by Robin Cook
As I pushed open the ICU door, the weird world enveloped me again, and of course I found myself the only doctor there, quite alone with two nurses beside the bed of the man with the irregular EKG. While my mouth formed an inaudible obscenity, my fingers involuntarily clutched the side railing of the bed as if using it for support. I was no longer the television intern, but a real one, complete with inexperience and terror. Who would support me if this man died? The nurses? The medical-school professors? The attendings? The hospital? Most important, I had not yet learned to forgive my own mistakes.
Looking back at the door, I hoped against the odds that a resident would suddenly appear; it came home to me why many brilliant and dedicated students go all the way through medical school and then, facing internship, change course and switch to research or some paramedical field. Anything must be better than internship. Something's wrong here. Why can't the intern know something useful when he runs into the ICU during the first couple of weeks? And why don't the attendings back him up? Even the helpful ones are mostly no better than quietly aggressive. They seem to be saying, "We waded through all this shit. Now, goddamn it, you do it, too."
Well, I was doing it, here and now in the ICU, with no chance of any help, but this time I got lucky. The EKG monitor displayed on the oscilloscope showed a wildly erratic electrical impulse, like the scribbles of an irritated child. As its beeping sound rose higher and higher, to an extremely rapid staccato, I realized that the patient had slipped into ventricular fibrillation; his heart muscle was just a quivering, uncoordinated mass. Now I knew what to do; I would "shock" him.
Actually, the decision was not so much mine as the nurses'. Always a step ahead, they had the defibrillator charged up and one of them was holding the greased paddles out to me.
"What's it charged to?" I asked, not really caring, but needing the control the question gave me.
"Full charge," answered the nurse with the paddles.
I put one of them on his chest, right over the sternum, and the other along the left side of the thorax. Oddly, he hadn't stopped breathing completely. Nor was he unconscious. The only sign of distress besides his gasping respiration was a sort of dazed look, as if the breath had been knocked out of him.
I pressed the button on top of the paddle handle. His whole body stiffened violently, and his hands shot into the air and down. The EKG blip was driven off the oscilloscope screen by the sudden tremendous electrical discharge, but it came right back, looking normal. I was reassured when the beep reappeared, too, suggesting a normal pulse rate, and the man took a deep breath. Everything seemed fine for about ten seconds. Then he stopped breathing, and right away the pulses went to zero, while the EKG continued along with the blip at a normal rate. That was crazy. EKG blips and no pulses was a combination not in the textbooks. My mind played a huge indoor tennis match, with concepts flying back and forth— electrical activity, electrical activity, but no beat, no pulse. "Get a laryngoscope and an endotracheal tube." One of the nurses already had them in her hands. He had to have oxygen. Oxygen and carbon dioxide had to move, and for that we had to insert an endotracheal tube and breathe for him.
The tube is put down by means of a long, thin flashlight affair called a laryngoscope. This instrument has a blade on the end of it, six inches or so long, that is used to raise the base of the tongue and bring into view the entrance to the trachea, where the tube must go. As the blade slides into the throat, you try to locate the lid that covers the trachea during swallowing—the epiglottis. All this time you are standing behind the patient, pulling his head far back, fighting through extraneous material like blood, mucus, or vomitus. Once you see the epiglottis, you slide the instrument past it, down a little farther, and pull up. With luck, you'll then be looking past the trachea at the vocal cords, which are creamy white, in contrast to the red mucosa of the pharynx.
That’s the ideal situation. In practice, you must often push this way and that on the throat with your free hand, looking for the trachea, and sometimes you never do find it. And even when you do, your troubles are still not over, because sliding the tube down can be devilishly hard. The precious hole between the vocal cords will be obscured at the last second by the rubber tube. Nothing to do but push it in blind. Too often your dead reckoning leads the tube into the esophagus, so that when you try to ventilate the patient—force air into him—his stomach blows up instead of his lungs. And all the while there is usually someone else pounding on the man's chest, and the laryngoscope is clanking against his teeth or jumping out of his mouth, and the whole area may be filling rapidly with fluid of one sort or another. Putting down an endotracheal tube was, to me, a subject fit for nightmares.
But there was no one else around to do it, so I pulled the man's bed out and got behind his head with the laryngoscope. "What's his basic problem?" I asked hastily, pulling his head back.
"He doesn't follow his pacemaker all the time," one of the nurses said.
Suddenly it made more sense. "What’s he been on? What's in that bottle?" I said, motioning to the IV bottle. "Isuprel," came the answer, and I told them to speed it up. I knew that Isuprel helped the heart with its contraction and was especially useful in cases where the heart wouldn't contract on its own.
"How fast?"
How fast? I hadn't the slightest idea. "Let it run." I couldn't think of anything better to say. His head was back now, and the laryngoscope far down into his throat, but I couldn't see the vocal cords. "Get me an amp. of bicarbonate." As one of the nurses vanished from the periphery of my vision, I realized that at last I had thought of something on my own. Then the vocal cords appeared. Their white contours stood out against the surrounding red like the gates to a subterranean chamber. For once I managed to get the tube into the trachea without too much of a struggle.
But no sooner had I slipped the tube in than the patient reached up and pulled it out. I was indignant, just for a second, until I realized he was breathing again. A strong, full pulse showed in his wrist. The nurse appeared with the bicarbonate. Stupidly, I wanted to give that stuff now, because I had thought about it and the nurses hadn't, and especially because I knew a lot about electrolytes and pH and ions. But I wondered what the effect would be on the calcium level. Both calcium and potassium combined with the pH in a tricky fashion. I was in danger of overthinking and getting all balled up, so I decided to save the bicarbonate; no sense rocking the boat.
Suddenly an anesthetist burst panting through the door, and another intern, followed by a resident, and another resident. All of them looked sleepy. One had no socks on, and there were pillow creases on the side of his head. The crowd continued to swell as another resident rushed in. This was about the time I liked to arrive, when everything was under control and decisions could be by committee. Actually, I was beginning to calm down, although my own pulse was still racing. The newly arrived house staff settled down on the counter and chairs. One of them leafed through the chart, while another called the private attending. I stayed beside the patient, who had started to talk. His name was Smith.
"Thank you Doctor. I'm all right now, I think."
"Yes, all your signs are good. We're glad we could help you." Our eyes locked, his showing more trust than I thought I deserved, and mine trying not to give away my inner uncertainty. The Isuprel was still running into him like crazy, and I didn't know whether to slow it down or not. Let the others carry the ball for a while. Mr. Smith wanted to talk.
"This is the third time for me, I mean the third time my heart has decided not to follow my pacemaker. When it happens, I don't have time to think, but afterward, like now, it all falls into a pattern. First, my throat tightens up, and then suddenly I can't breathe, nothing at all, and then everything goes gray and shadowy." I was listening hard, but only half comprehending. It was incredible to be talking with him when a few minutes ago he hadn't been there.
"A shadow, that's the best word I can think of, but the shadow doesn't pass. It goes deeper into blackness, until no light
is left in the world." He stopped abruptly. "But do you know the worst part, Doctor?" I shook my head, not wanting to interrupt him. "The worst part is coming out of it, because it happens so slowly; not like going down, which is quick. First, I have these wild, chaotic dreams. No sense to them that I can find, until finally—it seems forever—the room and the bed and the people come into the dream and eventually take over. I can't explain why, but the last thing to come back is an awareness of myself, who and where I am, and the hurt. My chest feels caved in, as if I'm smothering from lack of air, especially if there's a tube in my throat."
"That must be why you pulled the tube out. Have you had many operations?" I asked.
"Enough to fill a book. Appendix, gall bladder ..."
I interrupted him. "Do you remember what it was like to be put under anesthesia? Have you ever had ether?" That was one experience I remembered vividly, although it was a long time ago, when I was four or five. Back then, everybody had his tonsils out, and I remembered my terror as the ether mask was put over my face, the room began to fade, and an unbearable buzzing sounded in my ears. Then concentric circles moving faster and faster until they collapsed into a bright red center; then nothing, until I awoke vomiting.
"My appendectomy was in 1944," said Mr. Smith, thinking back, "while I was in the Navy, and I believe it was ether."
"Was that anything like the feeling you get when your heart stops? What about waking up?"
"No, not at all. The anesthesia is somehow pleasant, nothing like struggling with my heart—it seems literally like a struggle to keep it from jumping out of my chest, keep it under control. I can't remember waking up from those operations, but when my heart starts up again it is like a thousand unending nightmares."
He reached up and touched my hand, which rested on the bed railing. "God, I hope it doesn't happen again. You see, I can't be sure anybody will be there to help. You know, Doctor, there's another strange thing—this time I felt I was watching my own body from someplace outside of myself, as if I was standing at the foot of my own bed."
"Have you had that feeling before?" I asked, curious now; feeling outside oneself is a symptom of schizophrenia.
"Never. It was a unique sensation."
A unique sensation. A unique sensation. This man was telling me about dying, but the way he told it made death into a living process, something you could study in a textbook. Without that defibrillator, of course, he would have been dead, and with him all those thoughts. Tonight the line between life and death had hardly existed for three people—for him, for Marsha Potts, and for the old man with cancer. I was having trouble thinking about life and death at the same time, but I was happy this man wasn't dead, because he was so nice. What a stupid thought. Anyway, I couldn't imagine him dead. No matter what had happened he wouldn't have died, because he was alive right at that moment.
Does that make sense? It did to me. Who was I to think that I could have changed fate? Being alive and talking and thinking is so different from being dead and immobile that the transition seemed impossible now. It had been so simple, just a zap with the defibrillator, like slapping someone on the back to stop a cough, or running for a glass of water. Maybe he hadn't been fibrillating; maybe he would have come out of it on his own. He had before. I would never know.
The medical resident and another intern were still there, talking and adjusting the plastic tubes, scratching their heads and holding the EKG strips. They seemed happy and involved. As I went out I looked over at Mrs. Takura, who smiled broadly and waved with her free hand.
The strange nether world of the ICU vanished again as I turned down the corridor and descended the stairs. All of life seemed asleep. I thought of those nights in medical school back east when I had struggled to my apartment from the hospital through all that winter had to offer. Ironically, calm, star-filled nights like this one were even harder, so lonely you wanted to swear. In Hawaii almost every night was clear, blazing with thousands of stars and cooled by a gentle wind.
The thought of Jan back in my room kept me going. At times like this, when the medical tensions were beginning to evaporate, all I could think about was escaping the loneliness, being near someone alive and healthy, talking to her and loving her. A few times in medical school a girl had waited in my room while I went off to do something. That had always made it nice to come back. But too often she would just grunt a little in her sleep as I slid in beside her.
That "something" my medical-school peers and I found ourselves doing at odd hours of the morning was almost always a lab routine. The need for blood counts and Bence-Jones protein analyses seemed to occur to the residents primarily after midnight. So hundreds of times we had ended up spending the wee hours in what you might call the bowels of the medical ship, counting tiny blood cells, which grew even tinier with the passage of time. Meanwhile, the resident on the bridge was steering the patient through, frequently complaining about the slowness of his blood counters in the hold. The truth about blood counts is that if you've done one you've pretty much done them all. The point of diminishing returns on the learning curve is reached quickly, particularly at 3:00 a.m., when your mind tends to dwell on getting back to your room and, perhaps, to the young lady.
In one twenty-four-hour period I had done twenty-seven blood counts, a personal record, though by no means a hospital record. My last few, in the small hours, were, of course, no better than half-educated guesses. Thus it went in the big leagues, where you were trained for a cost of $4,000 a year, to be a lab technician. All of us had worked up fantastic scenarios wherein we threw the urine in the resident's face and told him to jam the bottle up his ass, or we went on a sit-down strike in the cafeteria. None of these scenes existed outside our imaginations, because, to tell the truth, we were quite intimidated. As the professors never tired of pointing out, others were standing in line to wear our little white coats. What, in fact, happened was that late at night, when you felt pissed off and exploited, you cut a comer here and there and invented a plausible result. But this happened infrequently, and only late a night.
But worst of all was later, not having anyone to listen. The whole world seemed asleep and quite indifferent to your conviction that medical education was shitty and irrelevant. So you hurried back to your room, to the sleepy girl, grateful, finally, for her warm body.
Quite a few students got married at the beginning of medical school. I suppose they were not so lonely, having the omni-present warm body. And the first two years were fine—courses during the day and hitting the books at night. They probably had a ball. But it was different when the blood counts came those last two years, and all the other Mickey Mouse in the middle of the night. Gradually, I think, some just gave up trying to communicate the frustration. The warm body wasn't enough. In any case, a lot of them weren't married any more when we finally got that piece of paper saying we were Doctors of Medicine. Actually, we had been champion blood counters, Doctors of Concept and Laboratory Trivia. Not one of us had known what dose of isuprel would save a life.
When I opened my door, I couldn't decide whether to make a lot of noise or be quiet. The kinder instincts won, and as the light from the hall flooded in I quickly rolled around the door and shut it. I took off my shoes. The room was perfectly silent, and so dark after the fluorescent lighting in the hall that I couldn't have moved around without knowing the position of the furniture. Some furniture! Of course, the hospital bed I slept on did have interesting characteristics. It could be cranked up into such a comfortable position for reading textbooks that I never managed to get through more than one or two paragraphs before falling asleep.
The rest of the furniture included an easy chair as hard as stone, a bookcase, and a desk designed for a small child. If I put both elbows on it, there was no room for the book, especially one of those five-pound, thirty-five-dollar jobs so popular with today's medical publishers. As I moved about in the dark, the only potentially serious obstacle was the surfboard I had hung from the ceiling. Gradually,
as my sight adjusted, I could see the outline of the window and the bed, and I put my hand down on the covers, running it back and forth, faster each time, until I was sure she had left. Sitting on the edge of the bed, I rationalized that I was exhausted anyway, and she probably wouldn't have wanted to talk. It was past two, and I was exhausted; I really was.
The phone rang three more times before morning. The first two weren't important enough for me to go, just nurses with questions about some order and about a patient who wanted a laxative. On the matter of laxatives, I have made a small independent study. The study proves conclusively that five out of six nurses are ten times more likely to ask for a laxative order between midnight and 6:00 a.m. than at any other time of the day. As for the reasons, they are difficult to figure out, hinging perhaps on a Freudian interpretation of the nursing profession's anal hang-ups. In any case, I felt it was a near-criminal act to wake me up for a laxative order.
Each time the phone rang, I'd sit bolt upright as a shot of adrenaline whizzed through my veins. By the time I got the phone to my ear, my heart was pounding. Even if I didn't have to leave my room, it would take me about thirty minutes after each call before I calmed down enough to fall back to sleep. On an earlier evening, answering from a dead sleep, all I could hear was distant mumbling. "Speak louder," I had shouted, closing my eyes tightly and concentrating, barely able to make out the remote words. They had been telling me that I was speaking into the wrong end of the telephone.
