Doctors are storytellers and every story starts with a case. The stories vary, of course. Some of them are about the patients: the prisoner who swallowed razor blades, the roller-skating champion who died of pancreatitis. Other stories are about us: how I learned to operate on neighbors when I lived in a town of 10,000.
Regardless of content, we tell two versions of almost all of our stories. The formal version is just fact. It is a dry rendition of signs and symptoms, tests and treatments. This formal version has a prescribed structure and its own distinct language. Almost all the words, in fact, are from Latin or Greek.
Much of medical school is devoted to learning this language so that we can communicate in a specific and technical way about the complex problems that we see.
The informal version of our stories is what we feel. We don’t have to study to tell this story. The words aren’t from the ancients. They’re regular old Anglo-Saxon words, expressing basic human emotions. I was mad when I saw swastikas tattooed all over the razor-blade swallower. My resident and I cried at the death of the roller skater. And operating on your next-door neighbors – it’s scary. What if they have a complication? Will we still be friends?
Mostly, the two versions of medical stories exist in two separate spheres. We relate the formal version on rounds and in conferences. The informal version bursts out in the locker room or over supper when we finally get home. The formal version has a written form, which is the medical record. The informal version is mostly oral and ephemeral.
Over the 30 years since I began medical school, I’ve become more and more interested in the inner lives of doctors, which are mostly revealed in our informal stories. Occasionally, though, the medical record contains clues about the doctor experience. Though their focus is always the patient, its physician-authors sometimes give away a little bit of what they felt as they were writing. In some subtle word or phrase, they give us access to what their day was like, to the emotional side of the doctor experience.
Recently, preparing for a conference, I reviewed the record of a patient from a few years ago. The patient was bench-pressing free weights when he dropped a 250-pound barbell onto his neck. It crushed his trachea and he couldn’t breathe until someone snatched it off him and then called EMS.
In the ER, he was breathing, but only able to whisper. His neck was barely bruised but each time he exhaled, the skin over his trachea blew up like a balloon. Everybody in the ER stared at his neck, riveted, as his skin puffed out like a sail in a gust of wind.
His inflating neck was ominous. It meant that his trachea was torn. Air was leaking from it into his neck, where it was trapped under the skin. Without intervention, the accumulating air would compress his trachea and smother him and everybody who saw his neck knew it. His presence made people nervous, because no matter how good you are and confident in your doctoring, it is anxiety-provoking to stand between death and a young person.
The patient went straight to the operating room and lived.
“Great save,” I said to to the ENT surgeon when he brought the patient to my ICU. “Thanks,” he responded with relief.
When I reviewed the chart, I expected the usual – Greek and Latin words and none of the anxiety that people had suppressed as they cared for this patient. What I found instead was a nugget of feeling, hidden in the note of the emergency physician. She had described the weightlifter’s puffing neck as “frog-like.”
She could have used formal words to describe it. She could have said that the neck was “expanding with exhalation.” She could have documented “subcutaneous emphysema” or “crepitus” – the crinkly , crunchy feeling of air under the skin. But she chose “frog-like,” a word from Old English, from our regular non-doctor world.
I smiled when I found “frog-like” hiding in the medical record. It’s a phrase I’ve never seen, though I’ve read thousands of records, and I bet the doctor chose it instinctively. Latin and Greek were too formal for this freakish neck. “Frog-like” gets your attention. It’s unique and startling, like the patient’s neck, and it conveys to whoever read the record the “holy cow” feeling that swept over her when she saw the patient.
“Frog-like.” It was the perfect word. In “frog-like” I could see the outside of the patient’s neck and the inside of the doctor.