NEAL CONAN, host:
This is TALK OF THE NATION. I'm Neal Conan in Washington. Doctors, nurses, health care workers usually remember that one patient. One of Sherwin Nuland's most memorable was a young man with a gruesome and highly unusual condition in his chest. So unusual, the then young surgeon thought it might come to be known as Nuland Syndrome. He learned better.
In fact, he says he learned from every single one of his patients, but yes, some more than others. He's collected the stories of his and his colleagues' most memorable patients in a new book, "The Soul of Medicine," where he channels Geoffrey Chaucer's trip to Canterbury and presents "The Cardiologist's Tale," "The Dermatologist Tale" and so on.
He joins us in just a moment to present some of his tales from the bedside. Later in the program, dumb mistakes to avoid when you file your taxes and, well, some more interesting questions, too. But first, if you're a doctor, nurse or a health worker, we'd like to hear from you too about that one patient and about what you learned.
Our phone number, 800-989-8255. Email email@example.com. You can also join the conversation on our Web site, that's at npr.org, click on TALK OF THE NATION.
Dr. Sherwin Nuland is clinical professor of surgery at Yale University School of Medicine. And he joins us today from the studios at Yale University in New Haven. And Dr. Nuland, nice to have you back on TALK OF THE NATION.
Dr. SHERWIN NULAND (Clinical Professor of Surgery, Yale University School of Medicine): Well, what a pleasure, Neal. Thank you.
CONAN: And that one patient, well, his condition was awful, but what you learned is, in fact, there is this sort of false idea that we have about medical history that everything has somehow been written down.
Dr. NULAND: Oh, of course. We're so impressed by what we've been able to accomplish in modern times that there is nothing that we expect has ever happened before. And we're always shocked when the literature is full of the case that we think is unique.
CONAN: Your case that you thought would be named Nuland Syndrome. In fact, your professor - your teacher there hauled out, well, a very thick and very old book and pointed out this had happened to a soldier, in what, the - 1870, was it?
Dr. NULAND: Oh, far before that. It was one of those many wars that used to occur in the 15th and 16th century between Catholic countries and Protestant countries killing each other off. This major had been hit with a harquebus shot, a primitive rifle and actually died of the problem that my patient was able to be diagnosed for and treated successfully.
CONAN: And your book is filled with these stories of patients and lessons learned from them. Why did you decide to tell them in the manner of "The Canterbury Tales?"
(Soundbite of laughter)
Dr. NULAND: When I was a young house officer, an intern, a resident, it was very common - and I think this happens in almost every teaching hospital - for group of us get together at what we call the midnight table or the midnight supper and swap the craziest things that had happened to us during the day. So I accumulated a vast pile, I can call it, of stories.
And as I went through my own training and my own 30 years of practice, more and more stories kept coming out. And I used them occasionally in other books that I've written because they epitomize the point I was trying to make. But it seemed that there were some that I should put together in one volume, so that people could see the extraordinary range of experience: emotional, physical, medical that we have as physicians, and we'll always continue to have.
CONAN: I was - well, some of them are also very moving. There's one that's in "The Neurologist's Tale," and in fact, there are two stories and both of them are quite moving. But one of them is the story of, well, it's a couple who met during the Korean War and lived an entire life together, and had children, and grew up and - just the, you know, the great American life you could only imagine. Then the wife dies and this - to the great shock of her husband, who a few months later starts to have - well, starts to have hallucinations.
Dr. NULAND: Exactly. And perhaps I might read the lines that end the story. He finally did recover, quote, "Though fully recovered, he had begun three days later to experience daily well-formed hallucinations, always exactly the same in nature. They were of Kate's face. I recommended that he take a drug called Perfenazine, which virtually guarantees that the hallucinations will stop. And it'd be a surprise to anyone reading this tale that he refused to take the drug. I'd rather see my Kate, he said."
CONAN: It's a wonderful story. And there are, after many of the tales in this book and most of them, again, are tales told by other doctors, you come back and write about some of the ethical dilemmas that are posed and some of the solutions that we might've come up with more - in more recent times. But because some of these stories are pretty old, it's interesting that after that one you didn't write anything.
Dr. NULAND: Well, there are bio-ethical dilemmas, actually, involved on a subtle level or sometimes on a much more direct level with virtually every patient an experienced doctor sees. It's easier to see them as - in that bio-ethical sphere, when you're a little older and you've had some contact with that discipline. But nevertheless, there's no interrelationship between two people, especially an interrelationship so fraught with complex issues that does not involve ethical ways of looking at each situation and sometimes with very difficult decisions to follow.
CONAN: And these are - become intimate relationships, very often.
Dr. NULAND: Well, actually, that's the ideal relationship. There's this mutual give and take where the doctor and the patient are both teachers, one of the other. The patient is teaching doctor about himself. The doctor is teaching his patient the ways in which a medical care situation can help him a great deal, teaches him. I hope that there's a pastoral role for each physician. The physician guides his or her patient through the most dangerous parts of the illness.
CONAN: Tell us the story of "The Cardiologist's Tale."
Dr. NULAND: That's a most extraordinary story, and I find it very inspiring because it brings out what is the best of the practice of medicine, where the doctor herself or himself feels not just an empathy for his patient, but he feels he knows how to - and here's that word again - guide the patient through the worst of a dreadful situation.
This story involved, as I tell it in the book, the rare book librarian at a school university called Canterbury - a thinly disguised Y-A-L-E - who had had some very interesting adventures procuring old books and dealing with con artist, and book dealers and things of this nature. And he was very seriously ill with cardiac disease, just got worse and worse over the years as his doctor, Dr. Harry Kronberg(ph), was treating him.
And finally it became necessary to put a pacemaker in because he had some terrible troubles with his rhythm, but he still continued to get worse, although the rhythm remained pretty good, pretty stable. And at one point, Kronberg realized there was nothing more he could offer his patient. And this man, this librarian would come first every month, then every week, and Kronberg scratched his soul trying to figure out what he could do to make this man's last months more comfortable, more worthwhile, more in the sense of contributory to everybody around him, as he had always done.
So on this final visit, he tore a piece of prescription pad off and he wrote next to the RX, one set of memoirs. And the patient immediately brightened up, became cheerful, as a matter of fact, where obviously he had been quite saddened and morose before that.
He went home and began dictating his memoirs to his daughter-in-law. And then it took only three months, he came into the office with a photocopy, the first photocopy of a complete set of memoirs, as though he was now ready to die but having had these glorious three months in which he relived his life.
And they decided they would turn off the defibrillator at a given moment, and they could do that, of course, from a distance, and the patient went home to await this happening, and several hours before they were due to turn it off, he has a spontaneous dysrhythmia and died peacefully.
CONAN: To one of the stories in Sherwin Nuland's new book, "The Soul of Medicine: Tales from the Bedside." If you're a doctor, nurse, health-care worker, there are stories that you've told around the midnight table. Well, it's our late-afternoon table here on the East Coast. Give us a call, 800-989-8255. Email us, firstname.lastname@example.org. Let's begin with Ann(ph), and Ann's with us from Denver.
ANN (Caller): Hi.
CONAN: Hi, Ann.
ANN: I worked as a registered nurse for 25 years, but in January of 1962, I was working as a nurse's aide, and they brought a schizophrenic man into our ward. He had been running through the fields, barefooted, in the middle, you know, in the middle of winter for about a week, and it took four huge sheriff's deputies to bring him in, and I was scared to death of this man.
So one day, when it was quiet, the nurses made me go in and offer him a drink of water. And I was so scared my voice shook, and my hands shook. And he'd been there for about six weeks, and that was the first time he spoke, and he said I don't care for any right now, thank you.
And it made me realize that that man could feel my fear and understand it, and no matter what we look like, we have that humanity within us, and if we just respect each other, it comes out.
And so for most of the time I worked psych, I just loved it, and you know, that type of experience happened over and over and over again. He really changed the course of my life, I think.
CONAN: And Dr. Nuland, there's any number of stories in your book, and I'm sure stories in your life, too, of people you think of every day whose lessons learned informed so many things you do from then on.
Dr. NULAND: Exactly right. One of the unfortunate things about medicine, and it's largely true of nursing, too, is that society has put us on a level higher than most of our patients, and a lot of doctors and a lot of nurses and a lot of patients can't overcome that. And in a short relationship, it often is not overcome. But if the disease goes on for a while, or a patient is hospitalized and people just do the kinds of human things that your callers are describing, everything begins to change, and it becomes a small society of equals.
ANN: Am I still on the air?
ANN: When people would float, you know, nurses or nurse's aides would float to our unit, and they'd be afraid of the psych patients, and they'd be afraid they would say something wrong - I would always tell that there would never be one thing that they could say that would, you know, devastate a patient.
They would have to say it over and over and over again or whatever, so not to worry about what they'd say. And if they gave them respect, just basic respect, they'd be in like Flynn, and they wouldn't need to worry. And you know, I mean, it proved true many times over.
CONAN: Ann, thanks very much for the call.
ANN: Thank you.
CONAN: Bye-bye. We're talking with Dr. Sherwin Nuland about his "Tales from the Bedside." 800-989-8255. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.
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CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington. We're speaking with author and doctor, Sherwin Nuland. His new book, "The Soul of Medicine," is filled with stories he's collected throughout his long surgical career and many of the stories of his friends and colleagues from dermatologists, cardiologists, pediatricians. They are stories from many bedsides. If you'd like to read one of them, "The Surgeon's Tale," it happens to be Sherwin Nuland's, head over to our Web site at npr.org. Click on TALK OF THE NATION.
If you've worked as a doctor or a nurse or health-care worker, tell us about that one patient whose story really stuck with you, 800-989-8255. Email email@example.com. Or you can to go to npr.org and click on TALK OF THE NATION. And let's see if we can go now to Judy, and Judy's with us from Norwich in New York.
JUDY (Caller): Yes, hello.
JUDY: I have a very simple experience that happened over 40 years ago. I was working as an oral surgery assistant on Long Island, and he did tooth extractions and mouth surgeries and so forth, and of course, everyone that came into the office was very, very nervous. Nobody likes the dentist. And they would all say oh, I hope this doesn't hurt, and I'm so nervous and so forth.
Well, one morning, an elderly gentleman came in, and I took him into the room where the doctor did the X-rays. And I got him draped and ready, and he's just calm, sitting there, small talk, no expressions of fear of any kind.
So we talked a little bit, and then I said I have to ask you. You're the only one who hasn't come in here and said how nervous you are and how anxious you are. I said why is that?
And he said something that has come back to me many times. He said you know, we have to do things sometimes that we just don't want to do, and he said for goodness sake, be quiet, deal with it and get it over with. And that's how he went through this little surgical procedure. And he left smiling, and I thought wow.
You know, we have to deal with things. Anxiety and getting frustrated and that, it makes it worse. So if we can just deal with it quietly, we know that it's going to be over with soon. And it was just a little philosophy I wanted to pass on.
Dr. NULAND: Well, it's a great piece of philosophy, but I'd like to add something you may not have been aware of the time, and probably now you are. For whatever reason, this man sensed something about you, and perhaps the dentist as well, that he could trust, and the element of trust is such an important thing in blowing away fear.
JUDY: Yes, you're right.
Dr. NULAND: I tell a story in the book of a man who had severe meningitis, and they really thought he was going to die. And he kept saying to his doctor, you're going to get me through, you're going to get me through, and the doctor was certain he couldn't possibly do it. And lo and behold, the man had a spontaneous recovery.
And it reminded me of that old dictum of Hippocrates: Sometimes a patient just gets better because of his trust in the doctor. And there's a lot more of this kind of thing than we would imagine. And I would also think that it may be at least as true of nurses as it is of doctors, because nurses are emotionally, very often, closer to a patient than so many of our high-tech patients.
JUDY: Well, they see more of them, and can I add one other thought?
JUDY: It's a Scripture. I'm not preaching, but it's very practical advice in the Bible. It said a joyful heart does good as a cure. And that's also been proven. If you have a good attitude and keep your spirits up, your body will reflect that. So that works, too.
CONAN: Judy, I heard a similar piece of advice from a schoolteacher dealing with a young girl worried about stage fright, and it simply came down to the fact of her saying well, just get on with it.
(Soundbite of laughter)
JUDY: Yes, that's true. All right, thank you very much. This has been really enjoyable.
CONAN: Thanks, Judy, appreciate it. Let's see if we can go now, this is Rick, and Rick's calling from San Antonio.
RICK (Caller): Hi. Thanks for allowing me to speak. I wanted to share a story about how you cannot allow yourself to be so overwhelmed and stay so busy as to ignore your intuition or signals that come to you from the outside.
In this particular case, this patient had not had her allergies checked from the time she was admitted, nor was it in her physician's assessment or the admission assessment. And in the morning, I went to start her penicillin drip, and I prepared everything, checked her chart. There was nothing on her door. She had no bracelet on indicating she was allergic.
So as I was ready to plug in the IV and get it started, I asked her are you allergic to anything, and she says oh yes, severely allergic to penicillin. I've got this.
She showed me the scar on her throat where she'd had a tracheotomy before. And I just remember feeling the blood leave my face, and I immediately pulled away, you know, and I said I'll be right back, you know. And I went outside and caught my breath.
But you know, it's just one of these things that - that much of a dosage would have most certainly killed her or put her into a coma at least, but you just cannot be so busy in your care of patients as to ignore those kinds of signals from the outside. You know?
Dr. NULAND: Well, one of the important things in a health-care worker treating a patient - they've got to obviously have knowledge - they've got to have a sensitivity to another human being, a shared humanity, as it were, and a great deal of empathy.
Now if you're very, very busy, your knowledge isn't going to disappear, but your sensitivity and your empathy sure will. And it's pretty clear that in this situation, you were not only going through the drill of asking the right things, but essentially you felt yourself emotionally in contact with this person.
RICK: And I think the talking part. It doesn't matter how busy you are if you talk to a person. If you walk in and smile and say something, I think you do get universal or divine guidance then, taking you to that place where you need to be.
Dr. NULAND: Well, there are ways not to look too busy, and it's something that you learn with a lot of training. That although you may be busy on a particular day, you allow yourself a certain amount of time for this patient or that patient. And as you walk into their room, you do so in a very relaxed manner, sit on the side of the bed, talk to them about one thing or the second thing. And both of you come away feeling like you're two human beings who've had a conversation, and you've gotten all the information you need, and you've transmitted all of the information you need probably in exactly the same amount of time.
CONAN: Rick, thanks very much.
RICK: Thank you. Thank you for allowing me to share.
CONAN: Sherwin Nuland, you'd think that doctors, or some of us outside the profession might think that doctors, given the opportunity to recount their most memorable patients, that so many of them would come up with the time they made the brilliant diagnosis or the life-saving surgery.
There are any number of doctors who go out of their way to tell stories that do not reflect well upon them, and I was wondering if you could tell us the tale of the anesthesiologist.
RICK: Well, this tale - and I'll share a secret with our audience, Neal - is actually my tale. I disguised all of the doctors and patients, but in certain cases, I've used stories of my own experience.
I was working at a hospital in London on the cardiac surgical service, where the chief of the service was a very distinguished - in fact, he was Lord something-or-other, British chest surgeon. And one afternoon, when we were through with our day's work in the operating room, we got the message that the daughter of the governor of Malta or Gibraltar - I can't remember which - a little girl of about seven, was being flown up because in trying to blow up one of those pool animals that float kids, she had sucked in the cap, and it was lying down in her left lung.
And he was an expert at putting what we call a bronchoscope, a long tube, down into the lung and grabbing these metallic foreign bodies and taking them out.
Well, he actually did that. We put her to sleep, and he put his forceps down into the lower part of the left lung, and he pulled this metallic tip way up into the windpipe, right up into the trachea, and it slipped out of his forceps and dropped down the other side.
And once it was down the right side, it was just deeply stuck, and he couldn't get it out, and it was necessary for him to open this little girl's chest and take the top off, the screw top off, mechanically. And then he had to go out, and not only feeling terrible about what he'd had to do to the little girl, but he had to go out into the waiting room and tell the governor of Malta or Gibraltar what he had done.
And here he was, one of the most esteemed chest surgeons, well really not only in the British Isles but in the world, and that's why I had gone over to be working with him.
CONAN: And yet he said the lesson to be learned is don't lose your concentration even for a second.
Dr. NULAND: Precisely. You know, you can't afford to do that.
CONAN: Let's get Maureen(ph) on the line, Maureen with us from Tulsa.
MAUREEN (Caller): Hi. Thanks for taking my call.
CONAN: Sure, go ahead please.
MAUREEN: Hi, I'm a registered nurse here in Tulsa, and I think there's a lot to be said for what doctors and nurses do at the bedside in terms of healing. But another thing that we do is we help patients to have a good death, and I think it's important for people to know that a good death is possible.
And I kind of had an out-of - kind of a supernatural experience, if you will. I had sent a nurse down to give pain medication to this man who was terminal, and he was unresponsive, and she came back, and she said he was talking. He was saying soon we'll be together, and it had reminded her of something in the Bible.
So, she looked up her verse and she went back and told his wife. And she said, well, that was the verse above our wedding invitation when we got married. And the whole room was just wowed and at peace and in awe.
And after that, his pain was in control and we moved him to another floor, and he died shortly thereafter. But there was peace there, and he was in peace after that, and you could tell by his physical symptoms of his body.
MAUREEN: It was pretty amazing.
CONAN: Dr. Nuland, not just this book - hardly your first. Indeed, you became very well known for writing a book called "How We Die." And Maureen's patient was fortunate.
Dr. NULAND: Maureen's patient was fortunate, but certainly was not the only patient in whom such a phenomenon has been seen.
For whatever psychic or subconscious reason, many patients will come out of the depths of something either very painful or very emotionally taxing, and have what you might call a spiritual arousal - see people from earlier in their lives, just get an extreme feeling of peace - and their last moments can be very peaceful.
My general sense about dealing with dying patients, I think, can be expressed in a few words. In the Hebrew, the word for funeral is levaya, which means to accompany.
And I think it is our responsibility - actually, it's our privilege as caretakers - when we recognize that we can no longer bring a patient out of the disease he or she is in, that we should accompany them during those last days and weeks of their lives.
And when people accompany each other or one another, they're on a completely equal footing, and there is so much gratification on both sides of this issue -both the physician who learns so much, feels that she or he can contribute so much, and the patient clearly who benefits from the what the physician or nurse is doing.
CONAN: Maureen, thanks very much for the call.
MAUREEN: Thank you very much.
CONAN: Appreciate it.
We're talking here with Dr. Sherwin Nuland. His most recent book, "The Soul of Medicine: Tales From the Bedside."
And you're listening to TALK OF THE NATION, which is coming to you from NPR News.
And we'll talk with Michelle(ph). Michelle, with us from Mcmillan in Massachusetts.
MICHELLE: Yes, hello. Hi. I just wanted to comment on what the doctor said as far as, you know, when you're busy sometimes the empathy goes away but the skill doesn't.
At times, however, the skill can go away when you're too busy. I'm only saying that because based on an experience.
We had a patient on the floor - I'm a cardiac nurse - and the nurse was so busy on the 3:00 to 11:00 shift. She had a very heavy patient load. And patient had congestive heart failure. He also had a biventricular pacer. And he was showing all the symptoms of, you know, acute CHF and - which is congestive heart failure.
The, you know, the nurse was so busy and she's just basically looking at, okay, he's short of breath. Let's get him some neb treatments, so on and so forth, and completely missed the fact that this patient also had a biventricular pacer.
It's just a matter of taking a look at the monitor and saying, oh, okay, he's not firing. So, there's an issue there. That wasn't picked up to the next morning.
And so, what I learned from that experience - because that patient was my patient the day before and I picked up a patient again the next morning. But based on that experience, I knew that, okay, no matter how busy you are sometimes, you know, you just have to always stay focused because these people that we are taking care of, they're not just people. They're, you know, our friends, our neighbors, our colleagues.
These people, they're human. They're human lives. And it's so important that no matter how busy you are, you really just really, really have to know what you know and know it at all times.
Dr. NULAND: Well, that's a fascinating story, particularly for me, Michelle, because when I'm talking at young doctors for whose education I'm partially responsible, I always try at some point to get across the thought that there are three characteristics of caregivers, which, if we can follow them closely, we're not going to make an awful lot of mistakes.
One of them is wisdom - very hard to come by. I don't mean knowledge, facts, I mean real wisdom - knowledge put in perspective and able to be used for another's benefit.
The second is equanimity. And it's not that we don't get scared at times, it's not that we don't feel overwhelmed at times, but we learn to deal with those emotions and manipulate them in such a way that we can control them.
And the third - I'm beginning to sound like the New Testament…
(Soundbite of laughter)
Dr. NULAND: … the third, 1 Corinthians 13, that wonderful word, agape, in the original Greek, which is translated most correctly as caring love. It's not just love, faith, hope and charity. It's a different kind of love.
It's a love in which one takes responsibility for the fortunes, for the experiences that this person whom we love is going through. And we can exhibit this as professional people. And in fact, it gets stronger and stronger, I think, as time goes on.
So, we seek wisdom, we seek equanimity, a control over our emotions, and we seek a sense of caring love - which begins to come with, I think, sharing what the patient is with the patient, identifying with her or him in certain ways to produce that quality that we always refer to as empathy.
CONAN: Thanks very much for the call, Michelle.
MICHELLE: Thank you.
CONAN: Let's end with this e-mail from Pat in Novelty, Ohio.
As a student nurse in the 1950s, I was taking care of six disabled children in a ward room. One of these was a three- to five-year-old child with severe cerebral palsy who is encased from head to foot in braces.
I could not understand his speech when he was very garbled. He kept trying to tell me something. The other children did understand him and said, he wants his cars.
So, I lined up his toy cars in front of him. He was lying on his tummy totally encased in braces. And I thought, oh, he wants to see them. I walked out of the room and turned back, and looking through the window, he was playing with his cars with his chin.
I have never forgotten the incredible, indomitable human spirit. My small cares were nothing besides this.
Thank you for sharing that, Pat. And thanks to everybody who called to share their stories from the bedside.
We were listening to Dr. Sherwin Nuland tell us some of the stories he's collected in the new book called "The Soul of Medicine." He joined us today from a studio at Canterbury University, right near Yale in New Haven.
Doctor, thanks very much for being with us as always.
Dr. NULAND: Thank you very much, Neal.
CONAN: When we come back, we're going to be talking about all you poor, beleaguered amateur accountants. This one's for you. A few tips for last-minute filers, plus a chance to learn from your peers' mistakes. What dumb mistakes have you made filing your taxes? 800-989-8255, email: firstname.lastname@example.org.
Stay with us. It's the TALK OF THE NATION from NPR News.
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