I was a minute late for the start of rounds.
As another long day of call ground into motion, I carried with me through the morning’s rituals a bleak sensation of change about to happen. Or perhaps, with the shift of a few numbers on a computer display, it already had, crossing over from the well-worn track Marie’s history had followed so faithfully for so long, to the other routine that plots the hospital’s daily round, the inexorable slippage into death. Marie’s electrolyte abnormality was significant not because it put her at risk of sudden death (although it did). The real significance was that the routine tune-up was over. Our only means of lightening the load on Marie’s heart had failed. This much, at least, had become brutally clear by rounds the next morning, even after another sleepless night.
When we reached her doorway I presented the data, and ground to a halt. I had no idea what came next.
The attending turned to the fellow.
“Now what?”
The fellow tugged at his lower lip. “I think we need to Swann her.”
The attending nodded. The fellow turned to me and said, “Move her to the Unit. We’ll Swann her after rounds.”
My legs sagged. I’d been up all night—all month, it seemed—and it was now ten forty-five; we’d been rounding since eight, and still had seven patients to see. It would be a miracle if we finished by noon. I wanted to go home, of course. I wanted to sleep, to stop thinking, more than anything else to stop thinking about Marie P. Beyond that, I hated the Swann. I hated the Swann because it takes at least an hour to set up, and hours more to thread a catheter into the jugular, through the heart, and into the lung. And then the fellow wants to spend hours more taking readings, before finally some decision emerges from the procedure, one I would be responsible for acting upon. I didn’t want to hang around to run scut afterward. Marie was just supposed to be a tune-up. She wasn’t supposed to take this much time.
It fell to me, as the resident, to float the Swann. Sometime around one p.m., the hour when, after a night on my feet, my higher functions start to wink out like so many overused lamps, I stood at the head of Marie’s new bed in the CCU, hieratically gowned and masked. Marie herself had disappeared under a wad of sterile green towels (it had required four milligrams of Ativan to get her to hold still for this), from which her tiny, rhythmic snores could be heard.
As I approached her neck with a four-inch needle, the landmarks by which I was supposed to find the internal jugular vein were awash in flesh, but I was lucky, and on the first pass an abrupt flash of blood swirled into the barrel of the syringe in deep purple arabesques. “Got it,” I announced. The fellow, whose customary moroseness had taken on an overlay of anxiety, rattled out unnecessary advice. “Hold your finger over the hub, that’s it, don’t lose it, now advance the wire, good,” rising in volume and frequency as the nurse on my right fed me a long, skinny tube, which I advanced into Marie’s neck. This went on for some time, until the fellow barked, “Stop. We got a wedge.”
“That’s a wedge?” The nurse, with fifteen years’ experience on him, sounded skeptical. I was content to stare at the ceiling, wishing I could scratch my nose. The rest of their back-and-forth floated past me like smoke. I picked out only the words I wanted to hear, the ones, finally, that meant my part was done: I slumped against the wall and peeled off my gloves. They talked on. The patient snored. With any luck I could be home by dinner.
Early the next morning I was back, studying the numbers the Swann had generated. They filled up Marie’s flow sheet. On the floor, where vital signs are checked perhaps once a shift, a patient’s flow sheet can fit a week’s records to a page. On the Unit, a single day’s sheet is a foldout thirty-four inches long, a grid with boxes dedicated to every physical parameter of human existence. Marie’s that day was dark with ink.
The section I was studying held numbers that were supposed to reveal Marie’s fate: cardiac output, cardiac index, left ventricular end-diastolic pressure, systemic vascular resistance. These were why we had put her through that exercise, but as I scanned the numbers back and forth, they told me nothing.
Not that I am an expert in the interpretation of Swann-Ganz catheter readings. We were getting into territory where I was clearly little more than a collector of information. But I knew enough to see that the numbers we were getting didn’t add up. If, three weeks into this rotation, I still knew how to add. If I still knew how to care.
“We see this sometimes,” the attending explained. “In the end stage everything just falls apart.”
“But what does it mean?” the fellow asked, waving the flow sheet. I was gratified to hear confusion in his voice, too.
The attending shrugged. “It means she’s falling apart. The physiology just isn’t there anymore.”
There was a long silence, during which the stately puffing of a ventilator in a nearby room became more and more distinct.
“So what’s keeping her alive?” I asked.
The attending turned to look at me. “Nothing,” she said flatly.
I HAVE A CLEAR MEMORY from this period, although what day exactly this might have happened I no longer recall, of the attending emerging from Marie’s room and stopping to brush at her eye before sitting to write in the chart. I remember it so vividly, like something glimpsed from a speeding train, because at the time it had no meaning. I could make no sense of it. It may not have happened at all. After three weeks of q3 call, dream and memory had become indistinct, the one unwelcome as a distraction from sleep, the other unwelcome always, the dead and discharged claiming time beyond any I had to give.
The next day we were on call again, the cycle starting to feel unbearably compressed. When the PA announced a code at the start of rounds we ran, but it was a sore, hobbling kind of progress we made, Alex and the intern and the medical student and I traversing the length of the hospital and up the old main stairwell to 5 West, where we found the usual melee in progress. Owing to our slow pace on the stairs (at the fourth floor we stopped running), the MICU team had gotten there first. From the doorway, over the crowd of nurses, techs, and assorted hysterics, I couldn’t even see the patient: just the rhythmic up-and-down of whoever was doing compressions. The MICU team waved us off. We walked slowly back to the CCU.
Marie’s room was crowded when we reached it on our rounds, three or four figures gathered at the bedside, their backs screening her from us as we stood outside the door. At a glance they were clearly nonmedical, probably family, and I tried to shut the door before I presented her, but after thirty years the doors in the CCU do not close. So I presented the data on Marie in a low monotone that no one but the attending could hear. No one else was paying much attention, the fellow and Alex fiddling with the radiology monitors, the intern slumped in her morning fog, the med student staring at his clipboard as though it held portents of his own impending death. There was little to report. Her ins and outs had been barely negative overnight, and her creatinine continued to climb. The Swann numbers were a random sprinkling of figures that I reported without conviction. As I trailed off, the attending simply shook her head, and swept into the room.
A laugh was ringing through the air as we intruded on the bedside, the sound of it bouncing unnervingly loud off the walls. A woman at Marie’s right elbow straightened, pushing back a stray curl, and smiled at us, a bright, airline hostess’s smile. She turned to Marie.
“Your doctors are here, honey. We’ll just be going along.”
“I’d like you to stay,” the attending said, and turned to Marie. “We need to have a conversation.”
Marie, floating in the bed like some enormous whipped dessert, gestured weakly at the two women at her sides. From somewhere on the peripheries, a pale, balding man wearing a failed comb-over and muted checked trousers shyly waved.
“Have you met my girls?” Marie asked.
“Not yet,” the attending said, holding out a hand to the one nearest, the one who had called Marie “honey.” “I’m Dr. Sparrow,” she said.
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br /> “Jeanine Wright.” She took the hand and they held hands briefly. “We’re her girls.” The woman at the opposite elbow nodded assent, but her gaze remained on Marie, a fixed, mournful expression I had seen before.
“Do you need us for something?” Jeanine said.
The attending, her lips thin, nodded. “I think Marie may.” She turned. “Marie.”
Marie looked up at her from the bed, the tremor that always inhabited her jowls momentarily quite pronounced and then still.
“How do you feel?”
Marie gazed back at the attending. For a long moment the two of them looked at each other.
Her voice came out with a husky sound. “Like it’s time to go, Doctor.”
The attending nodded. She reached out and took Marie’s hand. “Do you need more people to come?”
Marie heaved her gaze around toward the mournful woman on her left. “Did you talk to David?”
The sad eyes lifted. “He said he’d be here tonight.”
“And Ralphie?”
“Tomorrow.”
Marie settled back, shifted around to the attending. “Do I have tomorrow?”
The attending lifted Marie’s hand slightly, moved it gently side to side, then set it back down. “I think so.”
Marie subsided into the bed. “I’ll be here,” she said, and then her voice rose in a thin husk of a laugh. “If I’m not anywhere else.”
The girls at her elbows laughed too, bright bell-like voices breaking out of them, washing over us in our rumpled whites in a wave of human sound.
The code that morning seemed to have disturbed the rhythm of the day. The emergency room was quiet for once, the cath lab down for maintenance. The whirlwind of admitting fell strangely still. I had time to see my patients.
I left her for last, skipping over the alcoholic cardiomyopathy whose snores were audible from the door.
Her girls were still there when I entered, the two of them bending over the bed (the bed itself raised to elbow height because Marie, as she had observed, wasn’t getting out of it, and the nurses prefer not to stoop). The checked trousers were cross-legged in the room’s sole chair, nodding pleasantly at me as I entered.
“Doctor,” Marie said, as I came around the foot of the bed. “Have you met my girls?”
I held out my hand to Jeanine, who took it in a brief, soft clasp, then reached across the bed to the quiet one. “Francie,” she murmured, an apologetic smile. Her eyes were red.
Jeanine turned to Marie. “We met your doctors this morning, remember?”
“Not this one,” she said. “He’s the quiet one.” She turned to me and her jowls creased in a conspiratorial smile. “Aren’t you?”
“I suppose so,” I said, suddenly very shy.
Marie turned to her girls. “This is the one I was telling you about. My morning buddy. Aren’t you?” The same sly grin. “He’s the one comes in to squeeze my knee.”
The girls tittered. I could feel heat spreading over my face.
Jeanine, clearly the responsible one in the party, shushed her. “You’re embarrassing him, Mother.”
Marie peered at me. “Why, honey, you’re right. I never dreamed doctors could blush.”
Jeanine attempted to rescue the situation. “Mother says you’re very nice.”
A distinct pain stung me, centered in no anatomical structure I could specify. “Your mom’s been nice, too,” I replied.
We all stood there. Thinking about the tense I’d just assigned Marie, no doubt.
“She’s been telling us how hard you all have been working.”
Marie stirred, a proprietorial pride in her voice. “This one never sleeps.”
The girls made clucking noises as Marie expanded. “I see him out there all hours of the day and night. The nurses tell me he has a family, but I don’t think he ever sees them. Do you?”
“Do you have a family, Doctor?” Jeanine asked. I nodded. Additional questioning elicited the snapshots I kept in my pocket. Marie reached out an eager hand.
“Oh, they’re beautiful boys,” she cooed. “Look at that one, Jeanine. He looks just like Roger. Doesn’t he look like Roger, Francie, when he was little? Right down to the drool on the chin.” Uproarious laughter, and I realized Roger was the name of the checked trousers. “Come here, Roger, and tell us if this little boy doesn’t look like you.” Roger, shyer even than I, joined us at the bedside. “What’s his name, Doctor?” Marie asked.
There is a boundary I don’t cross over with patients. I don’t mind showing pictures of my kids: over and above the fact that I’m fond of my children, I’ve found that showing their pictures can humanize an otherwise awful situation. It’s useful. But I don’t tell their names. It’s a privacy issue, basic protection of hearth and home. But there’s also a primal superstition at work. Naming calls. To use the names of my children in the CCU would somehow connect them to this world and what goes on here. That’s where I draw the line.
But not that day. I told Marie their names, the names I withhold from this account, and she made the appropriate sounds, repeating them, identifying each in turn. The girls agreed they were sweet boys, and their names were lovely names. From which point it was impossible to proceed with the conversation I had come in to hold: just when and how Marie should die. But I proceeded anyway.
These things must be done delicately. This was a point the attending had underscored for me earlier that day, when she had reminded me that under no circumstances was I to switch off Marie’s dobutamine until I was certain she was past feeling. “The minute you turn that off, you know what’s going to happen to her, don’t you?”
I started to give the right answer, but this wasn’t one of those quizzes.
“She’ll drown,” the attending went on. “You don’t want her to be aware of that.”
We had reached the point of discussing the morphine drip.
“Morphine drip” is really more of an expression. It’s not often that you actually have a patient getting a continuous infusion of IV morphine. But we use the expression anyway, to signify the crossing of a threshold. We were about to put Marie on a morphine drip: we were about to make good and certain that, as she died, she would not suffer.
I remember crossing a street in a European city years ago, when a pigeon fluttered to the pavement after colliding with a car. It flopped helplessly for a moment, something clearly very wrong with it. Without breaking stride, a man stooped in the crosswalk, seized the pigeon in one hand, and with a quick twist stopped its fluttering. He set it back down and walked on. I remember most clearly the expression on the man’s face: a mask, concealing what? I remember also that he held his hands away from his sides as he went on. No doubt he washed them not long after.
Modern medicine cannot—thank God—administer that quick twist. The only way to save Marie from feeling that long fluttering was morphine. But my attending was instructing me that it had to be done carefully because morphine, while it masks the sensation of suffocating, also suppresses respiratory drive. And so it has to be done carefully. If at all possible, it should be her heart failure that kills her—not our attempt to save her from suffering.
None of this, of course, entered into my conversation with Marie and her girls. Despite its impossibility, the discussion went off well enough. I hemmed and hawed, then explained what we could do to honor Marie’s request. They listened to me with a respect that always unnerves me, nodding solemnly as I stepped them through what I thought Marie might need. When I was done, I looked at her. She was lying there with the washed-out look of someone who has in fact quit fighting. “What you think best,” was all she said.
Two hours later I checked back. Marie had absorbed two milligrams of morphine, a dose that does more to sedate than cut pain, which was fine. She needed to get some of it ahead of time, to feel it working in her and know what it was. More family were there. They drew me into the room, by some Brownian kinetics of handshake and question pulling me toward the head of her bed.
“Here he is,” I heard her say. The morphine had, paradoxically, livened her up a little. She was propped in bed, keeping court. As I was drawn into her orbit, the crowd parted and fell in behind me. “Here’s my doctor,” she said proudly. “Jeanine, tell him what we were just talking about.” She dimpled deeply, and Jeanine explained, “We were talking about her ice-cream cone. It’s a story we tell.” A general murmur, the laugh we give in appreciation of a long-loved joke, welled behind me.
I did my part, looking puzzled, prepared to be amused.
Jeanine started. “One day, years ago—”
“It was the year after Mother died,” Marie explained quietly.
“Yes. It was Easter. And Granddaddy took Momma and Aunt Ellie and Aunt Peg out for ice cream.” Jeanine paused, looking to Marie to take up the prompt.
“He promised us if we didn’t fuss in church we’d all get ice cream.”
Jeanine smiled. “After church, he bought each girl an ice-cream cone. And then he set them out on a bench in the park across the street.”
“He wanted a picture of us in our Easter dresses,” Marie said, coming in so quickly she almost cut Jeanine off. Her voice had taken on an authority I’d never heard there. “And he wouldn’t let us start to lick until he took the picture. They were starting to drip, but he wanted a picture before our faces got all messy. He had a Brownie camera that was always difficult for him, unfolding it and all the settings. We sat there wanting to lick our cones and so afraid they were going to drip and spoil our dresses.” She stopped, winded. The expression on her face was intent but turned inward, concentrating on her breathing, or pursuing something in the story she could not quite recall.
Internal Medicine: A Doctor's Stories Page 11
