Old Time Doc

Clueless at the time, when I applied to medical school I sort of imagined myself one day making house calls, good ol' Doc Schwab, paid in chickens and pies, smiles and blackberry jam. There I'd be, delivering babies on kitchen tables, patchin' up Old Lady Jones's leg on the sofa, shaking out thermometers and feeling foreheads.

One of my roommates in med school was the son of such a doctor, although instead of clopping around with a horse and buggy, he raced across the back roads of Kentucky in an Aston Martin DB4, before James Bond ever thought of it. State cops would look the other way: Aincha gonna stop 'im Jess? Do whut now?...hail no, that thar's Doc Munger, heading t' th' McCoy homestead, I reckin'...

I liked the whole idea of it.

More so in the early days of my practice, when I had a little extra time on my hands, but to some degree throughout my entire career, I actually made house calls. As time became more precious, I had to be realistic: not too far out of the way, people with a simple problem for whom a trip to my office was especially difficult. Or, once in a while, a friend. But as a youngster there were a few times when I went quite out of the way, and spent a lot of time.

For example: I've always had mixed feelings about "the phone call." A woman is awaiting the news of a breast biopsy; I call her and note the stoppage of breath at the other end of the conversation. To defer by saying she should come in is to let her know but provide no support. To give the news over the phone is in some way heartless. So I'd split the difference by breaking the news as gently as I could, and inviting her in for an immediate consultation. But sometimes, early on, I reversed the equation and said, "How about if I come over and we can talk about it?"

One time, in my pre-gray-hair days, after I'd spent at least an hour at their home, my patient and her husband gushed at how much they appreciated the visit and my care to that point, but they'd be going to Seattle to be treated. Probably thought I looked too young. And hungry. Pissed me off.

Most of the time, my house calls were to a post-op patient, usually older, having a hard time getting around: quick check of a wound, a little debridement, change a bandage, remove or unclog a drain. I'd load up with a few tools, some tape and gauze and ointments; sometimes I stuffed them into my black doctor bag, for my own nostalgia more than anything else. Walking to the door, wondering what the neighbors thought, figuring they'd be jealous, their neighbor had a heck of a doctor there.

Always the visit was greatly appreciated, and generally met with amazement. Sometimes it was my own: finding out how my patients lived, in a trailer, in an unkempt crumbling home, in a fancy joint with all the options. And I'd learn about how they were able, or unable, to carry out the instructions I'd given them. Which led to a much more practical and pragmatic approach to what I'd tell people about after-care at home. Dispensing with certain residua of academe.

Once I got a call from a feisty old lady for whom I'd recently done a mastectomy: she was worried about her wound, or a drain, or something. To her obvious delight I'd said, "Well heck, I'm almost done here, how 'bout I swing by your place on the way home and have a look?" She answered the door buck naked from the waist up, her unoperated side of the enormous variety; responding to my undisguised surprise she said, "Hell, I figured you'd want to see it anyway, so why get dressed?" Her home was right on a main street. No screeching tires, far as I recall.

Making those decreasingly frequent but career-continuous house calls always made me feel good. The benefits were invariably mutual. Part of my medical school curriculum was the matching of every first-year student with a family in which the wife was pregnant. We followed her through pregnancy and delivery and were involved in the care of the baby. At least one home visit was a requirement, and we met in groups afterward to discuss what we'd found. Among others, the import was in learning that patients' illnesses are part of an entire life and not just the little slice of the day during which we see them.

All doctors -- and most especially surgeons, who typically send people home very significantly altered (if only, hopefully, for a short while) -- would be amazed by and learn from seeing their patients in their homes. It is, of course, completely impractical and nearly wholly impossible nowadays, which are very good reasons why it rarely if ever happens. Not to mention the occasional fright of seeing an old lady naked at her front door.

Memorable Patients: Part seven

I'm certain that if I hadn't been just finishing a midnight appendectomy, Daphne would have died. Not fully balancing all the bad luck in her life, she fortuitously chose to exsanguinate when a surgeon and OR staff were immediately available. Nevertheless, vomiting all that blood, she damn near died before she got to the hospital.

Niceties like passing a scope to find the source go out the window when someone is bleeding to death from her stomach. When I'd gotten the call, I was writing orders for the previous patient. I let the OR know they'd be getting someone in a big hurry, flew down the stairs to the ER, and met Daphne, who wasn't in a position to be sociable. In shock, confused, continuing to vomit blood, she was also very obese and showed obvious signs of Cushing's syndrome: side effects of high dose steroids. Whatever I might find and do, healing would be severely limited by those drugs. And you can't stop them for surgery: it would cause general collapse. Daphne's husband had ridden along in the ambulance. Compared to her, he was a tiny wisp of a guy, looking appropriately worried. I told him -- no surprise -- that she needed immediate surgery, and we'd see what we'd find, and do what we could. It was a very critical situation, I said. Blood had been drawn for cross-match, and I ordered a bunch of O-negative blood, started a couple of big IVs, told the OR we were on our way, talked to the anesthesiologist, and drove the gurney myself, pointed the way to the waiting area for her husband.

One thing about operating on the hypercritically ill: when you start from zero, there's no downside: clearly, she's going to die unless I can do something. No decision there; and, at some level, no pressure, in a perverse sort of way. Which is not to say I'm cavalier about it: I know that I'm the only hope she has. But unless I make a horrible judgment, or a monster technical error, a bad outcome is the default situation: I can't make it worse. I think.

In the middle of the belly wall, the rectus muscles (the six-pack muscles, in the fine and fit) are separated by a fibrous band, called the linea alba, or "white line." It's pretty bloodless, and what you aim for in making a midline vertical incision. Off to either side, it can get bloody. But in the very fat, it can be hard to find rapidly. There's a trick, for those of you trying this at home: after cutting through the skin, if you and your assistant pull the edges away from each other, hard, the fat splits apart like the Red Sea (the yellow Red Sea), right down to the white line, fast and smack on. Then you can split the linea sharply, fastly, and get in there.

What you'd expect, based on the odds, is a bleeding duodenal ulcer, the surgical approach to which is generally quick and easy: make an incision through the pylorus, place a couple of well-aimed sutures, and it's all over but the closing. Cut a couple of vagus nerves for good measure (it reduces acid secretion). But Daphne was anything but routine: she had two enormous ulcers, huge, encompassing much of the middle of her stomach, front and back; one of which had eroded through the wall of the stomach and into the splenic artery. No wonder she was bleeding so massively: that's a really big one, and I'd never seen it be the source of gastric hemorrhage. Having eventually made a large incision in the front of the stomach, the next thing I did -- once I realized the source -- was to put my finger in the hole in the artery to stanch the flow and give the anesthesia team a chance to catch up on volume replacement. That took a few minutes, during which there was nothing for me to do but stand there, a warm-blooded cork. Several pints of blood and bags of saline later, I placed sutures on either side of my finger, and warily pulled it out of the hole. Dryness, welcome dryness. (A professor of mine once said, "You don't need to worry about bleeding, Doc, unless you can hear it." Ha ha. This bleeding, I actually had heard and it's scary as hell. A hiss, a jet, a roar, hauling life with it, like a raft in a river.)

Even when it's necessary, operating on someone in shock is not a good thing: it unavoidably adds to the trauma, even as it seeks to reverse it. The least you can do is the best you can do. Get in, get out. But Daphne was in a hell of a fix: these ulcers of hers took up over half her stomach; plus, I'd probably just killed her spleen. I actually tried to save some of her stomach, not wanting to do a total gastrectomy for myriad reasons, but it was clear the remnant wouldn't survive. So, despite everything that would be ideal in a dire emergency, I removed her entire stomach and her spleen, and fashioned a sort of stomach-substitute reservoir out of intestine, and stapled it to the end of her esophagus. Too much surgery, really, for such a sick and medically depleted lady.

In a book I could tell you about if you were interested, I mentioned the generally competitive and uncooperative relationship between surgeons and medical docs in training. In practice, happily, it's the opposite. I worked with a sensational group of intensive care specialists, and between the two of us we pulled a few people out of the fires over the years. Daphne was one. In fact, I picked up her chart in the ICU one day to see a note from her primary doc -- pretty much out of the picture at this point -- saying, "I stand in awe of the excellent care being rendered to my patient by Drs Schwab and OConnor." Never saw anything like that at San Francisco General Hospital.

Despite my having told the family to expect, at best, a long and complicated stay in intensive care, Daphne actually recovered on a semi-straight path. (Secret to caring for surgical patients on high-dose steroids: lower the dose as much as possible, give supplemental oxygen, intravenous multi-vitamins and extra vitamin C.) Her life was tough: she lived in a half-hovel, to which I made many house-calls over the years. Her kids -- whom she'd named after cartoon characters -- struggled in school; her husband rarely worked. Unlike most patients with a total gastrectomy, she had a hard time nutritionally (other than a need for injected vitamin B12 on a monthly basis, many actually eat fairly normally and do well.) It had, in part, to do with the mysterious disease for which she'd been put on steroids in the first place: she sort of wasted away over the next several years. But every Christmas I got a card from her, thanking me for another year of life she'd not have had, had we not met. Once in a while she'd call with some concern or another and, since it was hard for her to get around, I'd go see her and do what I could.

Several years later, she underwent a total cystectomy for a chronic bladder infection: an ill-advisedly (in my opinion) big semi-elective operation for a woman in her shape, and once again she damn near died. This time, it was from MRSA. Not directly involved, but feeling responsible, I visited her in the ICU and painted a pretty grim picture to her family. Yeah yeah, they seemed to say. Heard it all before. She'll be fine. And darned if she didn't make it, again. She had healing problems this time around, and I became the default home-health aide, debriding her wound for months at her sorry little home. I guess I didn't want those Christmas cards to stop. They did, eventually, but not for a few more years.