Tools of the Trade

incidental-findings-coverby Danielle Ofri
New England Journal of Medicine

(This essay, which later appeared in Incidental Findings, was the debut article for NEJM’s Perspectives section.)

My hand grasped the list of patients, fingering the crispness of the sheet that represented my first day of service on the medical wards. I knew the sheet would soon be crumpled and covered with scrawl, as I scurried about, meeting thirty-six patients, two residents, four interns and six medical students. But for now the paper felt cool, controlled, and reliable in my grip.

I was ashamed to admit it, but I was perversely thankful for the numerous comatose patients on my service because they made rounds faster and left more time to concentrate on the active GI bleeders, the patients in DKA, the ones with gram-negative septicemia, and the ones who spoke English.

Ms. Millstein was one such comatose patient, an elderly woman with Alzheimer’s disease who’d been sent from her nursing home in Brooklyn after falling and hitting her head. Overflowing hospital census and pure bad luck conspired to land Ms. Millstein on 7-East, galaxies away, for all practical purposes, from the medical wards on 16th and 17th floors. The combination of her flat-line mental status and her location in the hinterlands of the hospital ensured that my visits would be brief and infrequent.

The previous attending told me that he had spoken with the patient’s sister in Florida, the social worker from the nursing home, as well as the patient’s rabbi. All assured him that Ms. Millstein would not want any aggressive measures. A DNR had been signed and the plan was to place a permanent feeding tube then return the patient to her nursing home.

I poked my head in Ms. Millstein’s room on that first day of service. I saw a white-haired elderly lady, either sleeping or unconscious, but clearly comfortable. She was breathing well and her vitals were stable. The pen was already in my hand and I jotted the briefest of notes in the chart. I nodded to myself, checked off the box on my now slightly rumpled list of patients, and continued with my rounds.

I had no plans to call the sister—or do any additional work for this patient—since the previous attending had settled the main issues. But then the question arose as to whether Mrs. Millstein would consider the planned permanent feeding tube to be too invasive, and this would require family consultation. So I dialed the number and a heavily Eastern European accented voice met my ears. “Yes, I am Goldie. I am her sister.”

My fingers leafed through a medical journal as I explained to Goldie that I was taking care of her sister, that I was the new doctor taking on the service. She told me that Dora would never want any painful or invasive procedures. We agreed that a permanent feeding tube would not be necessary, that the temporary tube was okay, given Mrs. Millstein’s comatose state and likely abbreviated life expectancy. And that the patient would not get any IVs or blood draws. “Dora was a very cheerful person,” Goldie told me. “Everybody loved her.”

I paused, closing the journal. Cheerful, I mused, turning my hands over. It was always hard to imagine a comatose patient ever being cheerful.

The transfer process moved along. Papers were signed and stamped. Transportation services were arranged. Necessary authorizations were obtained. On the day of transfer, as I readied myself to cross one more patient off my now well-worn list, the social worker noted the last set of vital signs. There was a fever.

The great machinations of interhospital transfer ground to a halt: nobody, it seemed, could be transferred anywhere, anytime, at any stage of illness, with a core body temperature other than 98.7. Despite my protestations that the patient was already receiving oral antibiotics, that she would not get blood cultures or IV antibiotics, that she was DNR, that the medical team would not do anything about this fever, that in fact it was actually expected that this patient would have a fever, the social work rule was iron. I would not be able to cross Ms. Millstein off my list.

It was already quite late in the day, but I decided to call to Goldie. I assumed we could have a quick conversation and that she would be in agreement with my judgment that her sister could indeed return to her nursing home, despite the peregrinations of her body temperature. I glanced at my watch as my fingers dialed her number. Goldie sounded delighted to hear from me. While I packed my stethoscope and crumpled patient list in my bag to leave for the evening, Goldie asked me if Dora looked comfortable. I said yes.

“Dora had such a hard life,” Goldie said. “I am much younger and she was like a mother to me.” In the casual voice of someone recounting her afternoon shopping, she added, “We went through the camps together, you know. She took care of me after we lost our parents. She is the reason I survived.”

My hands abruptly ceased their activity and drew together with interlocked fingers, stiffly making their way down into my lap. Goldie and I proceeded to talk for the better part of an hour. Goldie told me about Dora’s escape in Europe, their harrowing adventures in the forest, their long journey to America.

After the phone call, I went back to Mrs. Millstein’s room. I put down my bag, pulled up the empty visitors’ chair, and sat next to Mrs. Millstein. Next to Dora. The sun had already set over the East River and the darkness from the windows was a rigid wall of black behind me. I looked at Dora under the fluorescent bed light for what felt like the first time all month. Her white hair was neatly brushed and someone had tied it with a fanciful green bow. Her parchment skin folded in fine wrinkles over her tranquil, sleeping face. There was not a trace of agony or stress. Dora’s left arm lay open on the bed, atop the neatly tucked white sheet.

There were the numbers.

I hadn’t seen them before, but only because I hadn’t looked closely. Blue-green numbers, faded with time, but still legible. I’d never seen tattooed numbers up close, and wasn’t prepared for the reflexive chill that they would induce in me. Haltingly, I placed my index finger on the numbers. I’d never before touched tattooed numbers and I feared—I don’t know what I feared; the numbers were simply frightening to touch.

I rubbed my fingers over her skin tentatively, and the silkiness of this soft side of her arm—the part free from a lifetime of sun damage—calmed me. The numbers, of course, didn’t smudge or disappear with my rubbing, despite my irrational thought that they might. I exhaled the breath that had been caught inside me and leaned in closer. Her fragrance—a combination of baby powder, Betadine, and the vague sourness of the sick—enveloped me and froze me in that moment.

I was touching Dora’s skin, the same skin that had been wrenched by a Nazi soldier, stabbed by a metal plate of tattoo needles, and then abraded with blue ink rubbed into the wounds. My fingers could almost feel the shivers and gooseflesh that must have rippled through the supple skin of a teenaged girl, one hand stiffened in a soldier’s clench, the other gripping the hand of her little sister.

More than a half-century later, I was standing in the same position and handling the very same flesh, as that Nazi. I shuddered to think of the connection that lay beneath my fingers, and that I could have a link with that German soldier, whose name would never be known, but whose features and touch, I imagined, were seared into the gray matter that lay in Dora’s quiescent mind. I was grateful that there had at least been the decades of loving touch on that skin from a devoted sister and husband, between then and now. Sixty years of caress to mitigate, somewhat, the vicious touch that had assaulted the tender underbelly of her arm and branded it with those numbers.

And now I was part of that chain of touch.

The next morning, as I girded myself for battle with the bureaucracy to get my patient transferred back to her nursing home despite the fluctuations of mercury, the intern came up to me and told me that Ms. Millstein had died at 8:20 pm last night.

8:20 pm: thirty minutes after I’d left her bedside. I stared at my fingers, rubbing the pads, suddenly entranced by the whorls and creases. Of all the thousands of fingers that had touched Dora in her eighty years of life, from the first that brought her into this world as a fragile infant, through the many that had touched her with either violence or affection, could mine have been the last?

These callused bits of skin that I scrub daily and unthinkingly with desiccating antimicrobial soap, that I sheath and unsheathe with airless latex gloves, that casually grasp my ever-crumpling list of patients, may have been the last in this particular chain.

Many industries have been automated, and medicine is no exception. I can’t deny the increased efficiency provided by computerized lab results, telemetry monitoring, and wireless email. And despite my intense dread of QA meetings, I fully appreciate the reasons we must institute quality control measures and uniform standards.

But no matter how much our field is pushed to streamline and to maximize efficiency, there is an asymptotic limit. In the end, medicine will always be about one patient and one physician who will be together in one room and who will connect via the most basic of communication systems: touch. In an age of breathless innovation, this is almost antediluvian. But medicine simply cannot be automated beyond that.

Every so often, when the chaos of clinic and ward life become overwhelming, I dump my computerized list of patients, the review article I’ve been reading, my phone, my prescription pad, and whatever other junk I’m carrying, onto the nearest table. I place my hands flat on the surface, absorb its comforting smoothness, then spread my fingers and contemplate their outlines. These—more than our stethoscopes, more than our textbooks, more than our clinical practice guideline—are our most fundamental diagnostic and therapeutic tools. I’m grateful for the inefficiencies of medicine, and their steadfast ineradicability.

And then I gather up my other tools, sigh, and move on.

Watch Danielle read “Tools of the Trade” from Incidental Findings.