One of the mementos I have left over from my training days is a small notebook with a list of the procedures I performed. It reads like an accounting ledger, and gives the impression that procedures are all very calm and matter of fact. Fortunately for my sanity, most procedures are very calm and routine, but there are notable exceptions.
Dr. Larry Greenbaum
One of my partner’s former patients described the last time he performed an arthrocentesis on her knee. "I don’t know what came over me, Doc. I just sat up all of a sudden and I pushed him away with both hands." Apparently, my partner didn’t care for this deviation from standard procedure, at least to judge from the patient’s recounting of the tale. "He got real red in the face and he walked around and around and he told me to get the hell out."
Now it was my turn to work on her knee.
She was already lying on her back on the exam table and I was prepping her swollen knee with povidone-iodine. At this point, I felt I could no longer politely back out, despite my growing second thoughts about doing the procedure. As I was glumly going through the motions, she sat bolt upright to describe her cherished memory of her assault on my colleague. She might have gone on to demonstrate on me the exact method of shoving that she had visited upon my partner, except that her husband restrained both of her arms and gently settled her back on the table again.
My aplomb was already somewhat shaken, and I think the patient had the same effect on the nurse who was bravely trying to assist me. I resumed my work, but she popped up about five more times – all before I even numbed her skin with xylocaine. With each new pop up, her husband, the pop-up blocker, dutifully popped her back down. He looked as if he was used to this role.
She screamed during the arthrocentesis. It was the sort of primordial scream that gives obstetricians gray hair early in their careers. "This is worse than having a baby," she informed me. I finally convinced her that she had not delivered any progeny, just one or two tubes of synovial fluid.
The screaming caused the waiting room to empty out a bit. Patients with less fortitude fled for their get-away vehicles, so I had a few extra minutes to steady my nerves before I had to see the other patients of the day. I instructed the nurse to put this patient’s name on our "Valium List". If she ever again needs arthrocentesis, she has to have a sedative first. Better yet, maybe I should take the sedative.
The worst arthrocentesis of my career occurred when I was a rheumatology fellow at the Cincinnati VA. I was trying to treat an older man with arthritic knees to whom I’ll refer as ‘the general’. There wasn’t a nurse available to help me, so I was alone with the patient and his wife. I had already finished injecting his creaky old knee without difficulty, when the general told me he felt funny.
"Are you okay?" I asked.
This must have been prescient on my part, since "Are you okay?" is the same question that is always addressed to CPR mannequins or patients just before you start pounding on their chest. My inquiry to the general was more of a beseeching request than a question. "Oh please don’t code, oh please don’t do that!"
He gave me a sort of noncommittal reply but my reassurance was short lived as he proceeded to turn purplish gray, stopped talking, and lost his pulse. The general’s wife didn’t like the looks of the situation. I threw her out of the room as gracefully as possible and called a code.
The house staff came barreling in with the "crash cart," possibly trampling the general’s wife and almost trampling me. Fortunately for everyone involved, the general had already started to moan and groan and show some small signs of life before the house staff began CPR and cracked all his old ribs.
All’s well that ends well. The general got a few days’ stay in the hospital and he forgot all about his arthritis. The general’s wife avoided widowhood, and I avoided the supreme professional embarrassment of having to write ‘arthrocentesis’ as the cause of the general’s death.
I would feel remiss if I didn’t mention the patient who looked like Robert Redford. Actually, he looked chronically ill, but he had this charming delusion that he looked like Robert Redford, and to disabuse him of this notion could only have served to make him feel worse. Despite his arthritis and psychiatric problems, he was quite pleasant. He always assumed that I was a regular at the country club. Although I explained to him that I spent my Sundays at K-Mart rather than the country club, he always asked me about life at "the club."