“Everything,” she whispered, her gaze still fixed on Ariel, who was trying in vain to place her tangle of red hair into a bun. “Has anyone considered,” Lalitha said, now addressing the entire group, “that this is all lithium toxicity? It would tie everything together.”
I certainly hadn’t; it was a situation I’d only read about. Rarely did a day pass where I didn’t find myself marveling at the brainpower around me. The hospital was filled with people with such different types of intelligence. Some appeared to have photographic memories, others were facile with logic and numbers. The interns and residents at Columbia were people who could do anything in life and they’d chosen medicine, working longer hours for lower pay, because it was important to them. It felt good to be surrounded by these people.
“Seems rather straightforward,” Lalitha concluded.
Turning to me, she whispered, “Yesterday my resident had me draw blood on four people. Not cool.” Doctors at other top hospitals weren’t expected to carry out this time-consuming task, but at Columbia we were.
“Totally.” I still couldn’t reliably draw blood; Lalitha could do it in her sleep. She had gone to a medical school where students learned phlebotomy. I had not.
“And what do you think, Matt?” Dr. Badass bellowed. “Do you concur?”
I scratched my chin, unsure, but hoping to appear deep in thought. “I think,” I said, “I think it would be a mistake to draw any conclusions before we finish hearing all of the details of this case.”
Lalitha rolled her eyes.
“But,” I said, “I’m tempted to concur.”
Lalitha scribbled something on her scut list, then tilted it toward me and cracked a smile. I looked down to see the word politician with an arrow pointing at me. Perhaps she was right. Maybe I was just trying to give vague answers on rounds that couldn’t later be used against me.
We stood in silence as Ariel presented the complex matrix of clinical information, repeatedly sweeping the frizzy red hair out of her eyes as the Badass pressed her to interpret the results of a transthoracic echocardiogram. Her sleepless composure was admirable; I knew I looked like shit after a night on call.
“All right, Dr. McCarthy,” the Badass said at the conclusion of her presentation, “you have heard the entire case. What is your diagnosis?”
“Everything I’ve heard,” I said as heads turned toward me, “points to lithium toxicity. Excess lithium led to kidney failure. Which in turn caused volume overload. Fluid overwhelmed the heart and lungs and she became—”
“Hypoxic,” he said. “Very good. I agree. Next patient.”
But I wasn’t ready to move on. My mind had been churning Baio’s advice—essentially to question everything—and as we prepared to move on to the next patient, I couldn’t shake something that was nagging me about Ariel’s case.
“But why?” I asked. Bodies froze mid-stride. I felt for a moment like a character in a network crime procedural. “It doesn’t quite make sense,” I added, looking from colleague to colleague. “Why was there too much lithium to begin with?”
“Overdose,” said a pert, strawberry-blond medical student with a freckle on the tip of her nose.
Meghan, my third pod mate, shook her head. She had a kind, open face, with penetrating blue eyes. Like me, she had done laboratory research as a medical student, and at orientation we’d spoken briefly about becoming hematologists someday. She was from Dallas and had a well-concealed twang, which appeared only after she’d been awake for more than a day. “The patient has been on the same dose of lithium for twelve years,” she said as she ran a hand through her butter-blond hair, “and has never had an issue.”
“Suicide attempt,” Diego, the brooding cardiology fellow, offered. “A call for help. Something like that.”
“I spoke to her husband,” Ariel said. “She’s been in good spirits. Got a promotion at work. Looking forward to a vacation in Tuscany later this summer. I don’t see her trying to kill herself.”
“It’s a good question,” the Badass said. “And I agree, some aspects of the case elude explanation. Dr. McCarthy, I invite you to investigate it further after rounds. But in the interest of time we should move on.”
Later I would realize his ruthless pragmatism was the only thing keeping rounds under four hours.
“Yes, sir. Will do,” I said and scribbled Lithium WTF!?!?
After rounds, we gathered on the black leather couches and divvied up the day’s remaining work. Diego and the Badass gave us this time to ourselves, to recover from rounds and to quickly eat lunch.
“Lalitha, I need you to draw a set of blood cultures on twelve,” Baio said as he stared at the scut list he’d constructed over the past three hours. “And, Matt, transport the patient in four to CAT scan. Meghan, we need a central line on—”
“Why the CT?” I asked. I was on a roll.
He looked up from his sheet. “That was the plan we came up with on rounds. CT to rule out pulmonary embolus. Is that okay with you, Doctor?”
The other physicians and the medical student slowly turned toward me. I’d spent most of rounds surreptitiously reading about the diagnosis and treatment of pulmonary emboli in preparation for this moment. “The patient has all the classic symptoms of an embolus,” I said timidly. “In critically ill patients, it’s recommended to start treatment before the CT scan. Why are we waiting? Seems like we’re wasting precious time.”
Baio smiled; his style was disarming. “Good stuff, Dr. McCarthy. Anyone care to respond?”
No one spoke.
“Or is everyone here just mindlessly following directions?” he asked.
I glanced around the room; heads were down, fixated on impending scut. My face felt hot. I hadn’t intended to implicate my cointerns as ill-informed automatons.
“When Matt heard ‘pulmonary embolus,’ he did the right thing,” Baio said, clapping his hands. “He looked up the essentials of diagnosis and treatment. Well done. He looked in a textbook and attempted to make a clinical decision.” It was strange to have our didactic sessions play out in front of others. I felt a creeping pride. “But he made a crucial mistake. He didn’t then take into account the particulars of the patient.”
My jaw clenched; I nearly bit my tongue. Baio was always one step ahead of me. Don’t run to the library when a patient is having a heart attack.
“In this case,” Baio went on, “if Matt had gone through the chart he’d’ve seen that this patient recently had a gastrointestinal bleed that almost killed her.”
“Oh,” I muttered.
He leaned over and patted me on the back. “Conventional therapy for a pulmonary embolus would likely kill this patient.”
“Shit.”
“But thank you for inquiring, Doctor.”
Baio spun to the medical student. “Remember, medicine is not one-size-fits-all.”
The student closed her eyes and said, “Of course.”
15
A week later, Baio was in our lounge drawing a grid with the word SHOCK at the top when I decided to ask him a question that had been gnawing at me since we’d met. “How do you know so much shit?”
He kept writing, putting the finishing touches on his grid.
“It’s like in one year,” I went on, “you’ve—”
He spun toward me. “Okay, five minutes on the basics of shock.”
“Photographic memory? Read a bunch of textbooks? What?”
“Flattery will get you nowhere, Dr. McCarthy. And sadly, medicine changes so fast most textbooks are irrelevant the day they’re printed.”
I thought of the textbook chapter I had slaved away at for months in medical school. “So what is it?” I persisted. Why was he being so opaque? I wanted to know what intern year had done to his psyche and how he’d apparently emerged unscathed.
Baio shrugged and stared out the window at a ship sailing south down the Hudson. “I guess you just see a lot intern year. And these little teaching things help. They help. You have to
know your shit if you’re going to teach.”
“Definitely.”
He slapped me on the shoulder. “Have to prepare yourself for all sorts of stupid questions.”
“You know what they say,” I said, “there are no stupid questions.”
“Just stupid people,” he concluded with a chuckle. “You know, you should be teaching.”
“Me? Who?”
“Teach the medical student something. Anything. And never underestimate,” Baio said, still fixated on the ship, “the power of humiliation. I still clam up when I see Jake. When I see some of the other docs. But they taught me so much it’s absurd.”
Was it enough to just show up every day? Were the daily experiences so dynamic and transformative that you had no choice but to learn medicine? I hoped so.
“I’ll be right back,” Baio said, leaping toward the door.
A moment later, Diego entered. He grunted in my direction and spent the next thirty seconds trying to decide if he wanted to eat an apple muffin or a cluster of grapes. I watched him from across the room. Diego commanded a lot of respect in our group. His not being Baio or the Badass put him in a position above me without quite being in charge of me, and though we didn’t have a close relationship, I admired his intelligence. Diego’s research had been published in some of the most prestigious cardiology journals in the world, but he preferred not to talk about it, telling me once that his work was “mostly boring bullshit.”
Suddenly I heard myself speaking.
“Diego, do you, ah, do you remember Carl Gladstone? The professor from a few weeks ago?”
Diego selected the muffin and spun in my direction. “I do.”
I held my breath, feeling like I’d just plunged deep underwater without an oxygen tank. Diego took a seat next to me.
“Do you know what happened to him?” I asked.
“Indeed, I do.” His eyes grew wide, breaking through the squint. I waited for him to continue, but he didn’t. I had considered every conceivable response to this question but still wasn’t prepared for the answer.
“Is he okay?” I finally asked.
He put down the muffin and sighed. “Do you realize, Matt, that I was in the ER when Gladstone first arrived, or that I was the one who wheeled his ass to the cath lab or that I was the one who first noticed the pupils and called neurosurgery?”
I flinched and took in a short, quick breath, almost a gasp. “I had no idea.”
Diego was right, I wasn’t really sure how the CCU admission process worked. And I wasn’t certain what Diego did with his day other than correct me on rounds. So what was Sothscott yelling about? Why that awful phone call?
“I got a call from one of the neurologists,” I said meekly.
“Who was probably very fucking confused after reading your note. It was nonsense.”
I tried to put the pieces of that first evening back together. Why hadn’t Diego told me? Why hadn’t I brought it up the next day?
“Why are you asking about him now?” Diego asked. “This went down weeks ago.”
“I don’t know.” Why had it taken so long? Shame and insecurity.
Diego folded his arms and leaned back in his chair. “There’s layer upon layer of supervision here, Matt. Even when you don’t think anyone’s watching…”
I folded my arms, mirroring him. “When did the neurosurgery consult happen?”
“While you were bullshitting with Benny.”
Pressure rose in my head; my breathing became irregular as I thought of Gladstone’s wife, Sasha. Things still weren’t adding up. “What about my presentation on rounds? The Badass said to scan his head.”
“I told him to cancel it. It had already been done.” I recalled them whispering during rounds. “He went to the operating room right after your presentation—”
“Were you going to tell me any of this?”
Diego lowered his head. “Were you going to ask?”
I looked out of the window, thinking of Gladstone’s pupils. What was the point in not telling me? It would’ve saved weeks of torment, weeks of anxiety. Was it just a test? Proving some kind of point? “Look, Matt,” he said, “I’m not going to scream. I’m not going to throw things. But it’s ridiculous that it took this long for you to ask about Gladstone.”
I wanted to disappear. “I’m really sorry,” I murmured. “I was embarrassed. I thought about Gladstone all the time.”
Diego stared out onto the Hudson and took another bite of the muffin. “You have to ask yourself some tough questions in this job. But before you can do that you have to ask yourself a very basic one: Who are you looking out for?”
I slouched in my chair.
“Yourself?” he asked.
I extended my neck and shook my head. “Of course not. I—”
“Your reputation?”
“I just—”
“Or the patient?”
Searching for words, I thought about the promising medical student I had once been. I recalled the look on Charlie McCabe’s face when I first sutured up the banana peel in his office and the disappointment, months later, when I told him I did not want to be a surgeon. And as I sat there, head in hands, I realized I had forgotten to send flowers to McCabe’s funeral service, which had taken place earlier in the week.
As I sat there trying to process it all, Baio reentered the room.
Diego shook his head and stood up. “You really think we’re gonna leave all the decisions to you two bozos?”
PART II
16
In medical school, after I’d broken the news to Charlie McCabe that I’d chosen internal medicine over surgery, he’d grimaced and said, “Let me introduce you to someone.” I followed him across the Mass General lobby to another set of offices where a man named Jim O’Connell was embracing a middle-aged woman in pink tights, a pink sweater, and bright red lipstick that had been haphazardly applied far beyond her lips. O’Connell was about the same age as Charlie McCabe and looked like a dad on a network television show: neatly parted gray hair, kind eyes, cardigan sweater, and a broad, welcoming smile. He immediately put me at ease.
“Jim!” McCabe exclaimed as we caught sight of him. McCabe turned to me and threw a thumb at Jim. “Someone should write a book about this guy.” Jim O’Connell waved McCabe’s suggestion away and extended a hand.
Both men had done their residencies at Massachusetts General Hospital, and like it had with McCabe, life had thrown Jim a curveball when he finished his training. He had planned to begin an oncology fellowship at the Memorial Sloan-Kettering Cancer Center in Manhattan, but at the conclusion of his three-year internal medicine residency, Jim had been asked by an MGH administrator if he’d consider spending a year assisting with a new program bringing health care to the homeless. He agreed, and his one-year stint with the homeless turned into twenty-five. And in the process, he cofounded Boston’s Health Care for the Homeless Program and revolutionized the way health care was delivered to the indigent.
“Until next week, Jimmy,” the patient said as she leaned in to hug him.
“Wouldn’t miss it, Sheryl.”
After the woman in pink stepped aside, McCabe asked Jim to explain his work to me. O’Connell summarized his career in the way one learns to do when soliciting donors is a way of life: after receiving a master’s degree in theology from Cambridge, O’Connell came to a crossroads; he joked that his liberal arts education had left him “uniquely prepared for bartending and driving cabs.” After bouncing around the country—teaching high school in Hawaii, waiting tables in Rhode Island, baking bread and reading in a barn in Vermont—he did the improbable and went to medical school. He arrived at Harvard Med at age thirty, around the time that Charles McCabe developed that first tingling sensation in his hands.
“Come out in the van with me,” Jim said as I scanned his spartan office and he prepared to see his next patient. “Come out tonight and meet our patients.”
It wasn’t clear why he was making the offer, an
d I wasn’t sure, as a medical student, what I could bring to his program. Perhaps he had a deal with McCabe—maybe guys who turned their backs on surgery had to pay penance by riding in the van with Jim. I turned to McCabe, who was smiling. “Do it.”
Later that evening, I met Jim at one of Boston’s well-known homeless shelters, the Pine Street Inn, wearing a crisp white button-down shirt, khakis, and a new Calvin Klein tie. Taking a seat in the corner, I looked on as Jim, dressed like Jerry Seinfeld in jeans, white sneakers, and a navy blue polo shirt, tended to a long line of men and women who were there to get their routine checkups. His unique skill, I soon discovered, was that he never cut anyone off. He let his patients ramble on about anything they wanted, mostly issues wholly unrelated to their health, while he poked and prodded, quickly and quietly looking into ears, noses, throats, and any other orifices in need of inspection. He was able to time the cadence of a story, applying his stethoscope when someone paused to catch his or her breath and removing it when the story resumed.
I wanted to take notes but there was nothing to write; he simply knew how to interact with each and every patient. And he was especially adept at interacting with people who clearly had mental illness. He knew the names of distant family members and the details of obscure conspiracy theories. His method was remarkable—there was something almost religious to it—like he was the priest and his patients were the confessors.
Hours later, after the last patient had been seen, Jim went behind the counter of the soup kitchen and loaded up two dozen Styrofoam containers with chicken noodle soup. From there, I tagged along as he hopped in a van and began seeking out Boston’s homeless who, in Jim’s words, were “temporarily off the grid.”
Our driver, a Haitian man named Pierre, followed his normal route, stopping at ATM branches, abandoned subway stops, and indeterminate New England wastelands searching for people who might appreciate a warm meal, a pair of socks, or their blood pressure medication. We were seeking out the people I actively avoided in everyday life, the ones wearing rags who hadn’t bathed in months. I couldn’t believe there was a man—a Harvard Medical School faculty member, no less—who was on a first-name basis with the scores of otherwise nameless people we encountered. And without fail, they were glad to see him.
The Real Doctor Will See You Shortly Page 9
