Here’s a story from my second medical memoir about the importance for doctors to learn from nurses. The book – Healing by Intent – will be released by HARP The People’s Press (www.harppublishing.ca) in 2021
Her arm dances a pronating ballet, radial hump
and hard straight metacarpal ribs familiar as
pictures in Cunningham’s Anatomy
St Paul’s Cathedral clock was striking nine as I entered the hallowed sanctum of Barts Hospital on July 1st, 1963. Rahere the Monk, courtier to Henry II, had swung open the hospital’s West Gates onto Giltspur Street in the City of London 841 years earlier to usher in London’s plague-ridden hordes. None of those original twelve-inch-thick walls still stand, but the primeval austerity of the place endures. A raw twenty-two-year-old medical student, I was shaking in my shiny lace-up shoes.
I peeked my head around the door of Annie Zunz ward, knowing better than to enter without Sister’s permission. Sister Annie Zunz was sitting bolt upright at her desk facing directly away from me, starched apron stretched over ankle-length, dark blue dress. To left and right sat a staff nurse, like two ministering angels at the side of God. I cleared my throat and asked permission to enter the ward. The conversation broke off; the white veil-cap inclined forward brief inches. I took this for assent. The ward stretched ahead of me, two lines of beds spic-and-span and precisely spaced as an army barracks awaiting the brigadier’s inspection. The patients mostly lay recumbent and immobile, as though loath to disturb the apple-pie order. I counted silently as I ventured forward, clutching the admission chart of my new assignment.
I knew her earlier medical charts would take several days to appear from some dusty hospital records repository. All I had was her name, address (somewhere in London’s docklands) and DOA (date of admission) to work with. Oh God, was it seven or seventeen? I was almost at the far end of the ward before I located my patient by surreptitiously reading off the name at the end of each bed. I recalled my house officer’s recent admonition that I would need a chaperone before carrying out my PE—physical examination—but it seemed safe enough to get rolling with the HPC—history of present condition—until Sister Annie Zunz saw fit to free up a probationer nurse for the lowly task of guarding her charges against possible medical student improprieties.
I sensed Mrs. Lovell had been awaiting my arrival. She proved to be ancient and frail and was propped up on no fewer than four pillows. Could this be an early clue—did she have trouble breathing if she laid down flat? Remembering the house officer’s injunction not to stand and loom over my patient, I lifted fresh bed linen from the chair onto the crowded bedside table to make room for me to sit. I laid my H&P—history and physical—aide-memoir on my lap and remembered to introduce myself by proffering my hand. As she extended her own, I caught myself naming the linear humps of her forearm bones easily visible beneath the papery skin. They danced a kind of port de bras as her wrist rotated and her fingers grasped mine: live anatomy displayed before me as though springing from the dog-eared pages of Cunningham’s Manual of Practical Anatomy.
Which is the radius and which the ulna? Is that pronation or supination? Are those metacarpals or phalanges? But I had already left my hard-won anatomy gleanings behind in Professor Cave’s dissection rooms, while wondering to myself what possible relevance it could have to my present ponderings. As my hand enveloped hers—a mesh work of tiny, quite unnameable bones—a tremor passed between us. Was it hers or mine? The house officer’s mandate to hold eye contact was ringing in my ears, precluding my peeking at the list of questions on my clipboard. I scrawled notes blindly as Mrs. Lovell unravelled her story, and I was swiftly cast adrift from the prescribed order of my H&P, powerless to stem the flow as she recounted each minute detail of her family circumstances.
“Not that I mind bein’ ’ere, Doc, but it’s me pussycat. Me ol’ man makes sure to give ’er ’er kibble, like, but ’e don’t ’old wiv changin’ ’er litter box. It’s allus a ’orrid mess when I gets ’ome. Oh, you’re not a doctor yet, though, are you, I can always tell, well, student doctor then, same difference is what I allus say.”
As her chatter gained momentum, I deferred all attempts to sort my clipboard scribbling until I could find a quiet spot, though where that might be amidst these alien surroundings totally eluded me. I registered the arrival of the promised probationer nurse, who was engaged in pulling the ceiling-to-floor curtains around to conceal the three of us from the outside world. I was still well short on the essentials of my ROS—Review of Systems—having completed only three: cardiovascular, respiratory, and E.N.T. Questions regarding Mrs. Lovell’s gastrointestinal, neurological, and musculoskeletal health still lay ahead, and when and how to fit in her PMH, FH and SH—past medical history, family history, and social history—I would have to leave to providence.
This would be my one and only chance to avail myself of this nurse’s services before she was whisked away on far more pressing duties. One glance told me she had to be straight out of high school and wouldn’t say boo to a goose. But it was high time to move full speed ahead to the clinical exam. Did either of my companions have any notion that Mrs. L was my first live patient? I stood up to carry out my PE, knowing I had to conduct it from the right side of the patient’s bed. I wondered briefly if any exceptions were made for left-handers? And why on earth must one sit for history-takings but stand for physical examinations?
I was forced to pause every few minutes to visualize the items on my PE list, but it was quickly clear my patient knew the routine far better than me, anticipating my every request and responding without demur. I pulled my-brand new flashlight from my pristine white coat pocket and gazed into Mrs. L’s mouth. After several long-drawn-out moments of flashing and peering, I learned only that she had but one tooth remaining from the set with which God had once blessed her. I limited my eye exam to checking for reactions and rotations, having forgotten to tote along my brand new ophthalmoscope. Its absence was no big loss, given that I hardly knew how to switch it on, let alone tap into its diagnostic powers.
I fumbled to capture the thready pulse at her wrist, remembering to turn her head gently away from me so that I could study the carotid artery in its steady up-and-down rhythm motion above her thoracic inlet. As I observed this conspicuous motion, I realized I had no clue as to whether the appearance of the impulse was normal or not. Then as I was locating the second hand on my watch to count her wrist pulse, it promptly slipped from beneath my fingers. Despite Mrs. L’s compliance, my H&P had to date failed to offer a single tip-off as to what might have brought her in here.
I glanced at the nurse, standing mute and patient at the other side of the bed, and took in for the first time how utterly ravishing she was. Her thick copper-coloured hair was pulled back tightly under her cap above the face of an angel. Her devastating prettiness, in such contrast to the ancient Mrs. Lovell, was stirring me to the core. I tried furtively to read off the name on her badge, bringing me in direct line of sight of her right breast. Blushing, I averted my eyes as she turned her attention to folding the sheets down. I swivelled my mind back to the job in hand as she helped Mrs. L with the straps of her yellow flannel nightgown. It promptly dropped to her waist, and I took in the thin arc of ribs jutting out from the sides of her breastbone. The years had left their mark on every inch of Mrs. L, her skin a discolored mass of blotches and wrinkles, paper-thin to my touch. Her breasts lay flat and dappled with brown marks like fallen leaves, blue venules crisscrossing their translucent surface.
How old was she, anyway? Eighty? Ninety? Oh lord, how could I miss such a glaring detail? I became aware of the growing ache in my braced legs but felt too shy to perch on the edge of my half-naked patient’s bed. I remembered just in time to rub the end of my virgin stethoscope up and down on my coat to take the chill off the metal. As the nurse delicately lifted Mrs. L’s left breast, I spotted the brief upward movement of what must be her cardiac apex. I laid first bell, then diaphragm, over it, tuning into gushes and murmurs that till this moment had been only stark words in Cecil & Loeb’s Textbook of Medicine.
I glanced surreptitiously at my cheat sheet, my mind a blank. A single row of words leapt out: inspection, palpation, percussion, auscultation—look, feel, sound, listen. God, I had totally skipped percussion—that business about flattening my left hand against her chest and tapping right middle and ring fingers against left middle, to try to determine if there was anything else in her lungs besides air. In other words, anything that shouldn’t be there. I offered up silent thanks that both patient and nurse were ready for my next move. The probationer was supporting Mrs. L as she leaned forward in the bed. I laid my palm flat over her left shoulder blade, trying to keep my overlong fingernails from penetrating the fragile skin. I started my tap-tap-tapping on the left middle finger with my right middle and ring ones and was rewarded with a hollow resonance indicating a nice clear lung cavity. I moved my hand downwards and repeated the performance, with the same satisfying result: resonance all the way to the bottom of her lung.
I switched to the right side. All was well until tap-tap-tap number three. It was dull as a stone. Hallelujah, something amiss … I murmured my mantra once more—inspect, palpate, percuss, auscultate …
“Breathe deep and slow, Mrs. Lovell, I’m just going to listen in.”
I worked my stethoscope down her back. Sure enough, midway down on the right side, all sounds of in-and-out air movement abruptly vanished. I pulled my stethoscope from my ears; Mrs. L had once more broken her silence.
“It ain’t me lungs, doctor, nuffin’ wrong with ’em. It’s me liver. It’s swellin’ up and dahn and all abaht. Cop a feel for yusself.”
A piece of information beyond the price of rubies.
The nurse removed all but one pillow and eased Mrs. L down to a supine posture, then folded her nightie and sheets down to her groin. The fullness and roundness of my patient’s tummy leapt out at me, in striking contrast to the scrawniness of the rest of her. My mind struggled to recall the primary causes of an overly protuberant abdomen. She for sure didn’t qualify for obesity. And I could safely rule out pregnancy—couldn’t I? All I needed now was to eliminate Cecil & Loeb’s other twenty-plus causes.
But Mrs. L had already started to clue me in. I laid a tentative hand over where her liver should be, started to slide it downwards, and had almost reached her groin before my pinkie abutted against something. A firm, thick lip that had to be her liver’s bottom edge.
“Feel it, dearie, do you? Big bugger, in’it?”
“Yes, er, yes, it is … er, big.”
As I continued my groping, I took in what had to be puncture marks, clustered in a line just below and to the left of her liver edge. Having broken her silence, Mrs. L was becoming a veritable treasure trove of priceless prompts.
“I spec’ they’ll be ’aving you stick a needle or two in me if you’re goin’ to be me new doctor. “
It took me a long moment to absorb the significance of her words.
“You mean you’ve had other students putting needles in your tummy, then, Mrs. Lovell?”
“Oh, dearie, yus, plen’y.”
“Er, you wouldn’t have any idea why, would you? By any possible chance?”
“Why, bless me, yus! Thought you’d never ask, love. Like I said, it’s me liver, it may be a big ’un, but it ain’t workin’ worth tuppence nowadays. Ever since the ’epatitis. So I get all this water in me belly—’scuse me, dear, I mean me tummy.”
The penny finally clanged to the floor. I peered more closely at the color of her skin. Yellow as custard! How could I have missed it? Not what you’d call golden, but—no doubt about it—she was lemon all over. Struggling to curb my glee, I turned my scrutiny back to her eyes, lowering each eyelid for a better look. The white parts weren’t white at all but lemony, too. I grew giddy at the thought of how close I’d come to missing the glaring signs that Mrs. L’s liver was failing fast. Maybe she had a few more vital clues to uncover? Why in God’s name didn’t I think to ask her what was wrong in the first place?
Mrs. L seemed to have read my thoughts. “You’ll be tellin’ the perfessor all about me case in the mornin’, then? ’E’ll be sure to want to ’ear about me bleedin’.”
“Oh yus, that’s wot brought me in ’ere this time. I was bringin’ up all this blood, and I got to feelin’ real giddy, I did. Me old man ’ad to ring up for an ambulance. They said if ’e’d ’ave left it any longer, I might not be ’ere at all. They ’ad to empty me stummich out, an’ gimme a blood transfusion. They think it’s stopped nah. The bleedin’, that is.”
I glanced back up at the nurse. I had almost forgotten her in my elation.
“Er, nurse, I don’t think I’ll need you to chaperone me anymore. I’m just going to chat with Mrs. Lovell, see what else she thinks I ought to know.”
Did I catch her smirking? Well, perhaps we’ll get to chat some more about Mrs. Lovell’s case. Now wouldn’t that be nice …
“’Ere, I wouldn’t mind sittin’ back up again,” Mrs. L interrupted my reverie. “Gets me quite aht of breath, lyin’ down does.”
The two of us moved fast to lift her back to the upright position and tuck her pillows in. As we did so, our fingers brushed, then pulled hastily apart. We avoided each other’s eyes as the nurse straightened Mrs. L’s nightie, tucked in her bedclothes, pulled the curtain back, and was gone as silently as she had appeared. I sat myself back down beside Mrs. Lovell as we recovered our collective breath. I loosened my itchy wool tie and slipped my top shirt button undone.
“Now, about these needles, Mrs. Lovell. Have they been taking fluid out of your tummy?”
“Lordie, yes, every time I’m in ’ere. Seems like it just keeps comin’ back. But I do feel ever so much better after they done it. Leastways, for a bit.”
Ascites! The word jumped into my head. What you get when your liver shuts down. Because of … what was that thing called? Portal something … portal hypertension, that was it! That was why her stomach had been bleeding—all that back pressure. I felt like Sherlock Holmes and Doctor Watson all rolled into one, unscrambling a baffling whodunit. Mrs. L was drawing my attention to a scattering of marks on her arms and hands. Pinkish circles, four or five on each side, a spidery lacework extending outwards like tiny flowers.
“They’re allus peerin’ an’ pokin’ at these ’ere thingummies on me skin too, doc. Dunno ’ow long they been there.”
Oh, God, what were those called? Spider thingummies … an inescapable sign of liver trouble. I could hardly wait to get at my Cecil & Loeb, become the world’s expert on liver failure before morning rounds. I love you, Mrs. L, I just love you. I’ll change your pussy cat’s litter box anytime.
As I scooted out into the corridor heading for the library, I nearly ran into my nurse chaperone. She was holding a sizable tower of bed pans, and I made a clumsy attempt to hold the door open for her. She paused to confront me.
“Look, I know Mrs. Lovell is a good case for the professor’s rounds. But you might not have shown such conspicuous delight at figuring out what’s wrong with the poor woman. She might well not make it in next time she has a bleed.”
I stood there chastened as she swept past me and disappeared into the ward.