My wife’s stay at Duke Hospital during her first bout with leukemia in 2005 made for a long and challenging summer.  I stayed in her room using a recliner chair as a bed during the ordeal.  Although we both hold in high regard the treatment unit’s staff and clinicians, the floor can indeed be a challenging, intimidating and frightening experience for many patients who learn the outcomes of others while also coping with their own mortality.  My roles included support, advocacy, chief cheerleader, and using my clinical research background to review lab reports, talk with physicians, and add a voice of encouragement.  Mary was quite the fighter and with the support of family, friends and the faculty/staff we prevailed.

That summer I took to extensive reading, not just news related, but a bit of fiction as well including 9 Stephen King works (my youngest son was quite a Stephen King fan and thought that I might find the books to be a useful escape – it did give us new ground for discussion as I had never read any of King’s works).  One of the books was entitled ‘On Writing’ where King discusses his approach to writing.  He often begins a work without knowing where it will lead and describes the process as being akin to an archeologist who continues to uncover more of a dig as it is unearthed.  The book did stir my creative side.

One day during our long stay on the hall, where on a daily basis I was following white cell counts (often quite low) during my wife’s recovery, she asked me took out the door of her room to see if her physician was available.  I found the hall empty at which point I uttered under my breath “The white coat count is quite low”.  The analogy to the human system literally hit me like a thunderbolt, a mix of insight and humor that simultaneously led to both awe and chuckles.  I left shortly to make one of my infrequent trips back to our home where I collected mail, did laundry and performed some other routine maintenance chores.  During the trip down I-40 the entire analogy flew through my mind and during a load of laundry I committed the piece to paper – about a 20-30 minute process.  I spun a copy to bring back to the unit.

I handed the piece, with a grin, to a nurse with whom we had developed a strong relationship, and it quickly circulated around the hall.  It found its way to the faculty that issued positive and humorous remarks to me about it.  The staff framed the piece and it now hangs in the cancer unit.  A member of the faculty submitted it to the Journal of the American Medical Association (JAMA) as a contribution from a family member of a patient.

Mary and I are now entering the fray once again against this stubborn enemy and it is our belief that the system, described in the piece below, will once again prove to be effective.

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The White Coat Count

My wife asked me look into the hallway to see if her physician was nearby.  Upon opening the door to her hospital room and looking down the hallway, nary a white coat was in sight.  The ‘White Coat Count’ was quite low.  It was at that point it dawned on me the close parallels that exist between the hospital floor and our own bodies in the fight against disease.

The White Coat Count was low because, like good white cells, the physicians had left the vasculature (hallways) and migrated into the tissues (rooms) where they performed their important role in fighting disease.  The nursing staff, like helper T-cells, closely interacted with disease (patients) and other white cells (coats), acquiring and transmitting information thus fulfilling their vital role in coordinating the response.  The housekeeping staff, like so many macrophages, traveled through the vasculature (hallways) penetrating into the tissues (rooms) removing debris thus keeping the tissue clean.  The food service staff transported nutrients through the vasculature depositing them into the tissues.  And we, the relatives of the patients, appear to play the role of therapeutic agents in this analogy, assisting and supporting the response.  I noticed a range dosage schedules for the therapeutic agents (visitors) on the hall varying from QD to BID to PRN and, in my case, continuous infusion.  It would seem that the choice of visitor would be as important as the choice of therapeutic agent as either could provide benefit or, as I’m sure we all know, be capable of eliciting an emetogenic response, hypertension, or some other untoward event.  Finally, in this analogy, if we are to consider the nursing stations and central offices of Suite 9100 as the brain of this entity, we therapeutic agents have little capacity to cross the blood-brain barrier and if found there would be expected to be in very low concentration.

It would seem that a system that so closely mimics the body’s own processes would be effective in fighting disease.

Arthur R. Kamm, Ph.D.

July, 2005