Carpooling with God

On Thursday night, I walked out of the VA into the dark and uncharacteristically cold night with visions of more than sugar plums dancing in my head. The end of my four weeks as the ID consult resident and intern at the VA was ending; I felt sadness realizing I would not be back there the next day. I wouldn’t walk around the halls and recognize half the patients’ names on the small plates by the door. Some of whom I’d admitted last November on my first intern month there. One in particular, a cantankerous one-legged bearded man, just kept living despite all physiologic and pharmacokinetic odds. The patient who had broken his hip and celebrated his 49th wedding anniversary with us was in rehab there. My patient who had danced with death from a GI bleed the week before had made it back out of the ICU. As I rounded with the ID team on his roommate, I gave his wife a hug. She and I had shared tears and talk about her decisions to decide not to try resuscitate him if his heart stopped again (he’d already coded twice, had a heart attack and pneumonia, after he broke his hip when he fell at an eye appointment a month and a half earlier). He kept going against all odds, too. She told me she didn’t know how to live without him. He used to play the piano and dance with her in their living room. When she looked at him, I know she saw the man who’d held her close, instead of the confused shadow who waved at people the rest of us couldn’t see.

I felt particularly sad to be ending my time with my attending. Dr. Vayairman is a long pause in the search for a word to describe him. A white haired intimidatingly kind man with a confident giggle, he has cared for patients and taught students and medical residents for the past 35 years. As he taught me over the past three weeks, I found myself scribbling notes on scraps of paper in attempts to hold onto his wisdom. The notes I have from him in my head, however, outweigh the words on paper, however. If I were dying soon, I would want him to be the one to tell me.

When I started as the ID consult resident four weeks before, I recognized him vaguely from my VA time last year. He always has something to ask or add at noon conferences. He maintains his curiosity and enthusiasm about medicine and the advances the field has made in his time as a physician. He combines his vast experience with a freshness that keeps him intrigued and awe-inspiringly real.

Of course, that first week, when I presented patients to him in ID clinic, I felt completely inadequate. Despite trying to gather the latest culture results and antibiotic history and hospital course, I didn’t have the answers to all the questions he asked—a combination of the patient’s macro health situation as well as the details of the last drug resistant microbe that infected the diabetic foot that the patient hadn’t felt in years. I knew that because he asked them, they must be important. I started to take notes in my head of what to look for next time. I needed to not get so caught up in the details that I lost track of the patient situation. Yet, I needed to know the details in order to affect the big outcome. This was an art he had perfected, and I was just beginning to learn.

A weeks or so later, when I was fortunate enough to have him as my ward attending, I watched him tell one of our patients he had perhaps a month, but not six, to live once we’d seen the metastatic lung cancer had spread to his brain. The way he told him made it seem to fit into the progression of life—made death a part of the journey—and somehow perhaps not the end.

The medical students were terrified of him. They literally sweated under his persistent questions when they would give “five-minute presentations.” He set high expectations on the first day of the rotation when he told us he expected full physical exams, which he modeled himself throughout the month with grace and skill, once picking up a stroke patient that even the neurologist had missed, always smelling the wounds to help decide if we need anaerobe antibiotic coverage also. He wanted concise, organized, relevant patient presentations. He wanted information and attempts at decisions. He wanted us to try to be like him. And this seemed an unachievable goal, especially to the two medical students who struggled under the weight of just beginning the grueling schedule and studying for exams.

On rounds with him, he displayed how to take the patient history into account when asking questions, to not discount details of travel or social situation, to look at the whole body, to listen for heart murmurs carefully, to watch the toes attentively when we tested for Babinski reflexes, to find skin changes named after orange peels, to pay attending to the relevant but not forget everything else. He showed us how to be gracefully perfect, and it seemed impossible.

Whereas other teams took the radiologist’s or the micro lab techs’ reports in the computers at face value, our team went to x-ray rounds everyday to see the films and discuss them with the radiology team in their dark rooms. We spent time at the teaching microscope in the microbiology lab looking at the gram positive cocci or the gram negative rods staining more darkly at both ends that might be Klebsiella. Of course, Dr. Vayairman is the head of infectious diseases there, and the chief of the micro lab, so it is part of his business to know all of the inner workings of the micro lab and the microbes that grow smeared across the agar plates or make clear circles around the drug saturated discs to reveal their resistant adaptations. He brought science back to clinical medicine for me. He took away the disconnect I felt when I got lost in frustrations about the impossibilities of trying to fix everything. He showed me how he tried his best to fix what he could, kindly and thoroughly and realistically.

With my patient who had died that month, he told us from the first day we saw him as a team that he wouldn’t make it long. His liver was too sick. As all of the consult services gave us different recommendations about what to try next, he let them try, but I could tell he knew most of our efforts were likely futile. He stopped us from pouring blood products into him in what he knew was a loosing battle. As I talked to my patient’s brother more and more frequently, trying to convey the severity of the situation, I wish that I had Dr. Vayairman’s confidence to say that I knew he wouldn’t make it. If had could have said that, I think his brother would have let us make his last days more comfortable, instead of a prolongation of the struggle. I could have given him morphine sooner than I did. Even given that, I fret over the decision I made with the consult service to do a trial of clamping his chest tube despite the infection there.

It is one of those decisions I think of now and cringe with guilt, wondering if it was wrong, if it made any difference in the overall picture. And when Dr. Vayairman said quietly to me that it shouldn’t have been done the next morning as we rode down to x-ray rounds in the elevator, the guilt and doubt rose up again. He would later put that in my evaluation, also. I needed to learn from it. I have. I just wish I could shake the feelings of mistakes and not expect myself to be perfect. In the end, I know it didn’t change the clinical course. My patient’s brother granted permission for an autopsy when I called him again the day after his brother had died. The pathologist called cause of death end stage liver disease, as we all expected. And yet, I worry. I get so tired of trying to be perfect. Perfectly right and perfectly caring and perfectly alone.

Dr. Share, my own wonderful primary care doctor, tells me I need to not expect so much of myself when saw her as I was falling apart with another lupus flare. Dr. Vayairman takes me aside a couple times during our time together to look into my eyes and ask how I’m doing. He means with my own illness—the lupus that makes call nights so hard and makes me tired and makes the blood clots in my head. He has told me at the beginning of the month that perhaps I shouldn’t do this demanding combined residency. Perhaps something with better hours would be better for me, he says: pathology or radiology. I tell him I would miss the patients. By the end of our ward time, he has submitted the online evaluation I see five days after he wrote it. At the end he has written, “I predict she will be an outstanding physician. She was coping with her own problems but never let that interfere with her care for her responsibilities to ward her patients.”

Coming from him, a man I respect so very much, this is huge. Even before I saw what he’d written I had run I into one of the chief residents in the hall. She calls him a genius, too, as does my own program director. We all talk of him with awe and respect and envy. In x-ray rounds one day, an x-ray of a man from the chief resident’s team was displayed and he comments in his infinite wisdom that only two things make that pattern on the chest x-ray: an upper lobe very round density. One of them is cryptococcus, a fairly rare entitiy. They send the serologies based on his passing comment and discharge the patient to home, only to find out that Dr. Vayairman has been right and they have to track the patient down to make sure the infection has not invaded his spinal fluid. “Your attending knows everything,” the chief resident says. She is doing her own first month of ward attending, and struggling with the responsibility and the transition of authority and involvement. She wants to be like him, too. When she has time, she tells me, she likes to round with the teams and she always chooses Dr. Vayairman’s team when he is on wards.

I tell her how much I have enjoyed working with him and how much I have learned from him. Before he fills out my on-line evaluation, he has given me feedback in person, as attendings are supposed to at the end of working with the house staff. “You are a good house officer,” he has told me. “Your physical exams are thorough and you are compulsive. My suggestion is: don’t be afraid to ask questions. You are here to learn. You are not supposed to know everything yet; that will come with time. We are here to teach you. You will be a good doctor.”

When I tell her he has said this, she’s shocked. “That’s huge,” she says a few times, “He usually thinks the house staff are all idiots. That’s huge coming from him.” I feel shyly and profoundly proud. I wonder if he still thinks I should be a pathologist.

I think that he sees me struggle with myself and he doesn’t want me to struggle the way that I sometimes now have to in order to make it through this training and these changes in my life. I think part of him wants to shield me and take care of me. And part of him wants to let me grow, even though he knows, in his clinical and personal experiences, that life has become much more of a challenge for me. His response to me reminds me of what my dad has told me when I hurt so much from having my heart broken: he wants to protect me from ever hurting, all the while knowing he cannot.

After Dr. Vayairman and I have finished our time together on wards, I switch back to a week of infectious disease consult service and am pleased beyond all reasonable glee to find that he will be attending there for the week I’m there also. I feel bashful around him. Like now that he has seen me, all I can do now is disappoint him. Again, I expect too much of myself. When he asks questions to which I don’t know the answer, I feel like I have failed and when I do know the answer I feel victory. Everything is blown out of all reasonable proportions. I calm myself down by just focusing on the patients—always my safety and my home. Even if I don’t know all of the workings of their disease, at least I can know what is important to them—at least I can assess their priorities and their fears and tell him about those things, because when you try to affect people’s lives, that’s how you do it, not by curing their illness, but by helping them integrate their struggles and health into the life they want.

I see a 40 year old man on a positive blood culture result auto consult, but it becomes much more interesting than that as I investigate his history and meet him. He is a full time student, studying sociology. He has been sick for almost a month with pneumonia and now with presumed pericarditis. He began to feel fatigued when he played soccer with his wife of one year soon after the fires burned through the hills north of town. I notice in his labs that he has a fairly profound eosinophilia. These are the white blood cells that usually respond to parasitic infection, I remember from med school microbiology classes. Before I have time to investigate further, it is time to present to Dr. Vayairman. I get out the ginger-chocolate biscotti and pumpkin cookies I have made and brought to share.

I tell him what I know of the man and point out the elevated eosinophils. He clarifies the clinical course with his piercing interest; he makes me be more precise with the dates and times of events and the trend of his elevated white cells. “What could cause that?” he starts to quiz me. “Parasites,” I start to feel inadequate again, “Strongoloydies.” I mention the only one I can remember, though knowing most of them affect the gut. They do have lung phases when they crawl around inside the body to reproduce. “What else?” I blank again. “Ameba?” he says. I don’t know. “No,” he answers himself. “Giardia? No.” My Midwest med school training comes back and I remember the lung infection endemic to the Ohio valley, “Histo?” I say tentatively. “Close.” Then I have it, “Coccy.” Relief comes along with the knowledge I will never now forget.

And then we start to work together to integrate it into the man’s clinical situation. I know he has not traveled much lately, but I have not asked if he has construction near his home. He is African American. Dr. Vayairman, who studies coccy epidemiology and behavior in his mice lab, tells us that the disease is more complicated in blacks and Filipinos, though no one is sure of the exact genetic basis of why. He pauses at one point while teaching us about the disease to take a bite of the biscotti, “Nice cookie,” he looks at me briefly, “Thank you” and then resumes his teaching, barely missing a beat. I take notes about the disease on my scraps of paper and scribble the compliment about the biscotti down in my head, again with disproportionate pride. When we look at our patient’s x-rays and chest CT, we see the pneumonia in the lingula (the lung lobe right next to the heart). “That is probably how he got the pericarditis,” says Dr. Vayairman. “Only two thin layers of tissue separate the lung and the pericardium there.”

From getting to know my patient earlier, I predict he may have gone down to the computer terminals to get in touch with his professors about the classes he is worried about missing. He’s not in his room when we first visit, and I go to find him at the computers and ask him to meet us up in his room. When we get there after reviewing his radiographs, the phlebotomist has a needle in the back of his hand to draw blood cultures. I cringe, knowing from my own experience of 24 blood draws in my ten days as a patient on a heparin drip that that is a painful spot to draw blood. Dr. Vayairman knows this too, of course, and comments to the phlebotomist about it with some quiet disapproval as we watch the young man grimace in pain.

When my antecubital veins were raw and inflamed from the sticks I got every six hours, the phlebotomist started to pick up my hand to look for vessels there. I pulled back and told her to keep looking at the inside of my elbow. Most patients think they have to accept what is done to them. It is always a choice.

Dr. Vayairman asks the patient more about his exposure to construction sites and finds that he has not been around many recently. He explains that we think he has “valley fever.” This will change his treatment from the normal pneumonia antibiotics that the team has chosen to fluconazole, an antifungal medication, that the patient may be on for an extended period of time, given the severity of his disease. We would recommend checking his serologies to confirm that this is what he has, but the clinical picture fits well enough, that Dr. Vayairman would start him on treatment before we knew for sure. I knew he had probably saved the man perhaps months of lingering illness and ongoing investigation into the real cause of his disease. How fortunate for him to have had a positive blood culture (which is likely an insignificant contaminant) and therefore had his hospital course intersect with Dr. Vayairman.

We rounded on one more of my patients—the cantankerous one I’d admitted a year before—who now had a severe cellulitis on his one remaining leg. Dr. Vayairman had been afraid the night before that it was progressing to necrotizing faciitis, a very severe infection that could take his life quickly. The night float intern had to get surgery to see him right away and get a stat CT of the leg to look for gas in the tissue. As we saw him the second day, the leg was still red, but better. The patient felt well enough to again mention the poor quality and quantity of the hospital food. Dr. Vayairman smiled at his return to his regular self and put his hand softly on my arm as I stood to his right, interrupting the complaints to say with a smile, “Well, she makes really good pumpkin cookies,” as we moved out beside the bed. “I’ll bring you one if there are any left,” I told the patient.

We had to hurry to infectious disease conference next. It is held at the university hospital campus a few miles and potentially a lot of traffic away. Brett, the infectious diseases fellow was stressed because he kept getting late requests for more consults that would likely keep him there late the next few nights. I knew I’d have to come back after conference to finish up my work for that day, which would likely make me late to the big medicine holiday party that night.

Dr. Vayairman asked if I needed a ride over to the other campus. I got immediately nervous again. My respect for him mingled with awe and intimidation and the persistent low-level fear that anything I would do now might disappoint him. “Are you coming back here afterwards?” Even as I asked hit, I knew it was a stupid question because why would he offer me a ride if he weren’t. He knew my car was at the VA. But I didn’t get the look that he usually gave when someone asks him a dumb question. I accepted his offer, feelings strangely like it was some sort of first date with someone I’d had a crush on for a year and never expected to take any notice of me.

I fiddled around anxiously, waiting for him to get his keys and wondering if the fellow would ride with us or if the offer was just good for me. Apparently just me. He changed from his white coat into his leather jacket in a medically comforting act that reminded me vaguely of Mr. Rogers. We walked together to the special staff parking lot and he picked up one of the local publications and offering me one as well, saying his wife was often in it because of her involvement in the local political scene. He explained to me about one of the journalists who kept up with all of the on-goings in the city scandals. We got to his car—an unexpected little two-seater Miata. He told me that his wife had bought the car when she’d given up on their three children ever getting married and having grandkids. Now they had three grandkids and his wife drove the sedan and he got to drive the Miata, which he said he loves to accelerate until something makes him stop. A side of him I hadn’t seen, but somehow wasn’t completely surprised to discover. We talked about his kids and how he suspected his daughter was, but would never admit, she was jealous of his son’s wives. And how his oldest son didn’t forgive his younger son for being born until he was a senior in high school. The three of them got along now. He got to see them often and for the holidays.

I remembered his granddaughter’s name and what she’d been doing from the first time I’d been in his office four weeks before when he’d called his wife to try to discover the name of a good restaurant he thought I should try for Thanksgiving. He had a new message from his granddaughter that he listened to then played out loud for me with a contented smile. Emily rambled sweetly on about wondering when he would be home and telling him about the gingerbread house she’d made with his wife that afternoon. I asked about her and the gingerbread house as we drove to the conference and his smile reappeared.

He remembered about Bryce playing baseball in New York; and I wasn’t even sure when I’d talked with him about that. Somehow the topic of my parents divorce came up. He asked how long they’d been married and we talked a bit about that as well. I felt safer away from medical topics, since with them I had every chance of saying something stupid and I would rather avoid the look he gave about those comments.

The conference was fascinating, too. A very sick patient with what appeared to be a disease that was based on the body making antibodies to a tumor which then attacked the brain. A difficult clinical diagnosis to make, but one that, once made, could potentially have a good outcome for the patient.

I waited for him and again offered to ride back with the fellow if he didn’t need to head all the way back to the VA. “No, I’m going back,” he reassured me, then asked with infinitesimal insecurity perhaps, “Unless you want to ride with Brett?” Did I make him nervous, too, in some strange complicated yet perhaps infinitely simple way? No, I would rather ride with him. Besides I’d left my stethoscope in his car.
We talked more on the way back, some about the science and medicine. He remained fascinated by the human body in all its complexities. I did too, commenting that I was awed that it worked as often as it did, knowing all the things that could go wrong. We talked about Bryce’s friends whose phenomenal beach house I’d visited the night before. I found out that he knew the man who had designed it. And his son had warmed the bench with Bryce’s friend’s father on their high school basketball team. I asked if he planned on going to the party tonight, “No, I used to go until I realized that all the house staff just waited until the attendings left to let loose.” I nodded remembering the drunken debauchery the year before as the group of socially stunted and overworked young doctors tried to relax and interact in some semblance of social comfort. I told him about the renal attending who had stayed late and danced a wild jig with one of the third year residents. He grinned and giggled in surprise and amusement.

When we got back to the hospital, I went into the resident room to finish my work and he returned to his corner office. I felt giddy—like I’d just carpooled with God. I wanted to tell him how much I’d enjoyed working with him over the past month, how much I respected him and how much I had learned from him and how much I appreciated his concern and understanding and what a wonderful clinician and person I thought he was and how I would always remember him and draw strength from his example. I didn’t know how to even start, though. I want to believe that he knows. He stayed for only a couple minutes to grab a few of his things before walking by our door and saying goodnight.

I finished my work and walked out into the cold dark night, hurrying to get home and get cleaned up and changed into my blue satin formal to meet my mom and brother who were my dates for the party that night. It would be the first time I’d seen them since my dad had dropped my brother off two nights before and my mom introduced her boyfriend to Bryce and handed my dad the divorce lawyer’s bill all at once. My dad was sobbing when I talked to him about it. And I was furious with my mom and realized how much I’d missed my little brother in the six months it had been since I’d seen him. That night, I finally had finally cracked about the divorce. I drank too much and felt guilty about hurting Bernie’s feelings and being mad at my mom and bringing it all up and crying with my brother as we sat on my bed and mom watched us hurt and started crying herself.

But I thought, in those dark moments as I walked away from the VA, mostly about the patients I would miss seeing the next day. I thought about missing working with Dr. Vayairman. I felt grateful for the time I’d been able to learn from him—and not only about medicine. I thought about life changing and how we all had challenges and stories and struggles. I wanted time to explore more than the edges of the thoughts that glanced off my consciousness. But I also wanted time to live and learn and do.

I tried to suppress the sadness that comes with a transition away from the time I’d spent at the VA and focus on looking forward to seeing everyone that night and the new rotation I would start in the emergency department the next day. I could take it with me, after all, all that I’d learned and thought and done. All of that was now mine, and portable. If I could minimize the guilt and learn from the mistakes and ask questions and not expect myself to know everything or be able to fix everything; if I could forgive myself a little more, maybe I could get centered again, for a while, on this ever-shifting balance beam of life.