“Just call me,” I replied. People in the hospital were always obsessing about disasters that never occurred. I had seen it myself in the CCU, where nurses would use PRN (“as-needed”) sedative orders to keep patients groggy and cooperative through the night.
When Mrs. MacDougal came out, I walked her back to bed. “You’re a nice young man,” she said.
“Thank you,” I replied.
“I like you.”
“Well, I like you, too.” That was the nicest thing I had heard all week. I was going to show these nurses that a little kindness could go a long way.
The next page came about forty-five minutes later. When I arrived back in the room, the scene was much the same as before, except now Mrs. MacDougal was standing in a slurry of feces. She was yelling some of the vilest obscenities—“Cocksuckers! Motherfuckers!”—that I had ever heard from a nonagenarian’s lips. The stench was overpowering. I cupped my hand over my face, but the putrid odor still registered in my olfactory lobes.
“Mrs. MacDougal!” I cried through my fingers. “What are you doing?”
“Who the hell are you?” she screamed hoarsely.
“Dr. Jauhar!” I said, incredulous. “Don’t you remember me? You promised you were going to stay in bed.”
“I need to go to the bathroom.”
I ordered her back to bed immediately.
“You’re not my doctor!” she shouted. “Call Silverman. Tell him to get me out of here.”
I told her that Dr. Silverman wasn’t available.
“Get out of my way,” she cried, swinging wildly at me. She slipped and fell into my arms, rubbing brown excrement onto my scrubs. Steadying myself, I felt my right sandal slide a bit. The nurses were looking at me with I-told-you-so satisfaction.
For a moment I fantasized about putting Mrs. MacDougal into a choke hold and dragging her by the neck to bed, elbowing the nurse and orderlies out of the way, hissing, screaming at them to end this godforsaken shitfest. But, of course, that couldn’t happen; I had to deal with the situation calmly. “Give her five of Haldol and two of Ativan,” I shouted out as I tried to keep her from tipping over.
“Yes, Doctor,” the nurse responded sarcastically before going out to get the medicine. The two aides and I managed to force her back to bed. When the nurse returned, she administered two intramuscular injections. Almost immediately, Mrs. MacDougal stopped struggling. Within minutes she was snoring heavily. I felt momentary relief, until the reading from the pulse oximeter started to drop: 99 . . . 98 . . . 97 . . . Pretty soon an oxygen mask was plastered to her face and I was turning a knob counterclockwise on the wall. Ninety-four . . . 93 . . . 92 . . . The brief calm quickly turned into another round of panic. Why had I been so impulsive? Was there an antidote for Haldol? Should I call an ICU consult? Where were the nurses now? For the next couple of hours I remained at her bedside, watching her snort like a pig. I stabbed her wrist with a needle to get an arterial blood gas, which revealed borderline oxygen and carbon dioxide levels. I prayed the drugs would wear off. Why had I allowed myself to be goaded so rashly? In an effort to protect her (or perhaps myself), I was afraid that I had killed her. It was an apt metaphor for my internship thus far.
By the next morning, Mrs. MacDougal had returned to her sweet, great-grandmotherly self. At lunchtime a few days later, nurses, social workers, and people with nondescript titles like “coordinating manager” met to discuss patient “disposition”—who was going to be able to go home, who was going to require long-term care, and so on. Rohit told me to attend on his behalf. At the meeting, everyone seemed to be having a rollicking good time talking about the patients, exchanging gossip about family dynamics, and so on. The subject of Mrs. MacDougal came up. “Dr. Jauhar had a wrestling match with her a few nights ago,” a social worker said, and everyone laughed except me. Someone asked where Mrs. MacDougal was going to go once she left the hospital. Her daughter wanted to put her in a nursing home, but she wanted to go back to living independently. “No way that’s going to happen,” someone said with a certitude I found troubling. Someone asked me for my opinion. I had had so little interaction with her, just one unfortunate incident, that I wasn’t sure how to respond. I was wary of saying anything that could send her to a nursing home for the rest of her life. She had been delirious, no doubt, and a danger to herself, but she had also been in an unfamiliar environment with people she thought were trying to hurt her. Surely that had to enter the calculus for predicting future behavior. It was anyone’s guess what she would be like in a more familiar environment. Wouldn’t putting her into an institution just increase the likelihood of further sundowning? I thought of the Chekhov story “Ward No. 6,” and the incarceration of Yefimitch. I did not want to be responsible for institutionalizing another person. I had seen it before on the psychiatry wards. If someone said they were well enough to go home, we would say they lacked insight into their disease and keep them even longer. Where was Dr. Silverman? I wondered. We were discussing the future of a stranger over sandwiches and soft drinks. And that was beginning to seem normal.
CHAPTER ELEVEN
psychotherapy
Yes, there are two paths you can go by, but in the long run, There’s still time to change the road you’re on.
—LED ZEPPELIN, “STAIRWAY TO HEAVEN”
I’d been working for thirteen hours straight, without even a toilet break. One week ago, as an October chill started to take hold, a gnawing tightness had developed at the base of my neck, extending into my right shoulder and radiating down to my elbow. Now, my eyeballs were stinging, too, as if they had been doused with salt water. Pressure extended from the back of the orbits into my brain and down into my throat, rendering it parched and my voice feeble. I could almost feel my cortex rubbing on the inside of my scalp, producing a kind of tactile white noise, like strips of Velcro being pulled apart. Extreme fatigue heightens physical sensation. It makes time run slower, trapping you in the moment.
I was supposed to meet the resident Josh for dinner to talk about switching to psychiatry, but first I had to drain the fluid out of a young woman’s cirrhotic abdomen. I had put off the procedure all day, and even though it was past seven and Rohit and Alphonse had already left, I wanted to get it over with today. I was on call again tomorrow, and Saturday calls were the worst. No cap on admissions, scores of patients to cross-cover. I wouldn’t have time for any extra procedures.
I walked over to the stockroom to get vacuum bottles for the drainage. In the large white bins I found the usual assortment of test tubes, catheters, syringes, bandages, gloves, plastic tubing, tape, gauze, dressing-change kits, drainage bags, syringes, scalpels, thoracentesis kits, bone-marrow biopsy kits, triple-lumen catheter kits, lumbar-puncture kits, saline bags, bedpans, cups, straws, socks, mouthwash, needles, diapers, sponge pads, iodine soap, hydrogen peroxide, masks, and bunny boots—but no vacuum bottles. Without vacuum bottles to speed up the drainage, the procedure was going to take forever. I went downstairs to the gastroenterology floor to find some.
Most interns have a favorite procedure. Already, mine was the abdominal paracentesis. I admired its brute-force simplicity. You push a catheter directly through the abdominal wall and into the abdominal cavity to drain accumulated fluid. It’s easy and safe. Plus, your patient almost always ends up feeling better.
Wafting through the corridor on 10-North was the sickly sweet smell of Clostridium difficile diarrhea. I marveled at how the nurses were able to go about their business, without masks, seemingly oblivious to the stench. The thirty-something woman, HIV-positive, was lying in a room at the end of the hallway. She had unruly black hair and bloodshot eyes, and apart from her protruding abdomen, which looked like it was carrying triplets, she was wispy thin. Her belly had been hurting for weeks, she said, and she had been getting satiated after only a few mouthfuls of food. She had to sashay from side to side when she walked. I set the vacuum bottles down on the floor at her bedside and told her that I had come to drain the fluid. “Ok
ay,” she replied flatly. She had gone through this procedure many times before.
I went over to the sink and washed my hands. After toweling off, I tried putting on a pair of gloves, but my hands were still moist and my fingers kept getting stuck in the latex fronds. I tried pulling on the latex but it clung tightly to my skin. I walked back to her bedside, the tips of the gloves hanging uselessly off my fingertips.
Her belly was laced with stretch marks, like thick, wrinkly worms. I pressed just below her navel, a sharp, shallow jab that set the fluid in motion, like water in a pail. There must have been ten liters in there, a consequence of cirrhosis, from hepatitis, AIDS, her insatiable thirst for rum—or all three. I tapped on her abdomen like a drum, using the transmitted sound to map out the location of the fluid. Dull was fluid, hollow was air—and as best as I could tell, the fluid was everywhere.
I scrubbed her belly with iodine soap—she shivered; it was cold—and then injected lidocaine into the skin and soft tissue of the left lower quadrant. The injection formed a mound the size of a fingerprint, which I pressed down to distribute the anesthetic, liberating a tiny spot of blood, which trickled away. I pushed a big 22-gauge needle through the site of the injection, forming a fleshy tract for a plastic catheter, which entered the abdominal cavity quite easily. Almost immediately, warm yellow liquid came bubbling back, soaking my gloved fingers. I attached one end of a piece of tubing to the catheter, plunged the end with the needle into a vacuum bottle, and then sat down to watch the fluid drain. It came out in a steady drizzle, like a leak in a water balloon. “Take it all out,” the woman insisted. “I’m only supposed to take out a few liters,” I replied. Someone had once told me that it was unsafe to drain more than that at one sitting. I had forgotten why, but I was glad to have a reason to stop so that I could keep my dinner date with Josh.
The bottle filled up quickly. Midway, I got paged. It was Josh. He wanted to know if we were still on. I told him I was running late but that I would meet him at the restaurant as soon as I was finished.
The fluid was really gushing; perhaps the catheter had settled into a high-pressure pocket. I reached for another bottle, but then I realized that I had stupidly left it on the other side of the bed, out of reach. I placed the nearly full bottle on a chair and hopped around the bed to get the unused bottles. I heard a snap, and when I looked back, the tube was whipsawing back and forth on the chair, like a garden hose, spraying lemonade-colored fluid on the floor. For a moment I was paralyzed. What happened? Did she move? Did I not secure the needle? I watched horrified as tiny puddles of HIV-infected fluid settled onto the uneven tile floor. My gloves were still hanging off my fingertips, so I tore them off and stepped around the spill to put on another pair. Then I grabbed the gushing needle and plunged it into a new vacuum bottle. Even with the fluid safely discharging into the glassy cavern, I continued to grip the needle tightly, my heart pounding in my ears. The young woman stared out at the room, oblivious to the disaster that had just unfolded. Fool! I shouted at myself. I had been rushing to get out on time, and now I had created an even bigger problem for myself, a veritable biological hazard. I was going to have to call Housekeeping, write an event note, maybe fill out some sort of incident report. The evening nurses were irritable enough without giving them another reason to be annoyed.
I filled up a second bottle and told my patient that we were done. Even with just two liters out (plus whatever was on the floor), her abdomen was noticeably less distended, and she said she was feeling better. I pulled the catheter out of her belly and threw the tubing and sundry sponges and towels into a red biological waste bag. I took the bottles over to a “soiled utility” room and left them by the sink. Back in her room, I got a roll of paper towels and wiped off the floor and chair, working quickly before anyone arrived. “Thank you,” she said as I searched the bedding anxiously for stray needles. “You’re welcome,” I said curtly.
At the workstation, I told a nurse what had happened. “You could have called me,” she said in an exasperated Caribbean twang. “I was sitting right here.”
I told her I was sorry, that I hadn’t wanted to bother her, and, much to my surprise, she told me to leave. She would call Housekeeping for me.
I sprinted the block back to my apartment, peeled off my scrubs, and jumped into the shower. My skin felt cool and sticky, and even though I was already a half hour late, the urge to wash away the hospital grime was irresistible. Under the warm water, amid the crackle of droplets ricocheting off the porcelain, I thought about Rajiv’s latest heroics. Just this week, he had inserted an intra-aortic balloon pump at the bedside into a patient with an acute myocardial infarction, then wheeled him to the cardiac catheterization lab, where he performed angioplasty and saved his life. What a contrast to my own incompetence! I had frozen on a simple abdominal paracentesis. I didn’t even have the presence of mind to pinch off the tubing when the fluid was spilling on the floor. Never rush a procedure! I had often told myself. But I couldn’t even follow my own rules.
Outside, around 8:30 p.m., Second Avenue was ringing like a sharply illuminated, multicolored carnival. Young people were stumbling drunkenly out of bars, smoking cigarettes. Rich kids in suits and evening dresses were stepping into a limo, perhaps on the way to a cotillion. Long, bare, sexy legs dangled off brownstone stoops. I had nearly forgotten there was a world outside the hospital, and it was neatly going on without me.
I thought about what I was going to say to Josh. Was I really going to quit internal medicine like Cynthia? I couldn’t help but think that all my work—the sacrifices, the debt, the suffering—would be wasted if I quit now. Yet the thoughts—the second thoughts—kept swirling in my head, like an obsession I could not block. What are you doing? You don’t belong here. The sacrifices I had made so far were minor compared to what would be required of me in the future—as a resident, or fellow, or attending physician. Medicine was supposed to lead me to a world of responsibility. What did it say about me that I had desired the challenge but couldn’t sustain the commitment?
I had struggled to feel interested, competent, but that state of mind had eluded me. Out of desperation, I had tried being more friendly with my supervising residents, hoping to find succor in fraternity, but they preferred to maintain the traditional resident-over-intern hierarchy. No matter what I did or how hard I tried, they always managed to find a weakness. If I thought I had picked up an unusual diagnosis, they would start pressing with questions that would force me to give up my hypothesis. If I thought I had composed a watertight case, they would find an oversight. “Where’s the EKG?” Rohit would demand in the middle of a presentation, and when I would pull it out, he’d look it over nonchalantly, hand it back to me, and say, “And the old one?” and then I’d have to stammer an excuse for why I had been unable to find it and feel deflated again. It was hard not to succumb to a culture where missing something gets magnified into personal failure. Even the language of medicine betrayed this attitude. The term failure was used to describe not only organs that had ceased to function, but also those that were merely insufficient.
Rohit admonished me for taking too long to write my progress notes. “How am I supposed to write my notes without labs?” I demanded. Test results weren’t posted in the computer until late morning.
“Just write ‘labs pending.’ ”
“Then how am I supposed to come up with a plan?”
“That’s not your job.”
“So what is my job?”
“To write a progress note.”
“Why am I writing the note?”
“To document that someone examined the patient.”
“That’s all?” I said angrily.
“That’s all,” he replied with brusque finality. “No one reads your notes.”
The truth was that I had already stopped writing long notes. I had stopped paying attention to social history, habits, the sorts of things that make a patient into a real person. I was writing down physical exam findings I beli
eved were present, even if I didn’t pick up on them myself. I didn’t want to make any more concessions. My progress notes belonged to me.
The hardest part was not having someone to commiserate with me. Sonia was in Washington, busy with her own clinical clerkships. When I told her I was living for the weekends, she thought I was referring to her near-weekly visits to Manhattan, which were nice, but what I really meant was that I was living for the days when I wasn’t in the hospital, with or without her. The few interns who complained openly only criticized the backbreaking schedule or an unhelpful resident or a rude attending. No one I spoke with, apart from Cynthia, criticized medicine itself or questioned their commitment to the profession. That seemingly was off-limits. My parents found it hard to sympathize, too. They (rightly) viewed the decision to go to medical school as my own choice and internship as a temporary phase, a sort of boot camp on the way to a better career. “Who told you to leave physics?” my father would say when he was fed up with my grievances. “You like to grumble. You like to blow on cold milk.” He had never had much patience for “flickering,” and nothing was going to change anyway, and wasn’t I just a bit too quick to whine and never see the bright side? “Going into medicine was the best thing that could have happened to you,” he often said. “You had landed into a ditch. Now at least you have some direction.”
When I got to the restaurant, a Hungarian holdover from a previous era, Josh was waiting for me outside. A tall, thin man with a bushy goatee, he always reminded me of a young Vladimir Lenin. He was doing a five-year joint “internal medicine-psychiatry” residency. A few weeks back, Rajiv had suggested that I talk with him about my career issues.
He shook my hand warmly and we went inside. We sat down at a table by a window overlooking a busy street. The waitress brought us bowls of cold cherry soup, and we started talking. Though I had intimated some of my concerns to him over the phone, I took this opportunity to more fully explain my disillusionment. He listened carefully but didn’t say much. This must be what psychiatrists call reflection, I thought. I felt like a patient sitting on the proverbial couch.
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