dumped out of her within an
hour of eating. Methodically timed eating and a diet of 80% fiber let her become the
designated driver of a close crony of friends. She had to drive the group of four to
bridge each week. She would poop before she left and when she arrived and before she
left and when she got home. She was the one with the license still.

“I have to renew it next year,” she said.

She came in with suddenly uncontrollable diarrhea. It would just run down her leg.
She was mentally crisp and thoughtful. I enjoyed speaking with her. My intern
“little Lucy” and I would joke with her. Lucy was an energetic bright eyed eager
girl. She was more than 18 inches shorter than me. I knew we looked like a circus
show to Alice. I endearingly called her Little Lucy but she was fierce and quick.
Little Lucy pre rounded quickly and jumped on the task list. She nodded when anyone
spoke and I imagine her cog wheels registering, “Got it. Yes. Ok. Done. Got it.
Done. Yup. Yes. Got it.” She was a resident’s dream. “Resident’s dream. Got it.”

Alice seemed to enjoy fashion and shoes so we all would lighten the talk of stool
output with talk about textures bling and what we were wearing under our white
coats.

“You two are lovely today!” Alice would say each morning. I think we missed our
families and our moms. I think we missed light hearted bantering and easy speak.
Little Lucy and I would joke with her. I remember even a bright orange scarf Little
Lucy wore. It was the preferred topic one morning. One minute it’s about never
leaving the hospital, 15 bowel movements a day, liquid diarrhea described as thick
coco then a reprieve, Little Lucy’s orange scarf with a streak of gold and some
squealing.

It was the first I heard of an old remedy called tincture of opium. It conjured
images of days of opium dens and satin smoke. We were going to stone her
constipated. She said, “Oh my!”

I wrote the order, flagged the chart, left for the day and day’s end.

I arrived the next morning to less diarrhea but to something worse. Alice had broken
her hip in the night. She has gotten up to have a bowel movement and in her opium
unsteadiness she slipped on a dripping bit of diarrhea. “Shit,” I whispered loudly.
“Shit. Got it,” Little Lucy registered and then I saw her really register it. “Shit.
Oh my god. That’s horrible. Alice,” Little Lucy was waking up out of training as we
all do into the world of the souls we were training to care for.

My heart ached. I was decimated. My dear Alice. The designated driver of a group of
close friends was more broken than when she came in. The feeling of failing laid on
me like an elephant and I couldn’t face her. The next step was to have Cardiology to
clear her for hip surgery. She had to get surgery. I did Cardiology rotation. She
would be high risk and then I did a year of surgery which meant they weren’t going
to touch an 87 year old. Would they?

By afternoon she was in atrial fibrillation. Cardiology deemed her high risk and
placed her on digoxin. Orthopedics said they would operate still not wanting to let
a woman die in bed and succumb to pain and the pneumonia of being bed ridden.

“Ok. We are back in business. We do the surgery, fix the diarrhea, she goes back to
driving,” I checked off loudly on pre rounds. Little Lucy was registering the plan.

Then the beautiful made up plan was all spiraling violently out of control. Alice
decided no surgery.

The plan was decisive and clear. Digoxin, surgery, diarrhea, rehab, home driving.
What was the problem? Digoxin, surgery, diarrhea, rehab, home driving!

We went in to talk to her. To beg her to try surgery. She was so sharp and so feisty
I felt she MUST be able to weather surgery. SHE was a god damn designated driver!
“Come on Alice! Stay with the plan,” my mind was screaming.

Alice held my hand and I cried openly uncontrollably. Lucy stood just behind me.

“Please Alice,” I begged. I was reduced to begging. I had never begged a patient
before but we were suppose to fix her and get her back to her duties. People needed
her. Were physicians suppose to beg patients?

“No, it’s ok. I know you both want me to but it’s ok. I know it’s time. It’s just
too much now,” Alice said reassuring me. She was doctoring us. We were in need of
reassurance. The weight of the white coat couldn’t hide our disappointment. Death
was winning. Diarrhea was kicking our asses. We both were crying. Do patients doctor
physicians?

We left the room and I collapsed in a chair. Lucy looked at me and I’m sure had no
idea what to think of a upper level resident so destroyed. Interns are looking for
strength and guidance. I was folding under the reality of a woman being killed by
diarrhea. Over and over I thought, “A beautiful soul has died of slipping on
diarrhea.”

Lucy was nodding slowly as she patted and stroked my back. I could barely feel her
tiny hand under the thickness of the double weaved white coat. “We can do harm
sometimes treating one illness. Got it. Treatments have side effects. Got it.
Physicians can get too close and patients become friends. Got it,” her cogwheel
spun.

What kind of symphony ends on this note?

I cried typing, I cried eating, I cried driving home.

I cried and cried. Never does the story leave me. Like the diarrhea dripping a
steady painful past I think of Alice.

When I lose my way, when patients look like widgets that are merely moved around,
when they ask for help to fix things so they can return to their normal life, when
someone older asks for anything that might alter their mind enough to become
unsteady I think of Alice and her car full of friends not going to play “a bit of
bridge”. I think of how we make friendships with patients and how now in private
practice the rotation doesn’t end. We are in the car with them. We are driving with
them for years! The harshness of my pain gets translated into the tone of my
precautions and hesitance sometimes. I can’t tell my patients I have been burned
badly. That I refuse to have them hurt. I can only hope they sense the carefulness
but also the strong desire to get them back to their lives. “Be patient,” I say. “Be
strong,” I say. I still beg a lot. “Please. Please try,” I ask. A lot of my patients
are older and some leave patting the back of my hand and tell me, “It’s ok. It’s too
much now.” I think that last deep ditch try with a cheering section help a few
transition. “At least I hope so, Alice,” I think each time.

God help us not die a humiliating death spinning out of control on a patch of filth.

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