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The Art of Medicine

Moments without an ICD-10 code

Maurer, Brian T. PA-C

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Journal of the American Academy of Physician Assistants: August 2016 - Volume 29 - Issue 8 - p 58
doi: 10.1097/01.JAA.0000488705.62915.e6
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I measure every Grief I meet

With narrow, probing, Eyes—

I wonder if it weighs like Mine—

Or has an easier size.

—Emily Dickinson

“This mother is talking on her cellphone,” the nurse whispers as she hands me the boy's medical chart just outside the closed door of the examination room. “It sounds like she's making funeral arrangements for someone in the family.”

“Thanks for the heads up,” I say, letting the chart fall open in my hands. I glimpse the immunization record. At age 11 years, this boy is due for a tetanus booster and his meningitis vaccine today. I flip back to his last physical examination and quickly review the note.

I open the door to find the mother sitting in the chair, talking in a low voice on a smartphone glued to her ear. Her eyes are moist. The boy sits upright on the examination table; his eyes meet mine with a questioning look. I offer him my hand in greeting. “I haven't seen you in a whole year,” I say. “How have you been?”

He shrugs his shoulders and tilts his head. “Okay,” he says.

“You're 11 years old now. Are you still homeschooled?” I ask, casting a fleeting glance at his mother.

She continues to talk on the phone. The boy answers me: “No, I'm in public school this year.”

“I see. How's that going?”


Despite my efforts to engage him in conversation, the boy offers no more than one-word answers. His mother dabs her eyes with a crumpled tissue and continues to talk. I decide to move ahead with the physical examination. The boy cooperates in silence. Finally, I ask him to come down off the table, stand up straight, and then bend forward at the waist so I can check his spine. He resumes his stance and hops back up onto the examination table again.

“I'm terribly sorry,” the mother says, tapping her smartphone screen. “I didn't mean to be rude. It's just that I had to take this call from my sister. She's at the funeral home with the director, and she needed to keep me in the loop.”

“I'm sorry to hear of your trouble,” I say.

She nods her head. Tears spill onto her cheeks. Again she dabs them with the tissue. “It was my brother,” she says. “He died in a house fire in New York a couple of weeks ago. We just got word this morning that they identified his remains. They used his dental records from the Army to verify it was him.”

More tears erupt and flow down her cheeks. “We had to wait almost 2 weeks to find out. They didn't know for sure until today. There wasn't nothing much left of him—he was all burned up.”

She taps the screen of her smartphone and brings up a photograph. “Here, this was him.” A bulky figure dressed in Army khakis smiles at the camera.

“He was a handsome soldier,” I say.

She smiles. “He was, wasn't he? He spent a tour in Afghanistan. He was never the same after he came back.” Lovingly, she stares at the small screen, then taps the phone again.

“So my sister and I are trying to have him buried in the veterans' cemetery with full military honors—you know, when they do the gun salute and fold the flag over the coffin.”

“How goes that battle?”

“They might be able to do it Sunday,” she says. “I sure hope so. Otherwise, we ain't got the money for a civilian ceremony.” A new flood of tears erupts from her eyes. Gently, I reach out and place my hand on her trembling shoulder.

As she sits before me within the confines of this small room, I reflect that this mother is in a different place.

Cellphone conversations during medical encounters turn me off; ofttimes I seethe beneath my carefully orchestrated demeanor. But somehow this time it's different. This time, what was scheduled as a preadolescent physical examination has turned out to be something else—an encounter largely unclassifiable with an ICD-10 code; one that defies the assignation of relative value units.

Healthcare delivery is one thing. Caring for the patient in the moment can be something entirely different.

Copyright © 2016 American Academy of Physician Assistants