Napalm ====== * Ted St. Godard * © 2004 Canadian Medical Association or its licensors I have never smelled napalm, and I pray I never will. But I have never arrived on the wards in the morning without being reminded of it, or rather of Robert Duvall's famous quip from *Apocalypse Now*. But the smell of the wards in the morning is the smell of life itself, the smell of human excrement. ![Figure1](http://www.cmaj.ca/https://www.cmaj.ca/content/cmaj/171/3/262/F1.medium.gif) [Figure1](http://www.cmaj.ca/content/171/3/262/F1) Figure. Photo by: Fred Sebastian And so perhaps on the morning in question the pungent odour was the only familiar to which I could cling; certainly, I remember it vividly. I was freshly turned out in my crisp white clinical jacket (not coat), timidly and confusedly attempting to navigate through one of my city's crumbling teaching hospitals in search of a patient whose name has long since escaped me. It was the start of second-year medicine. At home I enjoyed parading in front of mirrors in my little white jacket, but now I was nervous and perspiring, conspicuous and clumsy in my cloak of no colour but many implications (to those who know). Pockets bulging, clipboard in hand and bag of diagnostic paraphernalia slung awkwardly over my shoulder, I entertained the vain hope that perhaps the patient might already have been discharged. But that would have been too easy, and easy isn't always best. My assignment: CPA, comprehensive patient assessment, wherein neophyte not-yet-clerks interview, examine and “present” patients to a group of classmates and an attending, the patients having been semi-coerced into volunteering their stories and bodies in the service of medical education. It turned out my patient was on the ortho ward, a seventy-something gentleman, post-op day 1 following RTKA (whatever that was) according to the virtually illegible scribbles in the cryptic, cluttered, and (secretly) colour-coded document known as “the chart.” I fumbled my way through the dilapidated binder and discovered that TKA (obviously) referred to total knee arthroplasty (and R to the opposite of L; very important). Okay, the knee in 317. Off I went to discharge my duty if not my patient. And now the smell to which I earlier referred, powerful and fresh, reminded me that the gentleman whose acquaintance I was about to make was perhaps as exposed and vulnerable as I was in this encounter. “Mr. Knee?” I asked, trying to sound confident. In response to his affirmative reply I introduced myself too quickly and sought to remind him that he had agreed to be interviewed by a medical student, and that I, the lines on my face and grey in my hair notwithstanding, was that student. “Sure, sure, come on in,” groaned and grimaced Mr. Knee.* (*Not his real name.) “I'm having some awful heartburn or some kind of pain.” Oh boy, I thought, it's already complicated. “I just had a bowel movement,” he continued, “that's when it started. They gave me some Tylenol. Does that seem like the right stuff to you?” “Well,” I went out on a limb, “it's not necessarily what I would have suggested, but …” “Anyway, never mind.” Mr. Knee reassured me, and I was grateful. “I guess it'll get better. What can I do for you?” So I reiterated for him how things would go, that we'd chat, I'd examine him, then come back and talk about him in front of him but not to him. Time, and the comfort that came from rehearsing with Mr. Knee the choreographed nature of our visit, cleared the air somewhat. The smell dissipated, and I, seating myself beside the bed, dutifully began extracting identifying data, which I hoped would soon be followed by a chief complaint, concise and crisp, not unlike my jacket. A voice somewhere dimly whispered pain and symptom mnemonics. “PQRST: provoking/palliating features? Quality? Radiation?… ” But I cleared my head and focused; I had a job to do. Already he was telling me about his bloody family history when I hadn't even asked him about the limitations his bad knee had placed on his ADLs. I needed to take charge of this interview. The key is in the history, ladies and gentlemen. As I struggled to jot down everything he continued to volunteer, each fact under its appropriate heading (“Where do I put allergies, again?”), and attempted to leave enough room in each category to fill it in PRN (I like that one), Mr. Knee asked me “Shouldn't it have gotten better by now, this pain in my chest?” I was losing this guy. “Look,” I said, trying to focus on the task at hand, “do you have any pets?” I swear I said it, remembering something about pregnant women and toxoplasmosis, I think. “We used to have a beagle, but we had to put her down,” he groaned. “Maybe a few burps will help. What do you think?” “Ever had anything like this before?” I asked, hoping perhaps that a shotgun approach might elicit the information I needed, and only dimly aware that this was an important question. And then, as much to regroup as anything else, I told Mr. Knee that I'd let the nurses know that his heartburn had not yet subsided, and I so informed the people at the desk — whom I hoped but was not sure were nurses. And back I went, determined to succeed. When I returned to the room, although the air was now fresher, I had to admit that the patient looked rather like excrement. Well, he was in the hospital; he was sick. I determined to get a handle on how far he could walk before his knee hurt him so much that he had to stop; I knew that would be an important bit of information later. “You know, it's getting worse instead of better,” the now perspiring Mr. Knee lamented to his increasingly demoralized interviewer. And here's where my maturity came into play, my ability to empathize, and to anticipate patients' needs. I got Mr. Knee a cold cloth for his forehead, and asked him if he smoked. Now, I'm not a dumb guy. I realized that my patient was having what sounded like pretty bad chest pain, but for the life of me I didn't know what to do about it. Hadn't he described it earlier to trained professional nursing staff, and been given arguably appropriate medication? Didn't I have a job to do? But when Mr. Knee told me that he thought he was going to vomit, and I fetched a stainless steel basin, I think it dawned on my paralyzed self not only that this interview was going nowhere, but also that my patient (*my* patient!) might actually be in trouble. Central, unremitting chest pain. Diaphoresis. Nausea. Vomiting. Jesus, we both needed aspirin. I timidly approached the nursing station once again and explained that Mr. Knee was vomiting now. Rolling her eyes, someone told me,“I'll see if I can get an antiemetic,” and I went back to Mr. Knee, who now looked decidedly like Mr. Heart. So back to the nursing station I went, and said, “You know, he really isn't doing well.” I spotted a young man behind the desk reading through a chart. “Are you a physician?” I asked, painfully aware that I was not. “Nope, OT,” he replied. And here is where the gods of medical students, or of kind old people in trouble, smiled on us. As I headed back to Mr. Knee's room, I ran into one of my very bright classmates and related to him the events of the morning as they had thus far transpired. And bless him (really, and he almost didn't graduate, for a whole bunch of political reasons), didn't he say, “Think you should get an EKG?” An *EKG!* Of course. Off I went to the nursing station again, worried now that I couldn't remember whether Q waves or ST elevations would be more serious, or if flipped Ts meant anything at all. “Do you think we could get an EKG?” I asked the person I now knew to be Mr. Knee's nurse. She replied that it might be a good idea; looking at the length of my jacket, she asked, “Can you order one?” When I humbly admitted I could not, she deigned to call the doctor. Then it all got kind of busy. Having by this time forgotten that TKA meant total knee something-or-other, I now heard “EKG, twenty-five, three west” repeated over the PA system, and I slowly retreated, distanced in so many ways from the flurry of nitro sprays and oxygen and what I now know (from ACLS) to be MONA. It really happened this way, and it always gets a laugh when I tell people, but I have ambivalent goosebumps as I write. I might have done better, sooner, more. But I guess I did *something*. I kept presenting my inadequate short-jacketed self at that nursing station. And then, intensely aware of my limitations, I did a small service, I think. A CCU resident explained the situation to Mr. Knee very quickly (he'd been paged off his ward, he had work to do) and in an unpenetrable accent, and left. Displaying considerably more confidence than I felt, and not at all certain of the propriety of what I was about to do, I stepped up to the bed and asked Mr. Knee if he'd understood what he'd just been told. “No, Doctor,” he replied (and I let him), “but I feel better.” “Mr. Knee, you've had a small heart-attack,” I told my patient. “You're being moved to the coronary care unit now for a day or so, and they will watch you closely, and take care of you.” And as I left to meet up with my CPA group, and whichever attending I should have been presenting to, I hoped that the CCU would take care of Mr. Knee, and I didn't know whether to laugh or cry (I think I did both). And I wondered sincerely, and not for the first or last time, whether there was hope for me as a doctor. **Ted St. Godard** PGY1 Family Medical Centre University of Manitoba Winnipeg, Man.