Internal Medicine: A Doctor's Stories
Page 2
“Yeah,” I said. “That’s good. Call Respiratory.” Respiratory therapists know all sorts of tricks: complicated masks that somehow squeeze more oxygen into room-pressure air.
I went back to the workroom and paged Keith. It occurred to me that I was displaying weakness. I told myself I didn’t care.
He called back in a minute, cheery, calm. “What’s up?”
I told him.
“She’s DNR? You checked the chart?”
I set the phone down and found her chart. There in the “Consents” section was the legal form, witnessed and signed.
“Yeah. DNR/DNI.”
“Well, that’s it,” he said. “If it’s her time, it’s her time. Just crank up her Os and give her some morphine. That’s all you can do.”
There was silence for a minute.
“Do you need me to come up there?”
“No. I’m on it. It’s okay. I’ll call you if I need anything.”
“Okay. Have a good night.”
It was eight-thirty. I went back to the patient’s room. A respiratory therapist had arrived, bearing a tangled mass of tubes and bags.
“What do you want her on?” The tech eyed the woman in the bed speculatively. “Fifty percent?”
“Let’s try that.” I watched a minute as the tech unstrung his tubes, fitting valves together. The face on the pillow was blanker than ever now: she had closed her eyes. Without that glittering motion, her face looked as if it were simply waiting.
HALF AN HOUR LATER, the nurse found me again.
“Do you want me to do anything for twenty-six?”
“Like what?”
“She won’t keep her mask on.”
“Why not?”
“She says she’s claustrophobic.”
I threw my pen down on the desk.
THE EYES WERE OPEN again, looking out through the plastic skin. She was holding the face mask in her left hand, about a foot away from her face, as if restraining something that had tried to attack her. Her chest was still rising and falling too fast.
I went to the bedside and crouched beside her. The eyes slanted down with me, the head immobile on the bed. “I won’t,” she said, and pushed the mask into my hands.
“Why not?”
She shook her head. “Can’t.”
“Is it uncomfortable?”
“Suffocating. Can’t.”
I bit back an argument. “How about I give you something to help you relax?”
“Why?”
“You need the mask. You’re not getting enough oxygen without it. If we can relax you a little, maybe you’ll feel better about wearing it.”
The eyes closed for a moment. “All right,” she said.
I told the nurse to give her a milligram of Ativan and two of morphine, and to try to get the mask back on her.
Just after nine the nurse reappeared in the doorway of the workroom and shook her head.
“She won’t keep the mask on.”
I pulled myself to my feet.
The patient was propped up in bed now, leaning forward, her hands braced on her thighs to support her. The posture is called “tripoding”; it’s something people do instinctively when they’re having trouble getting air. Her shoulders were lifting and falling rhythmically with each breath. She was using what are called the accessory muscles, anything to help expand the ribcage with inhalation. It can buy you a little extra air exchange, but the price, in terms of exertion, is more than most of us can pay for very long. The mask lay in her right hand, hissing.
She didn’t seem to notice me as I moved across the room; her gaze was straight ahead, intent on something. Each breath, I thought. Or perhaps something visible only to her through the far wall of the room.
“Mrs. B?”
Her gaze flickered my way, a brief acknowledgment, then back to her inner vigil, intent.
My first impulse was to ask her how she was doing. I stifled it. I reached out instead and took the mask from her. Her hand was stiff; the fingers yielded slowly. Her eyes turned toward me.
“Does this bother you so much?” I held the mask out.
She nodded and drew away. As if it could bite her, I thought.
“More than the way you’re feeling now?”
Her gaze clouded a moment. Unfair, I thought. Arguing with a dying woman.
She nodded again.
I sat at her bedside, holding the hissing plastic coil, looking into the mask. Reluctantly, unwilling to place my mouth where hers had been, I fitted the mask to my face, pressed the vinyl against my cheeks. I took a breath.
There was only a smell of plastic, then a high, eerily open sensation of emptiness. I took a breath, feeling my lungs expand; a vivid impression of spaces opening everywhere. I found her looking back at me, the eyes from the depths of her immobile face dark and liquid and alive.
I took the mask off. “It makes you feel confined?”
She nodded, shrugged.
“Have you tried taking deep breaths?” I was still buzzing with the force of the oxygen; my lethargy and sleepiness were all gone. I felt ready to take this woman on and bring her with me to morning.
She looked at me only a moment before turning to the far wall again, shaking her head. It occurred to me that she probably couldn’t take deep breaths.
I was still holding the mask.
“Did the sedatives help any?”
No.
“Would you like to try some more?”
Shrug.
I went to find the nurse. We doubled the dose of the Ativan. I watched, this time, as the drugs ran in, saw the relaxation I hadn’t believed the stiff skin could show, the subtle slumping of the shoulders. I waited, and when sleep seemed about to take her I slipped the mask over her face. A hand stirred, rose a few inches, wavered, then fell to her lap; she settled back against the bed. I stood there beside her, holding the mask in place, watching. After a minute or two, we checked the pulse-ox: 94 percent. Her respiratory rate was settling into the mid-twenties. Hours of accumulated tension dissipated from my own chest. The nurse and I walked quietly out the door. “Keep an eye on her,” I said.
I don’t remember what time the next call came. Probably around two. I was back in the workroom, running blearily over the results of the one o’clock draw, fielding pages from the floor. There had been a shift change at midnight, followed by a flurry of pages from the new shift coming on with questions. There was a patient down on 3 West who was refusing his prep for a scheduled colonoscopy.
I heard a knock and an unfamiliar face appeared in the doorway. “Are you the doctor on call?” Shift change. I grunted something affirmative. “Do you know the patient in twenty-six?”
An uncomfortable sensation stirred in my chest.
“I got report on her,” the new nurse said. “Do you still want frequent vital signs?”
“How’s she doing?”
“I don’t know. Do you want me to check?”
“Please,” I said, and settled my head on my folded arms.
A HAND SHAKING MY SHOULDER. “Doctor?”
I stirred unpleasantly. My face was stiff. My sleeve was wet.
“I’m sorry to bother you, but that lady in twenty-six, she’s not looking so good.”
I sat upright.
“Her O2 sat?” the nurse went on. “It’s only eighty-two. And her rate is over thirty.”
“Is she wearing her mask?”
“No.”
“Christ.” I was out of the room, stalking down the hall.
She lay in the bed, looking expectantly toward the door, the mask gripped in her hand. Her other hand went up as I approached, waving me away.
“Mrs. B,” I called to her, pitching my voice as if into the distance.
The head bobbled for a moment, turned my way. The eyebrows were lifted slightly, but the skin above them was unfurrowed. The mouth was a hole air moved through.
“Mrs. B,” I said again, willing her to look at me.
She did.
She shook her head.
“If you don’t do it,” I said, reaching out to take the mask from her hand, “you’re going to die.” She made an ineffectual motion as I placed the mask over her face, looping the cord behind her head. Her hair was greasy with sweat. She reached up and placed a hand on the mask. My hand and her hand held it there. Did her breathing start to slow? I held the mask through one long minute, another. The nurse was a silhouette at the doorway. Another minute more, and I was sure the rate had fallen, the laboring of her shoulders lessened. To the nurse: “Let’s check a sat.”
Ninety-two percent. To Mrs. B: “There. That feels better, doesn’t it?” She nodded, faintly, and seemed to settle into the bed. I let my hand fall away from the mask, crooning, “There, there.” After five minutes pressing the mask to her face, my outstretched arm felt like wood. I reached behind her head to snug the cord.
She pulled the mask away. “I can’t breathe. I don’t want it,” she gasped. “It’s too tight.”
And pulled harder until she snapped the cord in two.
I grabbed the mask and held it on her face. She reached up and clutched my wrist, and for a moment I thought we were about to struggle over it, but then she stopped and her hand fell away. Her eyes were fixed on mine.
The nurse was still at the doorway.
“Ativan,” I said. “Two milligrams IV. And two of morphine.”
Mrs. B still stared at me, her face remote and motiveless behind the mask. My arm was aching. Was I pressing the mask too hard? I eased up, fumbled with the broken cord, but the ends were too short to make a new one. Mrs. B didn’t take her eyes off mine as the nurse reached for the port in the IV tubing. Just as the nurse’s fingers caught it she snatched her arm away.
“No.” The voice was a whisper.
The nurse turned to me, her expression stricken. “I can’t, Doctor.”
“What do you mean?”
“I can’t force a patient. It would mean my license.”
“She’s going to die if she doesn’t keep that mask on.”
“Then get Psychiatry to declare her. But until then it’s her decision. We can’t make it for her.”
Psych wasn’t going to declare her. I knew that. It was her decision. I knew that. But I couldn’t let it end this way. Surely I could make her see.
“Mrs. B,” I said finally, “is there any way we can make this easier for you?”
“How about a bucket?” said the nurse.
My expression must have requested explanation.
“A face tent, they call them. It’s open at the top. It works for claustrophobia. Do you want me to call Respiratory?”
“Please.”
THE RESPIRATORY TECH ARRIVED after an interminable period during which Mrs. B refused again and again to wear the mask. Eventually we found a compromise. She would hold it a few inches below her chin. It bumped the pulse-ox to 88 percent. But her respiratory rate continued to climb. I couldn’t tell if it was hypoxia or anxiety. A blood gas would have told me, but I was reluctant to try. I didn’t know what I would do with the information. When the tech arrived and fitted her with the bucket, I stood at the door watching. It seemed to be doing something.
The next page from twenty-six came around four. I had gone into the call room fifteen minutes before, but the moment I lay down it was clear there was no chance of sleep. I lay rigid in the lower bunk, unwilling even to turn out the light, bracing against the sensation of my pager at my hip. My thoughts were an incoherent jumble: scraps of medical education—the innervation of the hand, the watershed areas of the mesenteric circulation, drugs to avoid in supraventricular tachycardia—none of which was relevant to any of the calls I had gotten that night. I was thinking of anything but the patient in twenty-six, two floors overhead. The next page was, of course, about her.
The nurse picked up on the first ring. “Doctor? I think you’d better get up here.”
I was out of the door without a word.
The scene in twenty-six was superficially unaltered. But from the bed I was hearing small whimpering noises, rhythmic, paced almost to the beating of my heart.
She was sitting bent over, the exaggerated movements of her chest and shoulders making her head rise and fall, rise and fall. I counted, but lost track in the twenties, somewhere around half a minute. At least forty.
“Mrs. B?” I laid a hand on her shoulder. She didn’t turn. Just the rapid rise and fall of the head. Her shoulder was clammy, her gown damp. Was she febrile? Was there something I’d missed? Should I have gotten cultures? Hung antibiotics? Was she having a PE? The body on the bed wasn’t telling. Only the same carrier wave of distress, up and down, up and down. I looked to the door, where the nurse was standing. “Get Respiratory up here.” She started to go. “And get me two of morphine.”
The patient didn’t resist this time. I don’t know if she was even aware, but as the plunger went down on the syringe I could see a change in her; she settled and her breathing slowed. The pulse-ox, which had been in the mid-seventies, climbed up a notch or two, settled in the low eighties. I had no idea if that was something she could live with. I stood at the bedside and watched. Her respiratory rate was in the low thirties. An eye opened, swiveled around the room until it met mine. The mouth moved, no sound came out.
“Mrs. B,” I said, and my tone was frankly pleading now, “you’ve got to let me help you.”
The eye held my gaze for a long moment, the dim gleam of the nightlight streaking across the cornea. A hand made a brief sweeping gesture, fell. Away.
Somewhere in the course of the night I had developed a fixed idea: if I could get her to morning, it would be okay. I had no idea where that notion came from. Years later, after what seems like countless midnight vigils, the trust and hope of it chill me. But then I clung like a child to the thought of morning. In the morning, her primary team would be on hand; someone would know what to do. By the light of the morning, ill spirits flee. In the morning, it would be off my hands.
The respiratory tech was at the door.
“It isn’t working,” I said.
The tech didn’t actually shrug. “You don’t think you can tube her?”
“I can’t,” I gritted out. “DNI.”
“BiPAP?”
“I can’t get her to wear an ordinary face mask.”
“Why don’t you just snow her?”
It was a thought. She hadn’t refused the morphine. I could try adding on sedation until she would let me put a mask on her—perhaps even a tight-fitting BiPAP mask, the next-best thing to intubation. It could be done.
“Yeah,” I said. “Nurse? Bring me four of Ativan. And another four of morphine.”
I knew the risk: knock her out too far and her respiratory drive would suffer; she’d lose her airway; she’d suffocate.
But she was going to die this way, too. I watched, holding my breath as the drugs went in, trying to remember the doses of naloxone and flumazenil that would reverse these, if I had to.
Her breathing settled still more. Her eyelids fluttered and fell. “Get a mask on her,” I said.
In a minute the tech had her fitted with an elaborate device that gripped her face like a diver’s mask. There was no protest. The pulse-ox rose steadily to ninety, ninety-one, settled at ninety-two. I let out a sigh.
This time I did sleep. I must have, because my pager woke me from a dream of too many inscrutable objects, none of them fitting together, a puzzle I had to solve.
“Doctor? Twenty-six. She’s fighting the mask.”
SHE WAS SITTING UP, crouched as if clutching some secret to her chest. The mask was pushed up onto her forehead. Her shoulders rose and fell, rose and fell. She didn’t look up as I entered; her gaze lay burning on the opposite wall.
The pulse-ox was eighty-two.
I laid a hand on her shoulder, could feel her bones working as it rose and fell.
She shook her head.
“We’ve got to do something.”
She shook it again.
“What can I do for you?”
Her hand waved me away.
I stood beside her, watching her breathe, for a very long time. She lay on the bed within reach of my outstretched hand, within the sound of my voice, but behind the wall of her fatigue and her breathlessness, sunk deep in her adamant gaze, she was unreachable. Unreachable by me. I wondered if she even knew I was still there, and felt suddenly a revulsion—not at her, but at my own presence in her room.
Her pulse-ox was eighty-two.
“Call me,” I said to the nurse, “if she changes.”
AROUND SIX A.M. I was sitting in the call room, trying to shake myself awake. My pager went off. It was the eighth floor.
The room was different now. Light was striking in through the window, a dozen rising suns reflected off the opposite tower. The room was bright and still.
Fast asleep, even comatose, a living body moves. The chest expands, the nostrils flare, the eyelids twitch; pulses stir the skin, and over all of these there hovers an inarticulate hum of life. But a dead body is only that: dead, a body, given over to gravity and decay. The muscle tone that lends expression to the face is gone; the face is slack; the skin gone gray-green with the absence of blood (underneath, if you turn it over, you will find pooled at the backside a livid bruise).
I went through the motions of declaring death. Her eyes took my flashlight passively, the beam falling into the cloudy darkness of her pupils without a sign. I laid a stethoscope on her chest: only sporadic pings and creaks, sounds of a building settling in the night. Her flesh was cold, malleable, inert.
There were papers to fill out: organ donation, autopsy permission, the death certificate. I puzzled over “Cause of death,” wondering just what process I had failed to reverse.
Respiratory failure, I finally wrote, secondary to pulmonary fibrosis, secondary to systemic sclerosis. The last line asked if any underlying medical conditions (diabetes, hypertension, for example) had contributed to the patient’s demise. I looked at that a long time, and finally left it blank.