THE ART OF MEDICINE
A few gray hairs Harrison Reed, MMSc, PA-C
M
y friend pulled the colorful hijab back from her forehead and pinched a lock of black hair between her fingers. “This,” she said as she shook the tuft in my direction and laughed, “is how I knew.” I squinted to see her point: two strands had lost their pigment and ran through the darkness like rogue ghosts. I wanted to roll my eyes and counter that she was far too young to play the “wise old woman” card. But this time she had earned it. One day earlier, we sat in the ICU and talked, two PAs enjoying the relative calm of the afternoon. But new test results interrupted our conversation and presented a dilemma. An ultrasound had revealed blood clots in my patient’s legs. A simple problem in most cases, easily treated with anticoagulation. But this patient faced an awful paradox: her diseased liver struggled to manufacture platelets; every organ threatened to bleed. A young physician on our unit wanted to start the woman on a heparin infusion, attack the blood clots despite the risk. “No,” my friend said and slapped her hand flat on the table. “That is a terrible idea.” It’s easy to fall back from a fight, especially when the battleground is a tough clinical decision. It’s simpler to defer, to bow out and let someone else assume responsibility. And without the confidence of my veteran colleague, I might have faltered. But we swore to protect our patients, not to keep the peace. So we dug in and stood our ground. No heparin today. That night, our patient closed her eyes during dinner. She didn’t respond when her nurse checked on her and wouldn’t wake up despite shaking and shouting. The night team ordered a CT scan of her head and found the problem. Her brain had bled. The hemorrhage was troubling but small; it wouldn’t require a rush to the OR or a drill bit to the skull. But had she received the potent blood thinners, the results would have been catastrophic. And no surgeon could have saved her. Harrison Reed practices critical care medicine at the Cleveland Clinic, Cleveland, Ohio. The author has disclosed no potential conflicts of interest, financial or otherwise. Tanya Gregory, PhD, department editor DOI: 10.1097/01.JAA.0000458872.16678.c4
Copyright © 2015 American Academy of Physician Assistants
66
www.JAAPA.com
She would never take credit, but my friend had saved the woman’s life. It wasn’t an occasion to brag or gloat. Our patient had taken a nasty turn that no clinician would celebrate. But when the corner of my friend’s mouth turned up and her eyebrow raised, I knew what it meant. I could still learn something from the lady with a few gray hairs. A different type of knowledge comes when you leave behind the books and the classroom. You realize the right answer isn’t always a lettered choice listed below the question. You can’t always explain the suspicion that tickles the back of your skull or sits in the pit of your gut. “Gather evidence for every decision you make,” I tell my students. The courtroom approach. “Have proof to support your actions.” My own advice has served me well but, as the months pass, I tend to ignore it.
We swore to protect our patients, not to keep the peace. “This doesn’t feel like heart failure,” I find myself saying. I stand at a patient’s bedside and touch her skin, hold her hand, watch her eyes. These aren’t examination techniques I learned in school. They reveal far more subtle sensations: This is normal. This is sick. This is that tiny, elusive window between the two. There was a paralyzing moment of panic when I realized that facts and figures are flawed. When I realized the outdated knowledge of yesteryear—those dusty old textbooks that earn snickers and eye rolls—was once gospel preached from the pulpits of the grandest academic cathedrals. When the groundbreaking study I swore by my first year of practice was debunked by my second. Like finding out Santa Claus was just my father in a fake beard. But just as I grasped for that crutch of absolute certainty, I also discovered I didn’t lean quite as heavily on it. The limitations of scientific precision were reinforced by a more visceral instinct. The one that emerges from the shadows of our minds and nudges those close calls in the right direction. The one my friend used to save our patient. I still haven’t found my first gray hair. But by the time I do, I hope I’ve earned it. I hope it has sprouted from a follicle of wisdom. JAAPA Volume 28 • Number 1 • January 2015
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
A few gray hairs Harrison Reed, MMSc, PA-C
M
y friend pulled the colorful hijab back from her forehead and pinched a lock of black hair between her fingers. “This,” she said as she shook the tuft in my direction and laughed, “is how I knew.” I squinted to see her point: two strands had lost their pigment and ran through the darkness like rogue ghosts. I wanted to roll my eyes and counter that she was far too young to play the “wise old woman” card. But this time she had earned it. One day earlier, we sat in the ICU and talked, two PAs enjoying the relative calm of the afternoon. But new test results interrupted our conversation and presented a dilemma. An ultrasound had revealed blood clots in my patient’s legs. A simple problem in most cases, easily treated with anticoagulation. But this patient faced an awful paradox: her diseased liver struggled to manufacture platelets; every organ threatened to bleed. A young physician on our unit wanted to start the woman on a heparin infusion, attack the blood clots despite the risk. “No,” my friend said and slapped her hand flat on the table. “That is a terrible idea.” It’s easy to fall back from a fight, especially when the battleground is a tough clinical decision. It’s simpler to defer, to bow out and let someone else assume responsibility. And without the confidence of my veteran colleague, I might have faltered. But we swore to protect our patients, not to keep the peace. So we dug in and stood our ground. No heparin today. That night, our patient closed her eyes during dinner. She didn’t respond when her nurse checked on her and wouldn’t wake up despite shaking and shouting. The night team ordered a CT scan of her head and found the problem. Her brain had bled. The hemorrhage was troubling but small; it wouldn’t require a rush to the OR or a drill bit to the skull. But had she received the potent blood thinners, the results would have been catastrophic. And no surgeon could have saved her. Harrison Reed practices critical care medicine at the Cleveland Clinic, Cleveland, Ohio. The author has disclosed no potential conflicts of interest, financial or otherwise. Tanya Gregory, PhD, department editor DOI: 10.1097/01.JAA.0000458872.16678.c4
Copyright © 2015 American Academy of Physician Assistants
66
www.JAAPA.com
She would never take credit, but my friend had saved the woman’s life. It wasn’t an occasion to brag or gloat. Our patient had taken a nasty turn that no clinician would celebrate. But when the corner of my friend’s mouth turned up and her eyebrow raised, I knew what it meant. I could still learn something from the lady with a few gray hairs. A different type of knowledge comes when you leave behind the books and the classroom. You realize the right answer isn’t always a lettered choice listed below the question. You can’t always explain the suspicion that tickles the back of your skull or sits in the pit of your gut. “Gather evidence for every decision you make,” I tell my students. The courtroom approach. “Have proof to support your actions.” My own advice has served me well but, as the months pass, I tend to ignore it.
We swore to protect our patients, not to keep the peace. “This doesn’t feel like heart failure,” I find myself saying. I stand at a patient’s bedside and touch her skin, hold her hand, watch her eyes. These aren’t examination techniques I learned in school. They reveal far more subtle sensations: This is normal. This is sick. This is that tiny, elusive window between the two. There was a paralyzing moment of panic when I realized that facts and figures are flawed. When I realized the outdated knowledge of yesteryear—those dusty old textbooks that earn snickers and eye rolls—was once gospel preached from the pulpits of the grandest academic cathedrals. When the groundbreaking study I swore by my first year of practice was debunked by my second. Like finding out Santa Claus was just my father in a fake beard. But just as I grasped for that crutch of absolute certainty, I also discovered I didn’t lean quite as heavily on it. The limitations of scientific precision were reinforced by a more visceral instinct. The one that emerges from the shadows of our minds and nudges those close calls in the right direction. The one my friend used to save our patient. I still haven’t found my first gray hair. But by the time I do, I hope I’ve earned it. I hope it has sprouted from a follicle of wisdom. JAAPA Volume 28 • Number 1 • January 2015
Copyright © 2015 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
