“The overdose was six hours ago. He’s fine. His feet have good pulses,” she says to me.
The fetid stink from his feet hits me seconds after she takes off his shoes. “Have you had much trouble working in the ER during your first trimester?” I ask her. “I remember when I was pregnant with my daughter, I really had a heightened sense of smell, and also more of a gag reflex than usual. Are you doing okay?”
She smiles, and we have shared a moment; belonging to the same club and all that. Then it passes. We discuss briefly the fact that he can’t walk right now, which is a new symptom for him. I know he’s got a temporary syndrome from the compression of his sacrum, but I’m playing dumb, asking if he’s paralyzed from a stroke or something, hoping she’ll take him and do a head CT. She minimizes all his physical complaints, findings, and history, and is gently making it plain that she is still not signing the EMS sheet, not accepting the patient to her area.
“You’re getting hit with triages even worse than I am tonight,” I notice. It is a peace offering, my mentioning how busy she is, and she takes it as such. She smiles sweetly as I decide to do her a solid and take a hit for the pregnant doctor.
Back at CPEP, we wheel Mr. Martinez to the high-visibility area, right in front of the nurses’ station. I know a little about this man, because he has been admitted to Bellevue a handful of times in the past. He had a well-known hospital roommate awhile back, maybe a year and a half ago. A man on 12 South—admitted after he cut off his penis and the Bellevue surgeons reattached it—had attempted to escape from the hospital. The man spent days, or perhaps weeks, meticulously cutting strips off his mattress and braiding them together to make a rope. Then, he somehow pried open a window and attempted to rappel himself down the side of the building. Needless to say, the makeshift rope broke, and he fell roughly ten stories to his death on the street outside the hospital.
Mr. Martinez was traumatized by this, as were many other patients on the ward. He somehow felt guilty about his roommate’s death. But the real guilt that was driving his current behavior was that, in his eyes, he had killed his wife. His years of shooting drugs into his veins had left him with AIDS, and he infected the woman he loved before he knew he was ill. Since her death six months ago, he has made several attempts on his life.
Between the overpowering foot smell and his burst colostomy bag, this guy needs a shower in the worst way. He’s being nasty to the nurses, and irritable to the psych techs. He even spits at one of them.
“Go away!” he yells. “You babied me the last time I was in here, I don’t want to be babied. Get away from me!” He lets Magil, the psych tech, change his colostomy bag, but then he starts complaining loudly about the pain he’s having from his herpes zoster, aka shingles. AIDS patients, with their weakened immunity, often have herpes, which is a virus that lies dormant in the body waiting to be reignited when the patient’s immune system lets its guard down. The virus hides in the nerve cells of the body, and when the herpes infection flourishes anew, it is immensely painful. And this is not a guy who suffers in silence.
I call the pregnant AES attending, wondering if there is any medication she specifically likes for the neuropathic pain of herpes, which is often treated differently from other kinds of pain. She tells me to give him Tylenol with codeine, or morphine. She knows he’s shot heroin earlier today, but I go ahead and give him two Tylenol 3s, because his jaw is grinding away a mile a minute, which tells me the cocktail he shot up this afternoon must have had more cocaine in it than heroin. I write the order at ten thirty.
I’ve got five triages to deal with; I figure I better start in on the pile. As usual, I look for the easy T & Rs, people I can shoo out of the area with a minimum of paperwork. I leave the more complicated admissions for the resident.
The surefire T & R, one hundred percent of the time, is an arrested woman. If she’s calm and not dangerous to herself and others, she goes back with the police to get arraigned. If she’s insane or agitated, she goes to Elmhurst Hospital, which the city has designated for female forensic psych admissions, the counterpart to our 19 West, where the male cases are housed. I talk to the cop to see what the charges are, and why she was brought for psych clearance.
He shoots me a smile, and tells me, “You’re gonna love this one, Doc. Assault with a deadly weapon. She attacked her husband with a huge plastic Santa Claus lawn ornament.”
“‘Tis the season!” I quip.
I speak to the arrested woman briefly, enough to establish that while she is schizophrenic and mad at her husband, she is not acutely psychotic, dangerous, hallucinating, or agitated. I send her out with the cop, who is impressed at how quickly his Bellevue detour has been resolved. He heads back to the station to book this woman, and I head back to the rack to pick up another case. I’m on a roll, so I pick up another chart, hoping for a second T & R. It is a woman brought in by EMS, accompanied by her brother, who tells me that he’ll take her home with him after my evaluation, which is music to my ears. A family member willing to take responsibility for a patient means I don’t have to fret so much about her disposition. The EMS sheet reports that her neighbor called 911. The patient was drunk, complaining on the phone to her neighbor about her children, making some veiled references to suicide, wishing she were dead.
I opt to interview her at what I call the picnic table, a sturdy metal version set up by the EOU rooms, under a TV to glance at in case I get bored during the interview. I strategically place her back to the television; Saturday Night Live is on. I spend about five minutes trying to cajole this woman into telling me what she said to her neighbor so I can document just how suicidal she sounded.
She is still a bit drunk, coyly skirting her exact words, and I feel myself getting frustrated because she wants to tell me the backstory. She tries repeatedly to unload her sorrows on me, about her children, her loneliness. What I really need is a direct quote for the chart: Exactly what did she threaten on the phone? Just as she’s finally giving me the goods, I hear a frantic shout from one of the psych techs for me to come quickly. “Doctor Holland!”
“Julie. You better get over here,” the resident adds, nervously.
Mr. Martinez is on the floor, and they’re cutting away what looks like a long black shoelace from the stretcher, unwrapping it from around his neck. Once the string is removed, I can see its braided pattern embedded in his swollen neck. His face is mottled, purple and gray, and he is lying in an awkward position on the floor, his arms and legs arranged around his body at odd angles.
Bill, one of the psych techs, tells me, “He took off his hoodie tie and wrapped it around his neck.”
With the other end tied to the railing of his stretcher, he has thrown himself off the edge of the gurney, hanging off the ground just enough to choke himself. I squat down to feel his wrist while Bill feels his neck for a pulse. I feel nothing, but Bill says, “I’ve got a pulse!”
Jesus is unresponsive—not talking, not breathing, as I rub his sternum and call his name. His colostomy bag has burst onto the floor, the maroon liquid spilling out into an ever-widening circle as the hospital police and techs put on some gloves and lift him onto his stretcher. I stand there frozen for a moment, then quickly decide to bring this guy to the medical ER.
“Let’s get him to AES!” I yell. There is no way in hell I am running a code in the CPEP. It is such a rare event, and the staff, including me, is ill-prepared for it. He’ll surely die that way. There is no time to second-guess myself, but it is a decision I will have to defend repeatedly in the days to come.
Bill and I push the stretcher out the door, as I yell at the patients to clear the way. We maneuver the stretcher out the CPEP doors, making sharp turns, right, then left, then left, then right, until we reach the straightaway down the long hallway to AES. There are multiple sets of double doors. Why are there so many doors? Dangling off the edge of the stretcher, his right foot hits one door jamb and then another, as we do our best to steer the less-than-agile gurney. We pull
into the ambulance bay of the AES, as if we have a new EMS case for them.
“We need a doctor here!” I yell. (A real doctor, I think to myself. Not a shrink. Someone who can save a life, like they do on television.)
The chief resident runs over and directs us to wheel our patient into a spot by the door.
“He tried to hang himself from the stretcher,” I tell him. “He has AIDS, a colostomy. He overdosed on heroin and cocaine earlier today.”
The chief establishes that the patient isn’t breathing and requires oxygen. While he bags the patient, putting an oxygen mask over his face, he asks me, “How long has he been down?” By this he means without oxygen, and it will be the question that runs through my mind repeatedly as the code progresses: Why didn’t I bag him while we were transporting him here? I estimate a minute or two, taking into account the time it took us to speed him along the interminable corridor, but I can see the resident is skeptical.
A medical student begins compressions, and the chief says, “Real CPR, please,” to the student. It must be a tradition, I think, flashing back to the chaotic scene at the codes when I was a medical student, when doing compressions seemed like the best role to play in a resuscitation. You feel you are being productive, you are doing something physically to help the patient, and it requires a minimum of know-how. But then the person running the code comments on your form, and the critique cuts you down to size, transforming you from the one who is saving the patient to the one who is killing the patient through your incompetence.
This chief has a way of making everyone feel incompetent though, and that’s what he does to me when I make the huge mistake of mentioning to him, as he runs the code, that I had tried to get AES to take the triage and they refused.
“That’s not helpful to me right now,” he says testily, and I know he’s right. I tell him the patient had two Tylenol 3s at around eleven o’clock, in addition to whatever heroin he injected six hours earlier, and recommend Narcan, an opiate blocker. It’s the only useful piece of information I give him, and he begrudgingly orders Narcan, after making me wait and watch for a moment to see if he’ll gratify me in this way.
One resident is attempting to get a sample of arterial blood from the patient’s arm, another is putting a catheter into his penis, a third is putting an intravenous line into his neck. A nurse is filling syringes, serially—Epinephrine, Narcan, Epinephrine—stating the medication’s name with solemn regard as she hands the needle to the chief.
The patient’s heartbeat comes back after two rounds of “Epi”—a hormone similar to adrenaline—the stuff that is now surging through my veins and making my heart race, as I struggle to keep my hands out of my mouth and appear calm. The compressions cease, and the second-year resident tries for a second time to intubate the patient, craning the patient’s chin toward the ceiling to see down his throat. She can’t visualize the vocal cords, the landmarks to tell her she can proceed with the tube into his windpipe; because of the strangulation, there’s too much swelling. The chief resident finally takes over, the savior, the martyr, to do the intubation like it’s supposed to be done.
The pregnant attending ambles up next to me to watch her protégé run the code; I find it comforting to have her there. I imagine she’s glad he was in my area, and not in hers, when he made the second attempt that day on his miserable, dwindling life.
“His pupils are blown,” the chief tells the crowd. “Let’s call respiratory.”
I know what this means: Jesus Martinez is as good as dead.
He is placed on a respirator and admitted to the MICU, the medical intensive care unit, where they will likely try to contact the next of kin to discuss removing the respirator, assuming that he will stop breathing and die a natural death. Sometimes, however, these patients keep breathing on their own, and then we are left with what we call “a brain stem.” The medulla, a major part of the brain stem—south of the cortex where the real feeling and thinking is orchestrated—is still functioning, reminding the lungs to breathe, instructing the heart to beat. During my neurosurgery rotation in medical school, the bulk of the patients on the inpatient wards were in this state. I would write notes that said VSS, CVSP: vital signs stable, chronic vegetative state persists. And persists. If they don’t get an infection, “brain stems” can live for a painfully long time, being fed through a tube into their stomachs. We would also sometimes refer to these patients as “rocks,” immobile, immutable. We would come and go as we began and ended our rotations, but they never left the hospital.
I remember the afternoons on the neurosurgery wards, when the visiting families would come. The patients would lie there, dressed in their satiny sweat suits, breathing, blinking, hearts beating. Sometimes their eyes would move, a reflex of the lower brain centers; they seemed to follow their loved ones across the room, but a vegetative state is not fully alive, and the patient is not really “there.” The eye movements often give the families false hope, which can complicate their decision to turn the patients into DNRs. It’s hard for the families to understand that even though the eyes are open and moving, their loved ones are not truly seeing them.
So, Mr. Martinez hasn’t quite killed himself exactly. He has, thanks to our interventions, put himself into a medical purgatory. He’s not alive, but he’s not dead. His brain is functioning just enough to keep his heart beating, and our machines will keep his lungs filling with air, his blood oxygenated, his organs functional.
I come back to CPEP with the information that he is on a respirator in the MICU, which the staff takes as good news, that he has been saved, but they are wrong. He has basically killed himself on my watch, under our care, and it is only a matter of time and semantics separating him from actual death.
And now come the paperwork, the phone calls to the bosses, the questions, the revisions, the muted conversations, and the Monday-morning quarterbacking. I steel myself in preparation for the inevitable days ahead, when I will have to speak with the hospital administrators, the lawyers, my boss, his boss, and the boss above him, and the lawyers, the nursing supervisor, the next of kin, and the lawyers again.
MacKenzie calls me up at the house to ask me what happened, and I tell him everything I can remember. He tells me that on Thursday there will be what the Bellevue Department of Psychiatry calls a “Special Review.” These reviews are supposed to be dispassionate dissections of what occurred, but inevitably they morph into a reaming of one or more parties.
Shortly afterwards, Daniel calls me to strategize for the inquisition. He is upset when he finds out that I have already spoken to MacKenzie. He has a lot of specific recommendations for how best to answer the questions, and how to frame the situation in general. He jokes that I should cry during the Special Review. He figures if I look frazzled, they’ll go easy on me.
At first I don’t understand why he’s calling to give me any advice. Why should he care if I take a fall? But then it occurs to me that it will reflect badly on him if there is any blame shouldered. He’d prefer the whole CPEP look innocent.
He reminds me to keep my responses to a minimum. I have a habit of overtalking and overanalyzing; in my most awkward situations, I get a case of verbal diarrhea.
When I see the AES chief resident who ran the code at a downtown restaurant a few weeks later, I apologize for doing just that.
“I should’ve just shut up after I gave you the bullet, but I was stressed and I kept talking. I shouldn’t have said that you guys rejected the triage. It was right for you to respond the way you did,” I tell him. Better for me to make peace with him, I figure. I may have to work with him again down the line.
He did, after all, prevent my patient from actually dying, and for that I am thankful. But our patient, he really wanted to die. I am sure of it. He would not be so grateful his plans were thwarted.
Carry That Weight
Dr. Henderson, the director of inpatient services, pulls me out of the up-wards conference room just before the Special Review begins. He s
queezes my shoulder and murmurs, “Julie. No one thinks you did anything wrong. Go easy … go easy.”
I am stymied, and offer no response. Sweltering in my most matronly sweater set, a sickening shade of pale green, I’m finding that it’s only too easy to appear emotionally distraught. Daniel will be pleased that I am taking his advice.
I can’t figure out if Henderson is telling me to relax because I have nothing to worry about, or if he is soothing me because he’s afraid I will make a scene otherwise. I remember the phone conversation between us on that Saturday night, around one in the morning, shortly after the code. I started off on the offensive.
“Dr. Henderson, I know Bellevue,” I began. “I’ve been here long enough to know that in these situations somebody usually takes a fall; someone is always left to twist in the wind. I just want to make it clear, sir, that ‘somebody’ is not going to be me.” Maybe I even said it menacingly. I wanted him to know I wouldn’t take any of this lying down. I wouldn’t go quietly.
Everyone seems to be warning me not to sabotage myself at this meeting. They are all implying that my usual protection, my swagger, is my potential undoing. It certainly hobbled me at my oral boards, and I can’t let that happen again.
Weekends at Bellevue Page 24
