by Robin Cook
I once told a friend who was not in medicine the various reasons I got called out of my bed at 4:30 a.m. He didn't believe them. It was too disquieting for him; it shattered his colorful image of the intern awakened suddenly, all eager in white, flashing down the corridors, up the stairs by threes and fours, to save a life. Here was the real me, feeling shitty and stumbling down a hall swearing under my breath, on my way to say, How are you, patient?… Fine, Doctor… That's wonderful…Have a good rest, and please don't fall out of bed again.
When the phone rang again it was daylight, five-forty-five. Feet over onto the floor, sit up sideways, use my hands to push up. That slightly sick feeling again, and a momentary dizziness until the cold floor knocks it out of me. Over to the sink, hands on its sides, lean on it for a second. In the mirror my eyes are like aerial views of hot lava running into a muddy lake. The only reason the bags under them don't meet the corners of my mouth is that I can't smile. Ah, a trickle of water meanders out of the faucet. Holding on with one hand, I raise a few drops to my face.
Nothing about this morning was particularly noteworthy or different. It was just a morning, like other mornings. In two weeks I had worked up such a deficit of sleep that even when I did get six hours straight I felt the same way. The razor blade, much sharper than I was, left several points of blood on my throat. Mixing with the water on my face, it seemed like a lot of blood and, combined with my eyes and the dark under them, made me look like a Mafia heavy.
After thirty seconds or so I felt together enough to dress. Stethoscope, little flashlight, several different-colored pens, notebook, comb, watch, wallet, belt, shoes — on through the mental check list. Make sure socks are the same color. Mustn't spoil the tone of the place. One last visual sweep around the room to make sure there wasn't something else, some piece of paper, a book. Satisfied, I left, descended in the elevator, and stepped out into the morning air.
It had always been a point with me to walk around in front of the hospital on my way to the cafeteria. Somehow it lifted my spirits. This morning the sky was a pale faraway blue dotted with small clouds, half bathed in the east in golden tones of red; toward the west the colors faded off into pink and violet. The grass sparkled, still damp from the night air, even the trees sparkled, and birds were everywhere, producing an incredible din. Two types of birds predominated, the mynas, who strutted about gesturing awkwardly and making unharmonious, scolding squawks, and the less noticeable doves, moving more slowly, almost politely, some of them seeming to bob up and down as they fanned out their tail feathers and cooed in melodious voices. I liked that short morning walk. It was only a few hundred feet, but it made me feel happy.
Six o'clock in the morning is not my idea of the perfect time for a big breakfast, particularly after a sleepless night. But I forced myself to eat, stuffing the food into my mouth and relying heavily on water to take it down. By experience, I knew that if I didn't eat I'd be hungry in an hour or so, when it would be impossible to get food. Besides, I missed lunch about half the time because of the operating schedule. Another meal might not come my way for eight or ten hours.
After breakfast, I had about thirty minutes to see my patients before rounds started at six-forty-five. It was important to have everything in order before then, to know all the latest changes. The ICU was first. I never minded going there in the morning, or anytime during daylight, for that matter. Having other doctors around diminished that feeling of being alone on a high wire. Mrs. Takura was sleeping peacefully after her preoperative medication; the tube hung still in her nostril, wrinkling her nose from the tension. Pulse, urine output, blood pressure, breathing rate, temperature, electrolytes, BUN, protime, proteins, bilirubin… all the recent tests were back and recorded. Pausing to write a note about her status in the continuation sheet, I hoped she was ready.
Back in one corner Mr. Smith's machines were still beeping away, showing an EKG that looked pretty normal, although I was no ace at reading them, especially from the oscilloscope. He was sleeping, too. I went down to the wards.
On the ward, the name of the game was numbers and variety rather than crisis. I had several dozen patients, representing as many different types of people and problems. Most of them had had their surgery and were progressing well at various stages from postoperative, through having stitches out, to discharge. The length of their drains was usually a good indication of how many days had elapsed since they'd left the operating table. Drains are a somewhat awkward but quite necessary part of surgical practice. Planted deep with the wound at the end of the operation, they serve as an outlet for any unwanted fluid and help to keep down infection. The idea is to pull the drain out, inch by inch, beginning on the second postoperative day, thereby letting the wound heal slowly from the inside out.
Patients never understand these drains. To them, the dangling pieces of pale rubber are a source of endless conversation and discomfort, mostly mental. Mr. Sperry was two days postoperative for gastric ulcer, and it was time to begin pulling his drain. Grabbing it with a clamp, I gave the tube a good tug. But it held fast, just stretching a bit, so that it looked somewhat like a Chinese noodle. From his sitting position, propped up on two pillows, Mr. Sperry watched in dismayed fascination, his eyes as big as almond cookies and his hands gripping the sheets. Pulling at it again, I began to wonder if the drain had accidentally been stitched into the wound when gradually it let go and moved out a couple of inches. A bit of serosanguineous fluid escaped with the drain and was quickly soaked up with gauze.
"Doctor, did you have to do that?"
"Well, you don't want to go home with this drain hanging out, do you?"
"No."
I put a safety pin through the drain just above the skin to keep the tube from dropping back into the wound and then, with sterile scissors, I cut off the excess tubing. It was important to follow the right order in this simple procedure. Once, before I knew better, I had cut the drain off prior to placing the safety pin. The patient had been holding his breath all the while, and when he finally inhaled, the drain disappeared into his abdomen. Visions of a new operation crashed in my head, but fortunately a resident had retrieved the drain after taking out three skin sutures and fishing around with some forceps.
"Why don't you put me to sleep when you pull it?" Mr. Sperry looked at me, questioning.
"Mr. Sperry, putting you to sleep is not as easy as you think it is. Besides, anesthesia always carries a risk, but there's no risk in pulling out your drain."
"Yes, but then I wouldn't know about it."
"Did it really hurt when I pulled your drain?"
"A little, and it felt funny inside, like I was coming apart."
"You're not coming apart, Mr. Sperry. "You're doing great."
"Did you have to pull so hard?" he pressed.
"Look, Mr. Sperry, tomorrow I'll put these gloves on you, give you the clamp, and you can pull it out. How's that?" I knew that would get a response.
"No, no, I didn't mean that I wanted to do it."
Actually, I knew what he meant. After an operation I had once had on my legs, I felt the doctor was too rough when he took the stitches out. But I hadn't wanted to take them out myself. It's good for a doctor to be a patient now and then — makes him more responsive to all the patient's irrational fears. The solution is to tell the patient everything you are doing, even the simple things, because often it is what you take for granted that scares the patient the most.
"Mr. Sperry, you can move around as much as you like. In fact, movement is good for you. You are not going to pop open. This drain is the normal procedure. It lets out any bad juices while you heal. The safety pin is just to keep it from going back inside your abdomen."
All was well with Mr. Sperry, although I had surely given him something to talk about for the rest of the day: how the cruel doctor had yanked his drain and caused the wound to open and bleed.
That was the ward routine: checking drains, changing dressings, answering questions, looking at temperatu
re graphs. Although Marsha Potts was not my patient, I paused in front of her door almost instinctively. She looked worse now, with the daylight exposing her jaundiced color and the skin on her face so tight and drawn that her teeth were bared in a perpetual grin. She was in terrible shape; we were doing all we could, but it would not be enough.
Outside her room, where the grass came right up to the building, the birds paid no attention as they squawked and chattered over bits of toast tossed to them by the mobile patients.
Now, at seven o'clock, the ward had come alive, suddenly filled with breakfast trays and clanging IV poles as people made their way to the bathroom. Nurses scurried here and there, carrying pans, needles, ointments, and pills. Swept into this world, I no longer felt tired, at least as long as I stayed on my feet. There was an exhilaration to the routine; it seemed to say, "No one can die here, everything is under control." In the midst of all this bright efficiency, Roso was out cold from his Sparine. I had to shake him several times to get any response at all. But once half-awake he agreed he was more strong, Doktoor, before sinking back into sleep.
A lab technician asked me to help her draw some blood from a patient with bad veins. She had tried three times without success. Certainly I'd try, and willingly, because it was a source of great comfort to me having these technicians to draw blood in the morning. To nondoctors it might seem a small point, but medical students resented spending most of their time before morning rounds trying to milk blood out of patients; by the time rounds started they hadn't been able to see any of their patients and were therefore ignorant of their latest condition. When the questions started coming—"What’s this patient's hematocrit, Peters?" — you had to guess, because you hadn't had a chance to look at the chart, either. But it must not sound like a guess. Snap back, without hesitation, "Thirty-seven!" as though you'd stake your life on it. It was not a matter of honesty. Better to play the game than to tempt disaster by saying you didn't know, whatever the reason. No one cared whether you had done those twenty-seven blood counts except if you didn't do them. So you shot back thirty-seven so quickly that half the time the professor would pass on without thinking. But if he paused, you were in trouble, unless you could distract him by referring to a recent article bearing on the disease. Of course, if he checked the chart, you lost totally, unless by wild chance the hematocrit was, indeed, thirty-seven; otherwise, you said somewhat lamely that you had another patient in mind. This would bring about the last, fatal pause as the professor leafed through the chart, looking for another question.
"What about the bilirubin, Peters?"
Now you were really up against the wall, faced with an all-or-nothing gamble. If your bilirubin guess was wrong, too, the professor's suspicion that you were lax on patient care would spread like ripples through the hospital. But in the happy event that you were right, you were returned to a state of grace and moved on to the next patient to watch another student get his interrogation. Bilirubin is different from hematocrit in that everyone's hematocrit varies a good deal, whereas the bilirubin value is usually pretty much the same in everybody, except in liver and blood cases. So you decided to gamble, saying, "It was about one, sir." In medical school most of us learned to play the game; if you played it well, you won more than you lost.
In Hawaii, the technicians had lifted this blood burden, and I didn't mind helping them occasionally. Besides, I was pretty good at it. I should have been, after having drawn several thousand blood samples in medical school. We students had started by drawing each other's blood, which was generally a snap, although some of us made it look pretty difficult. Even this exercise had not been without its dramatic moments. One time, after vigorously palpating the arm vein of another second-year student, I had it standing out like a cheap cigar. The tourniquet had been on for about four minutes while I built up my courage, and when I finally pushed the needle in, my friend just disappeared. It all happened so fast. I went directly from concentrating on the needle breaking the skin to staring at a needle and no arm. My "patient" was spread out on the floor in a dead faint. We had all dreaded those practice sessions, but they were easier than having each student draw blood from himself.
I'll never forget the first time I drew blood from an actual patient. It happened early in third year, when we students were beginning ward medicine. As bad luck would have it, our first day on the ward had coincided with a shift change among the interns and residents. To the new residents, the opportunity was irresistible. They decided to check the diagnoses of all the patients, and for this they needed proof — cold facts, incontrovertible laboratory evidence. As a result, we students had to draw about a pint of blood from every patient assigned to us. My first patient, poor fellow, was a chronic alcoholic with advanced liver cirrhosis. His surface veins had disappeared years ago, and I had to stick him twelve times, groping around inside his arm with the needle, feeling each needle point break through unknown inner structures with a sudden, almost audible popping release. Finally, I had had the good sense to give up and be instructed by the intern on how to get the needle into the large femoral vein in the groin, a procedure known as a femoral stick.
Now the laboratory technician was having much the same problem with a Mr. Schmidt, whom I palpated for the usual arm veins as she handed me a syringe. It was obvious why she hadn't been able to get any blood: I couldn't feel a single decent vein in his arm. So I did a femoral stick, and it was over in a flash.
Farther along the ward I came to Mr. Polski, who was a problem for me mainly because I had failed to achieve any real rapport with him. He had diabetes, very poor peripheral circulation, and a deep infection of the right foot. About a week previously we had done a lumbar sympathectomy, cutting the nerves that were responsible for contracting the walls of the blood vessels of his lower legs. But he was showing very little improvement. Because of the pain, he insisted on hanging his leg over the side of the bed, and that merely inhibited what meager circulation he had. At first I had tried the friendly approach, explaining carefully what happened when he let the leg hang over the side. Regardless, every morning when I appeared, there it was hanging down. Switching tactics, I had pretended to be angry, yelling in feigned rage — which didn't change the situation except to make him like me even less. The foot, now black and gangrenous, was scheduled for amputation.
I nodded my head to Mrs. Tang, an elderly Chinese lady with a cancer growing inside her mouth. She couldn't talk, so we just nodded. The cancer was so big that it had dissolved some teeth and the bone of the jaw on the left side, becoming finally an uncontrollable, fungating mass that occasionally broke through the side of her throat. She was like many older Chinese people who thought of a hospital only as a place of death and would not come to us until the very end. There was little we could do for Mrs. Tang but try some X-ray therapy. The cancer got bigger every day, and somehow Mrs. Tang every day seemed less real — perhaps because she couldn't talk, or maybe because she was so resigned.
There were others: a lymph-node biopsy, a breast biopsy, two hernia repairs. I greeted each of them, passing from bed to bed, using their names — I knew them all by now. I even knew the families of many of the patients who had been with us quite a while. The other intern and a handful of residents arrived, including the chief resident, and morning rounds began. This was a rapid affair; we probably looked like a bunch of myna birds, moving awkwardly and quickly, almost stepping on one another in our haste, as we went from bed to bed. The haste was necessary since we now had only half an hour until the first scheduled operation. No articles were discussed; we didn't do much more than just count heads to make sure everybody was still there. Gastrectomy, five days postop, going smoothly. Hernia, three days postop, probable discharge. Varicose veins, three days postop, also probable discharge. Gastric ulcer, X rays complete, scheduled for surgery. Did the X ray show the ulcer? Yes. Good.
In the next ward, we stood in the middle and twirled slowly on our heels. Mass lesion, mediastinum, aortogram pending. I ran throug
h a staccato capsule description on each of my patients. The other intern did the same. There were four such wards, and we finished the last case in the fourth ward exactly seventeen minutes after starting.
"Peters, you do another cutdown on Potts while we go to the ICU and pediatrics." The little troop disappeared around the corner, and I turned toward Marsha Potts's room, confused and irritated, silently protesting. She wasn't even my patient. I knew I had been chosen because I didn't have any surgery until eight, instead of the usual seven-thirty, but even so I didn't want to get involved with her again, after fooling around with that venous pressure setup the night before. Moreover, a cutdown could be tricky. I hadn't done many of them. But mainly it was just so damn unpleasant in there. Still, Marsha Potts needed a cut-down because she needed intravenous fluid and food; with no more superficial veins that we could use for her IV, we had to cut down on a deeper vein.
As I entered that room, the cheerful morning bustle faded away. Even the bird sounds became inaudible to me, although of course they were still there. The smell was almost overpowering, so pungent and revolting it made the air seem heavy. It was the hot smell of rotting tissue mixed with the sweet, syrupy smell of scented talcum powder being used in a vain attempt to counteract the stench. The talcum powder only made it worse for me. Trying not to look at the poor woman's face, I put on three surgical masks to fend off the smell, but the layers made it hard to breathe and my diaphragm struggled to draw in the thick air. I didn't want to touch too many things in there. Death seemed spread on everything, almost contagious.
I pulled up the sheet from the bottom and bared her right foot. There were open ulcerations on the underside of her leg and the back of her heel. In fact there were sores all over her body, wherever it touched anything. After focusing a bright light on the medial aspect of her ankle, I pulled on the rubber gloves and opened the sterile cutdown tray.
