Internal Medicine: A Doctor's Stories

by Terrence Holt

  Well, of course, on some level I wanted something close. There was nothing complicated or remarkable about that. Any resident who is remotely honest will tell you we become, if not comfortable, at least familiar with the sensation of wanting patients to die. We feel that way because they’re going to die anyway, usually, and we know that, out of the available options, dying quickly is the best that could happen to them. But it’s also better for us. There’s the rub. It saves them agony, but it seems to save us something as well: the exhaustion of watching, of causing nothing but pain as we struggle to forestall the inevitable.

  Of course, it doesn’t really save us even that. Whatever hospitals once were, they are now largely places where people come to die. If they’re not at death’s door we rush them back home; only the dying linger, but in this parallel universe every dying patient is quickly replaced by another. The house staff come to see the ICU as the place where we manage that exchange, again and again and again. The feeling is understandable. It’s also, thank God, temporary, fading like bad dreams with the light of day as we get more sleep, more time with our patients, as we move up the hierarchy so that we’re not the ones actively, physically, holding off death just a few seconds more.

  So there I was, using all the rhetorical tricks I had at my command, I feared, to seem to push this family into pulling the plug on my patient. Was I really doing that? It would be better for the patient, after all.

  And it was my job, I told myself, to help them face up to a reality most of us would rather deny. Too few of us arrive at the hospital with a duly signed and witnessed DNR order in our hands. Too few of us have the conversation with our families. And nobody out there seems to understand that the survival we have to offer is sometimes worse than—I had been going to say “death,” but I don’t know enough about death to use it in a comparison. Worse than what? Worse than I want to give? Perhaps it’s that. I would save everyone if I could, but it’s a sorry gift I have to offer, sometimes. Life in a puddle of urine, bones laid bare as the immobile flesh turns black and rots away, long hours passing while a call for something simple—a drink of water, a runny nose wiped clean—goes unanswered. I didn’t want that life for Muriel Wallace, for any of my patients, for anybody.

  But with every unassisted breath Muriel Wallace took, I was beginning to understand that what I wanted did not matter. My rhetoric did not matter, except insofar as it might impose my half-baked wishes on events. Muriel Wallace’s life was following its own plot. It had always been that way, I knew, but just then the reality of it left me feeling bleak, uncertain of where to go next. And the entire family was still looking at me.

  There were more questions, which I did my best to answer, talking on autopilot about infections, fiber endoscopies, and skilled nursing. While the family threshed through the matter, discussing things I had no business hearing, I excused myself. They would let me know. I went across the hall and back into the Unit, moving through the noise of the nursing station to the dark and relatively quiet room where Muriel Wallace lay. She was still: a big, still woman with white plastic tubes taped to her face. Gently, I jostled the end of the endotracheal tube. No response. Out of habit more than any actual curiosity, I put my stethoscope to her chest: air moving in and out, backed by the rhythmic thud of the living. Her left arm was limp, utterly flaccid, falling when I let it go in a straight drop to the bed. A big, still woman lying motionless in bed.

  ANY PATIENT IN A HOSPITAL, when we take their clothes away and lay them in a bed, starts to lose identity; after a few days, they all start to merge into a single passive body, distinguishable (if even then) only by the illnesses that brought them there. In the ICU, with consciousness gone as well, there is rarely a trace of personality left behind. Spirit itself comes from a machine. The body remains behind, but all too often it’s a husk, doing the work of living for nobody’s benefit. It’s impossible to know what’s going on in there. It’s impossible to read how the body came to be there, what life it left behind. Just the rise and fall of the chest, the slow accumulation of data as labs and vital signs and consults and imaging fill up the chart, telling nothing about the person they surround.

  But the question of Muriel Wallace and her care had become a question not of medicine but of an unknowable will. What would Muriel want? It was clear enough that she had had a stroke that should have killed her, and was certainly, I thought, going to leave her hemiplegic forever. She had to look forward to a future of infections of the lung, of the bladder, and then the slow ripening of sores. There was no easy solution for the problem of being Muriel. None that I could give.

  And none that she could give, either. We go along in our lives, making plans, expecting things will continue the way they have, confident that we know what we want, what we might and might not have. But lives don’t go like that: no matter what we will for ourselves or others, time hides abrupt and wrenching dislocations, moments that change everything. Muriel had been through one of those moments. And after that, what anybody knew, what anybody wanted, was irrelevant. More and more the facts seemed to tell us that she was going to live. She was going to have to live with what happened to her. I picked her limp arm back up, folded it across her, covered it with the thin hospital sheet. She gave no sign. The ventilator heaved a sigh as I left the room.

  I WISH I COULD provide something neater to end this piece. It didn’t end neatly—hasn’t, for all I know, ended at all. Muriel survived our care. She did develop pneumonia, but anyone will in her situation: we were waiting for it, and she responded within a day or two to antibiotics. Later, she woke up, just as her family had hoped. She even greeted me one morning with a half-wide half grimace, a strong grip with her good right hand. She nodded vigorously to almost any suggestion, nodded and squeezed about getting the trach and the G-tube, and as soon as her fever was down, on two successive days she got them both installed, and we were able to wean her off the vent without a problem, and the nurses started to teach her family how to pour into her G-tube the cans of gray-green liquid that from now on would be her food. Then, her need for intensive monitoring past, we transferred her to one of the general medicine services, who would manage her care until she had a bed somewhere beyond our walls.

  AS LUCK WOULD HAVE IT, I followed her a day or so later, rotating off the ICU to general medicine. My first day on the service, the family greeted me like lost kin. They were no longer a collective tableau of grief, resolving instead into individuals, who spoke, gestured, laughed. That day they were laughing—gently, happily—at me. Pulling me into the room during rounds, they interrupted the intern’s presentation with a delighted—and slightly ironic—demonstration of Muriel’s ability to move the toes of her left foot, the ghost of a grip she had developed in her left hand. Muriel beamed at me as she showed us what she could do. The intern beamed and completed her presentation. The plan for Muriel, for the remainder of her stay, was physical therapy, speech therapy, occupational therapy, and social work consultation for placement. The family had agreed to place her in a nursing home for rehab, confident that it would be a short sojourn before returning to the life she had known. I beamed back at them, nodding blindly, not looking at the figure still splayed so limply on the bed.

  ON THE DAY OF her transfer to the nursing facility, Muriel was found unresponsive, and hypotensive to the eighties over forties. It seemed for a moment that her story had taken another turn, or turned back, anyway, into the usual course of things in the hospital. She spent that night in the ICU again, getting a liter of fluid. That fluid may or may not have been responsible for the recovery of her pressures. At any rate, something turned this climax into peripeteia: the story continued, again taking its own path to its own end. For now, at least, she rebounded. What set her back in the first place? Nobody knew. Things like this were to be expected. By the next day she was back on the general medicine service, and the day after that, her family took her away. I didn’t see her go.

  In the years since then, I’ve thought about her
often, wondering how she’s getting along. It would be easy enough to find out how her story finally ended, but I’ve resisted. I’d like to leave her the way she is, lying in that bed with her family so pleased, beaming at me because I was wrong.

  HEART

  FAILURE

  Let the lamp affix its beam

  MARIE P WAS ADMITTED TO THE CARDIOLOGY service from the Failure Clinic one day in February, a three-hundred-pound woman with a history of non-ischemic cardiomyopathy. Her heart was failing. I was a resident, one of nine staffing the CCU that month, just past the halfway point of my residency. It was my second rotation through the CCU that year.

  The CCU—cardiac care unit—was a critical care service, in which teams of residents rotated call not every fourth night, as the practice was on other services, but every third. This turned an otherwise grueling month—all months in the hospital are grueling—into a marathon. On the day Marie came in from the Failure Clinic, I was two weeks into the rotation and was already exhausted. Or maybe something more. After two years of constant call, I was empty.

  It was our bad luck to be admitting on the day of Failure Clinic.

  “Heart failure” is a fairly common diagnosis. It sounds ominous, and it is, but the reality is less dramatic than the words suggest. It does not mean, for instance, that the heart is about to stop. The disease is actually more of a chronic condition, what used to be called the dropsy, in which the heart, weakened by a poor blood supply or alcohol or untreated hypertension—the list is long—can no longer drive blood around the body as well as it should. Fluid backs up, one place or another. If the weakness is primarily on the heart’s left side, fluid accumulates in the lungs: you cough, get short of breath, can’t lie down flat without a sensation of smothering. If it’s on the right side, your legs and belly swell, the liver stretches; the veins on your neck stand out, pulsing. And because the whole circulation is connected, failure on one side eventually becomes failure on both. At that point the patient enters the terminal phase. Then “failure” comes to mean what we usually mean by it, like “breakdown” or “collapse.” But this can take years.

  The culprit in this persistent flooding is not the heart so much as the foolish kidney, which continues to do its job of regulating the body’s fluid levels, but does so in an increasingly misleading milieu. As the heart’s output drops off, the kidney senses decreased flow and in response holds on to water as tightly as it can: your weight climbs, your ankles swell, you start to feel congested: you’re suffering an exacerbation of congestive heart failure. When your doctor gets a look at those puffy ankles and hears the crackles in the lungs, she calls up the cardiology service and sends over what the admitting resident will describe to the intern as “another damn tune-up.” Marie was in for a tune-up, a four- to five-day process in which we wring out all that extra fluid, undoubtedly the dullest medical intervention a hospital can provide. Marie had gone through this so many times before that it was all I could do to lift her chart—heavy in proportion to her obesity, packed with details of prior tune-ups, diagnostic studies, lab values, and a pervading sense of futility . . . which was increasingly how my own fatigue had come to feel.

  By the time I met her, Marie P had long since passed the point where the occasional tune-up would suffice; she had been discharged from her last admission on a permanent infusion of dobutamine, without which her heart would simply grind to a halt. She got it through a Permaport installed over her collarbone, and a pump that followed her everywhere.

  What we were supposed to do with her was simply crank up the settings on the pump and see how much fluid we could draw off. And although this was not without risk (side effects of dobutamine include lethal arrhythmias), this is not the stuff of which careers in cardiology are made. My partner on the service that month, Alex, was applying for fellowships in cardiology. I took Marie under my care.

  Such as it was. She arrived on the floor sometime in the late afternoon, competing for my attention with a man having a genuine heart attack and a woman whose aorta seemed to be disintegrating. When the nurse informed me of her arrival, I scratched out a set of generic orders and returned to the gray, sweating fellow who was heading for the cath lab. I didn’t lay eyes on Marie until after ten that night. Her room was dark, her vital signs were stable. I should have awakened her and repeated the intern’s history and physical exam. But as I listened to her snoring, propped up in her bed so that her lungs wouldn’t fill from her internal seeps and springs, I thought about the two dozen prior admissions documented in her chart, and how little changed from one to the next. I didn’t wake her up.

  FOR THE NEXT SEVERAL DAYS, Marie hovered vaguely on the margins of my attention. She was a tune-up, someone whose progress I would measure in liters of urine. She was a body to examine each morning, a set of labs and vitals to record, a very simple story to present each day on rounds. She herself remained tucked into the end room on the intermediate care unit, a fat little woman with a tremulous manner and a wedge of tight pallid curls that made her head, from sharp chin to spreading jowls to the bed-flattened top of her curls, a cone. I hated her.

  “Hated” may be too strong a word. At that time, I hadn’t the energy for hatred. Certainly I didn’t like her. I think it was primarily the way she whimpered when I examined her. The sound she made grated on me, partly because I didn’t believe I was hurting her, also because that was all she would do—pucker her face around a sharp gasp, never looking at me or blaming me. After a week of this, my physical exam dwindled to a cursory prod at her ankles and the briefest auscultation of her chest.

  There was also the issue of her Xanax. Xanax, alprazolam, is a tranquilizer, a member of the family of benzodiazepines, the most familiar member of which is Valium. It is probably the most addictive drug in its class, primarily because of the speed with which it enters and exits the system. Users get a buzz off it, and four hours later they withdraw. Unsurprisingly, Marie was a Xanax addict. People with syndromes that cause shortness of breath tend to be anxious—we’re wired that way—and often wind up on benzos. Emotionally, at least, the drug becomes as important to them as oxygen. And although none of us balks at supplying oxygen to a patient feeling short of breath—even if we suspect the sensation to be imaginary—there is something about the Xanax addict that can inspire contempt. It did in me at that time in my life.

  So she was obese, she whimpered, and she had a drug habit. She also had a heart that beat with perhaps a fifth of the strength it should have. Had she been a younger woman, she would have been listed for transplant. But at her age, with her obesity and other problems, she was in a holding mode, circling the drain in rings that seemed still, at this point, so wide that the central vortex was only a dimple on the horizon. This pass through the hospital was just another one of those slow circles, routine, intolerably so. Had I known this was to be her last admission, I might have regarded her differently.

  It was on day five that the dullness of things broke. That day, rounds took longer than they should have, and I was due in clinic by one. By the time we reached Marie’s door, I was so tired of standing I had forgotten most of what I had known about her. I searched my notes through a fog of fatigue. All that emerged was data: her weight so many kilograms, her urine output so many mLs. I looked up to find the attending frowning.

  Not at me, thank god.

  “What do you think is going on here?” she asked me.

  I thought furiously. “Nothing,” I said, glancing back at my notes. Over the past few days, despite heroic doses of furosemide, we hadn’t wrung more than a liter of fluid from her overloaded circulation. “That’s a problem, isn’t it?”

  “Yes,” she said. “What’s standard of care here?”

  “Metolazone,” I said, naming a diuretic often used to increase the effect of furosemide. “And crank the dobutamine.”

  I had answered correctly, because she nodded, still thinking. “What’s tele show?”

  She was asking about the continuous telemetr
y of the patient’s EKG. “Nothing significant.”

  “Okay,” she said, jerking her thumb upward. “Get cranking. She’s losing ground here.”

  And so we moved on to the next patient, and by one p.m. I had signed out to the on-call intern that Marie was to be a liter negative by morning, and if not to hit her with an extra 120 IV at four a.m., but to watch her K.

  The next morning we were on call again. I spent the half hour before rounds checking up on the three patients I was carrying going into call. I left Marie to last, my reluctance to enter her room being by this time nearly insuperable. In response to my usual question, she gave her usual answer. “Terrible. I feel so weak, Doctor. Just so weak and shaky.” She said this in her usual tremulous voice, waving the back of her hand over her face to express her weakness. I couldn’t help but notice, uncharitably, her breakfast tray, every bowl and plate stripped clean to the last sheen of grease. Her vital signs were stable, and her urine output had indeed picked up: not the entire liter we had hoped for, but most of it. It was with a feeling of hope—I might discharge her soon—that I left her room for a last check of labs before rounds.

  But what I saw in the labs wasn’t good. Overnight, Marie’s serum creatinine—the general indicator of the kidney’s ability to clear wastes—had almost doubled. Worse, her potassium—the “K” I had asked the intern to watch—was over six. The number was highlighted on the screen in red. We watch potassium generally in hospitalized patients: it’s a critical element, its level easily perturbed, and too wide a deviation can throw the heart’s rhythm awry. A patient on dobutamine with a potassium greater than six was not something I wanted to present on rounds. I had three minutes to find a nurse and order the four different things that would take care of this. As I was scribbling the orders on the chart, somewhere in the back of my head I was processing the other half of this story, the one I could do nothing about. Her heart was overloaded with fluid her kidneys could no longer expel. And now, under the burden of her failing heart, her kidneys were beginning to fail as well.