The Machinist’s Story
By: Aniqa Azim, MD
Presenting a patient in medicine is like sending a telegram. Time is a precious resource, so every word must be chosen carefully. “My knee hurts like this a few times a year, usually after I drink some extra red wine with my wife- always the knee on the right, doc.” Write this as a telegram, take out the conjunctions, and translate it into medical-speak, and you will hear: this is a patient with recurrent monoarticular arthritis. The diagnosis then rises like cream in a glass of milk: gout.
But there are drawbacks to this art, this scriptwriting, the pattern-hunting. It is my first day ever on service as an attending, and I have just gotten sign out on “John,” 78-year-old man, blind since infancy, with long-standing alcohol use disorder, who presented with all the trappings of decompensated liver disease with a new diagnosis of hepatocellular carcinoma.
On my first day on service, I am tasked with discussing this news with John. It is never fun to be the new person with bad information. I feel myself dreading this conversation all morning. Does John know that he is at risk of this disease with his cirrhosis? Will he be open to considering that alcohol use may have led him here? Or should I not even go there, and frame this as a sad misfortune that yes, was associated with drinking, but could have happened to anyone?
I walk into the room and see him then, folding an intricate Origami crane with a gum wrapper. He is a thin man with sallow cheeks and well-worn skin, and a heavy furrowed brow. I watch his calloused fingers folding, creasing, and unfolding this tiny paper, all with his eyes closed. I clear my throat, introduce myself, and ask gently, “Do you know, sir, why you are here?”
He turns his face as if to look at me. “No need to sugarcoat things, Doc,” he says. “For thirty years I drank a six pack of beer every night. I didn’t stop when they told me to. I kept going even after I started throwing up blood, and after my belly filled up with fluid. And now, here I am, 78, a lifelong alcoholic, with liver disease, and cancer to boot.”
This sober synopsis, casually relayed, hangs like a heavy odor in the air. It is a bit unsympathetic, maybe, but, I also think, mostly true. As if he has not just alluded to his own mortality, John now hums to himself, his glassy eyes directed at the ceiling, as his careful fingers work on the final fold of his crane.
As I take a seat next to John, he feels around the hospital bed for my hand and slips the little crane into it.
I wonder where along my attendinghood I will be able to come up with the right things to say.
As if to rescue me from my own discomfort, John pats my hand, and says, “Hey Doc. Let me tell you a story.”
“I used to do a lot of work with my hands, you know. I was one of the first blind students in my program, at the University. When I joined, they asked, ‘What is it you want to do? What’s the dream?’ And I told them the truth, the most outrageous thing for a blind man in those days: that I wanted to make trains. And so I did. I went to a special training program, and these hands helped make a thousand trains. No one thought I could do it at first. But I showed them- I said, all I need is for someone to show me once, and I can do it from there.”
John’s face, worn and creased like the crane he meticulously folded, lights up. I can see that right now, as he talks to me, he is reliving these triumphant days of proving his meticulous skill and dedication to his craft.
“It was the joy of my life, you see, building things, when no one thought I could. But I had another joy too: my son Ben. I raised Ben to be like me- to dare to do what no one thought was possible. He was my next chapter. But he died when he was just 21. And after that, things were never the same for me.”
When I leave John’s room later that afternoon, I realize how misleading my telegram of him would have been. Yes, he is the 78-year-old man with chronic alcohol use disorder who developed a sad but not unexpected consequence of this disease. Yet, he is also: a pioneer for blind individuals in our state, a meticulous machinist, a lover of engines, and a dedicated father who could simply not deal with the unexpected loss of his son and turned to a sad but not unexpected coping mechanism. Where did those details fit in my summary statement?
Later in the afternoon, my students and residents finish rounding. I finish my chalk talk on the mechanisms of alcohol-related liver toxicity. My notes are mostly complete, my sign-out concise and updated. But I cannot stop thinking about John.
I hover near the door, at the time that I would usually let the residents finish their work and I would recede back to my office. I can hear the team rustling behind me, glancing at my back.
“Hey team,” I say, turning back and settling into the chair again. “Let me tell you a story.”
Aniqa is a Portland native and avid reader and writer. She is currently a Chief Resident in Internal Medicine at OHSU and is involved in helping integrate narrative medicine into the residency curriculum. In her free time, Aniqa loves to run moderate distances and hike around the Pacific NW.
