The clinic operates around my desk. At any one time I can hear three or four conversations. There is no way to avoid it and I wouldn't be as effective if I could. A few calls into the day and a few calls on hold I hear the medical assistant trying to room Mr. G for a sigmo. I call on the intercom and advise her that we've booked him in the only space available that day but the visit was for a "long talk". Those are our code words for a visit to discuss serious disease or grief. We like to see or hear from family members when a patient dies. We can't treat them in a vacuum. Our approach is to include all the family members and support systems the patient has available.
Last week I got a call on monday morning early. Everything around me was very busy, noisy, almost out of control. A womans voice asked to speak to Dr. A. "He's busy at this moment, can I help you?" She asks to leave a message for the doc. "Sure I can do that I'll let him know whatever" I say in a bright and energetic voice, reflecting the energy around me. "Tell him my husband died last week and I just wanted to let him know". I hear no tears in her voice. She sounds steady, matter of fact. I remember her husband an almond grower telling me the same joke about why we don't prounonce the 'l' in almond. "Because ya gotta farm the *ell out of 'em to get 'em to grow." This was no surprise his death. "I'm sorry to hear that" I say. "Tell me what happened?" She recounts an ER visit and probable MI. She says he didn't suffer and seemed to have an easy time at the end. There is a long pause in the conversation, a sigh, a wimper. You can sense her thoughts returning to that moment. I've learned how to move these conversations now, as an expert, no platitudes. " And you Mrs M how are you holding up?" Fine, the response. "Family in the area?" I need to asses her support system. She relates a story of family and friends. So, through the noise and distraction and carrying-on that is surrounding me, I listen. I listen to the expression of the way she sees herself and listen for the sense of future she expresses. "The neighbors are real close friends". I encourage her to lean on her friends now when she really needs a shoulder. "This is the time to let them do for you, as you have done for them in the past." I keep improving my skill of encouraging people to tell the story that will untie the knots of grief inside them. Let them cry and wash away part of the past, help them see the future. Life goes on.
Mr. G is back in my face now. It doesn't take much to elicit his story. He likes to talk. We are in person now . Different from a phone conversation. I see his eyes and quivering lip as he speaks of the gratitude he has for the hospice crew. He expresses a preference for a quick death. He rambles. I listen. I feel I know him well and he probably feels likewise. At 80 he still works as a street artist at Fishermans Wharf, a former circus performer. Eileen was his third wife. His wife before her died of liver cancer. Before that a fall from a high wire. His hearing aid doesn't prevent him from speaking in a loud voice thru ill fitting teeth. I direct the conversation to his upcoming esophagus cancer surgery. He discusses this part of his future in real terms. His cancer was detected early so he knows the chance for a cure is good. I am moved by his optimism and spirit. I will let this sense of hope fill up my cracks and crevices. There is a part of you that is worn away by this work. My conversation with Mr G will inspire me to sustain and repair the parts I've lost. I'll end up giving to the next person that needs emotional support. There is a sense of honor or nobility to be a person to whom others divulge the contents of their heart.
Mr G is crowded away from my desk by a gurney with a patient from the wards for endoscopy, NG tube, IV, two student nurses in tow. I close with Mr. G, introduce myself to the students and "the show must go on". Now I'm a role model for the students. I introduce myself to the patient, put my hand on her arm as I answer her questions, take a history, prepare the forms. I give the patient a sense of confidence, speak slowly, look right into her eyes. "Any questions?" I glance at the students and nod to repeat this interogative. Now let me tell the procedure nurse we've got more business. "Students" she shrugged. OK, re-think. I take the students to view the video we usually show to outpaitents prior to esophagoscopy. The video won't work. OK, try reading these handouts. I'll be back. More phonecalls, with a few finger snaps I hook the doc. Placing a hand over the mouthpiece,"talk to the students in room 6, they'll be observing your endoscopy". He nods.
On the phone, arrange transport for the last patient, relatives lost, urgent care appointments, questions about enemas. Then an 83 y/o lady who can't figure out where and when she sees the doctor. I pry her patient ID number from her and use the computer to find and answer to her querry. "Don't ever get old" she cautions me. "Whatever you do don't get old" she laments. "Well Mrs T," I say, "the only alternative to getting old is duying young. Given a choice I'd choose to get old". It worked! She's giggling like a schoolgirl into the phone and thanking me for my help.
In the background I hear Dr G introducing himself to the students and I know they are in good hands. He's good onstage and conveys the sense of wonder inherent in these fiberoptic exams as if it is his first not his zillionth exam.
"Tony!, chest pain, line 70". My next call is a handoff from a medical assistant that got a call patched through the operator. A 75 y/o man with bad lungs and complex hypertention. I know this man by name, we've talked many times. I know all his medical conditions are complicated by his stoicism hardened by time in Auschwitz. I asses the nature of his chest pain, duration, frequency, severity, response to nitro-glycerine. He experiences an attack of pain, gasping he can't speak. I wait, calmly thinking what to do in the event I hear him drop to the floor. I know where I can get his patient ID. The computer will give me his address. When he speaks again I slowly instruct him to dial 911. "But can't I drive in?" "Mr N if you have an attack when you're driving you might have and accident and kill someone" He agrees. "Now when we hang up I want you to dial 911. Tell them you are having chest pain and you've spoken to your nurse and you need an ambulance now". "I'll call back in fifteen minutes to be sure you are on your way". When I look up the students faces are before me blank like a pair of painted "Kilroys" on a fence in a Life magazine photo. Having overheard my conversation, only their eyeballs follow me as I bounce down the hall to notify the doc of this admit then a few steps to ER to inform the triage nurse that a code 3 is inbound. I give a history and get that usual knowing response. I have the greatest respect for emergency nurses. It shows.
Upon returning I pass a medical assistant doing an intake hello to another patient from the wards. "Unless you can speak Farsi he won't understand you. He's from Persia". Her grin widens for both of us as she pat his hand and continues to the paperwork in pantomime.
I confirm with the floor that it is legal for students to transport patients on a gurney, remind Dr G to have a final word with them as he is finishing the chart. To the procedure nurse, "Mr. N is on his way to ER for r/o MI". They are neighbors. I call his wife back. He's gone already. I arrange for her to call be before noon, give her the phone number for ER. We will speak throughout the day. Mr N will be admitted to the icu for unstable angina. He recovers.
I sip cold coffee, it's 10:30 AM. I check my desk for any disorder in this mess, put my headset back on and plug back into the phone. This is a glimpse of 2 hours of telephone triage/clinic nursing. Making decisions, expressions of caring, adjustments to rapidly changing situations, quality care, expert nursing. I guess I do it well. Taking a deep breath and a stretch I think of the words Mr G had for me earlier when I expressed approval of his plan to visit "show-biz" friends in a nearby town. "Well I've known these people for a long long time. They keep me busy and after all a busy mind has no place for tears".
An afterword: I had dinner with the home health nurse that visited Mr G after his esophagus surgery. He charmed her despite his initial fear of the g-tube and liquid feeding. He recovered completely. Not quite a year later he came in to say goodbye, with his new girlfriend in tow. Equal in age and presence with lots of red curly hair they were moving to Nevada so he could work as an portrait artist in a casino. She made AL smile so his teeth barely stayed in his face. She leaned over my desk to shake my hand straining her low cut ruffled blouse. "Hi babe",she said "Al tells me you're alright". All I could do was smile and nod. There was nothing more to say.