Gladstone grabbed his briefcase and Yankees baseball cap and headed out of the Hell’s Kitchen apartment to his office. A northbound train ride deposited him at a college in Westchester County, where he’d spent the entirety of his academic career, teaching accounting. After catching up on email, scanning the Yankees box score, and perhaps agonizing over the one thing that could possibly drive him to an early retirement—deriving new questions for his exams—he stood up, tucked in his shirt, and walked down the hall to an empty classroom.
As the students filed in for the 11:00 A.M. class, Gladstone methodically began to write on a chalkboard. Satisfied with his work, he pivoted to survey the room. He cleared his throat to call the chattering students to order. Then he felt a twinge in his right arm.
A moment later, he was on the floor.
Quick-thinking students dropped their backpacks and phones and lunged into action; an ambulance was called, and despite momentary doubts (“Do we really give our teacher mouth-to-mouth?”), a young man initiated CPR. After several awkward attempts at chest compressions, Gladstone regained consciousness as quickly as he had lost it. He stood up, backed away from the students, and asked everyone to return to their seats.
Within minutes, an ambulance arrived. After some haggling with the emergency medical technicians, Gladstone acknowledged that he was still having chest pain and agreed to be transported to the Columbia University Medical Center. As the ambulance took off, emergency room physicians and nurses received notification of Gladstone’s impending arrival. By the time his stretcher burst through the swinging doors of the ER, a cardiologist was waiting for him.
Nurses instantly slapped twelve EKG leads on his chest as the team transferred him from the ambulance stretcher to an emergency cot. Gladstone was surely unaware of the unusual EKG report the leads were generating just a few feet from his head. The report, which resembled a red-and-white checkered seismograph, was retrieved by the bedside cardiologist. It revealed broad, irregular waves that plateaued rather than forming sharp points, a finding known as tombstoning because of its grave prognostic implications. A large segment of his heart had suddenly and unexpectedly lost blood flow.
Seeing the tombstones, the cardiologist informed the emergency room staff that there was no time for X-rays or blood tests. Gladstone was rushed upstairs and into a dark room—the cardiac catheterization lab—where a team of interventional cardiologists went to work on his convulsing, failing heart. Gasping for air, Gladstone was quickly sedated and a large tube called a cardiac catheter was plunged into his groin, then snaked into his aorta. A doctor shot dye through the catheter and into his heart’s blood vessels, and the image was projected onto a flat-screen monitor for the team to see. There were a few silent nods as the image became clear. His left main coronary artery was blocked—an abnormality known as the widow maker’s lesion—and the cardiologists quickly went about opening it up by inflating and deflating a small balloon that rested on a guide wire at the end of the catheter.
Time to treatment is critical; restoration of blood flow in the obstructed artery is the key determinant of both short- and long-term outcomes for patients suffering heart attacks. Hospitals are now evaluated by the time that elapses from a patient’s arrival in the emergency room until the balloon has been inflated inside the clogged artery. This door-to-balloon time should be no more than ninety minutes according to the American Heart Association. For Carl Gladstone, it had been less than fifty.
After the senior interventional cardiologist deemed the procedure a success, a still-sedated Gladstone was placed on yet another stretcher and transported to the cardiac care unit, an eighteen-bed intensive care unit on the fifth floor of the hospital for cardiac patients requiring continuous monitoring. Dr. Gladstone would live to see another day, but he would not be able to appreciate the statistical misfortune of being placed in the care of a physician who had been practicing medicine for less than a week, a physician who could not yet interpret a subtle but potentially devastating clinical finding.
Me.
2
Seeing a new patient wheeled into the cardiac care unit, I leapt up from my seat.
“Easy,” said the physician next to me. He placed a hand on my shoulder and guided me back into my chair like a trainer gentling an unsteady colt. “Give the nurses a few minutes to do their thing.” He spoke softly and bore a surprising resemblance to a Charles in Charge–era Scott Baio, all black hair and good-natured smiles. His nose was perhaps slightly too small for his face, in contrast to mine, of which the reverse was true. “The nurses are going to do a lot more for him tonight than you and I are.”
I nodded and eased back into my seat. “Okay,” I said to Baio as I straightened my scrub top. I was anxious. I was excited. I’d just chugged a large iced coffee and could hardly sit still.
After my surgery experience with Axel and McCabe, I had moved on to Harvard’s rotations in neurology, psychiatry, radiology, internal medicine, pediatrics, and finally, obstetrics, where a young Jamaican woman let me deliver her child on my first day. She insisted on giving birth on her hands and knees, her back arched like that of a cat as the baby slowly emerged. An amused midwife later said that I had looked like a nervous quarterback, receiving a snap in slow motion.
As medical school graduation approached, choosing a specialty had proved to be difficult. Ultimately I had settled on internal medicine because it was the broadest field, the one that might allow me to feel like a jack-of-all-trades. But tonight was my debut in the big show, a thirty-hour shift taking care of critically ill patients and responding effectively to anyone who might roll through the door.
“We’ve got a few minutes,” Baio continued, “and I know this is your first night in the hospital. So let’s go over a few things.”
“Great!” I replied. Our orientation leaders, a peppy group of second-and third-year residents, had instructed us to exude a demented degree of enthusiasm at all times, which wasn’t difficult now that my blood was more caffeine than hemoglobin.
“Just relax,” he said, “and take a look around.”
Together we scanned the fluorescent room, an enclosed space the size of a tennis court containing critically ill patients and upwardly mobile Filipino nurses bustling between them. The perimeter, painted a regrettable shade of yellow, housed the patients in glass cubicles, while the center, where we were sitting, was mission control, filled with chairs, tables, and computers.
“It’s just you and me tonight,” Baio said, whipping his stethoscope back and forth around his neck. “And eighteen of the sickest patients in the hospital.”
Every night an intern and a second-year resident presided over the CCU. Tonight was our turn, as it would be every fourth night for the next month. All of the patients in the unit were on ventilators except one, a large Hispanic man who was riding a stationary bicycle and watching Judge Judy in his room. “These patients are receiving some of the most complex and sophisticated therapies in the world.” Baio reached for an antebellum bagel that was sitting on a platter nearby. “Patients get referred to the cardiac care unit when hope is lost or after something devastating happens. Balloon pumps, ventricular assist devices, transplanted hearts, you name it.”
Until a few days ago, I had never set foot in a cardiac care unit. Nothing about the setup looked terribly familiar. I continued to study the room, trying to decode the symphony of incessant beeps and alarms and wondering what each of them meant. It felt like I was sitting in the middle of a giant equation with infinite variables.
“These patients should all be dead,” Baio went on. “Almost every one of them is kept alive by an artificial method. And every day they’re going to try to die on us. But we’re going to keep them alive.” He paused for effect. “And that’s fucking cool.”
It was fucking cool. Back before my stint in the minors, I had studied molecular biophysics and briefly flirted with the idea of going to graduate school in that subject, using my degree to solve the structure of molecules
that were too small to be seen under a microscope. But the field lost me when a professor, a young crystallographer, introduced the importance of imaginary numbers in biophysics. Try as I might, I just couldn’t wrap my head around that quixotic concept. I wanted to translate science into something more concrete, more tactile, to seek a profession where I could touch and see and feel. So I changed course and pursued medicine. And thus far, it had seemed like a wise decision. Nothing about this moment with Baio seemed imaginary. Quite the contrary, it felt excessively real.
Baio wiped off the bagel crumbs on his scrubs and leaned in close to me, bringing scores of punctate pores on his nose into focus. “We have to work as a team. Everything is teamwork. So I need to know what you’re able to do. The more you can do, the more time I have to think about the patients. So rather than listing the shit you can’t do, tell me what you can do.”
My mind went blank. Or more accurately, I searched it and found it was blank. “Well…” I glanced at the sedated patient before us. He was on a ventilator and had a half dozen tubes in his neck, arms, and groin, almost all of which pulsed with medications I’d never heard of. As a medical student, I had been exposed to all sorts of patients. But all of those encounters had involved walking, talking, reasonably well-functioning individuals. Lying there, inert and blanched of all color, the patient before me seemed well beyond the reach of my limited powers. If he needed his appendix out or his face stitched together, I was his man. But intensive cardiac care? The learning curve in medicine was so unforgivably steep. What could I possibly do to assist him?
Finally Baio broke the silence. “All right,” he said, “I’ll start. Can you draw blood?”
“No.”
“Can you put in an IV?”
“No.”
“Can you put in a nasogastric tube?”
“I can try.”
“Ha. That’s a no. Ever done a paracentesis?”
“I’d love to learn.”
He smiled. “Did you actually go to medical school?”
Even I had to wonder. If Baio had been asking me to recite pages from a journal article on kidney chemistry or coagulation cascades, I could’ve put on quite a show. But I hadn’t learned much of the practical business of keeping people alive, skills like drawing blood or putting in a urinary catheter. Harvard hadn’t prioritized them. In fact I had been allowed to skip the CCU month of my med school training at Mass General so I could learn tropical medicine in Indonesia. Who had talked me into that?
“I graduated from Harvard earlier this month.”
“Oh, I know you went to Haaahvaahd,” Baio said with exaggerated fake reverence. “But do you know how to order medications?”
A bright spot. “Some!” I practically beamed.
“Do you know how to write a note?”
“Yes.” The moment I said it I realized just how paltry a contribution it would seem to him. Baio must have seen my face drop.
“That will actually be a big help,” he said. “Examine every patient and write a note on them for the chart. That will save me time. You need to be concise yet precise.”
I grabbed my small notebook and scribbled examine everyone/write notes.
“And listen,” he said while chewing on the stale bagel, “if I want a sandwich tonight, go to the cafeteria to get me a sandwich. And if I ask for a coffee when you return and give me that sandwich, do you know what you should do?”
“Head to Starbucks.”
“Correct.”
One of the nurses tapped me on the shoulder and asked me to order a blood thinner for a patient, but Baio cut her off. “Dr. McCarthy is not yet a functioning member of society,” he told her before putting in the order himself. I watched over his shoulder as he typed away.
“The nurses will know what medication the patient needs before you do,” Baio said.
“I’ve heard that.”
After finishing with the order, Baio turned and looked me up and down while grabbing another bagel. “You may be thinking, Why is this guy an asshole?”
I shook my head. “I’m not. I wasn’t.”
“Well, I’m not an asshole.” He returned to the computer. “I’m stuck in this enclosed unit for the next twenty-something hours. I can’t leave. The only way I can step outside of this unit is if a cardiac arrest is called over the intercom and I have to go bring someone back to life.”
“Got it.”
“And if that happens, you’re alone in here. It’s just you. All alone. And them,” he said, spinning his hand once around his head.
Jesus.
“Now, if you keep me well fed and caffeinated, I will be happy. And if I’m happy, I will feel inspired to teach you a thing or two about how to actually be a doctor.”
And that was the truth of it. Baio, one year my senior, would essentially be teaching me how to be a physician. It was hard to believe he had been an intern just last week; the man looked like a sample photo at Supercuts. At Columbia, as at most teaching hospitals, interns were paired with second-year residents to manage between twelve and eighteen patients, and were provided with varying levels of supervision by attending, board-certified physicians who met with us every morning at 7:30 to discuss our plans for the day. But the guts of the day, the minute-to-minute, I’d spend hooked to Baio.
“I want nothing more than to keep these patients alive,” I offered, perhaps a touch too earnestly.
He waved his hand at me. “Yeah, yeah. Just show up on time and bust your ass.” This I could do. It was a philosophy a former baseball coach of mine had sworn by. “Looking at you, I’m thinking two things,” Baio said. “One, you kinda look like someone I know. You both look like big ol’ meatballs.”
It was not the first time my admittedly WASP jock appearance had been skewered by a member of the healthcare community. In medical school, a female classmate named Heather had told me without prompting that I looked like my name was Chad and I attended prep school in Connecticut. This woman, who bore more than a passing resemblance to Anna Chlumsky from My Girl, would be surprised to learn that I’d spent the first decade of my life in Birmingham, Alabama, and the second in the indeterminate sprawl of a suburb outside of Orlando, Florida. I’d won her over after accepting a dare to ask a well-regarded diabetes researcher if he’d ever considered calling the condition “live-abetes” to give it a more positive spin. He was not amused. But she was; we’d started dating shortly thereafter and had come to New York together to join Columbia’s internal medicine training program. Heather was in her second year of residency, a year ahead of me. I wished she were here to whisper advice into my ear.
“What’s the other thing?” I asked Baio.
He smiled. “You look terrified.”
“I am.”
“Good. Go examine our new patient.”
3
“Still asleep,” the nurse said as I drew back the curtain and poked my head into one of the partitioned glass cubes on the unit’s perimeter. “He’s all yours.”
Behind the nurse, the room’s windows opened onto the Hudson River, but the view was obscured by a mountain of medical equipment. In the center of the room a male patient lay sedated in a large bed with guardrails that had been ergonomically designed to prevent bedsores. If too much pressure was applied to one side, sensors would activate and the mattress would inflate to balance the force. Behind the bed stood what appeared to be a stainless-steel coatrack upon which hung nine different plastic bags filled with clear fluid, each about the size of a breast implant. Above these, monitors slightly larger than an iPhone screen displayed the names of the medications in the bags and the rate at which they were being administered. If a bag became empty, an alarm would sound. If someone tampered with the rate, a whistle would blow. The whole setup looked like a cryptic art installation of sirens, machines, buttons, tubes, wires, and blinking lights. I had been given very clear instructions during orientation: aside from the patient, don’t touch anything in the room.
I took a deep breath
and approached the unconscious patient, a mustachioed man who looked a bit like Teddy Roosevelt. I grabbed a pair of gloves and prepared to examine this mysterious man who had been dropped into our laps by whatever fate had befallen him. I thought back to medical school and how I was taught to perform a physical examination.
“Start with the hands,” my instructor had advised. “It will put the patient at ease and will reveal how a person lives, how they eat, how they work, if they smoke…”
I put on the gloves and picked up the man’s limp right hand. It looked like a normal hand, pink and soft, and without dirt under the nails. No evidence of the small hemorrhages known as Janeway lesions or the lumps known as Osler’s nodes, named for physicians of a bygone era and each indicative of an infected heart valve. From the hand I moved up the arm, looking for track marks—signs of IV drug use, which could also predispose the heart to infection. From there I shifted my attention to his head, where I noted a small abrasion on his scalp. Throughout my examination, his chest gently oscillated up and down as the ventilator forced half a liter of air into his lungs every five seconds.
“Mr. Gladstone,” I said.
No response. I was almost relieved, but then I remembered another nugget of medical school wisdom. “You do not want to be the physician who assumed the patient was sleeping,” the instructor had told us, “when in fact he was dead.”
“Mr. Gladstone!” I shouted, too loud.
The patient let out a soft whimper. I moved to his eyes, lifting each lid up with my left hand while using my right to shine a penlight in; both pupils contracted as they should. I waved my finger toward his nose, assessing the ability to focus on a near object, a process called accommodation. His pupils, which easily reacted to light, could not accommodate. Before moving on to the nose, I noted that the left pupil appeared two millimeters smaller than the right.
As I jotted my findings in a small notepad, the ambient noise of the unit faded into the background. It was just the two of us alone in a vacuum. I raised my eyes from my notes and stared at the patient’s chest, watching it quietly heave with every manufactured breath. What was his heart doing under there? Was he recovering or dying? “You’re going to get through this,” I whispered, more to myself than to him. I wondered where Carl Gladstone was from and how he spent his days. Did he work? Did he have a family?
The Real Doctor Will See You Shortly Page 2