Nowhere Else to Be

The following story is by Jennifer Heidmann, MD, FACP. She is the Medical Director of Redwood Coast PACE in Eureka, CA, as well as a physician for Hospice of Humboldt and a hospitalist at St Joseph Hospital.

“You played with Oscar Peterson?” I said, and he looked at me for the first time. His feet hung off the end of the too short ER gurney, out of place as was the rest of him here. I fit in, white-coated, pockets weighed down with smart phones, twenty-first century pagers, getting through my review of systems and filing away his monosyllabic answers so I could finger-chat them to the electronic medical record. He is old and congestive heart failure is his ticket inside this hall, which I intuited not by his words which he held close but by his B-natriuretic peptide and plump jugular vein. Like any good musician knows, the well placed silence makes the notes played pop out and grab the listener.

I like to know what people have spent their life doing, in case I can use it against their disease. It might inform me of risk, exposures, personality. The danger in this is defining health as having a role to play. Band member, surgeon, teacher, mother is no one without air to blow their horn, steady hands and sharp mind, a class to prepare, a child in the nest. Fluorescent emergency room shines a spotlight on current frailty. Even outside the ER, in any context: too slow, not productive, and thus disabled.

What is my job? I wield elixirs to right physiologic wrongs. I take clues gathered from words and my prodding touch and produce a finished product, titled by its ICD 10 code. Everyone wants my autograph. I exist because someone else is sick or dying or breaking down little by little.

My experience is expressed in the grey hairs which assert themselves enough that I am no longer asked if I am old enough to do this job. I should have so much to say. Yet what geriatrics and hospice and hospital medicine has taught me is to sit still and be quiet. It has occurred to me that the person I sit across from is my Zen Master. The musician with CHF spoke little by choice, not prone to waste air or add to the cacophony of the emergency room. The teacher with Lewy Body Dementia had words stolen from her. She always had well-meaning sentence finishers at her side. I decided to wait, sitting on my rolling clinic chair, looking at her intelligent face. I can because I practice “don’t-rush-us” medicine. Over the months she told me astounding things about loss, and I discovered she had a wicked sense of humor. The silences between my words and hers were long, the kind of focused emptiness where you forget anything else in the world exists. When she could no longer speak at all, I sang and she joined me. You are My Sunshine.

Is it possible we create disability with our definition of health and wholeness? Would dementia or a slow gait or dyspnea on exertion be as pathologic if we did not so worship keeping up? What if the ones we leave behind in our wake of productivity hold the key to the meaning of life in their trembling hand? We have created a society that cannot tolerate and is frankly terrified of infirmity and decline and death. The bills stack up, our careers demand attention, our friends have things to do. If we dare to stop and acknowledge humanity in someone who can no longer wipe their own butt, what does that say about our own rushed existence?

You, patient, are a problem for me to solve. I can reach out and control your atrial fibrillation with the force of my education. I can tell you with some certainty what kind of dementia you have. I can cure your pneumonia and let you see another day. What are your goals of care, I am trained to say. Though I prefer now simply what are your goals or what is important to you? Which is undeniably important but hard to express if you cannot talk or cannot recall what you had for breakfast this morning. In which case I want you to know that I see you. Right here and now, not what you do or who you were or who the world wishes you could still be.

The man with CHF improved, because of or perhaps despite his hospital stay. I brought in my iPad, handing it to him and pushed play. As he stared at the album cover that included his name on the screen, a tune played. He played. He turned the iPad over, wide-eyed, as if to say “what magic is this?” The magic is just this-you and I sitting here together, with nothing else in the whole world we need to do