She took a deep breath and dabbed her cheeks with her scarf. “Is she suffering?”
“That is a concern, yes.”
“I don’t understand.”
We sat in silence as I considered my words. I wasn’t sure I was handling this conversation the right way, but it didn’t feel like the wrong way either. I felt my pager buzz and fought the urge to throw it against the wall. “Sometimes there’s no rhyme or reason,” I said softly.
“I just don’t…How can she be suffering if there’s no brain activity?”
I did not have an answer. And then, a moment of terror. What if this was the moment Baio had been talking about—a time when I was instructed to do something that I shouldn’t? Something that was wrong. “There are certain things we know,” I said. “We know that—”
As the words trickled out, I became less certain. During rounds, when the team had discussed Marlene Hansen, I had been called away to transport a patient to the MRI scanner. I hadn’t been there to hear just how dire her case was. It was clear from reading the notes of other physicians that a consensus had been reached that she no longer needed to be in an ICU, but I was technically relying on secondhand information. I was basing my conversation with Ingrid on the opinion of Don and experts whom I barely knew—medical consultants who had only met Marlene Hansen a day or two ago. What if they were wrong? What if I deferred this conversation until morning, when the rest of the team was available? What if that caused Benny to remain stuck in the emergency room because no ICU or CCU beds were available?
“I’ll do what you want,” Ingrid said softly, removing her hand from mine.
“You shouldn’t do what I want. And difficult as it may be, you shouldn’t do what you want. You should do what your mother would want. Have you ever discussed what she might want in this situation?”
“No.”
“But you are her healthcare proxy?”
She nodded. “She doesn’t have anyone else.”
“There is something called comfort measures only. We won’t draw blood, we won’t poke her with needles. We’ll make her comfortable.”
“I thought she couldn’t feel anything.”
“Right.”
“If she gets an infection, would you give her antibiotics?”
I wasn’t sure. I hadn’t even been present for the discussion on rounds about what was appropriate. Ingrid took her mother’s hand and kissed it. “I don’t want her to suffer,” she said. “I trust you. Just show me what I need to sign.”
I closed my eyes and bit my lip. I had been sent in to carry out a mission—to get Marlene Hansen out of the ICU—but it was clear that I didn’t have all of the necessary information. Maybe in a few hours I would, after I’d reviewed all of the notes from other doctors, but at that moment I wasn’t sure about very basic things like whether we’d provide antibiotics.
I mostly believed I was doing the right thing, but I wasn’t certain. It was impossible to know everything—I’d never know how to read an electroencephalogram, I’d never be the one to perform dialysis; those were jobs for experts in neurology and nephrology, and I had to trust them. If they felt Marlene Hansen had no hope of recovery, they were probably right. But what if I’d met Marlene instead of Benny? What if she was the patient trapped in the hospital—the one I visited day after day—the one I felt an emotional attachment to? Would this conversation have played out differently?
I wasn’t sure.
A moment later, I returned with the paperwork and handed Ingrid a pen. As she signed her name, I imagined myself taking the pen back, tearing up the papers, and telling Don that Ingrid wasn’t entirely sure what her mother would want. That was the truth of it. With space available, it seemed prudent to keep Marlene Hansen in the ICU until Ingrid figured it out. But what purpose would that serve? Was Ingrid going to suddenly recall some distant conversation with her mother about her end-of-life wishes? Was she going to remember that Mom actually wanted to be kept alive at all costs for as long as possible, even if she was brain-dead? The reality was that Don had a better grasp on how to keep the flow of traffic moving in the hospital; allowing emotions to get involved would introduce subjectivity. And subjectivity could screw things up for all of the other patients.
I kept my mouth shut and let her sign the papers.
—
“Nice work,” Don said as I leaned over a filing cabinet and placed the paperwork into Ms. Hansen’s chart. “We’ll send her out in a few hours.”
“Few?”
“They got a bed for Benny in the CCU.”
I jolted upright. “What? So Hansen can stay?” I felt like I had been punched in the gut. Don took a bite out of a tuna sandwich and patted me on the shoulder. “Hospital doesn’t function when we’re at capacity, Matt. Gotta have a bed available if there’s an arrest on the floor. Hansen needs to go. This is a no-brainer.”
“Gotcha,” I said softly.
He inhaled the remainder of his sandwich. “Get something to eat and then let’s do a vitals check on the unit. There’s more tuna in the lounge.” And with that he headed down the hall, looking like a man who knew much more than I did.
35
It was approaching 3:00 A.M., the witching hour, when my body temperature inexplicably plummeted and the pace of work finally calmed down. Or exploded. We never knew. On a quiet night, it was the ideal time to throw on a sweatshirt and pick a supervisor’s brain, catch up on paperwork, or prepare for the firing squad of morning rounds. On a disastrous night—one in which there were simultaneous cardiac arrests or a half dozen new admissions—3:00 A.M. was the time when you daydreamed about business school or working as a medical consultant for a hedge fund.
The ER sending Benny to the CCU meant we had dodged a bullet. There would be time to talk, time to check labs and vital signs, time to process the matrix of data and tidy up the unit before the rest of our team arrived at dawn. And maybe, if we were lucky, there would be time for Don to impart some wisdom. I attempted to nudge him in that direction.
“I heard about that diagnosis you made,” I said. “Takayasu’s arteritis. Very impressive.”
Don grinned. “Attention to detail, my friend.”
“There are so many details.”
“Key is figuring out which ones are important. That’s what intern year is about. They call them vital signs for a reason.” I noted a hint of swagger in his voice. “I was just heads-up.”
“I’ll say.”
He ran his hands through his blond hair. “They asked me to give a talk about it to the department. Can you believe that? What the hell do I know?”
I shrugged. Beneath Don’s glimmer of swagger was vulnerability. I’d seen it when Baio had called him out on the phone. It occurred to me that we were all wrestling with some form of impostor syndrome, unable to internalize and appreciate our own accomplishments. There was always someone more impressive, someone who could make you look foolish if they really wanted to. Underneath the glimmering personas, some of us—including me and the women in my pod—secretly worried that we didn’t deserve to be doctors, we didn’t deserve to hold life in our hands, we weren’t the ones who should be leading complex discussions about comfort measures and vegetative states. The key to residency was figuring out ways to ignore those feelings without turning into a monster.
“On second thought,” Don said, “let’s hold off on the vital signs. Get some food and grab a few minutes of sleep if you can. You just know the ED is teeing someone up for us.”
He pulled out his cell phone and showed me several pictures of his son. The kid was crying in every one, but Don was beaming.
“You sure?” I asked. I was wide awake—stress was a remarkable stimulant—but Axel’s axiom wafted into my head: When you can sleep, sleep.
“Couch is all yours.”
In my six months at Columbia, I had observed two types of interns—those who couldn’t sleep on call and those who desperately needed at least a few moments of shut-eye during the thirty-
hour shift. I fell into the latter category; just eight minutes of sleep and I felt reasonably refreshed. By contrast, after a sleepless night I looked, as one colleague put it, “like someone vomited on dog shit.”
I had been snoozing for two glorious hours when a brown paper bag dropped on my chest with breakfast. “How was the night?” Lalitha asked, pushing my legs off of the end of the couch. “Lounge is a mess.”
“Not horrible.”
Her appearance meant I’d survived the night. Hallelujah. She patted my thigh with an old Us Weekly and shook her head. “I can’t believe you have a subscription to this.”
I grabbed the magazine from her. “How else am I going to know Candace Cameron just lost twenty-two pounds?”
Lalitha and I made it a point to engage in conversational nonsense for a few minutes every day before the sun rose and the storm of work and morning rounds rolled in. Our lives together were so intense, so structured, so stressful, that it felt good to talk about something other than our critically ill patients.
We all struggled with the weight of our work, but having the occasional dopey conversation was a reminder that we weren’t simply using each other to get through the day. We were normal people who could engage in idle chitchat. But because our personal lives were so limited—the rare off day was often spent catching up on sleep—we rarely had normal things to talk about. Celebrity gossip became linguistic currency, something we could bring up when we needed to disengage from medicine. For me, the levity of the tabloids helped balance out the tragedy of watching people die day after day.
Lalitha scanned Candace Cameron’s new figure and pulled out a compact and brush from her bag.
“Did anyone ever tell you,” I said, as I watched her groom, “that you look like Rudy from The Cosby Show?”
She rolled her eyes. “Did anyone ever tell you that you look like Pat Sajak?”
“Pat’s a national treasure.”
“Sajak crossed with ALF crossed with Chandler from Friends. When he was on drugs.”
Don entered the lounge, and we sat upright. “At ease, Doctors.”
“What’d you do to Matt overnight?” Lalitha asked. “Looks like a truck hit him.”
I parted my hair, held the magazine over my face with my right hand, and flipped her off with my left. These little moments brought us closer.
Don shook his head. “Gotta say I love working with you two. Get along better than anyone I know.”
“It’s because I’m afraid of her,” I deadpanned.
“He is definitely afraid of me.”
“How could I not be?”
The door burst open, and the nurse manager poked her head in and calmly said, “Jones is crashing.”
I dropped the magazine and grabbed Lalitha. This was the scenario Don had prepared me for: Mr. Jones, the man with the unusual lungs, had dropped his blood pressure. I felt a surge of adrenaline. “Let’s do this,” I said, feeling momentarily like Baio. The transition from goofball to physician was instantaneous.
“Blebs?” Lalitha asked as we bounded out of the lounge. She was a step quicker than I was. Her ponytail sashayed from side to side like a broom as we blew down the corridor past Ingrid Hansen, who was staring blankly out a window.
As we entered Jones’s room, the first thing I noticed was a large window at the head of the bed. A container ship could be seen in the distance, floating south down the Hudson. The room—with its khaki walls, framed Impressionist artwork, and muted television—was oddly quiet. I was accustomed to a cacophony of alarms blaring whenever I encountered a patient in distress, but this room was silent. I imagined myself as the second-year resident, about to lead Lalitha through a resuscitation.
ABC, ABC
A nurse increased the amount of supplemental oxygen as I turned to Lalitha and announced, “Please assess the patient’s—”
“Tension pneumothorax,” she said quickly. “We need to decompress.” She reached for two butterfly needles as I felt for a pulse. Mr. Jones’s eyes were closed and he was gasping for air.
“Got a pulse,” I said firmly. I stared at the man’s heaving chest, relieved that I didn’t need to start CPR. His ribs would have snapped with the first thrust of my palms. Jones was suffering from end-stage AIDS and pneumonia; he was emaciated, weighing less than one hundred pounds, and his cheeks were sunken in. His arms were like two Wiffle ball bats, flailing as he gasped for air. As I estimated his heart rate—it was well over one hundred beats per minute—I pictured myself doing chest compressions on this frail man, and I imagined one of the shattered ribs piercing through his heart like a warm knife through butter.
Don hung back and watched. Standing next to him, in what momentarily seemed like a mirage, was Baio. Instead of going home after his night shift, he’d come to the ICU to check on Darryl Jenkins. They both folded their arms. Part of being a strong supervisor is knowing when to let your intern take the lead, and this was apparently one of those times. Mr. Jones’s eyes bulged as he squirmed in bed, panting for air. I took a deep breath. Lalitha and I were on our own.
“Have you done one of these before?” she asked as we hovered over the patient. “Needle in the chest?”
“I watched the video last night,” I said, feeling like an actor in a commercial saying, “No, I’m not a doctor, but I did stay in a Holiday Inn Express last night.”
“Good enough.” She felt for the man’s left clavicle. “I’ve done one. Just do what I do.” She tilted her head toward his right clavicle and handed me a needle that had been attached to rubber tubing. Lalitha plunged the needle into Mr. Jones’s chest and turned to me. “Go.”
I felt for the landmark on my side and with my left hand thrust the needle deep into the man’s meager chest. In my right hand I held the rubber tubing that was attached to the needle. Don and Baio sidled up behind us and peered over my shoulder. I waited for a gust of air, but there was nothing. “I thought a rush of air was supposed to come out,” I said, “if a bleb really burst.”
Lalitha and I looked at each other nonplussed as Mr. Jones continued to gasp for oxygen. Don and I hadn’t discussed a Plan B. I readjusted the needle and waited for something to happen, but nothing did. I waited for Baio to say something encouraging—you can do this—but he just stood behind me with his arms folded and his mouth shut.
Beads of sweat gathered above my lip as Mr. Jones writhed in his bed and his blood pressure continued to plummet. Two nurses entered the room; one quickly injected a medication into the man’s arm while another checked vital signs. ABC, I said to myself. He had an airway, he was breathing, and he had circulation. What was next? I was watching a man suffocate and I wasn’t sure what to do. Intubation? I readjusted the needle a third time. Nothing.
I looked at Lalitha and she looked at Don. We would need to intubate him if things didn’t turn around quickly. He’d also need a large IV in his groin if his blood pressure dropped again. After what felt like an eternity but was actually ten or twenty seconds, Baio handed Lalitha and me a small Styrofoam cup filled with water. I was about to take a sip when he grabbed it and said, “No.” I looked at Lalitha, who had placed the tubing into the cup, and I followed her lead. Again, nothing.
I readjusted the needle a fourth time and with Baio’s gentle prompting, dropped the plastic tubing into the cup of water. We both peered into my cup, which was now bubbling vigorously, and smiled. “There it is.”
Air rushed out of Mr. Jones’s thorax and into my cup. It was a moment straight out of MacGyver, not an instructional video. How did Baio come up with this stuff? I felt the muscles in my face relax just slightly. Lalitha nodded and glanced at her watch. Minutes later, Mr. Jones was breathing comfortably.
“Well done, Dr. McCarthy,” Baio said, as he headed toward the exit sign. “Amazing things are indeed happening here.”
36
“Not good,” Benny said the next morning in the CCU. “Not good at all.”
He’d lost more weight and was now using the webbed, throb
bing accessory muscles of his neck to breathe. After reviving Mr. Jones in the ICU, I spent the next few hours presenting our new cases on rounds and stumbled, punch-drunk, into my apartment around noon, roughly thirty-one hours after I’d left it. When I woke up, it was 5:00 A.M. the following day. Ninety minutes later and I was standing at the foot of Benny’s bed in the CCU, watching him struggle for air. His breathing wasn’t as dire as Mr. Jones’s—the respirations were labored, like those of a chain-smoker with emphysema—but if Benny’s condition worsened, it might soon become similar. I cringed at the thought of plunging a needle under his clavicle, watching air rush into a Styrofoam cup.
“Hang in there,” I said, taking a seat at the edge of his bed. We both knew time was running out—the man needed a damn heart. His legs were swollen, filled with fluid from his toes to his knees, and his jugular veins were visibly pulsing. Fluid was collecting in places it shouldn’t be—I didn’t have to look under his gown to know that his scrotum was probably twice its normal size—all because his heart couldn’t do its job. Soon it would fill up his lungs, slowly drowning him from the inside. Benny was scared and so was I.
“Talk to me,” he said. “What’s new?”
My mind hopscotched across the events of the past couple of weeks; I was due back in the ICU for rounds in just a few minutes. “Why didn’t you tell me you’d been discharged?” I asked. I had no right to feel slighted, but I did.
The Real Doctor Will See You Shortly Page 22
