Thread by @TheRealDoctorT

The Toyota is a dark blur in the corner of my eye. At freeway speeds I barely see it before it careens across in front of my car.

As I slam on the brakes, for a moment I see everything with terrible clarity.

It misses me by inches, and accelerates away.

Oh no you don’t... 1/

A cold fury is flowing through me. I’m so angry I can barely see straight. How DARE they?

A detached part of my mind calmly observes that I’m in the throes of full-blown road rage, but I don’t care.

My car’s engine roars to life, and I give chase.

I start catching up. 2/

I’m not one for swearing, or using the middle finger. But when I catch them, I’m going to make some glorious exceptions.

They take an exit and I follow. I know this is getting out of hand, but my heart is still pounding.

At a red light, I pull up alongside them and... 3/

Later that day, I’m at work.

It’s interesting how our entire day can be changed by the cumulative effect of a thousand tiny things. Or just one.

I’m still thinking about my morning commute as I start seeing the day’s consults.

Things are rarely as simple as they appear. 4/

The consults run the gamut, from kidney failure and dialysis, to electrolyte disorders, to hypertension, to fluid overload, to poisonings.

One of the most crucial skills in medicine is the ability to triage quickly and effectively.

It’s a skill that’s always evolving. 5/

One of the unexpected benefits of nephrology is that sometimes it can let you retreat into a haven of numbers.

In a world of infinite complexity and constant flux, the kidneys often go about their work with a mathematical precision that is reassuringly predictable. 6/

As I see the first consult of the day, I go through the chart to get a “lay of the land.” I was taught never to treat anyone else’s history-taking as gospel. To always ask my own questions. To carefully sift through the data, in context.

Context is everything.

Everything. 7/

The potassium is high!
Is it hemolyzed? What’s the glucose? What’s the bicarb?

The sodium is low!
Sample drawn correctly? What’s the glucose?

Calcium is low!
What’s the albumin? Is there an ionized calcium level?

Numbers, alone, tell me nothing.

Context is everything. 8/

I retreat, for a moment, into my fortress of solitude. My haven of numbers.

Seeking the context, the clues within the raw data.

Anion gap, osmolar gap, hidden culprits and bad actors.

Anticipate what should be happening, what’s expected. Then analyze what IS happening. 9/

Patients and their families often don’t have the benefit of a fortress of solitude to retreat into.

There is no raw data.

Just raw emotion, palpable fear, and the often overwhelming avalanche that encompasses “illness.”

There is no separation.

One cannot be distant now. 10/

As I sit at the bedside with the patient and family members, the beeps of the monitors are in the background.

This is that delicate intersection between hope and prognosis, data and destiny.

I answer their questions as best as I can. And I listen.

Mostly, I listen. 11/

And so the day progresses. Patient. Context. Data.

Then reverse the process. Data. Context. Patient.

When it flows smoothly, both ways, I’m on the right track.

It starts and ends with the patient, routing through data, with context as the fulcrum.

This is my method. 12/

At lunch, I sit with a group of Hospitalists, and a cardiologist. They discuss our mutual patients, and our plans. They talk about life in general.

As usual, I find myself wordlessly listening to what they say.

And my mind wanders to where my day began... 13/

As I pull up alongside the Toyota, I can feel my pulse throbbing in my temples. I lower my window and I’m about to yell something ugly, and gesture vengefully.

And then I see inside the car, and my anger evaporates.

Context is everything. 14/

A little boy is in a carseat in the back. He looks at me with wide eyes.

A woman is driving, and looks distraught. Perhaps she’s his mom? Her eyes are reddened, as she turns to look at me.

I say nothing, but offer a small wave that turns into a “slow down” gesture. 15/

She nods, and mouths “sorry.” The light turns green, and she drives away.

Her car has stickers on the back window. A stick figure family of four with Mickey Mouse ears.

For a moment, I feel a wave of nostalgia.

There is no separation, and nowhere to move but forward. 16/

I am ashamed, as I drive away. I can link most of my regrets in life to moments of poor judgment in the face of anger, or fear.

It’s okay, I’ll learn from this.

Christmas is around the corner.

Christmas is my birthday.

I’ll wish for empathy, and red lights turning green...