A perfect day

Mike Ellman, MD

The University of Chicago, Illinois, United States

Hematology rounds start with chalkboard presentations. After posting the admission date, the laboratory results, the hospital course, and our recommendations, we hunch over microscopes to view the blood smears and bone marrow aspirations before marching en masse to the patients’ rooms. As the senior resident in charge, I direct this conglomeration of medical residents and students, a crowd infused with youthful enthusiasm that has difficulty being quiet. “Inside voice, please,” I say, a disciplinarian, seriousness drawn on my face, sometimes singling out a miscreant, making an example of him, finger to my lips, loudly shushing.

There are also other things that I insist on. But they are meant to embellish our horizons. Such an insular bunch we are, as if our memory bank is missing a primary color. Just outside the east window, Lake Michigan rolls in big as an ocean. “Which one of the Great Lakes lies completely within the United States?” I ask. No one knows. Medical students shun the slippery stuff like sociology and philosophy, but apparently geography isn’t part of their catechism. Neither is great literature. Thursday afternoons after Journal Club, we read fiction. My choice. Salinger’s Nine Stories has nothing to do with muscle insertions, or innervations, or cell lines, but I shouldn’t remain the sole aficionado.

Herb Rhoban, the chief of hematology, leads our procession, smiling in the face of too-often gloomy news. He is tall and fit, almost too good looking for a doctor, aided by his shock of unkempt graying hair and ready smile. He dresses casually but expensively, with creased wool slacks (not the wide-wale, tan corduroy or khaki pants that were de rigueur for the rest of academia), and leather dress shoes with matching laces of the correct length and color.

Herb is the go-to hematologist for much of the city, an expert on platelets—the tiny particles in our circulation that assist with clotting. If you have a blood abnormality or enlarged lymph nodes, you see him, or it is off to the Mayo Brothers.

Herb’s clinical skills allow him the freedom to be up front about his opinions and decisions, never second guessing himself. It makes life easier for us probationers when your boss is not wishy-washy. He is aggressive about treating cancer, more so than many of us think necessary.

“I only know how to try everything possible to keep your mother alive. I don’t recommend halfway measures,” he would tell families. If he sensed hesitation, he would offer names of physicians using gentler management.

Herb and I play tennis. It is always wise to play aerobic sports with a doctor-in-training. Better even than life insurance. One never knows when cardiac resuscitation might be in order when middle aged, trying too hard, breathing short, and at match point.

Herb circles around the tennis ball like a wounded pelican—he has a feeble backhand and no second serve to speak of. When he loses, he becomes morose. A winner in everything in life, tennis is not to be an exception. Hitting the top of the net or just over the baseline takes considerable skill on my part. I drop the racket in disgust, choreographed with a stare up to the heavens and a sharp talk with the divinity. Herb gets ecstatic—another victory against an opponent nearly half his age. The quid pro quo for my genius provides entrée into his circle.

Contrast the happy us with the surfeit of ill-chosen prints and posters hanging on the sterile white walls of the depressing institution where we conduct rounds. We gather by Mrs. Stone’s bed, adjusting the curtains around her, as if that would muffle our pronouncements and offer privacy. The hospital room is small, and the other occupant politely feigns sleep. The hanging poster board centered between them on the wall states Today is: Friday and Your Nurse is: Gloria. It also should add that Nurse Gloria is never around.

The ominously dark room, the grime-encrusted windows, and the tattered blinds deny the late afternoon sun entry into this part of the universe—the room very much missing its glow. The thin and faded over-starched sheets have a mixture of urine and iodine melancholy. Contributing to the surrealism, the housekeeper hangs around, her cupped hand funneling our wisdom to her ear so that she can disseminate the news.

“Everybody, this is Mrs. Stone,” I start. “Mrs. Stone, you’ve met most of our team, and I know you’ve already met Dr. Rhoban.”

Herb shakes hands with Mrs. Stone and bows slightly, saying, “Pleased to meet you” for the fourth time that week.

I present Mrs. Stone’s story of fever, weight loss, anemia, bone pain, and fatigue and remind the team about her bone marrow slides, which we reviewed less than an hour ago. “You remember Mrs. Stone’s bone marrow with the monotony of all those ‘P’ cells?”

We talk in code about the presence of sheets of plasma cells filling her marrow cavity. Everyone knew the “P” cells established the diagnosis of multiple myeloma, a fatal blood disorder. Everyone, that is, except Mrs. Stone. I nod knowingly at everybody, then smile at Mrs. Stone—as if I had favorably commented about her handsome husband’s face shining from the photograph propped lengthwise on her bedside table, rather than announcing her death sentence.

Mrs. Stone lies deathly still, hoping her cooperation makes us more astute and kind, while she pictures her appointment in Samarra. Earlier, I told Herb about an abnormal physical finding, and he plunges his hands into Mrs. Stone’s left supraclavicular space feeling the same mass that I did.

“Does anyone know what a Virchow’s node is?” Herb asks the crowd, always the teacher.

We all knew what a Virchow’s node was. They are abnormal lymph nodes buried behind the left clavicle, usually indicating cancer metastasis arising from the gastrointestinal tract, especially the stomach. But being a well-rehearsed team, we shake our heads negatively to please him.

“I thought at least one of you would know what Virchow’s nodes are. I’m really surprised about what they don’t teach you in medical school nowadays. Pay attention to me, and I’ll provide you with a lot of information,” he smiles and stands even straighter, if that is possible. His day, not Mrs. Stone’s, is becoming a success. “I’ll tell you outside what it means.” It meant that Mrs. Stone likely had another malignancy besides the multiple myeloma.

Herb tells Mrs. Stone about her multiple myeloma diagnosis and that treatment needs to start right away. “We’ll prescribe oral cyclophosphamide and intravenous and oral fluids, and you’ll feel much better soon. And this excellent doctor,” pointing to me with a big comforting smile, “will stop by later and explain your illness.” Herb neglects to mention the side effects of treatment: hair loss, anorexia, infections—and the dismal prognosis of multiple myeloma.

“Telephone Mrs. Stone’s private doctor and bring him up to date about the diagnosis,” Herb says as we exit the room, and under his breath, “But what a prick he was to have missed the diagnosis for so long.”

“Arrange for a surgeon to biopsy the lymph node after we go to radiology and review her X-rays. Schedule an upper GI barium series, and inform Mrs. Stone and her private doc. Would you mind meeting with Mr. Stone later? Sit down with him; bring him up to date because he’s been telephoning all day.”

As usual, Herb is pleased with his treatment plan. If he became depressed with every cancer, he would not enjoy a personal life. But as far as I know, there is no cure for multiple myeloma whenever it is diagnosed. Sometimes, actually more often than not, I think: Wouldn’t it be better if the team just met in the cafeteria, gorged on the mystery food until immobility, and slept the afternoon away?

Next patient. And so it goes.

 


MIKE ELLMAN, MD is a retired professor of medicine at the University of Chicago, rheumatology clinic director, and previously chief of rheumatology at Michael Reese Hospital. He is now full-time writer.