St. Paul’s Cathedral clock is striking nine on this first day of July, 1964, as I mount the worn stone steps to the third floor of St. Bartholomew’s Hospital’s medical–surgical block and peer around the door of Dalziel ward: a callow 22-year-old medical student, shaking in my shiny black shoes.
My first sight: two lines of beds stretching ahead, precisely spaced as in an army barracks, the patients immobile, loath to disturb the apple-pie order. I take in the bolt-upright back of Sister Dalziel at her desk, starched apron stretched over dark ankle-length dress. I ask permission to enter; the only response is a brief inclination of the white veil-cap. I clutch my new admission chart, knowing Mrs. Lovell’s previous admissions records will take days to appear; all I have is her name, address and date of admission. I read off the names surreptitiously on each bed rail until I locate her, ancient and frail, propped upright on four pillows.
The house officer’s words ring in my head: “Remember the chaperone for your physical exam!” I decide I can get rolling with the history of present illness while Sister sees fit to free up a nurse to guard against my all-too-probable improprieties. I remember to offer my hand as I lay my history and physical on my lap. As Mrs. Lovell’s fingers clasp mine, I catch myself naming the bones visible beneath the papery skin: images from the grease-stained pages of Cunningham’s Text-Book of Anatomy given sudden life.
Is that the radius or the ulna? Is she pronating or supinating? Are those metacarpals or phalanges?
The mandate to maintain eye contact preempts my checking the questions on my clipboard; I’m fast cast adrift from their prescribed order as Mrs. Lovell unravels her story. Impotent to stem her flow, I resort to scrawling blind notes.
“Not that I mind bein’ ’ere, doc, but it’s me pussycat. Me ol’ man gives ’er ’er kibble, but ’e don’t ’old wiv changin’ ’er litter box. Allus an ’orrid mess when I gets ’ome.”
![Figure](https://www.cmaj.ca/content/cmaj/187/17/1315/F1.medium.gif)
Image courtesy of lucky_spark/iStock
A nurse is pulling the ceiling-to-floor curtains around us. I’m well short on the essentials of my ROS, and when to fit in my PMH, FHx and SHx utterly eludes me. Full-speed ahead with the examination.
Does anyone have the faintest notion that this is my first live patient?
I stop every few minutes to visualize my list, terrified I’ll forget some critical detail. My patient is clearly familiar with the routine, responding to my every request without demur. After long drawn-out moments of beaming my new flashlight inside her mouth, I learn only that not one tooth remains from the set God gave her. I limit my eye exam to checking for reactions and rotations, having forgotten my ophthalmoscope. No big loss, given I barely know how to switch it on, let alone tap its diagnostic powers. I fumble for the thready pulse at her wrist, which promptly slips from under my fingers as I am locating my watch’s second hand.
Despite Mrs. L’s compliance, my history and physical has failed to offer a single tip-off. I glance at the nurse: patience on a monument on the other side of the bed. Her devastating prettiness, in striking contrast to my patient’s time-worn features, stirs me to my core. I try to read the name on her badge, bringing me in direct sightline of her left breast beneath her apron. Blushing, I avert my eyes as she helps Mrs. Lovell with the straps of her yellow flannel nightie. As it drops to her waist, I take in the thin arc of ribs jutting from her breastbone, breasts flattened against her chest, dappled with brown marks like falling leaves, blue venules criss-crossing their translucent surface.
How old is she? How did I miss such a glaring detail?
I rub my virgin stethoscope up and down on my stiff white coat to ease the chill. As the nurse delicately lifts Mrs. Lovell’s breasts, I tune into gushes and murmurs that were until this moment only stark words in Cecil–Loeb Textbook of Medicine. I had certainly never heard anything like this from my anatomy cadaver.
I breathe a silent thanks that the nurse knows what’s next: supporting Mrs. Lovell as she leans forward. I sneak a glance at my cheat sheet; a row of words leaps out: inspection, palpation, percussion, auscultation.
Totally skipped percussion! That thing about knocking one middle finger on the other to tell if there’s anything in her lungs. Besides air, of course.
I strive to keep my overlong fingernails from penetrating fragile skin as I tap-tap-tap left middle with right middle and ring. A resonant sound rewards me, right down the back of her left lung.
I switch to the right; all’s well till tap-tap number three: dull as a stone.
Auscultate.
“Deep and slow, Ma’am, just listening in.”
I work my stethoscope down; halfway, air sounds abruptly vanish.
Hallelujah, something amiss …
“Nuffin’ wrong with me lungs, doc, it’s me liver. Been swellin’ up an’ dahn and all abaht. Cop a feel.”
A piece of information beyond the price of rubies.
The nurse eases her down to supine. Mrs. L’s tummy’s fullness is at glaring odds with her overall scrawniness.
Surely can’t qualify for obesity …and I can safely rule out pregnancy, can’t I? So all I need is the other 20 causes of abdominal protuberance.
I lay a tentative hand over where her liver should be and start sliding south. I’m almost at her groin before my pinkie abuts a firm, thick lip.
The bottom edge?
“Feel it, dearie, do you? Big bugger, init?”
“Yes, it’s … er, big.”
A cluster of puncture marks encircle her tummy button. My gold mine of priceless prompts continues to gush forth nuggets:
“’Spec’ they’ll be ’avin’ you stick needles in me, doc.”
“Ah! You’ve had other students putting needles in your tummy, Mrs. Lovell?”
“Deerie, yus, plen’y.”
“You wouldn’t have any idea why, would you?”
“Thought you’d never ask, luv. Me liver may be a big ’un, but it ain’t workin’ wurf tuppence. Not since me ’epatitis.”
The penny drops. I peer more closely at her skin.
Yellow as custard! How could I miss it? Must have been her nightie.
Silently absolving myself from blame, I lower each eyelid: golden yellow! I grow giddy at how close I’d come to missing it: her liver is failing fast. What other clues are there to uncover?
Mrs. Lovell has read my thoughts: “The perfessor’ll be sure to want to ’ear about me bleedin’.”
“Bleeding?”
“That’s wot got me stuck in ’ere this time — vomickin’ up blood. ’Arold ’ad to send for the ambulance. If ’e’d ’ave left it any longer, I wouldn’t be ’ere. They emptied me stummich aht, then gimme me this blood transfusion. ’Ere, wouldn’t ’arf mind sittin’ up. Gets me all aht of breath, lyin’ down does.”
As nurse and I lift her back upright, our fingers brush, pull hastily apart. We avoid each other’s eyes as she straightens Mrs. Lovell’s nightie, tucks in her bedclothes, and is gone, leaving only an alluring something on the air.
“About these needles, Ma’am. Have they been collecting fluid from your tummy?”
“Ever’ time I’m in ’ere, deerie. Feels ever so much better arter they done it.”
A word hops into my head. Ascites! When your liver shuts up — because of … portal something … portal hypertension. That’s it! Back pressure, or some such.
I’m Sherlock Holmes and Doctor Watson rolled into one, on the track of a baffling whodunnit. Mrs. Lovell is pointing out a scattering of marks on her arms and hands. Pinkish ovals, several each side, a lacework of spidery flowers.
“They’re allus pokin’ at these ’ere thingummies, too, doc. Dunno ’ow long they been there.”
What in hell’s name … spider somethings?
I can hardly wait to get at my Cecil–Loeb, become the world’s expert on liver failure before the prof’s rounds.
I love you, Mrs. Lovell. I just love you. I’ll change your pussy’s litter box anytime.
“I wonder sometimes, doc, what’s goin’ to ’appen to puss if …”
“Oh, I’m sure you’ll be home in no time, Mrs. Lovell.”
I scurry from the ward and almost headlong into the same nurse, bearing a tower of gleaming bedpans. She stops, speaks without preamble.
“I know you’re new at this, and Mrs. Lovell’s a good patient to learn from. But I couldn’t help noticing how delighted you were when you caught on she’s in liver failure. You know, it’s hardly a cause for rejoicing.”
Holmes and Watson take a tumble; it’s all I can do to stammer through my blushes.
“Really sorry, you’re absolutely right. Of course. Just that … well, I’d have had egg on my face at prof’s rounds if I’d missed it.”
“Well, you were nice and gentle with her. Most of you lot are much worse.”
“Thanks.”
I head for the library to bone up on liver failure — etiology, diagnosis, prognosis, management. But that backhanded compliment nags at me: maybe it’s not just patients who can teach us stuff; better look to those nurses, too.
Footnotes
This article placed third in the prose category of the 2015 Humanities Poetry and Prose Contest, jointly sponsored by ARS Medica and CMAJ.
All characters in this work are fictitious. Any resemblance to real persons, living or dead, is purely coincidental.