“Good. Here’s the deal. Very simple,” she said quickly. “I understand your physical exam skills are quite good, but you, ah, need some work in other areas.”
“Right.” I wondered if the Gladstone episode had reached Ashley.
“So let’s play to your strengths. You’re the eyes and I’m the brain.”
“Got it.”
“Examine the patients, tell me how they’re doing, and I make the plan.”
I scribbled down Me eyes/Ashley brain.
“And then, Matt, you carry out that plan. Make sure shit gets done.”
I no longer trusted myself to remember anything unless it was written down. There were literally hundreds of small tasks and new factoids that popped into my brain over the course of the day, and I found it impossible to keep track of them all without committing them to paper. And prioritizing it all required yet another set of skills. “Yes, ma’am,” I said awkwardly. My daily scut list looked like a madman’s diary, every inch covered in scrawl. I often thought of Axel, imploring me not to write on my hands.
“And if I can give you one piece of advice, it’s this: be efficient.”
“I’ll do my best.”
“But efficiency necessitates competency,” she said. “There’s too much to know. Information is generated so quickly. And at your stage you’re still trying to learn the basics.” Again, Ashley was right. Scores of scientific journals were constantly churning out new and at times contradictory medical information. We would never have time to read it all and were in need of a competent curator. In many ways, Baio had filled that role for me in the CCU. But I needed to do it myself now; Ashley didn’t seem like the type who would spoon-feed me information.
A young man wearing just underwear walked by us, demanding to be read his Miranda rights. “To that end,” I said, trying to ignore him, “I’ve actually started using UpToDate,” referring to a website that summarizes expert medical opinion.
“Wonderful,” she said. “It should be your bible.”
“It’s incredible.”
“Just don’t reference it on rounds—attendings think it’s lazy.”
Two nurses escorted the hallucinating man back to his room.
“Use it for everything but anatomy,” Ashley said. “Netter for anatomy.”
Netter referred to Frank Netter, the physician-artist whose medical illustrations are the standard for human anatomy. Ashley tapped her pen to her cheek and fought back a smile. “Being from Harvard, your anatomy skills must be, ahem, disastrous.” She was referring to the worst-kept secret among top medical schools: a paucity of corpses meant Harvard students had to choose to dissect either an upper or a lower extremity but not both. I’d been a leg man.
“Guilty.” I smiled. “I’ve actually been trying to read at home when I can.”
“Don’t,” she commanded. “Reset your brain at home.”
“Okay.”
“Bust it here. But when you’re home, you’re home.”
I thought of the mindless hours I’d logged at home since starting internship watching reality television and reading tabloids in the name of mental health. Our generation of physicians was undoubtedly different—it was hard to imagine the Badass doing something similar. Did he take a look at Baio and think Happy Days? Or Joanie Loves Chachi? Doubtful. Maybe he played golf or flew single-engine planes.
Ashley looked at her pager as she took a large gulp from her latte.
“You know,” I said, feeling momentarily unguarded, “I continue to feel overwhelmed. Trying to wrap my head around everything and learn how to do procedures.” I wasn’t entirely sure why I was opening up to her, but chronic sleep deprivation led most of us to behave in unusual ways. I found myself more willing to confide in my colleagues; others burst into tears when the cafeteria was out of ketchup.
She frowned. “That’s not something you should go around advertising.”
“Just being honest.”
“No one wants to hear that you’re struggling. I certainly don’t.”
I flinched. “True.”
“Be confident. You know more than you think. But enough with the teeth grinding.” She held up an EKG. “Anyway, would you rather have a doctor who’s right or who’s certain?”
A moment later, a medical student named Carleton joined us. He was from Princeton. Or an Abercrombie & Fitch ad. Possibly both.
“Just spoke to Ms. Sarancha for an hour!” he said with a mix of enthusiasm and frustration. Medical students were first against the wall when a demented patient requested to chat with a doctor. At Mass General, an intern once sent me in to talk with a patient but neglected to mention that the man was capable of saying only one word: “Why?” After exhausting my meager explanatory skills, I picked up the patient’s chart and realized he wasn’t overly inquisitive; rather, he’d suffered a massive stroke that impaired the part of the brain responsible for producing language. As pranks went it was relatively harmless and ultimately built camaraderie between the intern and me. It was the kind of thing Baio would do.
“Thank you for doing that,” I said to Carleton. “Morning’s going to be busy, but let’s spend a few minutes this afternoon talking about shock.”
Ashley shot an unsparing look. “Why are you discussing shock?”
It was one of the few topics I had mastered, that was why. And because Baio told me I should teach. “Fundamental topic to discuss,” I offered.
“To cover in the ICU,” she said, “but not here. We should focus on learning all we can about HIV.” In that case, I thought, Carleton was out of luck. I knew little about the virus, certainly not enough to teach. “That’s how things stick with you,” she said. “See the condition, read about it, and associate the patient’s face with the condition.”
“I just think it’s—”
“This isn’t a dialogue,” she said, her distaste palpable. “That’s the way to do it.”
Ashley’s approach was reminiscent of a drill sergeant. Even on our most hellacious days, it had never felt like Baio was crowbarring a teaching session into our dialogue; it just flowed naturally as we hopped from one patient to the next. But though their styles may have differed—Ashley seemed to talk down to me while Baio propped me up—both wanted to impart vivid images that I would never forget. Teaching points and patient scenarios that would stick in my brain for decades.
“Okay, Carleton,” I said as Ashley picked up her phone, “if things calm down this afternoon we can talk a bit about HIV.”
ARREST STAT, EIGHT HUDSON NORTH! ARREST STAT, EIGHT HUDSON NORTH!
Ashley and I shot out of our chairs and sprinted toward the stairs.
ABC, ABC
In the hallway, I darted past a bewildered Peter Lundquist, nearly colliding with the Tupperware container in his hand. Peter brought in cookies and cakes for the CCU staff day after day, even after Denise had been transferred out of the unit. They had been a delightful change from the pungent Filipino ginger desserts we were accustomed to.
When I reached the arrest, two dozen physicians and nurses were already at the bedside.
“Too many people,” one of the nurses said. “People out now.”
Intern orientation had introduced me to the concept that more physicians equals more chaos. I backed away from the lifeless body. A few steps past the door, someone grabbed my arm.
“Where do you think you’re going?”
It was Baio.
“Too many people,” I said, throwing a thumb toward the crowd.
He shook his head. “You never leave an arrest. Never.” He escorted me toward the room. “If someone tells you to leave, you move behind a curtain. If someone pushes you back, stand in the doorway. You need to see as many of these as you can. Let’s go.”
We stood in the doorway, watching the madness unfold. “Michael Jordan said the game would slow down for him,” Baio whispered, “when he was in the zone. The more of these you see, the slower things will move.”
I nodded, watching an anesthesiologist
place a breathing tube down the throat of a middle-aged Dominican man while a nurse attempted to insert an IV.
“Keep an eye on the arrest resident,” Baio said and nodded toward the physician at the foot of the bed. “He’s in charge. How do you think he’s doing?”
“I can’t really tell.”
I peered around the crowd as someone beat on the man’s chest. I thought I heard a rib crack.
“Exactly, you can’t tell because he hasn’t established that he’s in charge. You have to take command of the room.”
“Got it.” I reached for my pen.
“Don’t fucking write this down. Just watch.”
The arrest resident began to address the room.
“Speak up,” Baio shouted.
The resident’s voice rose.
“Second, you have to find out what happened,” Baio continued. “First thing you ask is: Did someone witness the arrest? If someone was there to say ‘I saw this guy swallow a marble’ you’ve got your answer.” Blood splattered near my feet; placing an IV in this man was proving to be difficult. “You know more than you think you do.”
It was the second time I’d heard that this morning. “This is getting messy,” I whispered back. After a month in the CCU, the sight of blood flying across a room didn’t freak me out, but this still seemed like a lot. It was enough to fill a small coffee cup. If I’d seen it in a movie or on television a few months ago, I would’ve cringed. But it no longer bothered me, and no one else acknowledged the mess coagulating under our shoes. We were a roomful of people comfortable with projectile blood splatter.
“Check out the guy doing chest compressions,” Baio said. “How’s he doing?”
“Fine, I think.”
“Stayin’ alive?”
I watched and hummed to myself. “No, he’s going too fast.”
“Exactly, so if you’re in charge you tell him to slow down.”
“Should we tell him?”
“No, definitely not. There needs to be one person in charge.”
“This is gruesome,” I said after blood again splashed in my direction, landing on my scrubs, just below the knee.
“How long has it been?” one of the nurses asked me.
“Fourteen minutes,” Baio said softly. While I had been dodging blood, he had been quietly keeping time.
“Yikes.”
“Always keep an eye on the clock. This is a ghastly funeral.”
I looked up at the small black and white clock above the patient’s bed. It was the kind my high school had used, and for a brief moment I was transported back to a senior-year classroom, wishing the clock would move more quickly, wishing time would speed up so I could go off to college and start real life. Now I was trying to figure out a way to make time slow down. “Should he stop?” I whispered.
Cardiac tamponade was what the more senior doctors in the room suspected, a condition in which blood accumulates around the lining of the heart, leaving it unable to pump properly. The only way to urgently correct it is via pericardiocentesis, a procedure in which a doctor blindly plunges a needle under the patient’s rib cage and into the lining of the heart so the fluid can be drained. In this case, it would be done while chest compressions were being performed, making the heart a moving target. Anxious physicians looked back and forth, wondering who should attempt the procedure. It was dangerous. Inserting the needle in an inch too far would pierce the ventricle, almost certainly killing the patient.
“This is not the way you want to go,” Baio whispered.
“Should the arrest resident stop?” a nurse quietly asked me. “The guy’s been dead for twenty minutes and now they want to stick a needle where?”
“I would,” Baio murmured. “I’d stop. But funerals are like weddings—you have to ask if there are any objections before you go through with it.”
The pericardiocentesis began and the room fell silent. The physician performing the procedure, a slight Asian man, held the large needle with both hands as it pierced the skin and gradually sunk into the chest. I held my breath as the needle disappeared. The thought of doing this procedure terrified me.
Drops of sweat beaded on the man’s wisp of a mustache as the needle submerged deeper. He bit his lip as the needle fully disappeared under the ribs. He pulled back on the syringe, first gently and then with great force, hoping to obtain fluid. But there was nothing. I craned my neck to get a better view.
“I didn’t get it,” the man said after several minutes and stepped away from the body. Chest compressions continued unabated. A second physician took the needle and prepared to repeat the procedure. A wave of nausea cascaded over me.
“Okay, stop,” the arrest resident shouted. “Resuscitation efforts appear futile.”
CPR had been attempted for twenty-two minutes.
“Time of death is eleven-fifty-two A.M. Thanks everyone.”
And with that, it was over. Nurses and doctors stepped away from the bloodied, lopsided chest and stoically filed out of the room. There were no conversations, no eye contact. Everyone calmly returned to their scut lists and the next task at hand. Baio shook his head and disappeared down a long corridor.
It was the first failed resuscitation that I had witnessed. As the crowd thinned, I moved in and peered over the body. Eventually the room was vacant except for me, the corpse, and another intern. She closed the eyes of the dead man and then softly said, “I would’ve kept going.”
18
The next day I was back on infectious disease rounds, presenting a patient to the team. In contrast to cardiac care unit rounds, this discussion took place around a conference table. Glazed donuts were passed as I spoke.
“So,” I concluded, “the patient is doing really well. I actually think he’s ready to go home today.” David was thirty-four and had walked into our emergency room a few days earlier covered in painful purple and yellow abscesses. A simple staph infection was the cause, but his immune system, ravaged by HIV, was unable to fight it off. It was the third time in the past year that he had come to our hospital with these erupting, rancid skin lesions.
Dr. Chanel ran her hand through her ponytail. “I agree,” she said, “but I’d like to get one more set of labs. I’d like to see how the liver is doing before we send him out into the great unknown.”
It was 10:15, and morning labs had already been drawn; a phlebotomist would not be on the floor for six more hours. “I’ll just draw the labs myself,” I announced. I’d come a long way from those first few incompetent days in the CCU. I wasn’t ready to do a pericardiocentesis, but I could draw blood.
“Can I join you?” Carleton asked.
“Make it quick,” Ashley said, “we’ve got two waiting for us down in the ED.”
I slipped on my white coat, put the dark green stethoscope around my neck, and walked with Carleton across the hall to David’s room.
“So exciting,” Carleton said. He was far better at faking enthusiasm than I would ever be, which irritated me. My colleagues could sense my hesitancy the moment I walked into the hospital’s lobby. But Carleton was the kind of kid who could adapt, who could play the role that was required of him. He was a medical school chameleon; if he needed to be passive—like during psychiatry, where more of the time was spent listening—he could, and if he was called on to be assertive, perhaps during the surgery rotation, he could do that, too. He was the student who would breeze through medical school and residency free from torment, free from anguish. A few years from now he would summer with other beautiful, carefree people in the Hamptons, tossing back cocktails on a private beach.
I tapped on David’s door as I pulled it open. A large man with thinning brown hair, he mock-cringed when he saw me.
“Not you again,” David said. He shook his head and reached for a magazine.
“Me again,” I said cheerily. “This time I have company. I’ve brought along a medical student, if that’s okay.”
“This guy tortured me yesterday!” David said with a smile
to Carleton. He put the back of his hand to his forehead and added, “I don’t know if I’ll ever recover.”
A day earlier, I’d spent hours lancing every one of his abscesses with a small scalpel and even more time scooping up the pus with gauze. In college, even in medical school, the sight and smell of those abscesses would’ve made me nauseated, but not anymore. I had been told that every doctor eventually discovers which bodily fluid he or she finds most disturbing, and this realization helps guide the choice of a subspecialty. I didn’t mind blood, spit, piss, or pus. I did mind diarrhea, which meant I wasn’t destined to become a gastroenterologist.
“Antibiotics weren’t going to work,” I said. “You know that. I had to open those things up.”
“I know, I know,” David said, waving his hand dismissively, “you had to do it. But why the CAT scan? That took up my whole afternoon!”
I flashed to Gladstone and shook my head. I was now ordering potentially unnecessary head scans several times a week and neurosurgical consults nearly as frequently. “The good news is you’re getting better. The CAT scan was normal and you’re going home soon.” Even though I suspected that Gladstone was going to be okay, his image haunted me. Whenever I felt like I was starting to get the hang of things, like I was starting to become a real doctor, I was reminded of him and my colossal oversight. More than anything, I was reminded that I needed supervision. Fortunately, Columbia had a structure in place that provided it. But what would happen when I was the supervisor? It was okay to practice defensive medicine for now—I had people like Ashley to tell me when I was being overly cautious—but eventually I’d need to cut the safety net.
“Thank God,” David said.
“I’m proud of you for starting the HIV medications. Your numbers were through the roof.” I set down the equipment for the blood draw and turned to Carleton.
“You know, it’s actually better today to have HIV than diabetes.”
“But I have diabetes,” David said.
I frowned. “Let’s get started.”
I knelt down by the side of the bed and again turned to Carleton. “The key to drawing blood is finding a vein. Help yourself out by using a tourniquet.” He quickly scribbled on a notepad as I spoke. “Sometimes one isn’t available, so I just tie a latex glove around the patient’s arm.”
The Real Doctor Will See You Shortly Page 11
