“Just give me a cough,” he might have instructed his patient, still disbelieving, hoping the sounds would clear and things would proceed as he’d expected them to—a quick exam, a healthy young man. Sam coughed. He felt nervous without knowing why. “Is everything okay?” he asked. But his doctor was quiet. He was already listening, his face intense and eyes unreadable as his mind shifted into focus. He leaned down again and felt the legs. The slight swelling, so easy to dismiss moments before, now took on a whole new meaning.
The doctor did not tell Sam the extent of his worry, not at first, because there was no point in upsetting the young man before gathering more information. Sam was scared, too scared to ask questions because he did not even know what he should be afraid of and he didn’t want the answers, so their conversation was brief. Sam would get a chest X-ray the same day. When the image came back hazy with fluid that had filled his lungs, Sam returned for an ultrasound of his heart, which revealed that the muscle was beating at only half of the strength predicted. The doctor called Sam with that news and told him he would have to go into the hospital. When he heard Sam’s breath quicken on the other end of the line, all he wanted was to reassure his patient, and so the doctor kept talking, filling the silence. He told Sam that it was probably just a virus that had affected his heart, and if that was the case, then it could pass, as viruses do, and Sam would get better. So Sam focused on this idea of a virus and told his boss at work that he would have to take a couple of days off, something about a virus, but that he would be fine. He called his mother, too, and though he spoke in generalities, she understood enough that her stomach sank and her hands shook and she started to cry, even when he told her it was probably just a random virus, that he’d get better soon, and so she shouldn’t worry.
He didn’t get better. He left the hospital with a set of prescriptions, and his mother bought him a pillbox and brought it over to his apartment. She arranged her adult son’s medications by morning and evening for the seven days of the week. Two weeks of meds passed. Then there was a biopsy. Sam lay on the cardiac catheterization table, feet dangling over the edge, cold and scared and uncomfortable. His doctors placed a thick catheter into his neck, into the large internal jugular vein that sits next to the carotid artery. They threaded a smaller catheter with little jaws at the end down to his heart to steal a microscopic piece of the muscle for the pathologists to inspect. Finally, there was a diagnosis. It wasn’t a virus at all. It wasn’t something that would pass. Sam’s immune system had decided to attack itself, and none of the pills he kept in the box his mother had bought for him, not the high-dose steroids his doctors prescribed nor the host of other meds—each with its own side effects that he tolerated wordlessly, belly pain and numbness and infections—could stop it.
His heart grew so sick that instead of working in sync to pump blood through his body, the chambers started to move in a dangerous rhythm called ventricular tachycardia. The doctors gave him improbably high doses of medications to calm this storm inside him, and when that did not help either, they implanted a machine under his skin, called a cardioverter defibrillator, so that when his heart slipped into this potentially lethal rhythm, a jolt of electricity would shock it back into its normal pattern. The first time it happened, it felt as if a bomb had gone off. Now the shocks were coming more and more frequently, and so he had been sent from the hospital near his home to our medical center in the hope that our team of experts could take care of him. He had been shocked by his defibrillator three times since he had arrived the night before—he might have died, that is, three times before being brought back with jolts of electricity. And we were to keep him alive while he waited for a heart transplant.
My father is a cardiologist, and when I was growing up, I liked to play with his model of the heart. It was heavy and intricate, and each of the heart’s four chambers opened with a silver latch that allowed me to look inside. My father taught me the name of each part. I learned how blood travels from the body to the right atrium, through a valve to the right ventricle below it, and then out to the lungs to pick up oxygen before returning to the left side, where the pattern continues again—atrium, ventricle, out to the body. Years later, in medical school, when we cut open a cadaver and lifted the heart from its silent cage, it was beautiful and unreal. But that morning, standing outside Sam Newman’s room, it was clear to me that there would be no poetry or metaphor. There was only this.
As my co-residents pored over our twenty-eight-year-old patient’s electrocardiogram, jockeying to see who could name the most arcane of abnormalities in the simple tracing of his heart’s rhythm, I glanced around the half-drawn curtain into the young man’s room. I watched our patient lean over and pull out a laptop from the drawer next to his bed. I felt my own heart pounding, regular and insistent. Three times overnight this young man could have died, and yet there he was, alive and trying to navigate the hospital’s wireless network to get on the Internet.
Sam Newman was hands down the most interesting patient in the ICU. “A great learning case,” my attending pronounced that first morning. Sam was young and had a particularly nasty form of a rare disease, so I should have fought for the opportunity to be involved in even the most banal aspects of his day-to-day care. But this young man scared me. And so I avoided him. It was easy to do, at first. When we split up the daily Scut List tasks, I simply claimed the blood draws and transports and phone calls for the other patients. But one day my resident told me that the intravenous line in Sam’s neck needed to come out. He had started to spike fevers, we didn’t know where they were coming from, and since the catheter could represent the entry point for bacteria, one of us had to pull it. I was the intern in charge of procedures that day, so the job was mine. I put it off all morning and through our lunch of tuna fish and chicken salad sandwiches, hoping that the fevers would subside or the empty “Pull Line” box on the list would somehow disappear. But by 1 p.m., that box was still empty. “I’m going to go pull the line now,” I announced to no one in particular. I grabbed one of the pale yellow gowns we wear over our clothes to keep us from transferring antibiotic-resistant bacteria from patient to patient, and stepped into his room.
I had seen him on rounds each morning, but those exams were brief, and he was often half asleep. Now, for the first time, I took in my patient. His face was swollen and his arms were bruised from the steroids that had done nothing to stop his heart’s self-destruction. He was wearing a hospital gown and compression devices on his legs to prevent blood clots. Hopeful get-well cards bearing inspirational Hallmark-style messages covered the bedside table.
“Hey,” I said. “I’m Daniela, one of the interns. I’ve seen you on morning rounds, but you’ve generally been sleeping.”
He was typing on his laptop and barely looked up from the screen. I told him that we needed to take out his central line because it might be the source of his fevers. He shrugged, which I took as assent.
“So, here’s what I’m going to do,” I explained. “I’m just going to cut out the stitches. That might hurt a little. And then I’ll pull out the line and hold pressure on your neck until it stops bleeding.” He might bleed for a while—the fluid that his heart couldn’t pump had settled in his liver, and as a result, his body wasn’t working well to make his blood clot. I didn’t tell him this. Instead, I told him that I was going to ask him to help me out by doing something.
“When I pull, I’m going to ask you to hum,” I said.
He looked up from his computer. “Hum?” It was the first time I’d heard his voice. He sounded so regular that I felt my heart break a little. I explained that by humming, he would increase the pressure in his chest. This would decrease the chance that in the moment I pulled out the intravenous line, before I covered the tiny hole it would leave with a piece of gauze, an air bubble might enter his body, travel to his heart, and kill him before his disease would.
“Okay,” he said. “Hum.” He looked amused. We had asked so much of him, and this must
have seemed silly in contrast. He closed his laptop and set it down on the bedside table. “I can do that.”
I leaned over and gently peeled off the dressing that covered the spot where the line entered his neck. I used tiny forceps to lift the stitches and then cut them, one by one. I had to lean in so close that I could hear him breathing. He smelled warm and a little bit like sweat, but not bad. It was time to take out the line. I lowered the head of his bed. “You all right with that?” I asked. “Uh-huh,” he said.
“One, two, three. Okay now! Start humming.”
“Mmmmmmmm…”
I yanked out the line and covered the spot with gauze. A drop of blood dripped down his neck, and I watched it land on his hospital gown. I moved the bed back into an upright position, my hand still on his neck. “Just a minute or two,” I told him.
It was snowing outside. It was going to be a bad winter. Inside, it was quiet. “Looks like Siberia,” I said to fill the silence, gesturing out the window, where snow had already blanketed the New York City streets.
My patient turned toward me, into the pressure I held on his neck, and flinched. “Sorry,” I said. “Just a little longer.”
He turned back. “You know, I was in Siberia once,” he said.
“Really?”
I continued to hold the gauze. It was the longest I had spent in a patient’s room in weeks or months, or maybe ever. He told me that he and some buddies had taken the Trans-Siberian Railway a few years back. They’d traveled all over, to places I had never seen, some I had never even heard of. “That must have been amazing,” I said. It was, he told me. It was awesome. “That would be so cool to see,” I offered.
“Are you on Facebook?” he asked. “I posted the photos. I’ll friend you. Then you can check them out.”
I lifted the piece of gauze. He had stopped bleeding. I covered the wound with fresh gauze and a piece of tape, and dropped the large IV that had been inside him into the orange biohazard bin on the other side of the room. I would let his nurse know that I had soiled his gown. “Yeah, I’m on Facebook,” I said. “Line’s out. I’ll go tell your nurse.”
Outside the room, I took a deep breath. I was sweating. I placed a big X in the empty box on the Scut List.
“That went all right?” my resident asked. “Of course,” I said. Pulling out a line was barely even a procedure. “Totally fine. What’s up next?”
When I got home that night, I logged on to Facebook to find a request from my patient waiting for me. I paused for a moment, then selected Accept and clicked on his name. The patient whose line I had pulled earlier that day was puffy from fluid and steroids, with a protruding belly and bruised arms and legs, but this boy on Facebook was healthy and good-looking in a way that made me think of basketball and beer. He was “single,” the page said, and he liked Radiohead and Tom Clancy. He had been sending updates from the ICU. You’d have thought he was in the hospital with a sprained ankle, the way he joked, but I had held pressure on his neck that day and I knew the truth.
I didn’t enter his room the next day, nor did I tell any of my co-interns about his friend request. I almost did, but then thought better of it. It would have felt, in a way, like betraying a confidence. A week passed. On rounds, we talked about how his fevers stopped and then returned. It hadn’t been the line after all. Shortly afterward, my time in the cardiac ICU came to a close. I moved on to the general cardiology inpatient service, the next in my seemingly infinite intern-year lineup of rotations. My days were full. I didn’t often think of our exchange. But sometimes at night, when I had opened up my computer to log on to Facebook, I found myself flipping through my patient’s photos or reading his status updates. They were unfailingly optimistic. When a severe skin infection on one of his legs sent him to the operating room, he reported, “Back from surgery and doing GRRRRRREAT.” Meanwhile, from his medical record, I learned that his fevers had continued, that his defibrillator kept going off, that he was still waiting for a transplant that might never come. Then one day, at least a month later, I found a message waiting for me in my Facebook inbox. It was from him. He had written, “Can I stop humming yet?”
There’s a version of this story in which I replied, something friendly but restrained, and the next day I went back to the ICU to visit my patient. Maybe I would have sat down this time, and we would have talked some more about the places he’d seen while traveling and what his life was like before and what he was hoping things would be like afterward, if he got the transplant, if he did not die. Perhaps if I had done this, he could have taught me a little bit about what it is to be twenty-eight and in limbo, waiting for a transplant, for an infection, even for a response to a Facebook message. Or maybe it would have been smaller than that, and I would have done nothing more than allay a bit of his boredom before heading to noon conference. But this isn’t what happened. I started to type a reply and then I stopped. I’m not sure why. Maybe I knew that I had crossed some invisible barrier. Maybe I just didn’t want those boxes on the Scut List to expand into something real. I know that it wouldn’t have mattered to me if he had looked at my photos or if he saw me with my friends, wearing something silly or drinking champagne out of the bottle on the way out for a night. It wasn’t that. I think I was more uncomfortable with my level of investment, with how well I knew his pictures and his updates. So I signed off. I stopped looking at his page, too, scared that he would somehow sense my online footprints.
Months passed. I didn’t think of him until one evening in the spring when, on a whim, I returned to his Facebook page. The pictures and status updates I knew by heart had been replaced by dozens of messages of condolence. They stretched for pages, and I read each one. Then, knowing what I would find, I logged on to our online medical records system. After my rotation in the ICU had ended, my patient’s heart rhythm had calmed and he had made it, briefly, to the general medical floor. But then his heart failure had worsened. His kidneys had shut down and he was started on dialysis. Ultimately, when it became clear that he was too sick to undergo a transplant but that he would die without one, his parents and his doctors had said, Enough.
He was dead. But his message was still in my inbox, hopeful and waiting. I scrolled through his profile one more time, uncertain how long a Facebook page lingers after its owner dies, before closing my computer and going to sleep.
Spring turned to summer, and by the time I became a second-year resident in charge of my own interns, I’d grown accustomed to the pace of hospital life. I worked to distill my patients into a sequence of empty Scut List boxes, as I had so rigorously been trained to do. I taught my interns to arrange CT scans and update grief-stricken families, to draw blood from the tiny veins on thumbs and feet, and to wait on hold for minutes that felt like hours to secure insurance approval for outpatient antibiotics. I fancied myself a sort of air traffic controller, the model of efficiency as I fielded phone calls and tracked lab values. If I thought at all about our overall goal, it was only to say that we were to keep our patients alive until they were discharged or someone told us not to. Goodbyes were the hasty summaries we wrote when our patients left us for the general medical floor or the brief death notes when our shocks and chest compressions had gone nowhere. There wasn’t time for contemplation. There was barely even time to get the room cleaned before the next patient arrived.
I thought of that unanswered Facebook message from time to time during my predawn treadmill sprints and in the murky moments between sleeping and waking. I even told the story to a few friends with careers outside medicine, with the same “Isn’t the hospital weird?” tone I used to describe how one step of declaring death actually requires us to stick a piece of gauze in a person’s eye to make sure he doesn’t blink. But something about our exchange and my silence continued to bother me. And so one night, after another long day in the hospital, I decided that I would write about it. I changed my patient’s name and his disease, but everything else was true. I wrote the piece in a single evening, and I couldn’t
have been more surprised and proud when it ran in the New York Times Lives section in the spring of my second year of residency. I received a message a few days later asking me to set up an appointment with one of the hospital administrators.
On the day of the meeting, I wore scrubs. I was on call and I didn’t want to have to change, or else I think I would have made the effort to wear real clothes. This was the first time I had set foot in the executive suites at my hospital. I walked slowly through the wood-paneled halls, marveling at how clean and quiet it was compared to the smells and the incessant beeping and movement just a few floors up.
A trim assistant in a neat ensemble led me through the maze and ushered me into the administrator’s office. I sat down in the chair across from the big wooden desk. Until that moment, I hadn’t focused on why I was there and what might happen. It was only while sitting there, conspicuously underdressed and suddenly cold in my scrubs, that I realized how nervous I was. I could tolerate being disciplined for accepting my patient’s friend request, if that was going to happen. I had already faced more than my share of negative responses to my piece. There were those who found me an objectionable human for my inability to reply to that Facebook message, and a terrible doctor. Some suggested I leave medicine, or if I refused to find a more suitable career path, then at least I should pursue a specialty like pathology that required minimal patient contact. That didn’t hurt me. But what I couldn’t stand—and the thought I found myself, all of a sudden, unable to shake—was the possibility that my patient’s family was upset with me. Maybe it was wrong for me to have taken the moment that I shared with their son and told it as my own story. My stomach started to ache. There was a mini jellybean dispenser on the desk, and I turned the handle and watched as half a dozen jellybeans cascaded into my palm. I glanced at my watch. How long was this going to take?
You Can Stop Humming Now Page 2
