An excerpt from Tornado of Life: A Doctor’s Journey Through Constraints and Creativity in the ER. Reprinted with permission from The MIT Press. Copyright 2022. The appendix is a body part with an image problem. Derived from the Latin word for “hanging on,” the term can mean a bodily outgrowth or a supplementary material attached at the end of a document. The anatomical appendix is a tubular sac tagged on to the lower end of the colon. The point being, it’s extra—tolerated, but never celebrated. Poets rarely, if ever, invoke the appendix with the passion reserved for the heart. The brain and the mind can rest for eternity on the lofty “I think, therefore I am.” The eyes have been hailed as the doorway to love and the windows to the soul. The appendix, however, is a humble organ of lymphoid tissue. The lymphatic system works as the body’s infection-fighting network, but remove the appendix and the immune system still functions quite well. Taking out the spleen, also composed of lymphoid tissue, creates a susceptibility to certain bacterial infections. The spleen’s absence can change people’s identity. Should they become sick, doctors consider them immunocompromised. The appendix, like many body parts, earns our attention only when it misbehaves. Appendicitis, an angry state when the walls swell and turn inflamed, can produce intolerable abdominal pain. After this harsh introduction, the surgeon typically comes in and calmly assures us we’ll feel better once it’s gone. Convincing someone, anyone, to lament its loss is a tall order. The appendix is a vestigial organ whose moment of glory belongs in the long-forgotten evolutionary past and must now fight for relevance and self-worth. But what if there’s more to this tubular ribbon than anatomy and physiology? Almost thirty years into a life in emergency medicine, I’ve been asking myself, “What if I am an appendix, facing similar challenges and perhaps, similar fates?” There is an old medical aphorism: “Heal sometimes, treat often, comfort always.” For much of my career, I could be downright arrogant in my belief that nothing could rival the moral force of caring for patients. Today, this nugget has become: “Contribute to the profit margin always, document to maximize billing, comfort if you have the time.” My value as a doctor in the modern health care enterprise is a product of multiple factors, including the number of patients I see, how quickly I see them after they hit the door, and how much revenue I generate. My worth is highlighted on spreadsheets and bar graphs and pie charts. Left out are skills more difficult to measure, such as how well I listen, my ability to connect, whether I turn away or acknowledge my patient’s struggles even if I can’t alleviate them. I’m monitored by yardsticks that look at health quality in particular and often contradictory ways. For example, I receive a slap on the wrist if I don’t start antibiotics early in patients whose vital signs point to possible sepsis. But if another explanation arises to explain those findings, and the patient doesn’t have a blood infection, I’m faulted for prescribing antibiotics unnecessarily and contributing to the antibiotic resistance problem. The disconnect between what patients value and what the system expects of me leaves me feeling appendiceal. A misplaced and outdated cog in a health care system that treats patients as commodities while it counts on physicians to remain moral creatures, to adhere to the ancient precept, “The patient always comes first.” In the modern age, the dogged persistence of the appendix is a source of inspiration. Hundreds of thousands of years into the human experiment, the appendix is still with us. Along the way, the body has ruthlessly shed much of what was considered unnecessary. Tail? Gone. Gills? Extraneous to life on land and a challenge to garments with sleeves. Researchers claim the appendix has evolved over thirty different times across multiple species. Recent evidence suggests it serves a previously unknown function as a vital reservoir for gut bacteria. This discovery might earn the appendix its “Rocky” moment. Even so, I believe its real value isn’t medical but metaphorical. The appendix is a stubborn reminder that we must remain defiant when we feel irrelevant, ignored, and valued only as lines on a spreadsheet. During every clinical encounter, an act of rebellion is to ask yourself, “How do I do what’s best for this patient?” In the not-too-distant future, the time will come for me to leave emergency medicine. After I’m gone, after goodbye drinks and the sharing of old stories, the system will grind on just fine without me. Whenever I think of that, I can’t blame the appendix for making a little noise before getting cut from the body. Maybe the gallbladder is a better anatomical comparison to my present state. It’s a globular sac that spits out bile and breaks down fatty foods. The body functions well without it, too, though it’s not necessarily forgotten. Overindulging in that cheesesteak will quickly remind you of its absence. We all hit against moments when we question how we derive meaning in our lives. To this end, the vestigial appendix excels as a crafty provocateur. It demonstrates how there’s nobility in hanging on, sticking around, and even being a pest. It challenges us to continually examine what we value in ourselves and others and why. The appendix is worthy of a poem or two. Source
