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The Last Word

By Hujefa Vora, MD, TCMS Publications Committee Chair

Last month, I wrote about choices.  We all seem to encounter hundreds, if not thousands, of choices every day.  And who really knows how the slightest choice affects the next set of choices that present themselves before us.  Our choices at times can appear meaningless to us.  As I prepare for my day, I choose my scrubs from my closet.  Unconsciously, I make the decision to wear the blue ones.  I decide to just grab a granola bar for breakfast as a matter of convenience on my way out the door rather than to sit down with my wife at the dining table for the coffee and omelet and communion I am truly craving.  On my way to work, I decide to stop and fill up some gas, though my truck still has a quarter tank.  The floor nurse messages me that my patient’s family has decided to try and meet with me around lunchtime today rather than meet me for my morning rounds.  I let her know that I am not sure that this will work, as there are likely to be another few hundred choices that I have to make before I get there.  I will try.  That seems to be all I can do in any given situation.  At any rate, I decide to go by and see the patient first this morning.  This will give me a moment of clarity without the interference that sometimes follows families into a room.  I make the choice to turn left rather than right—I will start my day in the ICU and make my way back to the orthopedic facility later.  I know that I will make it to all of the patients before the end of my day.  My choices thus far have been mundane rather than the life and death decisions which we are glorified with when others speak of our profession.

The choices I made that morning were not anything but ordinary.  And yet, as we find sometimes, they guided me exactly to the place where I was needed most.  

As I arrive at the hospital, the cafeteria’s coffee machine calls my name.  The granola bar wasn’t quite enough.  I chose a decaf vanilla latte.  Now the coffee machine is not that place, but it is certainly the place I needed most.  Caffeine would make it better, but that goes without saying.  My coffee and I meander onto the unit.  The nurses are busy at their bedsides, assessing the patients at the start of their morning.  As I walk toward the central nurses’ station, I note the rhythms of the telemetry monitors. Muffled underneath is the low hum of air flowing through endotracheal tubes.  The aroma of the coffee hides the scent of hand sanitizer and bleach.  Just the granola bar was a poor choice, but the choice of coffee from the cafeteria more than compensates for that.  It is all entrancing, calming, and yet chaotic.  The ICU has its own music.  Occasionally, the better choice of words is controlled chaos.  My moment is broken by a flourish from the room 20 feet in front of me.  The rhythm is broken as a woman flies out of the room, hurtles towards me, and demands her nurse.  For a moment, I hesitate.  I then realize that the blue scrubs I chose this morning happen to be the same blues worn by our ICU nurses.  I follow her into the room.  The patient is bucking the ventilator.  In his bed, he is strapped down, but from the spasms in his shoulders and neck, his arms look like they will try and pry loose.  I hit the Code button on the hospital bed.  The ICU machine is awakened by a cacophony of deafening alarm bells.  Three nurses barrel into the room with a crash cart.  A few simple, unplanned choices have guided me to this moment.  

“The choices I made this morning were not anything but ordinary.  And yet, as we find sometimes, they guided me exactly to the place where I was needed most.”

There were no decisions this morning prior to this moment that required my four years of college, four years of medical school, or three years of residency.  And yet, they were a doctor’s decisions and choices.  The next few choices were those of a seasoned physician with more than 20 years of working in hospitals and ICUs.  

I don’t have any history, as this is not the room of the patient I have yet to visit this morning.  All I have is the information the nurses start barraging me with.  The patient is seizing, so IV benzodiazepines are administered. Another choice.  The patient starts to calm, spasming muscles relaxing.  Calm washes over the scene for a moment.  Everyone, including the patient, pauses to breathe.  The momentary silence is broken by the sobbing of the patient’s wife, I presume.  She asks if the doctor has been called.  Without skipping a beat, I reassure her that the intensivist is on his way.  The wife stutters out a prayer, then thanks me for my actions.  My choice in that moment is not to correct her, but rather affirm to her that we will take good care of her husband until the intensivist arrives.  I remain in the room for several more minutes until the intensivist comes in to relieve me.  He assesses the situation, thanks me for intervening while he was indisposed with another patient situation, and then allows me to walk back out of the room.  As I leave, he pokes his head out of the glass door and shoves a cup into my hand.  “Don’t forget your coffee.”

Every choice we make in our days is governed by several principles.  I am about to speak in generalities, a choice I am making in this moment.  We are physicians.  Our lives revolve around this choice.  Being a physician is not just a job, not simply some way to make money, but rather a life choice, because being a physician is not my job, but it is my Life.  We are called upon, above all else, to do no harm—our choice is to take this oath and live by it.  No matter the moment, the situation, the patient comes first, above all else.  We apply our knowledge, our skills, and our hearts to every patient individually, understanding that it is our oath and the choices that have followed thereafter that define our most noble profession at its core.  As a physician, it should always be my choices, and my patients’ choices, which guide me to those moments and through those moments when I am needed most.   One might say that I am pro-choice.  I choose to agree.  My name is Hujefa Vora, and I choose the word “choice” as this, The Last Word.

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