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Mindful Practice

The Horde

Cogan-Drew, Thea MMSc, PA-C

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Journal of the American Academy of Physician Assistants: August 2018 - Volume 31 - Issue 8 - p 1-2
doi: 10.1097/01.JAA.0000541486.46987.69
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I am late for my shift at the hospital, two states away. My train was delayed and then canceled. I text my colleague who is scheduled now, and yes, she can cover for me until I arrive. I'm doing an overnight and have brought a change of clothes, toothbrush, laptop, and a book. The patient is my dear friend.

She's not technically my patient. Margi was diagnosed nearly 4 years ago with metastatic colon cancer, prognosis uncertain. She endured a toxic regimen of three-drug chemotherapy for 6 months and then continued maintenance chemotherapy, the combination of which halted the growth of her tumors until about a year ago. Then she and her team (some of the best in the world) decided surgery was the next phase. Five days ago, she survived 13-hour abdominal surgery and has been recuperating well. A group of mostly women are staying with Margi every day and night: internists, pediatricians, NPs, and one PA—me.

I arrive, finally, in the late afternoon. She's resting in the chair and her hair is sparser than the last time I saw her. She's thinner too, but the smile in her eyes is the same. She feels okay today and is pleased that her diet was advanced this morning. She ate a whole plate of eggs! A little later, Margi walks the hall with her mom, me, and the IV pole, as her teenage daughter works her phone like a pro, draped across the hospital bed, thumbs flying. The visitors leave. Margi drinks a nutritional supplement. She starts to feel worse.

The next set of vitals reveal a low fever, and Margi is sweaty, hot, and then chilled. What is going on? Does the fever indicate pneumonia or an abscess, or is she septic? It's too late, really, to be related to anesthesia. What's on my differential? I'm a primary care PA who now works in academia, more comfortable with uncontrolled diabetes or an asthma exacerbation, but this.... Wait, no. I'm not her clinician. I'm her friend and advocate and personal caregiver. I text G, who lives across the country. She's the leader of the Horde, which is the name for this group of clinician-caregivers given to us by Margi's surgeon, Dr. C, as he respectfully humored my queries and politely listened. G is an internist and has suggestions, and she tells me her thoughts for the eventual fever workup. I talk again with the team at the hospital. I draft my own “sign-out note” to the 79-e-mail chain that the Horde keeps adding to.

The Horde cares about Margi. We are her family beyond her family. We are people from different parts of her life: her college friends; friends from summer camp nearly 40 years ago; friends from her medical schooling and residency; couple-friends from her short marriage to the love of her life, with whom she has two girls; friends from her close-knit neighborhood community where she is a soccer- and hockey-mom, well-respected pediatrician, widow, and running buddy.

The fever gets worse, then better. Margi has a white count in the high teens but no obvious infection. Her gut has slowed down and there might be some fluid on the CT scan. Not enough to drain, says her surgeon, so Margi is started on antibiotics and milky white parenteral nutrition.

A few days later, I take another shift. I drive this time. Margi is uncomfortable and distended. I watch and hold her hand as the PA on her surgical team drops an NG tube, which her older daughter later names the “elephant nose.” “It's called a trunk, honey,” Margi says, with a wry smile, in a moment of teenage daughter–mom interaction that is lovely in its normalcy. The tube has helped; Margi's ileus is resolving. She naps. I tidy up the room where she's been living for a week, where the flowers and cards are overflowing. We watch some shows on my laptop. We walk the loop on the floor. I help her sponge-bathe, fill her hot water bottle, take notes for the next shift. I'm watching and listening to Margi. I think about her progression, but I don't have to diagnose and treat. G occasionally reminds the Horde—gently—of our role. Margi's team at the hospital is doing their job; ours is different. I'm able to think about my friend and what she might need but do not need to consider nor interpret her latest laboratory values.

This opportunity I've been given to care for another person in a most basic way, without the complexity of medicine and outside of my trained and proscribed role, is a gift. While I'm with Margi I think about her; I consider what she might need and how I can help. These concepts are at the root of why I enjoy taking care of patients and teaching students. I'm reminded of the joys of friendship and the frailty of life as we expect it.

Margi goes home nearly a week later, right before the holidays. She's able to relax while her daughters are home from school, see friends, and enjoy a few nights of Chanukah. Then in mid-January, the Horde gets an e-mail that Margi is back in the hospital with a small-bowel obstruction. She stays a day to see if it will resolve, but no. Surgery again. Dr. C is able to complete it laparoscopically, but Margi's gut doesn't like this disturbance and takes several days to start moving. I get another shift. I drive again. Margi looks so well, I ask myself what I'm doing there. We have a nice day together like two old ladies, reading, walking a mile by way of laps on the floor, doing some work on our respective laptops, and watching clips on YouTube. The role of the Horde shifts a little bit more, and we are there for her as company. Then Margi goes home again, and the routines of life slowly resume.

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