Chapter 1: Loomings
Call me Dr. Ishmael. Some years ago—never mind how long precisely—having little or no money in my purse and nothing particular to interest me, I thought I would go to medical school. I wanted to feel an enlarged spleen and learn the circulation.
Chapter 2: A Bosom Friend
It was the evening before the start of a long rotation, and I had to find quarters. I had been assigned to share a call room with another student. It was late and I dimmed the lights and fell into a disturbed sleep. Suddenly the lights flashed on, and a sight unlike any I had imagined came before my bleary eyes. It was a huge man, covered in tattoos, with strange piercings and wires sticking from his ears.
“Nizetameetya,” he mumbled. He pulled off his shirt, and I could see a large caduceus motif filled the canvas of his back.
“Watchaheerfaw?” he asked. It was some time before I could translate his strange island dialect. His name was Queequeg and he was from the island of Long. Before the sun had risen, we were best of friends. Better yet, we had been assigned to the same medicine service.
Chapter 3: The Hospital
A strange old building was the Pequod Hospital, an outreach of the Nantucket General Hospital. It was a hospital of the old school. The wooden floors were shiny with use and the walls a dim yellow. It had the distinct odor of disinfectant with a trace of stale urine; it smelled like a hospital. The spirits of patients lingered in the air.
Chapter 4: The Warning
As we entered the lobby, a student in a short white coat stumbled by us. Bedraggled, he was splattered with nameless filth. His name tag read “ELISA.”
“Doing a rotation are you? At the Pequod? You on Ahab’s team are you? It’s not too late to switch services. Not too late. Too late,” he said as he staggered off.
Chapter 5: Two Squires
We entered the ward and met an intern, Dr. Flask. A short, ruddy young fellow. Very pugnacious concerning scut. He was bent over a patient’s arm prodding for a vessel. He looked at Queequeg.
“Oh lord what have we here, are you a medical student or a freak show?” he barked. Queequeg pushed him aside, pulled a needle from a loaded pocket, and without hesitation plunged it into the patient’s arm, hitting the vein instantly. He turned toward Flask, who was now smiling broadly.
Several minutes later, a second intern named Dr. Stubb walked in. A mellow dude, neither serious nor intense. He was calm in a code; fearless in the face of an angry family. He constantly twirled a drug company pen, revolving endlessly around the fingers of his left hand. During rounds, while taking a history, perhaps while asleep, that ballpoint spun continually on a journey nowhere. It was hypnotizing.
Chapter 6: A Knight
I smelled him before I saw him. It was a scent of the islands, of roasted beans and cinnamon. It was Dr. Starbuck. He held the largest cup of coffee I had ever seen.
He caught my eye and rightly read my thoughts. “It’s a triple soy latte with a twist,” he said between sips. I never saw him without a cup in his hand. Lattes, espressos, cappuccinos—cold or scalding, frothy or black, Kona or Colombian—these were his passions. It was only about the divine essence of the bean that I saw him show his true emotions.
Chapter 7: Rounds
And so the strange rotation began to take shape. We headed down the long old ward, the patient’s beds in groups of two. For those of you who never rounded in these days gone by, not corrupted by the mighty powers of Microsoft, it was an odd sight. A mass of physicians huddled around a chart rack. From this rack were pulled clipboards: long wood or plastic holders with strange colored papers barely held in place, waiting to fall out and flutter to the floor, their normal order destroyed. The rack was our lifeboat, our master, and our servant. We went from room to room to see patients, discuss them, make a diagnostic plan. Then the resident turned to the interns and began to grill them. And Lord help the student who could not withstand the devious pimpage.
Knight Starbuck was no exception to this rule. He would scour the physiology and pharmacologic depths of our souls between sips of Jamaican roast. When we did not know, he would turn to Flask or Stubb. Stubb would generally answer, his pen incessantly turning.
Something felt wrong about this service, though. Some foreboding. Some hint of disaster to come. I realized then we were a ship without a rudder, dismasted without our leader, our attending physician. We heard footsteps coming our way. I could not say precisely how, but the air seemed to become charged, as if before a storm.
Chapter 8: Enter Ahab
Dr. Ahab strode upon the ward. His whole broad form was bronzed from some strange ailment or weeks at the beach. A large scar ran along the anterior part of his neck, white against the dark skin. A mark of some desperate wound or endarterectomy. But it was not this that left me speechless in his presence; it was his great white coat.
Each of us, except Queequeg who rejected such formalities, wore a white coat. Mine was short (in measure to my educational rank), filled to the brim with anything I thought might be of value. I was not one to be found wanting when an item was needed. The residents wore longer versions, their pockets stuffed with their own totems of power.
But Ahab’s white coat was of another dimension entirely. To call it pristine would fall short of its purity: It was incandescent. A wrinkle would have expired of loneliness. It was starched and unbending, like Dr. Ahab himself. It went nearly to the floor, the tops of his wing tips barely visible beneath. It was his armor, his shield, it was Ahab.
“Do you know what I’m looking for team?” he asked each of us in turn, as the hair rose on the back of my neck. “It’s evidence I’m looking for. And not just any, but Grade A-1 that we’ll be seeking”
Chapter 9: The Chase for Evidence
And so rounds began again. Each patient in their turn was prodded and poked. The medicines were reviewed; the care plan discussed. With each case Ahab became more agitated. He demanded proof that our therapies were supported by the literature. He worshipfully spoke of articles and references like they had a life of their own, a hierarchy of existence.
As we came to the last patient, Ahab began to pace nervously. It was Stubb’s turn to present.
“The next patient is a morbidly obese 74-year-old with a DVT and PE, on heparin. We are starting Coumadin now,” began Stubb.
Suddenly Ahab erupted: “Why is this patient in the hospital? Why isn’t he on LMWH and home already?”
“I thought he needed heparinization, and I’m concerned about hypoxia,” stammered Stubb.
“Aye, but what’s your evidence that inpatient is better than outpatient treatment? Can you drive blindfolded? Are your thoughts and concerns worth the wasted resources?” hissed Ahab.
The pen fell from Stubb’s hand and lay lifeless on the floor.
Suddenly the nurse ran from the patient’s room, calling a code. We rushed into the room. The patient was a huge man—a leviathan—his flesh an off-white in the fluorescent light. Flask jumped on his chest and began to pump; Stubb intubated and bagged, while Starbuck sipped his coffee. Queequeg plunged a needle into the patient’s femoral artery for a blood gas and a central line in his subclavian before I could move my feet. A small jet of blood streamed out while Queequeg positioned the tubing. The patient was resuscitated and wheeled to the ICU. I stood helplessly, thinking about evidence.
I then noticed that Ahab, who seemed shaken, was rooted to the floor. He stared at his own chest, a streak of clotted blood across his perfect white coat.
“Oh, lonely stats of death and life. Toward thee I strive, thou all-consuming data. From a cohort’s heart I randomize thee; to the last I graph with thee; for evidence sake I control my last study.” He stumbled from the room.
Chapter 10: Epilogue
I watched Ahab head to the elevator, his perfect coat tinged now with red. He waved to me three times, beckoning me to follow. But I leaned against the chart rack; it was solid. It kept me afloat. I stood there until the other team came by and joined them for their teaching rounds. TH
Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.