This is a true story about a housecall I made when I was a young internist, just turned thirty, fresh from internal medicine residency and specialty board certification, and brand new with a group of three older internists. They gave me the call because it sounded urgent and I had no patients scheduled that afternoon.
The address I was given was in the old part of town, a small white clapboard cottage with a small veranda and a foundation made of protruding big round granite rocks, with a single old palm tree between the curb and the cracking sidewalk, similar to the others on the block, standard Southern California architecture of the 1920s.
I rang the doorbell. About a minute later an older lady with gray hair (not bluish gray) opened the door. Before I could ask anything about her situation -- it was clear she lived alone, -- she was telling me, with no more emotion than in commenting on avocadoes at Ralphs new supermarket, about the terrible chest pain she’d had – nothing like it before, ever.
“What kind of pain was it? Can you say?” I asked. “Was it in your rib cage or deeper? Did it hurt when you breathed? Was it stinging or aching, boring? Or what?” Most patients can’t say. She could, clearly.
“No, it was … ripping. I’d say it was tearing.”
“Oh? Hmmm… Anywhere else besides chest?”
“Yes, odd place, in my back. It kind of moved around.”
“Any nausea or vomiting with it?”
“Nope. None of that. Just pain. And it moved.”
“When was this? How long ago?”
“Yesterday. I didn’t call until I felt better. I never call doctors for anything.”
“But you seem pretty spry now.”
“I am, now. So I called an hour ago. I never call doctors.”
“OK, I need to check a few things.” First thing I did was slip my stethoscope under her floral robe – in those days doctors actually put stethoscopes directly onto skin, not on the sweater or jacket as all health professionals, nurses, doctors, all of them, do now. I’ve never ask why, privacy laws? Auscultation is just token anyway, because the CAT scan tells more than any stethoscope?
And there it was, an aortic insufficiency murmur so loud I could have heard it through a corset. And sure enough, the blood pressure in one arm was too high and very low in the other.
The diagnosis was certain. Dissecting aneurysm of the aorta, with intramural excavation of the aortic valve ring, causing the insufficiency murmur. It’s a very rare condition, mercifully. Few cardiologists see such a case throughout their careers.
It had so happened that as a medical student I had been invited by two of my professors to join in writing a review of the world’s literature and reported cases – over 500 cases – of dissecting aneurysm, for the journal of Medicine. I had spent a summer doing literature searches and abstracting cases on 3x5 cards.* And now I was seeing a textbook case.
Such a unique case is itself worth reporting. But that isn’t the end of the story.
“What’s the scoop, doc?” She asked, even-toned.
I pursed my lips, frowned, looked wise, looked down, took a deep breath, sighed. “Well, it’s not a heart attack anyway. But it’s still bad. I’m afraid you have a dissecting aneurysm.” I explained what it was and how it worked. It’s always fatal, essentially always.
“Am I going to die?” she asked in her do-Ralphs-have-avocados? voice.
“’fraid so…” I was more nervous than she.
“Oh. Well, that’s that.”
Of course I sprang up and commanded that she be hospitalized forthwith. I’d call an ambulance -- may I use your phone? But, getting up from her worn overstuffed chair, she cut me off and gestured at the living room. She had taken charge. “No point to it,” she said with quiet authority. “Might as well show you around as anything else.”
Submissively, a novel feeling for me, I did look around the old room, at the sofas with antimacassars, mismatched tables, narrow-necked vases. Hanging on the patterned-wall papered walls there were the usual, but surprisingly few, old lithographs and faded and blotchy photographs. She caught me glancing, I was trying hard not to stare, at a certain one, a triptych of a slender, dark-haired young nude in three arty poses.
“That’s Me, in Paris. I was an artists’ model,” said the old woman in the same voice as before. “But what I want you to see is the garden.”
No larger than a badminton court, it had no lawn, only gravel, freshly raked, and many succulents of various sorts and sizes with colorful pods, and scattered yuccas, some with candelabras of pale blossoms, and pansies here and there, but no roses. But the jaw-dropping feature was the multitude of elephantine cement and plaster-of-Paris statues scattered among the aloes and cacti. Many Madonnas and an equal number of Buddhas, also cherubs, gnomes, and huge frogs, stark white or crudely painted bright red, yellow, blue. My guess is she had painted them herself. Hardly your picture-book Victorian garden, nor the Forest Lawn Sculpture Park just over the hills in Glendale. The word “kitsch” hadn’t been invented yet.
Now, that’s the end of the story. That’s how my college creative-writing teacher would have it end. That's the way the New Yorker might publish it, if I had bothered to submit it, and been lucky. And it's how, at his next class reunion, and to the local Medicine Residents’ Club, a young hotshot internist (me) would tell (did tell) it, playing up the brilliant diagnosis, confirmed by the Coroner’s autopsy. But it’s far different from the way the old internist, reviewing again his collection of most remembered cases, would analyze and reanalyze it, mull it, and, from it, meditate his career and medicine and his own life, all life. It’s that kind of story.
Making that diagnosis, just snapping it off only from the clinical history and a roaring murmur, was pretty sharp, I’ll still say so. Fifty years later I almost cringe at such insouciance. But that’s how I was taught in my internal medicine residency at Harvard and Washington Universities, where the spirit of Vienna and the ghost of Osler still lived. Young internists and fighter pilots are like that, were, anyway. Just a decade later I would have said, would be required to say, “I’m pretty sure of the diagnosis but it’s the kind that shouldn’t be made without an x-ray at least, at the hospital.” That would ruin the story but play better in court and on the blogs.
Everything was different, back then. Besides the police (whom I figured should be notified), no agencies, bureaus, counselors, politicians, government, insurance companies or oversight or regulatory review boards at the local, state, or federal level, were involved; no admissions or care accessibility approval agencies, databases of quality or diversity and equality standards criteria, no SNOMED codes even existed, and nobody missed them. Nor were there collection agencies, business managers, accountants, more personnel filling out forms and ensuring compliance than tending patients; no depositions and predator malpractice lawyers and trial lawyers like John Edwards in court flaying doctors. No activists, advocates, media, blogs, tweets, seminars, outrage. Life-and-death transactions and decisions were between only doctor and patient and made on the spot, informally and often casually. I just walked into an old lady’s house and told her she was going to die, and walked out. Come to think of it, mention of a bill never came up. I don't remember submitting a charge.
One thing is sure – if it were the present I wouldn’t be there. 911 paramedics would be swarming the place, rushing her to the ICU and surgery, oblivious to the garden and the statues. And I wouldn’t have that story to tell, or, as an old man, older than the lady in the story, the memory to cherish. And the part I am cherishing ever more strongly is not the brilliant diagnosis I made -- that part has faded, as has the world in which it was flicked off -- but that old lady, the kind of person long extinct, and us strolling in the garden.
But another thing is even more sure. By simply informing the old lady of what I, so very smart, could foretell, she was soon to die, with her rewarding me with The Stroll, I did not, after all, do for her what I could have. As a graduate of the College of Medical Evangelists I should have have informed her not only of her imminent death but also of God who offers deliverance from death. I know that now, at age 88
* I also submitted my version of the introduction to the professors. They rejected it. Not academic-sounding enough. Reference: A. Hirst, V. Johns, S.W. Kime, Medicine, September 1958, Volume 37.