“Did you know that you were in the hospital?” I asked.
“No.”
“What did you think when you saw the nurses?”
He looked away, straining to remember. “Well, then I gradually came to know it. But it had never happened to me before like this. This sense of not knowing the place.”
“Were you short of breath?”
“No,” he replied. “Just confused. But it never happened before.”
I nodded, having already seen a few cases of ICU psychosis. “That happens here sometimes,” I said.
“Oh, okay.” He looked relieved. “Was your wife here with you?”
“No, she came later.”
“Tell her to visit more frequently.” He said he would do that.
At six-thirty Amanda and Nancy arrived. Amanda brought breakfast for me—a toasted bagel with cream cheese and coffee (it was customary at New York Hospital for the on-call intern to bring in breakfast for the post-call intern). We sat at the conference table while I reviewed overnight events. I told Nancy about Mrs. Piniella; she thanked me for filling out all the death forms. Then the three of us went out to preround. Nurses kept asking me to do things, seemingly oblivious to the fact that I was post-call, so I tried my best to avoid them. On rounds, Dr. Carmen mostly left me alone. Periodically I’d nod off and yank myself awake, momentarily disoriented. Trying to stave off sleep was like trying to pull open a screen door in a hurricane. It took every last ounce of energy.
We rounded quickly, and I was essentially done with my work by late morning. Before leaving, I stopped by to say goodbye to Mr. Waldheim. Per his son’s request, he had been moved to a room with windows. I walked in to find him sitting in a chair, admiring the Queensboro Bridge. He gave me a thumbs-up, and his message was clear: all he wanted was a room with a view.
At noon, when rounds were finished and progress notes were done and orders had been written and consultants had been called, Steve and I walked out together. I could hardly believe it: my first call night was finally over. Only 140 more to go during residency. The thought might have depressed me, but I was giddy at the prospect of going home after thirty hours on and having a free day. I had heard about the brutally utilitarian post-call routine of one of the senior residents. When she would get home, she’d pop a couple of pills of Valium and go straight to her bedroom, locking the door, often sleeping for sixteen hours until the next morning. It didn’t matter if the baby wanted to play, or if her husband wanted to talk, or there were errands to be done. She was totally focused on getting her sleep. But not me; I was going to stay up; leisure time was too precious to squander on sleep. I was going to check stocks or maybe go for a run. I was going to watch the talking heads on CNBC. I was going to order lunch from Chicken-fest. I was going to call my mother. I was going to write in my journal. I was going to read the newspaper. I was going to read magazines. I was going to read . . . well, anything but medicine.
We walked by the information desk in the lobby. An administrator had called me during rounds to tell me that I had forgotten to sign the death certificate. She had been waiting for me, and scolded me for taking my time to come down. I just smiled and apologized and signed my name. The night was over and I wasn’t going to let anything bother me.
Steve led me out an emergency exit and into a courtyard. The day was bright and sunny. In a daze, I walked to the main thoroughfare. “Thank you,” I said to Steve when we got to my corner. “I couldn’t have gotten through the night without you.” He smiled and patted me on the back and told me to get some sleep. I walked the two blocks back to my apartment, my shadow cutting the sidewalk ahead of me. The summer sun reflected off the smudges on my glasses, breaking into tiny speckles, like puddles on a crater-filled road. In the living room, I sat down on the couch, turned on the television, and collapsed. When I woke up, it was after dark.
CHAPTER SIX
road trip
The doctor has paid for the power with suffering.
—MELVIN KONNER, BECOMING A DOCTOR, 1987
Morning was the busiest time in the CCU, when patients were wheeled off for catheterization and other procedures. One of the most common reasons for admission was to rule out myocardial infarction. Residents called it a ROMI (pronounced “roamie”), and this was the bread and butter of the CCU, often requiring a trip to the catheterization lab. There was always a long line of gurneys by the front desk, like airplanes on a runway waiting to take off.
After rounds I usually hovered around Steve, my resident, like a groupie. He was a lanky man, over six feet tall, with long arms that dropped down below his knees. He told me that he was planning on getting a job in a small town after he graduated. In small towns, he said, internists were doing a lot more than their counterparts in big cities: stress tests, flexible sigmoidoscopies, even implanting pacemakers. “Once you get out of the city, it’s a whole new world.” He had briefly considered becoming a “hospitalist,” a new breed of internist that exclusively took care of hospitalized patients, but he had decided against it. He said he believed that primary care medicine would provide ample intellectual rewards. Like Steve, at one time I too had worried about being challenged in medicine. Now my fears were very different.
One morning, Steve taught me a mnemonic for organizing the problems in my daily progress notes: RICHMAN (respiratory, infectious, cardiovascular, hematological, metabolic, alimentary [or gastrointestinal], and neurological). Another time, he taught me how to insert an arterial line. I put on a sterile gown while he threw a sterile sheet over the patient. Then he tore open a procedure kit and spilled its contents onto the drape. His long fingers started moving rapidly, opening packages of needles, drawing up saline flushes, arranging the instruments we were going to use with the meticulousness of a sushi chef. After he was done, he taped the patient’s right arm to a bedside table so it wouldn’t move. Then I cleaned it with antiseptic soap. With a needle I stabbed a small vial of lidocaine he held up in the air, drawing some of the medicine into a syringe. I injected a tiny bleb into the patient’s arm to numb it up. “Go deeper,” Steve advised, and I did. Then I took a longer “finder” needle and poked it through the skin, trying to locate the artery. The patient winced.
“Go in at more of an angle,” Steve suggested. “Okay, pull back a little bit, I think you went through the artery. A bit more. Pull back. Pull back.” A burst of maroon filled the barrel. “Okay, perfect. Now take off the syringe. No, leave the needle where it is—” but I had already pulled it out of the artery. “That’s okay, just put the syringe back on and try again.”
I tried again, but this time with no luck. “Go in at the same angle,” Steve said, making a jabbing motion with his hand, but I was unable to draw back any blood. “Okay, sharpen the angle . . . sharpen . . . sharpen . . .” With each attempt, the patient groaned, and I started to sweat. I was reminded of a patient I had tortured as a third-year medical student trying to get an arterial blood gas. Dean Dowton had told us to come up with a code of ethics in his commencement address; my first rule was that I was only going to allow myself three attempts at a procedure before asking someone more experienced to take over. But now I found myself wanting to try again and again.
“Let me give it a shot,” Steve finally said. I was hoping he’d miss, at least once, but he hit the artery on his first attempt. When he removed the syringe, blood spurted out the hub of the needle, splattering red dollops onto the table and the tile floor.
“Okay, hand me the wire,” he said. My hands were shaking so badly that the wire, which resembled a guitar string, kept flopping about wildly. Perspiration was trickling down my face. He inserted the wire through the bore of the needle and into the artery. Then he pulled out the needle, leaving the wire inside the vessel. With a scalpel, he made a deep nick in the arm, and forced a stiff plastic catheter, a dilator, through the soft tissue to create a track for the catheter that was going to follow. The patient groaned but did not move. Blood started gushing. Steve slipped the catheter
over the wire and tried pushing it into the artery, but it buckled. He tried again but it still wouldn’t go. I looked on nervously as the wire protruded unnaturally out of the man’s forearm, like a nail askew in a thick plank. “It’s probably bent,” Steve said. He turned to the nurse who was with us and politely asked her to bring him another wire. Then, with his finger pressed on the wound, he casually turned to me, like a man waiting for a train. “Never let go of the wire,” he said, and I nodded nervously. I couldn’t believe that even at that moment, Steve was still trying to teach me something.
The nurse returned with a new wire and Steve quickly inserted it into the artery. The catheter passed over it easily. He pulled out the wire and connected the catheter to a manometer. Soon a blood-pressure waveform was prominently displayed on the monitor above the bed. “Okay, sew it in,” Steve said. While I made stitches, he gathered up the needles, discarding them into a sharps box, threw away the procedure tray, and stripped off his gown. “Congratulations,” he said. “You just put in your first arterial line.”
“You did it,” I replied, not wanting to be patronized.
“Yes, but you’ll do it next time,” he said encouragingly. “See one, do one, teach one.”
That night I wrote in my diary:
Next to Steve, I feel lame, effete, like a shell of a resident. He has a feel for the hospital that I don’t have. They say I’ll develop it, but I cannot imagine a time when he was as confused as me.
I know I can learn a lot from him. He is truly a wonder to behold. The only thing I would fault him on is his tendency to denigrate patients in conversations with other doctors. But that’s hardly unique to him.
ONE AFTERNOON IN THE CCU a few days later, an Australian man was returned to his room after an electrophysiology procedure. Within an hour his blood pressure plummeted. His eyes darted back and forth, like a scared child’s, even as he insisted that he was fine. The consensus among doctors in the room was that he was in cardiac tamponade, where fluid rapidly accumulates in the sac around the heart, hindering its ability to fill with blood. The only effective treatment is to drain the fluid. “Page your brother!” someone shouted to me.
When Rajiv came barreling through the double doors, I breathlessly told him that I had paged him 911. “Don’t ever fucking do that,” he barked, marching past me. In the room, a technician was performing an echocardiogram, which confirmed that a massive amount of blood had accumulated in the pericardial sac, compressing the heart with every beat. Suddenly Rajiv was in a sterile gown, and I was being asked to step outside. A nurse threw a blanket over the patient. Rajiv tore open a pericardiocentesis kit. Everyone, including attending physicians, watched raptly as he drew lidocaine into a syringe. He seemed to relish the attention, chatting comfortably with the nurse who was assisting him. “Can you move the table over, please?” he asked politely. This was not the brother I knew from childhood, the one who was easily intimidated, who feared dirt-biking in the hills behind our house. I had always been the fearless one, doing cross-outs and tabletops while he adopted a more conservative style. Now I was the one perched on top of the Islander Hill on my Univega bicycle, fearfully looking down.
Rajiv had always been good with his hands, much better than me. Growing up, he had been the tinkerer and I had been the thinker. It was disheartening to realize how useless my skills were now.
The patient had stopped moving under the drape. He was either being extremely cooperative or was sinking into cardiogenic shock. Rajiv stood on a step stool. After numbing the skin below the breastbone, he pierced it with a six-inch-long needle, directing the tip, with the aid of ultrasound, toward the left shoulder, directly at the heart. I stepped away; I couldn’t watch. I could hardly believe what was happening. Wasn’t there someone better equipped to do this than my older brother?
I had always been in Rajiv’s shadow, and never more so than in the CCU. Dr. Carmen and the others expected me to do well because of Rajiv. I couldn’t just worry about myself; I had to worry about his reputation, too. “I don’t want to mess this up for you,” I had told him the night before starting the rotation. “You can’t,” he replied confidently.
A few minutes later, while I was sitting at a computer checking labs, the mood of the crowd suddenly changed. People started filing away. When I went back into the room, the drape was off, the patient had regained his color, and his blood pressure was almost normal. Bloody fluid was draining into a plastic bag. I found Rajiv chatting with some fellows by the nursing station. People were walking up and patting him on the back. When he saw me, he snapped his fingers loudly. “Did you see it?”
“I missed the last part,” I replied.
“Well, it was fucking awesome!”
“How did you know where to go with the needle?”
“I didn’t. I just pushed and prayed.” Then he broke into a cackle that usually meant he was pulling your leg, but you could never be sure.
I stared at him, incredulous. In twenty-nine years, I had never wanted to be like my brother more than at that moment. He was so calm, cool, and collected. He seemed to view hospital dramas as some sort of Vedantic play in which he was merely another actor.
“It’s an amazing feeling,” Rajiv said. “Here this guy goes from being in shock to actually talking.”
“What did he say to you?”
“Ah, that was the best part. He apologized.”
“Apologized?”
“Yeah, the first thing he said when he woke up was, ‘I’m sorry for not being a good patient.’ ”
“What did you say?”
“I said, ‘Shut the fuck up.’ ” Then he broke into another full-throated cackle.
As he was walking away, he stopped. “Don’t ever page me 911. I thought something bad had happened.” I started to say something: “Wasn’t this—?” He cut me off. “You know what I mean. Like with the family. Like something had happened to Dad.”
MRS. WILLIAMS NEEDED A CAT SCAN. She was on a stretcher, in a tangle of wires and tubes, a woman of about seventy with thinning gray hair and a churchgoing face. A nurse was giving me instructions for the road trip. “Just keep the monitor on her at all times,” she barked, like a quarterback calling out a play. She picked up a section of clear plastic tubing. “This is your arterial line. And this here is your central venous pressure. I’m going to disconnect it; you don’t need it. This is the heparin. This is the nitroglycerin.” She pointed to the bulky yellow monitor at the foot of the bed. “The yellow line is your oxygen saturation. That’s your heartbeat and that’s your blood pressure.” She reached underneath the stretcher, where a green metal canister was lying on its side. “That’s your oxygen. It should last about thirty minutes.”
She paused to take a deep breath. “This is your code box,” she said, holding up a sealed gray box that looked like a mechanic’s tool kit. Inside it were drugs—epinephrine, atropine, lidocaine—that I had never used. “Just break it open if you need it. Of course, if she arrests, you’re going to use the paddles.” I nodded; I had never used defibrillator paddles before. “You charge it like this, see.” She turned the knob back and forth quickly. “One hundred joules, two hundred joules, three hundred joules, see.” My face must have betrayed terror because the nurse offered an almost sympathetic smile. “Don’t worry,” she said. “If you need to, you can always call a code.”
The middle-of-the-night road trip is an intern rite of passage. Steve and the other residents had done it, and there was no reason to think that I couldn’t do it, too.
A young black man in dreadlocks and lime green scrubs showed up. He was my escort. Without a word, he grabbed hold of the back of the stretcher with one hand and a metal IV pole with the other and maneuvered it to the double doors. Then he punched a plate on the wall, the doors flung open, and we were off.
Coming out of the CCU, with me holding on to a side rail, we tried turning left, but the stretcher went crashing into the far wall. “Oh my!” Mrs. Williams exclaimed. She had few teeth, h
ollow cheeks, and kind of gummed her words when she spoke. I didn’t know much about her, except that she had been admitted to the CCU with chest pains. That was pretty much all Amanda had signed out.
We rolled the stretcher down the checkerboard-tile floor, toward the freight elevator.
Even at this late hour, I could see white-coated men sitting on stools in the satellite pharmacy, sorting pills. Their presence was both creepy and oddly reassuring. More banging, but we managed to steer the stretcher onto the corrugated metal floor of the freight elevator. With each bump I checked to make sure the IVs were still connected. An EKG sticker had come off her chest, dangling uselessly on a wire, making the heartbeat tracing temporarily go flatline before I pressed it back on. We rode up to the sixth floor in silence, except for the reassuring blip-blip-blip from the monitor.
Coming out of the elevator, we made a left and rolled up a ramp and down a hallway, past the pediatric oncology wing. Suddenly we were in an old part of the hospital. The corridors were lined with beat-up chairs and rusting file cabinets below peeling paint. We stopped at an intersection. I looked up from the monitor nervously. “I hope you know where you’re going, because I don’t.” My escort’s flat, somber expression did not change. “I’ve only been here two weeks,” I tried to explain.
Without a word, he turned left. A couple of turns later, we entered a darkened hallway. It had a faintly chemical smell, like that of a darkroom. “This is it,” he mumbled, disappearing into a room. From the corridor I could see a doughnut-shaped CT scanner sitting on a metal gantry that looked like it could use a good scrubbing. After a couple of minutes, the escort came out and started walking back in the direction of the main hospital. “Hey!” I called out. “Where are you going?”
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