Friday, January 4, 2013

The Monday Morning Quarterback.

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He was crying in a way that didn't seem natural for a man his age. For a man period. Men seem to inherently know restraint. The feelings are there, yes. Yet somehow they get masked by a carefully mastered impulse control.

But not in this instance.

His shoulders were curled inward. The unspeakable grief oozed from his eyes and his mouth had fallen open as if under the control of some faulty hinge. Words kept trying to come out but became garbled each time. It was awful.

I was on his immediate left. My chair scooted as closely to his wheelchair as it could possibly get and my hands tightly gripping his forearm and wrist in the most supportive way I could. His daughter stood behind him, arms draped over his shoulders and repeatedly burying her face into the top of his head to hide her own emotion. Her brother, his son, was two chairs away from me, lost in his own world of grief. Seeing his father so broken while saying goodbye to his mother at the same time was too much.

It was just too much.

This was my very first day knowing this family. I was the attending who had just taken on the inpatient service where this woman, his beloved wife, had already been a patient for several days. Most doctors who work on hospital wards will tell you that there are some positives and negatives to having someone come in with a fresh set of eyes to a critically ill patient. The "Monday morning quarterback", as we always call it, is the one who wasn't there for all the dirty work or the parts when all of the puzzle pieces weren't yet available. It's that Monday morning quarterback who strolls in, surveys the big picture and makes a quick assessment. A lot of the time, this kind of thing is annoying. But sometimes, it's advantageous.

This was one of those times.

I listened to the residents telling me her story. It was convoluted, complicated and unfortunate. Right up against her ninth decade and initially admitted with this pervasive febrile illness. The kind that the very advanced elders get that we go ahead and admit them for even though you can't quite put your finger on its origin.

The team before me data-mined and gathered information. They put out campfire after campfire while a wildfire was ravaging the countryside. And I know from experience that this happens sometimes. We hyperfocus on individual things such as sodium levels and Vancomycin titers and the teeniest perturbations in kidney or liver function. Each going awry and then slightly improving while we lose sight of the entire landscape. The one that has these flames that we keep tackling with handheld hoses when somebody needs to call in the helicopters.

So after hearing all of this, her hospital course, I became that Monday morning quarterback. Then I saw her with my own eyes, strengthening my position. "Wow, y'all. This management is awfully aggressive. Has anyone talked about end of life issues and the fact that this patient is dying?All of this--these labs and her exam--this is a patient who is actively dying."

And the resident and his interns communicated to me that indeed this had been considered but that no one, including the family or their prior attending physician, was on that page. A feeding tube was in her nose since she wouldn't and couldn't eat. And her chest was rising and falling so rapidly that it was exhausting to even witness.

"It doesn't matter at this point who is on what page. I cannot see where this can end in a meaningful recovery. I see that she wants all heroic efforts in the event of an arrest. Is this her wish or is this just the default?"

"The family was very upset when this was brought up. Not doing everything."

I glanced over my shoulder toward the room during that discussion. Per the monitors, she was breathing nearly forty times per minute despite the one hundred percent non-rebreather oxygen mask fixed onto her face. She was no longer conversant in the last four days and had so much edema that all of the bony architecture in her extremities was distorted. But on top of that, her labs and images collectively spoke loudly and clearly.

This woman--this wife, this mother-- was dying.

Of course, we could do everything. And, in this situation, that would mean CPR and intubation in the next few hours. It would also mean fracturing her fragile ribs and eventually putting the family in a far more difficult position with de-escalating care.

But I had just gotten there. Yes, I felt strongly about my clinical opinion, but still. They didn't know me. At least, not really they didn't. I imagined myself strolling in like some kind of grim reaper poorly disguised by my stiff white coat. It wasn't a good mental picture.

There are times when we have no choice. My rule with my patients and their families is this:

"Whatever we're talking about when it comes to you or your loved one and their care outside of your room is exactly what we'll discuss when we get inside of your room."

At least, as close a version as we can. But how would that work for this situation? One where this woman had been worked on dutifully for eight full days by well meaning doctors only to fully declare herself on the day some new lead doctor arrives? There was no easy answer. There wasn't.

But then, in the snap of a finger, I remembered something. This woman--and her dear husband of over sixty-five years--was under the care of a geriatrician. One who'd cared for them for nearly a decade and who'd carefully built a relationship with that entire family brick by brick.

Her doctor. Her doctor. Yes! Her primary doctor--her primary geriatrician--needed to be called and brought into this. This would comfort the family far more than I could. Of course. Not the Monday morning quarterback but the offensive coordinator. The one who'd been there when the plays were being drawn out and who'd stood with them during inclement weather to cheer those pass completions.

Of course. Dr L. Her doctor.

"I'm going to call Dr. L." I said this quietly and matter-of-factly to the team. They'd been communicating with him, but this would be a different call. Not the "your patient has been hospitalized" call, but a call to him as the offensive coordinator from the Monday morning quarterback.

And so I called. I explained what as going on and what I saw. How ill she'd become. How concerned I was of her imminent demise and whether or not us feverishly pressing her sternum and filling her veins with central lines was the right thing to do.

"Please come," I implored him. "If you can, please come."

That is exactly what he did.

And so, some forty-five minutes later, there we all sat. In the family waiting area as the offensive coordinator of my patient helped us navigate the next step in her care.

Yes, I was to her husband's left. That daughter stood with her arms encircled behind Daddy trying her best to protect his heart and hers at the same time. And Brother was perched on the edge of that distant chair weeping into the crook of his elbow.

And Daddy.

Daddy was tremulous and angst stricken in that wheelchair. The one that Dr. L had put him into when he arrived on the ward --not because he could not walk, but because this kind of grief knocks people off of their feet and he knew that from experience.

The other part of that picture included Dr. L., her primary geriatrician. Kneeling in front of that husband and staring into his eyes. Both of his hands overlying that husband's and pressing down into the veiny network on each of them. There was trust in that gaze. Those words came from a knowing place and that husband--his patient,too--received them.

That's why he was so grief-stricken.

The saliva between his crying lips stretched like violin strings and finally he mustered out a word to his doctor, the offensive coordinator.

"Do you really think. . .she 'bout to go home?"

And Dr. L closed his eyes and exhaled through his nose as he nodded. A hard, deliberate nod that couldn't be confused for anything but the affirmative.

"Eeeeee. . . . eeeeee. . . . .eeeeeeeeeeee!" 

That is exactly how his guttural cries came out. They pushed beyond the masculine impulse control and stoic code of manhood. And he felt safe doing that with Dr. L. in front of him. This was the cry of a man who was just told by someone he knows and trusts that he would soon have to say goodbye to the love of his life. A woman that he'd lived more years with than without and who'd first spoken words of mutual love to him on a humid summer night nearly seventy years before.

"Eeeeeeee. . . . Loooo. .hooo...horrrd. .. Jeeeeee. . . huh huh. . . suuuusssss. . . . .eeeeeeeee. . .eeeeeeeeeee!"

It was quite possibly one the saddest moments I have ever seen in my career. I swear that it was.

Dr. L. patiently let him have his moment. He knelt right there in front of that wheelchair for well over fifteen minutes, not once appearing to tire or lose his resolve. And me, I sat quietly on the left, holding his forearms and saying nothing. Nothing at all.

Shortly after that, our patient peacefully slipped away. With her family beside her and without a single thing beeping in any of their ears.

I learned a lot from being a Monday morning quarterback that day. Just like in "real" football, the very best plays handled by quarterbacks--Monday morning included--involve carefully executed passes to able-bodied teammates. Sometimes there are days when the QB runs it in for the score, but the ones we remember the most always manage to know when someone is open.


That means less glory for the quarterback, but the win is somehow sweeter for everyone. 

Thank you, Dr. L. for teaching me the importance of looking for who's open. And thank you for reminding me that I don't always have to use my own playbook.

Happy Friday.


  1. I am very moved. Thank you. You give us life-lessons when you talk about death. I know you know that but I wanted to say it out loud.

  2. Sometimes the hardest words to hear are the truth. I hope I can learn from this. Thank you for sharing.

  3. Sad but beautiful and real too. Thank you for helping her to make her transition with grace and dignity, and being there for her loved ones.

  4. You are amazing. I don't know you, but from what you have shown your core, despite the inevitable human foibles we all have, you are something special. I have said it before and I am saying it again.

    Maria, fellow Meharrian


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