Mr. Posey’s doctor was at the nursing station, sitting comfortably in a rolling chair, with his feet on the counter and a handful of charts stacked on the floor next to him. To one side of the pile he had balanced Posey’s chart, and as I approached him, he picked it up and waved it around while asking me to come over and help him find some missing lab work. I pointed to the morning lab work that I had clipped to the front of the chart earlier. He laughed distractedly, and started leafing through the paper printouts as if he had always known they were there, as if the joke were on me and not him. I pretended to get the joke.
I talked to him about Mr. Posey. He looked at me as I talked. I looked at the breakfast he had left on his lab coat. He looked tired, disheveled and slightly oily, as if the person who had been making biscuits in his brain for breakfast had mistakenly buttered the outside and not the inside of his head.
Standing next to him as I spoke, I told Dr Q about Mr. Posey’s breath sounds, breathing rate, and swollen feet. I had positioned myself carefully next to him, so I was sure he heard me, though I got no indication that he was listening to what I was saying from any of my senses. He just stared at me as I talked, but the eyes looked a bit iffy, and the body language he was expressing was facing a closet. I finished talking, then walked away to the IV room to check for any new medications that had been delivered from the pharmacy. I kept within earshot of Dr. Q in case he wanted to mumble something at me.
(He communications style consisted of mumbles and sharp barks, if he bothered to communicate at all.)
Unit doctors didn’t talk about the prognosis back then, it was something that rarely got brought up by, really, anyone. Most unit doctors focused on the treatment of symptoms, and avoided looking too hard at outcomes of patients. They seemed to feel their job was to do what was in front of them to do, and that what happened after they did it was social science or philosophy – something soft and squishy and to be avoided.
Doctors talked about things they could do, or tell us to do, -- interventions, treatments, testing – the stuff of action and moving, not the make a wish stuff of dreams and prediction.
It would have never occurred to Dr. Q to give Mr. Posey an option about his treatment – Dr. Q was dealing with a disease, something to be fought to the bitter end. Just as no one thought to ask the people of Atlanta if it was a good idea for Sherman to set it on fire – questions about prognosis didn’t get asked until after the war, and only the winning side asked them.
(At the time, I also thought prolonging the inevitable was the best approach, if for no other reason than to allow practice for new nurses.)
Dr. Q was a quiet, old time doctor who didn’t play well with others. He probably ran with scissors too, but then really, who didn’t back then? He rounded on his patients after dark—sometimes after midnight, sometimes in the hours before the crack of dawn. He made little noise when he walked, and although over six feet tall and kind of beefy, he had a habit, as many doctors do, of showing up out of nowhere.
Sleepy nurses sometimes fell out of their chairs when he barked a question at them in the dead time of the early morning.
What Dr. Q was known for on our unit was his impatience—he just could not wait for help, and hated trying to explain himself to others in order to get that help—it just took too damn long for him to tolerate. He was a legend in this way -- nurses told epic stories of the times he would take potent medicine from our stockroom and inject patients with them without mentioning that he was doing it to anyone. The first they would know of it was when drastic changes in heart rates and blood pressures suddenly started showing up on the monitors of previously stable people. As the nurses rushed breathlessly into the room, with calamitous thoughts in their heads, they would see the good doctor, in a shadowed corner of the room, hunched over the patient and looking curious. Never excited, he was just causing and effecting to beat the band— with the live person filling in for the band— which all kind of freaked everyone out a bit.
Most of the nurses on our unit were gun shy about Dr. Q. He had an enormous cruel streak in him that exploded on special occasions, and sometimes just randomly, as if it the anger were scheduled on a pre-set timer. At other times, the outbursts came after a slow build up, in a Mt. St. Helens kind of way. And like Mount St. Helens, sometimes he didn’t just blow his top off- he blew his sideways off. He got messy with his anger - lots of collateral damage to things invisible but felt—things like ego, self-esteem, and professional happiness.
Records weren’t kept on this, but unofficially, I think he made almost everyone he worked with cry at some point. He had the gift of assholeness, which he shared with others, though he wasn’t known for sharing much else.
Dr. Q believed that the process of drawing information out of people was the same as the process for getting a burrowing guinea worm out from under a victims skin. First he would slice them open – for access, then he’d wrap the slimy worm of knowledge around his pencil of inquiry and slowly twist and slurp the little bugger gently out of a now gaping wound. He would then plop it into the basin that was his head and leave. The clean up he left to be done the less worthy. The satisfaction he took from this was not of the grim sort – it seemed to be the only thing that made him smile. I loved him for this – it was our greatest bond. It was the thing that separated him from an angry bear in a zoo. He acted like he did with other people on purpose, and for a reason. He wasn’t the bear – he was the one poking the bear.
Except with me, but then I was special—and big. I was also a little bit scary myself at that stage of my emotional development. I had a carefully cultivated reputation for being self destructive, and at times, I used this reputation to leave cautionary lessons for others that would do me harm. I don’t recommend it, it comes with a high price, but it’s worked for me at the time, at least in some limited, dysfunctional sense.
Dr. Q was also one of the smartest people that I had ever met. He thought faster than other people, and his impatience probably came from that. I think, for him, working with others was one long dream sequence in which all the participants made their every move from the inside of a large barrel of molasses—except for him. It must have been excruciating for him, like playing chess with animals that had only cloven hoofs to move around the pieces.
I also think he just didn’t like people—probably genetic, or due to some form of abuse as a child – high school could not have been easy for him. He was not warm and fuzzy—but, if seen in the right light, he could be amusingly absentminded, and this was the best you could hope for. If he wasn’t mean, he wasn’t really anything but alone with thoughts that begged to escape.
Because he was both unapproachable and unavailable—and because he needed an interpreter in order to communicate with those people slow of thought—I was his man, his go to guy. We got along in that sloppy way of the unconnected; we bonded though the attractive draw of symbiosis; we attracted in the way all one-track multi cellular beastie boys seek out when they are looking for a way to make a bigger pile. I liked playing with him; he never threatened to take his ball home when I poked him with a stick.
Dr. Q left the nurses station without speaking to me, and went to Mr. Posey’s room. I pulled up a chair at the station and started charting notes in the nursing part of the medical record. I wrote the notes in bullet form, and used incomplete sentences, just the way other nurses had taught me. I charted the facts as I objectively saw them, and made an effort to leave out opinion and feeling.
As I charted, I kept one eye on the heart monitor in front of me, evaluating the strip of the electrical activity that represented his heart function as it slide by (EKG.)
What I monitoring was a simplified form of the 12 lead EKG, – the standard kind that people get when they are old and see a doctor on an office visit.
The heart pumps by using chemicals to interact with muscles, which then make squeeze and relax. The contraction part is started by electrical activity that’s generated from specialized areas of the heart. This action can be measured from outside the body – the skin. An EKG is a continuous picture of the electrical wave that a heart produces as it works. Weak areas show up as less electricity, delays in the conduction of the wave show up as absent, or blocked, areas. It’s a simple idea – much like radar, but with less energy and with much more fine and subtle indicators– it can be tough to interpret, even the newest machines need a cardiologist to review results for accuracy.
A standard 12 lead EKG measures electrical activity as it comes out from the heart from many different angles. Some of the angles are used to better to see certain parts of the heart. Since it’s standard, and been used for generations, it’s the best picture of heart function that you can get without poking around inside someone – everyone understands the wiggles, and everyone is on the same page when evaluating the them, (This has changed over the years – Echocardiograms are now used routinely at patient bedsides, as well as many other non-interventional techniques.)
But 12 lead EKG’s require stillness. Leads are placed on the arms and legs, and a suction cup thingie is moved across the chest, progressively, as the test proceeds – and movement messes it all up.
Because of this, a three lead EKG was used in the unit to monitor patients. The leads were all placed on the chest, and the nurse could vary the leads to get better looks at different parts if they needed to. It was not as good as a 12 lead, but was good enough to see any big changes.
As I watched the monitor out of the unused corner of an eye, I noticed depressed “t waves” on Posey’s EKG. Depressed “t waves” indicated a dead area of heart muscle. I also noted the appearance of some thing new – a “Q” wave, also an indication of heart death, and something that predictably appeared on an EKG 24 hours after a big heart attack.
I was looking for things that would indicate to me that the thing I knew was going to happen, wasn’t going to happen.
I wasn’t having much luck.