Standing in front of my patient’s home, I reach out to ring the bell. On the other side of the door live a man and his wife, who have been waiting patiently for my arrival. I hesitate for a moment before pressing the button.
As I wait uneasily for the door to open, I think to myself that this is the first time I make a house call on my patient Bernie, and it will be the last.
Earlier in the day, as I sign on to the office EHR at my clinic, a message pops up on my computer screen: “Please call Debbie D … Patient in rapid decline … wants defibrillator off.”
This is not an uncommon request in my line of work, as I care for many elderly patients with serious heart conditions. In response to such inquiries, I often sent in my trusted defibrillator manufacturer representatives to complete the task.
But on this day, I have a different plan.
After reading the message, I close the dialog box and glance at my schedule for the afternoon — 30 patients packed into 4 hours, all familiar names, all waiting for months to see me. It is going to be a long afternoon, or more correctly, a long evening. Struggling to prioritize things in my head, I walk into room #1 to see my first patient.
In between the 10th and 11th patient of the clinic, I quickly review Bernie’s chart before giving Debbie a call. I introduce myself to the hospice nurse, and inform her of my plan to personally visit Bernie that evening.
Elated, Debbie replies, “I will let his wife know.” And then she adds, “Arlene will be very happy to see you!”
I hang up the phone to ponder the situation and reminisce on Bernie, who has been in my practice for many years. He was a typical patient referred for defibrillator surgery — history of heart attack, bypass surgery, and heart failure. After I implanted a defibrillator, his condition stabilized over the next few years. The last time I saw him was 3 months ago. He was cheerful, upbeat, and clinically stable.
Back at the afternoon clinic and in the midst of examining my 20th patient, my phone suddenly buzzed and startled me. A text from my wife throws my schedule into a loop and my mind into frenzy.
“Don’t forget Alex’s back to school night at 7 p.m.” The short text reads. Oh crap! I have completely forgotten about my son’s school program this evening!
As physicians, we have all learned to multitask, a critical survival skill in medicine. But no matter how hard we try, we still have not figured out how to be at two places at the same time. Hence, very often, we have to choose.
On this afternoon, the choice between going to my son’s school night and visiting a dying patient is not difficult, for I have only one shot at the latter. Besides, my wife can always take notes for me.
In preparation for the visit, I refresh myself on my patient’s medical history. Images of the old man flash vividly before me. A soft spoken, easy going gentleman in his 80s, Bernie was one of the most pleasant patients in my clinic. The quarterly visit for his defibrillator check had always been congenial, and sometimes even fun.
One day, Bernie surprised me with a statement. “Dr. Ong … I like you because you look like my brother,” the man said. He then turned towards his wife for confirmation, “Doesn’t he kinda look like Jerry?” Arlene smiled back and nodded.
Really? A physician of Chinese descent looking like the brother of a Jewish patient?
Nevertheless, I was happy to take the credit. In my career, patients had liked — or even disliked — me for far stranger reasons than this.
On the other hand, that conversation opened up topics outside of medicine, which proved far more interesting than those on heart failure and defibrillator. Bernie and I talked for half an hour about his life, his career, his marriage, and how he retired after his first heart attack. I suggest I might make a house call on him some day.
All of a sudden, a buzz on my hip brings me back from memory lane. It is another text from my wife, which reads “Are you going tonight?” I struggle for a good answer, but procrastinate to reply. For, I do not know how to explain a complicated situation in a short text message.
An hour later, as I finish up with my last clinic patient of the day, I turn on my iPhone to figure out how I can be at two places at the same time. The Waze app tells me it will take 30 minutes to reach Bernie in Simi Valley in the evening traffic, and another 45 minutes to get to the school in Calabasas from Simi.
“I don’t know,” I finally send a short text back to my wife. This is the only honest answer.
Then my mind drifts back to the last time I saw Bernie, or, more correctly, Bernie and his wife Arlene. Married for 25 years, they were inseparable. It was the second marriage for both of them. As the story goes, Bernie and Arlene had known each other for many years while being married to their previous spouses. Twenty-six years ago, they became widowed, serendipitously, on the same day — a coincidence that ultimately brought them together.
Over the years I had known them, Bernie and Arlene always came together on every office visit, he sitting on the patient exam table, she standing faithfully by his side. The image of the two joined at the hip had been seared into my memories for years, but that image was about to change.
Even though on these office visits, Bernie always appeared cheerful and clinically stable, beneath the calm was an incurable disease called myelodysplasia that was slowly killing my patient.
Returning from deep thought, I find myself in the company of hundreds of cars heading at snail’s pace towards Simi Valley. My car’s GPS and my phone’s Waze differ in their opinions as to the best route to take. In life, as in medicine, there is always more than one solution to the same problem. In the end, we often get to the same designation regardless of which route we take.
And on this afternoon, neither navigation system gets me to the right place, because of an unmapped tall wall separating two streets by Bernie’s house. I eventually find my way to a quaint community in the heart of Simi Valley. There, tucked away at the end of a cul-de-sac, is my patient’s house, a cute little cottage with a small but well manicured yard.
The door bell rings and Arlene comes to the door. She hugs me as I enter Bernie’s house for the first time. This elegant lady is no stranger to the tricky world of medicine — she herself is a liver transplant recipient. She goes on to explain how Bernie had struggled, physically and mentally, during the months since our last visit.
For years, Bernie battled his mylelodysplastic syndrome, a disease affecting red blood cell production which required intermittent blood transfusion. As his bone marrow failure progressed, the frequency of transfusion increased, from every few months to every month, then every week.
In the process of fighting an unwinnable war, Bernie lost a quarter of his weight. Finally, Bernie had enough.
“I’m very tired,” one day, out of the blue, Bernie told his wife of 25 years, “and I don’t want any more transfusions …”
That critical decision put a stop to the endless rounds of doctor visit and the futile cycle of phlebotomy and transfusion.
In life, no matter which route we choose, we often end up in the same destiny. The best route may not always be the ones given by our external GPS.
After greeting Debbie and members of Bernie’s family, I walk into my patient’s room. There, in the middle of a large hospital bed lies a man, a diminutive figure just a shadow of his former self. His body ravaged by the relentless attacks on his bone marrow, Bernie looks truly tired and needs a long nap.
“Bernie,” I proceed to greet my patient, fulfilling a promise I had made to him a few months before.
Unfortunately, by this time, Bernie has already slipped into a coma; he has not uttered a word for a day. The man, however, appears comfortable, as if sleeping snuggly in the arms of his Creator. He is at peace.
This is the first time I have visited a patient on his “death bed” at home, even though I had done it many times in the hospital setting. And what a difference it is! Before me is a picture of ultimate serenity — a man completing a long journey in the comfort of his own home, surrounded by friends and family. I contrast this with the alternative scenario — a man dying in the chaos of an ICU, imprisoned by tubes, alarms, CPR, ventilators, and IV drips.
Reflexively, I reach for my patient’s radial pulse, a ritual for a physician who has cared for tens of thousands of cardiac patients. For me, taking the pulse is like a handshake. It is a quick way to see if my patients are OK, a simple first step towards fulfilling my fiduciary responsibility of ensuring the well-beings of my patients — whether they are alive, dying, or dead.
Right there on Bernie’s right wrist, I detect a calm, steady, and reassuring pulse, being guarded by the faithful defibrillator I had implanted in him two years prior.
Then, under the watchful eyes of an entire room, I power on the defibrillator programmer, interrogate my defibrillator for one last time, select the “off” setting, and then I click the “program” button.
“Press this button again to confirm,” a message pops up on the programmer screen as the man-made machine appears to question the clinical judgment of the doctor. I press the button again without hesitation.
I then examine my patient for one last time, paying particular attention to his facial features, in search of any traces of genetic resemblance to mine. But, again, I find none.
Bernie is Jewish and I am Chinese. He is Caucasian and I am Asian. But in the eyes of our Creator, we are all brothers in the same humanity.
That evening, I drive from Simi to Calabasas, by way of Box Canyon Road. While ascending the Santa Susana Pass, I witness one of the prettiest sunsets in recent memory. Below me are thousands of glittering lights of the valley beautifully poised against the glorious hue of the setting sun.
Those shimmering city lights strike me as being the teardrops of humanity, in celebration of the extraordinary journeys of life and death, and the incredible gifts of living and dying.
That evening, I did make it to Calabasas, just in time for the second half of the school program. As for the first half, I will have to take a makeup session with my wife.
James Ong is a cardiologist.