A Country Doctor Writes:

The call from one of the big city radiologists came out of the blue. A patient of mine at one of the boarding homes had seen a surgeon about an abnormal mammogram and a stereotactic biopsy was recommended. As the primary physician, I was the one who had to order the test. I was in the middle of something when I got called to the phone for Dr. Dinsmeyer’s call.

“This patient, Suzanne Brown, referred for a stereotactic biopsy…”, the radiologist began, “… I looked at the films and I don’t think she needs one. This is benign. I’d like to cancel the procedure.”

I explained that I was just the middleman, and had ordered the test based on the surgeon’s recommendation. The whole exchange didn’t take two minutes, and I went back to what I was doing, feeling terrible about Suzanne travelling to the city for nothing. She doesn’t get around all that easily in her wheelchair.

Yesterday at the boarding home as I began my rounds, I found out that Suzanne was on her way to the city for her breast biopsy.

My heart sank. I had thought Suzanne was at the breast clinic when Dr. Dinsmeyer called. If the appointment wasn’t until yesterday, did the breast clinic assume I would contact the boarding home about the cancellation?

Just then the breast clinic called. “We have a Suzanne Brown here, but her procedure has been cancelled.”

“Let me talk to her”, I said. Very carefully, I explained to Suzanne what had happened when Dr. Dinsmeyer called me. I apologized for the confusion and her inconvenience, adding that she did get some good news after all from a full-time breast radiologist about her mammogram findings.

She seemed okay with that, and I was left more with my own concerns about how errors in communication like this might be avoided in the future.

Today I had most of the afternoon blocked off for one of my least favorite things to do as a doctor, a deposition in a case where a patient of mine is suing another community member for injuries from a car accident a year and a half ago. Two city lawyers and a court stenographer were scheduled to grill me for three hours in our combined lunch and conference room.

I waited and waited, wondering if the attorneys had underestimated how long it takes to drive down here from the city on winter roads. Twenty minutes into our scheduled appointment, Autumn called my patient’s attorney’s office to see if they were delayed.

“It’s been cancelled”, she announced after a brief phone call, “last week – they just forgot to tell us!”

When 87-year old Hildegard Mott was discharged from the hospital for the last time she was given less than six months to live. Her aortic stenosis was severe enough to cause chest pain at the slightest exertion, yet if she took nitroglycerin she invariably passed out. Sometimes she would pass out even without taking nitro.

She was given a prescription for liquid morphine to take if her chest pain became unbearable and Hospice nurses started to visit her a couple of times a week in her modest but spotless trailer in the Rainbow Hills trailer park just outside town.

The hardest part about coming home was that Sumner, her husband, friend and soul mate, wasn’t there. He had died from a stroke just before Hildegard ended up in the hospital. 

My house calls were special for both of us. She treated me like a son and never failed to tell me about her Scandinavian grandparents. Her own two sons live far away and I live an ocean away from my own mother. She told me of her symptoms and her worries. She knew her remaining days were limited; I had to certify a number less than the cutoff for Hospice services. Ironically, it was the hospitalists’ idea to sign her up for Hospice, but I ended up certifying her prognosis.

She often spoke of Sumner in present tense. “I know he is here”, she often said. “He comforts me when I am sad and calms me when my anxiety builds up. He helps me remember where I put things.”

She seemed to hold her own as far as her symptoms went, but her days were long and her nights were lonely.

“I don’t know why I am still alive”, she would say. “If God wants me, I’d be happy to go.”

“He must still have plans for you here”, was my usual reply.

Many months went by and Hildegard had very little chest pain. She almost never took morphine and she seemed to know exactly how to pace herself. She always looked for the bright spots in everything that happened and lived her life in one-day increments.

Hospice finally terminated her case and she saw fewer interruptions in her solitude. She was weaker, there was no question about that, even though the more dramatic manifestations of her condition were less noticeable. She decided to look for placement in a nursing home.

That was four years ago. Hildegard settled in quickly at Leisure Ledges, and I visited her there now and then. Her favorite visits were the ones when I brought samplings of traditional Swedish foods. She always had visitors in her room because of her positive demeanor and kind interest in others.

Last Saturday night, almost five years after the hospital doctors pronounced her terminal, 92-year old Hildegard died in her sleep.

John and Elizabeth Tuttle had only one son. Noah was born with pneumonia and he didn’t look like other babies. His nose was thin and his ears were pointed. He was very small and he didn’t cry the way other babies do.

Noah never learned to speak in full sentences and he never grew up to find his own way in the world. He stays at home with his mother and father and spends most of his time playing quietly with his toy animal collection, his sticker books and his View Master 3-D pictures. He always seems happy and always has hugs and kisses for his parents.

A few years ago he developed pancreatitis and had to stay in the hospital for almost two weeks. He cried for his parents, who, both in their eighties, were too exhausted to stay with him in the hospital all the time.

I visited Noah on the surgical ward during that time, and I can still vividly see the image of the small, elderly-looking man with a plush zebra in bed with him, his hands without wrinkles or calluses, his face without beard growth and his eyes so deep and sad.

“You my doctor!” He smiled when he recognized me.

“How are you feeling, Noah?” I asked.

“Noah’s sick” was all he said.

“You’ll be okay soon; you’ll be home soon”, I promised.

John Tuttle is a soft-spoken man with a thick Yankee accent, who never wastes his words. He hates to take pills, and he is on several. He should be on more because his blood pressure is still too high. He blames it on stress and I agree that his plate is full. Once, about a year ago, he spoke to me of his biggest fear:

“I worry about Elizabeth’s heart and I worry about Noah. What will happen to him after we’re gone? I hate to think of him in an institution. He’s always been with us.”

A few months ago Noah suddenly gained weight. His legs swelled and he became short of breath. His chest x-ray showed only a mild enlargement of his heart, but his echocardiogram showed a severe weakness of his heart muscle and a critical aortic stenosis. The main valve of his heart was closing and choking his entire circulation.

After a few days in the hospital he was breathing comfortably again, but he was homesick and cried when his parents weren’t there.

There had been no warning. There was no heart murmur. Noah had always lived a very sedentary life. His aortic valve had calcified without causing the usual symptoms until he became short of breath just playing in his room.

The chief of cardiology, Dr. Thomas Wentworth, said that an aortic valve replacement could be done, but because Noah’s heart was so weak there was little hope that it would recover. It was not likely his symptoms would go away by just replacing the valve.

I met with John and Elizabeth shortly thereafter. They had made up their minds not to put Noah through open-heart surgery with such an uncertain outcome. They wanted us to manage Noah’s heart failure with medications.

Noah is out of the hospital. He takes several new medications and is breathing comfortably. Noah talks about not liking the hospital. He stays at home with his mother and father and spends most of his time playing quietly with his toy animal collection, his sticker books and his View Master 3-D pictures. He always seems happy and always has hugs and kisses for his parents. 

John and Elizabeth wonder quietly whose journey will end first.

At the nursing home the other day I saw a young man in blue scrubs push a laundry cart up the hall. He must be new, I thought, trying to catch a glimpse of his name tag. As he approached the nurse’s desk he made a sudden noise.

“Bless you”, one of the nurses said.

The young man smiled briefly. “I didn’t sneeze, but thank you. I am probably the most blessed person around.”

I wasn’t sure what that little exchange was all about and continued reading the hospital discharge summary of my new admission. In the periphery of my visual field I saw the young man starting to sort through the items on his cart.

Suddenly he made the same unusual sound, kinked his head and snorted twice again before picking up a pile of clean towels.

Tourette’s syndrome, I thought to myself. Naturally, people must mistake his verbal tics for sneezes all the time and say “Bless you”.

I remembered the day I made that diagnosis for the first time.

It was a bitterly cold Tuesday morning in early December. I was doing a rural rotation six months into my residency, back in my hometown in Sweden. One of my assignments was to hold a weekly clinic for the inmates at a remote prison in a wind-battered coastal town twenty miles from our hospital.

Five miles into my commute the heater in my second-hand Volvo wagon was still blowing cold air, and the base model didn’t come with heated seats. Shivering, I turned the radio on for some distraction from the cold. Just then, the announcer came on the air and said that John Lennon had been shot.

I drove the remaining fifteen miles in a daze, unaware of the temperature or the scenery. I walked up the stairs to the prison clinic and settled into the sparse consultation room. Through the surprisingly thin walls I could hear the clinic nurse escort my first patient of the morning down the hall and into the adjoining exam room.

My daily schedule listed each patient’s name, birth date and chief complaint. As I glanced down the list I heard strange sounds coming from the exam room. By now the inmate was alone in the room – the nurse’s clogs had echoed down the corridor moments before.

Through the wall to my right I heard muttering and a series of coughs and snorts, each punctuated by a sudden, unintelligible monosyllabic outburst.

I began to worry. I was about to enter the room with this individual, and I didn’t know how safe that might be. Was this a violent, uncontrollable person I was hearing, tormented by horrific hallucinations and delusions, likely to snap at any moment? I looked at the patient roster, where his chief complaint was listed as “tics”, which I knew very little about.

I looked around the office. There were only two books on the blond government issue office desk – a Swedish drug reference and the Merck manual, in English.

I searched the index of the Merck Manual and hurried to the section about tics. There, I quickly found exactly what I was hearing through the wall to my right: Gilles de la Tourette Syndrome. I vaguely remembered hearing something about it in medical school, but I had never seen a case of it, and in 1980 there wasn’t the public awareness of this condition that there is today.

Armed with my newly found knowledge about the condition and its treatment, I entered the room, facing only my fear of getting hurt.

The young man seemed gentle and soft-spoken. He greeted me politely and I introduced myself. He told me he had these tics that nobody seemed able to help him with. Suddenly he snorted, kinked his neck and swore under his breath.

“I know what you’ve got”, I said. “I think I can help you.”

“Really?” he said and smiled with tears in his eyes.