The Real Doctor Will See You Shortly

by Matt McCarthy

  If scheduled toward the end of the academic year, the Allen ICU was said to be the ideal setting for a promising intern to become comfortable making tough decisions in solitude, without the second-guessing and hand-holding of a more senior resident. But it was also a place where mistakes would be amplified; making the wrong diagnosis or selecting an improper medication could inflict real harm rather than just a tongue-lashing from a supervisor. I had heard stories of interns breaking down in tears from the existential terror of presiding over an ICU in solitude. As the sun settled below the Hudson River and I said good-bye to my ICU colleagues on that first night alone, I only had one thought: Don’t fuck up.

  —

  Glancing around the ICU—the room was about the size of a Little League infield—I noticed the fluorescent lights weren’t as bright as they were at Columbia and the place smelled different, vaguely antiseptic, as if the tiled floor had just been mopped with chlorine and the room had been infused with industrial-strength air freshener. It wasn’t better or worse than the hospital on 168th Street, just different, like I had moved into a new apartment—a strange sublet with unfamiliar neighbors and appliances that I’d eventually get used to but for now felt foreign.

  Before me in the unit were a dozen unconscious bodies attached to ventilators and large-bore IVs, just like at Columbia. There were bleating blood pressure monitors, energetic nurses, and grieving families, just like at Columbia. There were familiar stacks of EKGs and day-old bagels, but there was no Baio and there was no Don. It was just me, alone with a group of very sick, very complicated patients. This was not ICU Lite.

  I stared at my scut list on that first evening alone and tried to devise a plan of attack. Where would Baio begin? How would Ashley triage this list? There were perhaps two dozen assignments that needed to be completed before sunrise, and I could do them in any order I wanted. I’d be able to do them with ease if the night remained uneventful, but it would be foolish to assume the night would be quiet. Unforeseen developments—fibrillating hearts, profound electrolyte disturbances, intractable vomiting—would undoubtedly keep me busy, not to mention new patients coming up from the ED. I slung my stethoscope around my neck, checked my pager, and made my way to the nearest patient.

  The small room was dark and cool, shielded from the ICU’s fluorescent lighting by a large beige curtain that ran around the perimeter. An LCD screen that projected ventilator settings faintly illuminated the mottled skin of a chemically sedated, morbidly obese Vietnamese woman with pneumonia and impossibly long fingernails. As I approached the bed, I felt a silent partner at my side. First it was the voice of Ashley, gently reminding me to feel for hidden lymph nodes; then it was Jim O’Connell, reminding me to peek under the fingernails. I introduced myself to this unconscious woman as a formality, knowing she would be unable to respond. But I spoke loudly, just in case a word or phrase might register.

  I felt ready for this challenge, but in those first solitary moments at the Allen, I realized how much I relied on others, how often I tugged the sleeve of a colleague and said, “Hey, quick question.” For me, bouncing ideas and treatment plans off of others had become a way of life, a safeguard to prevent a medical mishap. But now, I didn’t have that option. I put on a disposable gown and a pair of gloves and lightly pressed my stethoscope to the woman’s sweltering chest.

  Soon Don was in my head, forcing me to describe the sound of the woman’s heart murmur in greater and greater detail. Glancing at her ample belly, I could hear him reminding me of the proper way to perform an abdominal exam. Look, listen, palpate. As I scribbled my findings and the voices bounced around my brain, I felt less alone. I knew that if my judgment failed me, memory would not. I had diagnosed and treated pneumonia so many times that I just needed to draw on prior experience to guide me.

  During our series of nights together, Don and I had encountered pneumonia at least a dozen times, and with each successive case he had pulled back, giving me more authority to generate the differential diagnosis, order tests, and concoct a treatment plan. I had felt in control, and developed a modicum of comfort making important decisions, although I knew he was my safety net, double-checking my work in the background. And when Don disagreed with me, I no longer felt compelled to say, “I’m not wrong,” even though I might have been. If I had made a real error, I knew he would’ve caught it.

  “Continue broad-spectrum antibiotics for another twenty-four hours,” I said softly, as I exited the Vietnamese woman’s room, “and try to get her off the ventilator tomorrow.” I briefly closed my eyes and imagined my erstwhile supervisors gently nodding in agreement. Then I scribbled the plan onto my scut list.

  Moving on to the next patient—a frail Italian man with what had been dubbed a fever of unknown origin—I imagined the voice of Lalitha rattling off the uncommon causes of fever. Don’t forget about familial Mediterranean fever, Matty. Then it was Ariel chiming in, reminding me of the more common causes of fever that might have been missed. Did you check for tuberculosis, Dr. McCarthy? So much of my medical knowledge had come from rounds, simply listening as my pod mates dissected hundreds and hundreds of cases. As I quickly jotted down vital signs, I felt the urge to text them: Wish me luck! or Feel free to come back if you’re bored at home!

  But I didn’t text them. In fact, I took my cell phone out of my back pocket and placed it in the center of the unit, next to a computer keyboard. Service was so spotty in the hospital that doctors rarely communicated via cell phone; the thing would only serve as a distraction, and I wanted to immerse myself in the essence of being alone and unassisted. I knew it would take complete focus to get through the night without making a mistake.

  I had seen and done so much since the Gladstone episode, and the pitiful note I’d written for Baio that had so enraged Sothscott. I was always someone who liked a challenge, but the Gladstone incident had transiently suppressed that, turning me into a gun-shy physician who was afraid of screwing up. Now I had finally moved beyond that, receiving enough positive feedback from supervising physicians—for my ability both to perform procedures and to present complex cases concisely during rounds—that being in charge of delivering care was no longer a stomach-churning thought. Now I could look at a patient like Carl Gladstone with unequal pupils and make a long list of things that could be responsible. I could narrow and rearrange that list, creating a hierarchy of probable causes, and from there I could page an expert—a neurologist, neurosurgeon, or ophthalmologist—to confirm or disprove my suspicions. I felt different now because I was different. After nearly a year of being an intern, I knew I was almost a real doctor. Almost.

  —

  After examining the remainder of the patients in the Allen ICU—there were no medical emergencies, just a handful of conversations with distraught, confused family members—another voice drifted into my head. When you can eat, eat. As I wandered over to a box of chocolate donuts in the center of the unit, the ward clerk handed me a telephone and said, “It’s the emergency room.” Here we go.

  An ER physician named Dr. Brickow quickly introduced himself. “Just examined a twenty-five-year-old guy named Dan Masterson,” he said. “Guy’s in rough shape, gonna need an ICU. I take it you have beds?”

  I remembered the back-and-forth between Baio and Don, trying to find an ICU bed for Benny, as I scarfed down a donut. “We do.” Masterson would be the first new patient I cared for alone. That responsibility no longer felt like a burden; it was something I wanted. “What’s his deal?” I asked.

  “It’s a weird story,” Brickow went on. “Wife gets pregnant with their second kid, so he switches jobs to pay the bills. Had to get a health clearance to start work and out of nowhere he tests positive for hep C.”

  I grabbed a plastic chair and took a seat. “Huh.”

  “Happened a few months ago.”

  “So what happened? Why’s he here?” I started to create an illness narrative for this new patient. It was something I had learned from Don. It was his way of trans
forming a two-dimensional story about a set of discrete symptoms into a three-dimensional image of a human being grappling with a disease. It was often helpful, but it occasionally led me to jump to premature, unfounded conclusions.

  The narrative started to come together in my mind: I imagined Dan Masterson’s unkempt body stumbling into the Allen emergency room with belly pain. Or cirrhosis. He had prematurely aged—Dan was probably a young old man—and he’d initially chalked up his symptoms to stress. Trouble at work, having another kid, something like that. He’d ignored some warning signs—weight loss, shortness of breath—and now he was with us, clinging to life. I wondered if he was frail. I wondered what he was wearing. I wanted to know when he had contracted the virus and how his wife had reacted.

  I took a sip from a can of soda and glanced around for a Styrofoam cup, wondering if I might need it for later. How sick was this guy? And would I know what to do? Suddenly, I wasn’t feeling so eager to get a new patient. I hoped I wouldn’t see a new medical condition tonight. I wanted something routine, something I could handle. I wasn’t looking for a teachable moment, especially since there was no one around to teach me.

  “Here’s the strange part,” Dr. Brickow said, the pitch of his voice rising slightly. “The guy walks in here from work a few hours ago—walking, talking, totally normal guy—and tells me he thinks he’s gonna die.”

  I again recalled the terror I had experienced after the needle stick. I had felt that way more than a few times and I hadn’t been that sick. “Yeah.”

  “And he tells me he’s been doing some experimental treatment. Inhaled nitric oxide therapy.”

  “Really?”

  “Yep. Found it on the Internet. Read some testimonials that it cures hep C, so he thought he’d give it a whirl.”

  I shook my head. “That’s kinda weird.” Earlier in the year, I had learned a bit about inhaled nitric oxide therapy after a patient in my clinic with sickle cell disease asked about it. It turned out there was a black market for the stuff and people were trying it for all sorts of diseases. But it wasn’t a treatment for hep C.

  Dr. Brickow covered his mouthpiece and gave an order to someone in the ER. Something about a CAT scan.

  “So,” I said, “I assume his wife knows he’s—”

  “That’s the other thing…says he hasn’t told his wife anything. And the second kid just arrived a month ago.”

  “Oh.”

  “Yeah, and I gotta warn you, he’s going south quickly. Blood pressure is tanking. Probably need to tube him. I don’t know if it’s the nitric oxide or what.”

  “All right,” I said, “send him on up. I’m ready.” It was the only acceptable response, but I was fighting nerves. This scenario was a blank area on my canvas.

  A few minutes later, the ICU doors burst open and a team of emergency room physicians and nurses wheeled Dan Masterson into the last open bed in the unit. Unlike Columbia’s ICU, there was no unlucky corner pocket at the Allen. Frantic energy filled the room. “Lost the pulse,” someone shouted as I scrambled over. “Start chest compressions,” said another. My new admission, my first new patient, had flatlined en route to the ICU.

  I quickly scooted up to the head of the stretcher and crashed into Dan Masterson’s sternum with the heels of my hands. Before I’d even seen his face, before I’d noted what color hair or eyes he had, I had cracked one of his ribs. Probably two. I pumped up and down on his broken chest as another physician barked out orders, and in the midst of the madness—as a breathing tube was quickly snaked down his trachea and a nurse pumped adrenaline into his lifeless body—I stole a quick glance at my new patient. Dan Masterson looked nothing like what I had imagined. The man was large—well over six feet tall—and he had a barrel chest and thick, muscular arms. He had short blond hair, stormy green eyes, and tattoos all over his chest and abdomen. He looked like a youngish, healthy guy, not someone we should be trying to pull back from the brink of death.

  A tall, slender ER physician stood at the foot of the stretcher, calmly leading the resuscitation as I furiously mashed on Masterson’s chest. “I need calcium, insulin, and bicarb,” the doctor said to the nurse next to him. Addressing the rest of us, he said, “The patient has been asystolic for three minutes. Please continue CPR.”

  Sweat accumulated on my forehead as I smashed my hands into Dan Masterson’s sunken, lopsided chest. A few drops trickled off the tip of my nose and hit him in the neck. Soon the drops were landing on his face. After five minutes of compressions, my scrub top was drenched. As the minutes ticked by, I found myself smashing harder and harder on the lifeless body, searching in vain for a flicker of life in his eyes. But there was nothing. Just an expressionless face that was gradually becoming drained of color.

  At some point during all of this, my supervisor appeared. He was a boyish forty-something named Dr. Jang, who had been tending to patients on a different floor. He was pudgy—one of the few doctors I met who could be described as overweight—and we exchanged a brief grunt of an introduction as I continued to pump away on Masterson’s chest.

  Every few minutes, just when I thought my arms were going to give out, Jang would nudge me aside and take over compressions. During those moments, as I stood behind him trying to catch my breath, I wondered what role nitric oxide had played in all of this. What was happening inside Masterson’s body? And how long were we going to attempt to revive him? I’d never seen a team go beyond thirty minutes. But this guy was young and had a wife and two kids at home. How could we ever stop CPR? As I stood hunched over, with hands on my knees, I thought, Don’t let him die. Don’t let this fucking guy die.

  Over the course of the year, I’d developed a belief that if I had touched a patient—if our flesh had made even slight contact—that person was my professional responsibility. This admittedly unusual view of the doctor-patient relationship had started sometime after my interaction with the drug mule, when I reflected on how absent I’d been during my exchange with her. That was me at my worst, a doctor just going through the motions, unmoved by the plight of a frightened young woman. That was not the physician I wanted to be. It wasn’t the person I wanted to be. Once my palms had slammed into Dan Masterson’s chest, I considered him mine. My patient. My responsibility. My problem.

  Standing upright and straightening myself out, I again heard the voice of the ER doctor at the foot of the stretcher. “We have been performing CPR for twenty-two minutes. During that time the patient has remained pulseless. He has received three rounds of epinephrine and…”

  I felt a tap on the shoulder and was instructed to resume chest compressions. More sweat fell as an IV was inserted into Masterson’s groin and dozens of medications were administered. At one point, perhaps twenty-five minutes into the resuscitation, there was a brief blip on the cardiac monitor, possibly representing ventricular fibrillation. It was a good sign, potentially a sign of life, and we were all instructed to stand back as Dan Masterson was shocked with 120 joules of electricity. But it did nothing. There was no pulse and the monitor showed a flat line.

  The flicker of hope had given us reason to press on, but as the minutes ticked by, one intervention after another failed. I found myself inadvertently holding my breath as each new medication was given. As I prepared to step back in and resume compressions, Dr. Jang cleared his throat and asked, “Does anyone object to calling it?”

  I froze. We had performed CPR for nearly twice as long as I’d ever seen it done, but still, I didn’t expect to stop. Dan Masterson was my patient, my first solo patient. On tomorrow morning’s rounds, I was responsible for presenting every patient who’d been wheeled in to the ICU on my shift, and now I’d have to get up and say that we couldn’t save him. I imagined the attending ICU doctors exchanging glances as I fumbled through an explanation of why we had failed. I imagined the whispers: Does McCarthy know what he’s doing? I didn’t want it to end like this. Dan Masterson had too much at stake.

  There’s always someone in the crowd who wan
ts to keep going. I looked around for that person, but no one spoke. That someone was me. Let’s shock him again, I wanted to say. Let’s shock him ten more times if we have to. But I knew that wasn’t the answer. You don’t shock someone with a flat line on the monitor and no pulse. You need a fibrillating heart to use a defibrillator.

  “Are we sure?” I asked. My eyes scanned the room, looking for someone to speak up. I felt for a pulse one last time. Nothing.

  “Does anyone object?” Jang asked again. Every head gently shook from left to right, except mine. I knew they were right, but I didn’t want to formally acknowledge it. I didn’t want to accept that we had failed. “All right,” Jang said, as he put his right hand on Dan Masterson’s left foot, “time of death is ten twenty-one P.M.”

  My head dropped. My first patient was dead mere minutes after I had met him. I couldn’t help him. What did this say about me as a doctor? Sure, I wasn’t responsible for what had happened before he arrived—and I hadn’t been the one running the arrest—but I hadn’t been able to step in and revive him. I wanted to believe that repetition improved all of my clinical skills, every single one of them, from diagnosing pneumonia to cardiac resuscitation. But that wasn’t the case.

  So many parts of medicine are about process, and resuscitations are no exception. We were taught an algorithm for advanced cardiac life support. If no pulse, begin chest compressions. Get the patient on a heart monitor to see what’s going on. Is there no heartbeat or a fibrillating heart? The best doctors move seamlessly through the algorithm, and the doctor who had run Dan Masterson’s resuscitation had done a bang-up job, staying clear and focused during the longest effort I had been part of all year. And I had, I thought, been a perfect cog in the wheel. The whole resuscitation was a feat of well-orchestrated doctoring. The only problem was that the patient had died anyway.