But why was it in his lungs? He said he had undergone a barium-swallowing test a few months earlier when doctors suspected he was aspirating food into his lungs. To rule out esophageal narrowing, a common cause of swallowing difficulties, he ingested barium and had X-rays. Some of it accidentally went down his lungs, and stayed there.
His breathing trouble, I suspected, was caused by intermittent aspiration of barium, food, or whatever else. I told him he should strictly regulate his diet, avoiding thin liquids that are easily aspirated. He would have to eat sitting up, and in small bites. But he said he had already found such a diet too burdensome.
When a person swallows, both voluntary and involuntary mechanisms ensure the food ends up in the stomach and not the lungs. First, the tongue pushes the chewed-up food to the back of the throat, where sensory receptors cause muscles in the pharynx to contract. As the muscles tighten, the epiglottis, a flap of cartilage, flexes protectively into place over the larynx, preventing food from entering the windpipe. The food is propelled into the esophagus, where contractions usher it down to the lower esophageal sphincter, which allows entry into the stomach.
Several things can disrupt this reflex. Cancer or blockages can narrow the opening so that food does not pass easily to the stomach but backs up in the pharynx, where it can be aspirated into the lungs. Muscular dystrophy and other muscle disorders can paralyze the pharyngeal muscles. Neurological dysfunction, too, from nerve diseases like polio and Lou Gehrig’s disease, or brain disorders like Alzheimer’s dementia or strokes, can disrupt the complex signaling.
The reason for Mr. Caner’s swallowing trouble wasn’t obvious. A brain scan revealed no strokes. There was no esophageal constriction. Nerve studies were normal. In the end, we were faced with a condition we could neither explain nor treat very effectively. The safest treatment was to stop him from eating and insert a feeding tube. It seemed the only surefire way to prevent him from aspirating and getting repeated pneumonia and developing respiratory failure. But he so loved to eat—it was one of the few remaining pleasures in his life. He even raved about the hospital food. I presented the option of a feeding tube to him. He said he wasn’t interested. It was too high a price to pay, even for a longer life.
One night a nurse called to tell me that Mr. Caner had choked on his dinner. When I saw him, his breathing was labored and he looked miserable. A chest X-ray showed a new “infiltrate” in the right lung, where the pea soup, sliding down his windpipe, had finally come to rest. I ordered IV antibiotics, supplemental oxygen, and a dose of steroids, and in a few hours his breathing and blood gas concentrations had improved. But I knew that it was only a matter of time before he aspirated again.
After discussing it on rounds the next morning, the team decided to make him NPO—“nil per os,” or nothing by mouth—and schedule the insertion of a feeding tube. I felt conflicted about this. It was our duty to protect him—perhaps even from himself—but there seemed something barbaric about not allowing him to eat. He had no family, few friends, and no hobbies. Some mornings his only complaint was not being able to eat fast enough. In medicine, I had learned, there is often a fine line between the barbaric and the compassionate.
The following night, a nurse paged me to tell me that Mr. Caner had aspirated again. Somehow, even though his diet orders had been rescinded, he had obtained a dinner tray, and while gulping whipped potatoes, he had become acutely short of breath. When I saw him he was wheezing again and his blood oxygen tension was dangerously low. His chest X-ray showed yet another infiltrate—it even looked like a smear of mashed potatoes—at the base of the right lung.
Security was tightened. Signs were posted reminding the staff of his NPO status. Food delivery people were given strict instructions not to enter the room. At first Mr. Caner appeared to take the restrictions in stride, but after a few days of emulsified feeds through a nasogastric tube, he became mute and distant. “Why are you here?” he’d say when we made rounds, curling up in a fetal posture, pulling the blanket up to his chin.
On the morning the feeding tube was supposed to be inserted, I snuck into his room. I brought a couple of small juice cups with me. “Drink this,” I urged, handing him a six-ounce carton. Without a word, he took a sip. “Try again,” I said, ready to slap the cup out of his hand if he started choking. This time he drained the carton. Giddy, I handed him a piece of bread. He chewed it to extinction without coughing. Elated, I offered him other foods, all swallowed successfully. His swallowing trouble had somehow abated! Perhaps he had willed himself to get better, and just in time, too; transporters were on the way to take him to the operating room. That morning I wrote in the chart that Mr. Caner had passed a swallowing evaluation. It was supposed to have been conducted by a trained occupational therapist, but I had just done it myself. I had risked his getting aspiration pneumonia—risked his life, really—out of pity, sentiment, but the outcome seemed to have been worth it. I wrote an order to start an aspiration-type diet. I called the gastroenterology team and canceled the feeding tube. No one objected. By then I think everyone realized that a feeding tube was going to kill him a lot faster than aspiration ever would.
THE DAYS IN THE ICU ROLLED ON. “We changed the artificial tears from twice a day to three times a day,” an intern quipped on rounds one morning, describing the treatment plan for a comatose patient. I perfected my technique for inserting central lines, even supervising the interns on a few. One afternoon I performed a lung tap with the ICU fellow. The patient was a frail elderly man with bad, cyst-ridden lungs. I knew what had happened as soon as I pulled back on the syringe and got nothing but air: a partial collapse of the lung. The patient had to have a tube inserted through his ribs to evacuate the air. I felt bad; I probably shouldn’t have done the tap. There was no reason for me to do it; the fellow could have done it much better than me. But I had to learn.
Most of the patients we had started the month with were gone. The paralyzed Russian man with the raccoon eyes was transferred to a rehabilitation facility. A young woman with severe brain damage developed sepsis and died. The plastic surgery fellow had tended to her bedsore, slicing away dead tissue like a butcher, deeper and deeper, until white bone was visible, but eventually it got infected, leaking bacteria into her bloodstream and causing her demise. Even the woman with terminal leukemia finally had her ventilator turned off. For weeks her family had maintained steady pressure on her estranged husband. “I respectfully request you to stop life support,” her father wrote in an appeal placed in the chart. “My daughter trusts her family to act in her behalf to do what she would want. She would not want her body maintained with life support. I am asking that she be allowed to go in peace.”
Her brother added: “We had an uncle that died in the hospital when we were young children. We talked about how he looked on that machine, and we said that we would never want to look like that. I’ve known my sister for many, many years. She did not like having to ask for assistance but was always there to assist. If she knew she was being supported this way, she would be extremely unhappy.”
In the end, her husband relented. “I now doubt that my wife will be able to sustain the meaningful life which she always lived,” he wrote in a note that was cosigned by a notary public. One afternoon, she was put on a morphine drip and her breathing tube was removed. At first her breaths were rapid and shallow, but they quickly turned deep and sonorous, a sign of imminent death. About fifteen minutes later, they stopped altogether.
But one patient lingered on. Curtis Williams had as torturous a medical history as any patient I had ever encountered: AIDS, syphilis, hepatitis C, pneumonia, infective endocarditis, kidney failure, and cirrhosis. He was also blind, deaf, and brain-damaged from a bout of meningitis. He had been hospitalized with a blood infection, likely from an infected dialysis catheter, and despite intravenous antibiotics, his condition had deteriorated. He eventually developed respiratory failure requiring the insertion of a tracheotomy tube in his throat. On rounds, when nurses c
hanged his bedsheets, the ravages of his many life-threatening diseases appeared in excruciating view. Mouth wide open in an impossibly wasted face, he looked like he was emitting one long, continuous wail.
He had a cardiac arrest on the one call day I happened to be fifteen minutes late to work. “Cardiac team, 5-South . . . Cardiac team, 5-South . . .” the intercom blared. Goddammit! I shouted in my head. What were the chances of a code occurring between seven and seven-fifteen? I raced down the corridor, spilling my coffee into a brown paper bag, which got warmer and wetter with every stride.
It was the moment I had been waiting for since the debacle of my first code in the ER that first day on call. I had practiced for it, committing the resuscitation protocol to memory. At night in bed I had envisioned various code situations: ventricular fibrillation, bradyasystolic arrest, pulseless electrical activity. I had mastered everything else as an ICU resident. I had gotten the hang of inserting Swan-Ganz catheters and interpreting hemodynamic data. I felt comfortable managing a ventilator. I could even intubate on occasion. I was doing a competent job supervising interns and medical students. But running a code was a skill that eluded me. It was a rite of passage, seemingly the last major hurdle in my education. I had to prove to myself that I could master it before moving on.
When I arrived in the room, the code team was in its usual positions. An intern was squeezing oxygen from a balloon into the tracheotomy tube, while another was performing chest compressions. “He needs a central line,” Paulie, a third-year resident, called out, and almost immediately a resident pulled open a triple-lumen catheter kit and started pouring brown antiseptic soap onto the groin. “Glad you could make it,” Paulie said when he saw me. He was a wise guy from the Bronx with an affected macho bravura. People called him a code monkey because he liked coming to codes, even when he wasn’t on the code team, which he wasn’t that morning.
I stared at the monitor. Tiny squiggles were meandering across the screen. Ventricular fibrillation. “How many shocks has he gotten?” I asked. “Just one,” someone said. Defibrillator pads were affixed to his chest, charged up and ready to go. “All clear,” an intern announced. Everyone took a step backward, she pressed a red button and Williams’s whole body hiccupped. I looked at the monitor. Still fibrillation. “Push a round of epi and lidocaine,” I said to no one in particular.
“God, are we really going to do this?” a nurse said, shaking her head in disgust. I did not respond. This was my code, and I had something to prove.
The rhythm briefly normalized, but after a minute it degenerated once again into ventricular fibrillation. “All right,” I called out. “Epi, lido, amiodarone. Epi first.”
“I think I blew the line,” someone said, holding a giant syringe of sodium bicarbonate.
“So put in another one,” I commanded, surprised at how easy it was to issue the order.
Then Paulie spoke up. “You, Manetta”—she was still doing chest compressions—“tell us when you need a break, and you”—he pointed to an intern who was standing and watching—“take over. You”—he pointed to another intern—“continue bagging. You finish getting that line in. What’s taking so long? You over there, help him. I want everyone who doesn’t need to be here to leave,” he announced like a drill sergeant. “And keep it down. I can’t hear myself think.” His tone was crisp and forceful. The coup was smooth and bloodless. I did not resist it.
Paulie ordered injections of calcium gluconate, sodium bicarbonate, and epinephrine. The EKG continued to show disorganized electrical activity. “He’s still fibbing,” Paulie bellowed. “Charge the machine.” Williams’s whole body jumped as electrical current discharged into his chest.
Someone said he thought he felt a pulse but he couldn’t be sure. “Check the blood pressure,” Paulie shouted. An intern wrapped a cuff around the arm and placed the bell of a stethoscope at the crook of the arm. “I’m not getting it,” he said nervously.
“Get me a Doppler probe,” Paulie cried. “We need a blood pressure.” He waited for about three seconds. “Hello! I need a Doppler probe in here!”
“We need to run and get it,” a nurse said, looking annoyed. Paulie made a face. “Is the bicarb in? Hello! Is it in?”
The person who was pushing medications into the central line said, “I just pushed it. We need a flush.”
“You heard the man, get him a flush!” Paulie shouted. “Watch the needles, guys. There are too many hands in the field.” He grabbed an errant needle and plunged it into the mattress. It was the sort of impetuous, decisive behavior I seemed incapable of. A thought passed through my mind like an evanescent gust: Will this mattress be reused?
More drugs went in as I silently looked on. I resented Paulie for usurping my authority, but at the same time I felt relieved. At one point Williams regained a weak pulse, but it quickly disappeared. “Want another round of epinephrine and atropine?” I asked softly. Paulie looked at me askance. He didn’t want suggestions; he wanted people to do as they were told. With fluid running into several IVs, he ordered escalating doses of epinephrine. Soon people started murmuring, “How long has it been? When did we start?”
“Hold compressions,” I finally said, staring at the monitor. Wide electrical complexes raced across the screen. “Ventricular tachycardia,” I said. “Get the paddles ready.”
“That’s not ventricular tachycardia,” Paulie cried, squinting at the screen. “That’s electromechanical dissociation!”
The squiggles looked like a sine wave with plenty of noise. “It’s VT,” I murmured.
“No it’s not,” Paulie shouted. “It’s EMD. That is not a shockable rhythm!”
An intern was standing tiptoe on a step stool, waiting for the order to shock or not. Doubt started creeping into my mind. What was EMD? How were you supposed to distinguish it from slow VT? How was it treated? Atropine? Epinephrine? The confidence was draining out of me quickly. I found myself wondering what people in the room were thinking. What kind of impression was I making in my second attempt as code leader?
Then I turned to Paulie. “Who’s running this code?” I snapped. I turned back to the intern. “Give him the shock.” She hesitated. “Give the shock,” I insisted. An alarm sounded, and Williams’s body jumped up and down as the defibrillator discharged into his chest. On the monitor, the blips narrowed. Sinus tachycardia. A picket fence. A normal rhythm.
A resident had his hand wedged into the groin. “Pulse . . . pulse . . . pulse,” he yelled out. A trembling relief washed over me. This time, the pulse did not go away.
Before the code team dispersed, Paulie went on a rant. “This was the worst code I’ve ever seen,” he bellowed. “You guys are shocking EMD! You’re not doing proper chest compressions.” He put one hand over the other and pumped up and down to demonstrate how it should be done. “This poor guy will be lucky if he doesn’t lose the two neurons he has left.” I glared at him but did not say anything. Williams was alive, after all. I had made the right call, and I had done my job.
After ordering an intern to ventilate Williams with an oxygen bag, I went out to the nurses’ station to call Williams’s brother. I had never met him. In fact, I had never even spoken with him.
When he answered the phone, I told him that his brother had had another cardiac arrest. I explained that the high potassium level in his blood, a consequence of kidney failure, had probably been the cause. “We revived him but he is obviously in critical condition,” I said. “Will you be coming to the hospital to see him?”
“I can’t come today,” he replied.
“Well, when you do come in, would you please ask a nurse to page me? I’d like to talk with you about your brother’s long-term plan.”
“What plan?” he asked suspiciously.
“I’d like to talk face-to-face, if possible.”
“Let’s talk now.”
“All right, if you prefer—” I hesitated. “I just wanted to know . . . Has anyone talked to you about DNR?” I knew the subject
had been brought up, but I couldn’t think of a better way to get the conversation started.
“We’re not talking about that again!” he said fiercely.
“I’m sorry, sir, but we need to talk about it because your brother just had a cardiac arrest.”
“I told the doctors before; I want everything done to keep him alive.”
“That’s fine; we can do that, but—” I decided to try a line I had heard Dr. Morales himself once use. “Some people think that when the heart stops beating, it’s like the person is already dead. I’m not saying we won’t treat him. I’m just talking about not trying to revive him again if his heart were to stop or if—”
“Who do you think you’re talking to?” he interrupted angrily. “You’re trying to bullshit a bullshitter.”
“I’m not trying to bullshit you,” I replied. “Your brother is terminally ill. Continuing to resuscitate him won’t prevent his death. It’s just torturing him for no good purpose.”
“You guys have been trying to make me kill my brother for years. Curtis wanted to live for as long as possible. ‘Don’t let me die,’ he told me. Now how am I supposed to go against his wishes?”
“Do you think he’d still feel that way if he could express himself now?”
“It doesn’t matter,” he snapped. “It’s what he told me. Look how many times you guys thought he was gone and then he turned the corner. He’ll surprise you. I’ll count him out when they pull the sheet over his head.”
“Sir—”
“Put him on a heart-lung machine if you have to. I don’t want his blood on my hands.” Then he hung up.
That afternoon, I found Dr. Morales at the nurses’ station writing notes. I told him about my conversation with Williams’s brother. I asked him if we were going to have to resuscitate Williams again in the event of another cardiac arrest. I did not want to be involved in another code on him.
“He’s Dr. Batton’s patient,” Morales said defensively. “She should have made him DNR years ago. Now we’re at the mercy of that nut brother.”
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