ARREST STAT, SIX GARDEN SOUTH! the intercom blared overhead. ARREST STAT, SIX GARDEN SOUTH!
I turned away from the patient to see Baio sprinting past the room, grinning, a man utterly in his element. “It’s just you, bud!” he said as he pushed the unit doors open. “Hold down the fort!”
And with that, I was alone in the unit, the doors swinging gently on their springed hinges in Baio’s wake. I closed my eyes and cursed under my breath. Quickly completing my examination of Carl Gladstone, I typed up a note to reflect my findings. With every sentence, I looked around the room, certain that someone’s heart had stopped. I was alone, and filled with an electrifying sense of nowness.
Baio returned after twenty agonizingly long minutes.
“How’d it go?” I asked.
“Just saved a life,” he said, smiling. His jockish pride reminded me of former teammates and my former life. “How is our new patient?”
“Wow, that’s great. What happened?”
“Priorities, my friend. Tell me about our new patient first.”
“Sure, sure,” I answered, pulling up my notes. “Fifty-eight-year-old guy had a heart attack. Kinda random. Just went to work, teaching a class, and dropped to the floor.”
“Not random,” Baio said flatly.
I paused, recalling our conversation on rounds a day earlier. Baio had mentioned that cardiovascular functions are influenced by circadian rhythms, and as a result, heart attacks are much more common in the morning hours.
“Right.”
“Go on,” Baio said. “You have my undivided attention.”
“They took him to the cath lab and fixed him.”
His eyes locked onto mine and he wrinkled his brow. “And that’s it?”
“He’s a little sleepy right now, but yeah, that’s it.”
“Anything else you’d like to tell me?”
“I think that’s the big picture. On exam he looks pretty good. Still sedated but stable. I’m sure there’s more detail in here,” I said, reaching for his chart.
Baio grabbed the cranberry chart before I could and shook his head in frustration. “You have told me almost no useful information.”
I scratched my chin, avoiding eye contact. I hated to disappoint this man. I wanted to be like him. I wanted to be him. “One pupil is smaller than the other,” I offered.
Baio looked up. “Well, that is interesting. What do you make of it? What’s your differential diagnosis?” he asked, referring to the systematic process of elimination in which a clinician considers an array of maladies before arriving at a diagnosis. This was how I had been taught to approach any symptom or clinical finding in medical school. The cause of something simple—a cough, for example—could ultimately be so obscure that we were encouraged to initially think as broadly as possible. This expansive list, which was quickly pared down, was known as the differential diagnosis. Our professors at Harvard had routinely amazed us with the inconceivably long lists they could generate.
I had been pleased with myself for noting the unequal pupils but hadn’t really taken the next step and considered the cause. I was the dial-up to Baio’s broadband, the MySpace to his Twitter. I thought back to a mnemonic I’d been taught in medical school to generate a differential diagnosis: VINDICATE.
V—Vascular
“He could be having a stroke,” I said. “Maybe there’s a vascular process in his brain causing one pupil to constrict.”
I—Infection
“He could have an infection of the pupil—something like herpes of the eyeball.”
N—Neoplasm
“He could have a neoplastic process—a tumor of the eye or brain cancer.”
D—Drugs
“He received a number of painkillers in the ambulance and a sedative before the catheterization. I know narcotics can affect the pupils.”
Baio touched his index finger to my chest, almost sweetly. “I’m impressed.”
“Thank you,” I said, fighting back a smile.
“Now, it’s great to rattle off a bunch of possible causes, but what are we actually putting our money on?”
Medical school was for generating a list, I thought. But being a doctor means knowing how to narrow that list. “Well,” I said as my eyes quickly moved back and forth, “I doubt it’s cancer, might be a stroke. Less likely infection. It’s probably the drugs.”
“Sounds reasonable,” Baio said, closing the chart. “Listen, we need to work on your presentations. I need to know about these patients in far greater detail than you just gave me.”
“Okay.” I reached for my notebook and quickly jotted down details!
“But first let me tell you about that cardiac arrest.”
“Yeah, that’s right. What happened?”
“Whenever I run to an arrest, I whisper ‘ABC, ABC’ to remind myself that it’s got to start with airway, breathing, circulation.”
I scribbled ABC.
“Don’t write this down, just listen,” he said. “So I get into the room and this dude isn’t moving. His eyes are open but nobody’s home. Not responding to anything. So imagine you’re me. What do you do?”
The thought paralyzed me. “I have no idea.”
“That is not the right answer, Dr. McCarthy. Think.”
“Let’s see…”
“But remember, in real time you don’t have the luxury of thinking about it.”
“It has to be instinctual,” I said awkwardly.
“What did you say to yourself while sprinting?”
“ABC…” A hint of a smile from Baio. “So,” I went on. “A…airway. I would assess the airway.”
“Bingo.”
“Did the patient have an open airway?”
“I checked his airway and it was blocked. So we intubated him on the spot.”
“Nice.”
“And when the tube went into his throat, all this shit came out.”
Baio removed his white coat, displaying innumerable smudges on his scrub top.
“What do you think it was?” I asked.
“Oh, it was shit. Actual feces.”
I put my hand over my mouth. Holding on to his undershirt with his right hand, Baio pulled the scrub top off with his left and bundled it into a ball.
“But how could—”
Before I could finish the thought, the scrub top hit me in the face.
“We’ll talk more about it later,” he said, as he sauntered away to examine Carl Gladstone. “Go introduce yourself to the rest of our guests.”
4
Looking for a patient with whom I could interact, I elected to begin with the only one who was ambulatory: the large man on the stationary bike.
“Hello,” I said, gently tapping on the glass divider separating the patient’s room from the rest of the unit. He stopped pedaling and took off his headphones. A Hispanic man in his early forties, he had a shaved head and a room littered with books, magazines, and scraps of handwritten notes. He was stocky, barrel-chested, and broad-shouldered like an ex-linebacker, and by the looks of things he had been in the unit for quite some time.
“Hi,” I continued as I entered the room, “I’m…”
“One of the new guys.”
“Yes.”
“Benny Santos,” he said, extending a hand. “It’s a pleasure.” He spoke softly and deliberately and had a surprisingly smooth hand. Unlike the other patients, he was not in a hospital gown. Instead, he wore a New York Giants T-shirt and jeans.
“I’m one of the new physicians here,” I said, avoiding the word intern.
“Welcome.”
Catching sight of a notebook by his bed, I paused and tried to figure out how to ask this rather large, well-appearing man why he was in a critical care unit.
“Why am I here?…Is that what you’re wondering?” he said, flashing a smile. His voice was so soft that I found myself leaning in close to catch his words.
“It is.”
“Need a new ticker,” he said, pointing at hi
s chest.
Outside his room, we overheard a senior physician giving an evening tour to a group of medical students. “Many of the patients in this unit,” the guide said, “are among the more than five million Americans living with heart failure—a condition in which the heart is unable to pump sufficient blood to the body.”
“That’s me,” Benny said cheerfully, “star attraction.”
“Failing to deliver blood to starving organs,” the guide continued, “fluid gradually backs up into the lungs as the kidneys and liver inevitably fail. At that point, no medication or dietary modification can save them. It’s transplant or bust.”
“Been here for several months,” Benny said softly, “just waiting.”
I thought of how I’d spent the past few weeks—graduation parties, move to Manhattan, orientation cocktails. “That’s tough,” I offered. On the other hand, his relatively stable condition meant one less patient for me to worry about.
“Just trying to sneak up the UNOS list,” he said. On rounds as a medical student I had been introduced to the United Network for Organ Sharing and its sophisticated algorithm for allocating organs; it varied significantly by city, but the median wait time for a new heart was expected to be just over 150 days. Benny, however, was on his way to becoming an unfortunate outlier.
“What are you listening to?” I asked. This was a mistake. I wanted to make a connection, but discussing music was a huge weak spot for me. In college I’d once been laughed out of a dorm room for saying that I felt like the Goo Goo Dolls were playing the sound track to my life.
“A little Babyface,” he said. “You a fan?”
“I can’t say that I am.”
“Okay, okay. That’s cool.”
“Judge Judy, on the other hand,” I added, motioning toward the television, “huge fan.”
He smiled, and we looked up at the television. “Yeah, she’s great. Very wise.”
My teeth grinding came to a halt and I took a seat on the edge of his bed. “They call her the White Oprah,” I said.
Benny wrinkled his brow as Judy banged her gavel. “Who calls her that?”
“Didn’t someone call her that?”
“I don’t think so,” he said. “Definitely not.”
Benny looked out of the window, onto the Henry Hudson Parkway, where traffic was backed up for miles. “I really appreciate you guys coming in here, checking on me periodically, shooting the shit and whatnot.”
“Of course.”
“You know, one of your colleagues used to come in here, spent fifteen or twenty minutes with me every single day. Talk about Scripture, talk about music, anything.”
“That’s great.”
“One day we were both here on a holiday. I was down, and she could tell I wasn’t my normal, charming self. So we’re looking out the window just like this and she says, you know, more traffic accidents happen on holidays. Drunk drivers, more people on the roads, stuff like that.”
I nodded.
“And she smiles and says, ‘Every drunk driver, every family coming back from the beach…those could be organ donors.’ Every crash brings me closer to a transplant.”
He turned from the window and looked at me.
I wasn’t sure what reaction was called for here. “I suppose that’s one way of looking at it,” I responded.
He frowned. “That’s a horrible way of looking at it!”
“Yes, that is a horrible way of looking at it.”
I blushed, embarrassed by the exchange.
“She meant well,” he said, glancing up with a smile, “but no one would mistake your colleague for White Oprah.”
5
“New patient looks okay,” Baio said of Gladstone a few minutes later as he grabbed two chairs and led me to the back of the unit. “His wife is coming in shortly. Needs to wake up a bit, so I stopped the sedatives.”
“Got it, I’ll put in the order.”
“I already took care of it. Okay, let’s play a game.”
Our last conversation had ended with a shit-stained scrub top landing in my face; I shuddered to think how a “game” could turn out.
“A year from now, you’re going to be in charge of running a cardiac arrest. Dozens of doctors, crammed in a room, looking at you while a lifeless patient lies in the middle. This year you get off easy—you just do chest compressions or draw blood or put in an IV. But next year you’re the conductor.”
“Fantastic,” I deadpanned. Running a cardiac arrest was not a scenario that had been covered much in medical school. And perhaps with good reason—the mere thought of it would have given many of us nightmares. We had been more focused on learning and perfecting the basics of listening to patients and examining them.
“I’m going to throw scenarios at you and I want you to tell me how you’d handle them. Ready?”
I laughed. “I think we both know the answer is no. But…yes.”
“Okay, it’s six A.M., you show up for work and start checking on your patients. You enter a room and the patient is unresponsive. Twenty-four-year-old black girl. Go.”
He pointed at me, and I slowly exhaled. Beeping ventilators and vital signs monitors were momentarily ignored. “Unresponsive?”
“Unconscious, unresponsive. Whatever. She doesn’t move when you shake her. Go.”
“I suppose…I suppose I’d start with the ABCs.”
“Fine. She has a patent airway, but she’s not breathing and her heart’s not beating.”
I smiled, trying to buy time. “We should fix that.” My mind was in overdrive, desperately trying to draw on the events of the one cardiac arrest I’d witnessed at Massachusetts General.
“Indeed.”
“I would intubate her,” I said, “and start chest compressions.”
“Good, and can you do both of those things?”
“No. Not at the same time.”
“So…” he said, jutting his chin forward.
“I’d get help. I’d yell for help.”
“Excellent!” Baio patted my arm. “In this case, your inclination to react like a small child is correct. Everything in medicine is based around teamwork. Never forget that. So, what else?”
“I’m not sure.”
“You’ve started CPR, you’re giving her oxygen. But why would a young girl’s heart stop?” His green eyes narrowed slightly, focusing on me intently.
It shouldn’t, I thought. “Congenital something or other?” I offered.
“I said she was a twenty-something black girl. Does that help?”
“Maybe she overdosed?”
“Easy”—he laughed, leaning away from me—“not all black kids are on drugs.”
I was aghast. “No, no, no, I just—”
“I’m kidding—drugs are a reasonable thought. What would you do about it?”
“I could give something maybe to reverse the drugs.”
“Yes. Narcan. It’s incredible. Turns someone from a stuporous zombie to agitated and annoying in seconds. What if I told you she had a fistula on her arm?”
“She could have a kidney disease.”
“Go on…”
“Maybe she missed dialysis or maybe her electrolytes are off. I’d ask someone to draw labs. Maybe the potassium…”
He shook his head. “The woman’s heart isn’t beating. Do you have any idea how long it would take our lab to process her blood and tell us about the potassium?”
“No.”
“She’d be in the morgue before you had your answer.”
I rubbed my forehead. “Shit.” I had reached for the textbook again and the patient was dead. So when was I supposed to reach for the textbook? How could I know what to do if I didn’t know what to do?
“You have to be one step ahead,” said Baio. “Treat empirically. Assume her potassium is off and treat it. You have to be comfortable flying blind. And please stop grinding your teeth.”
“I’m trying.”
“Let’s do another. You enter the room, and t
his time it’s a banker that’s unresponsive.”
“What kind of banker?”
“I don’t know,” he said, waving his hand, “a banker. Shuffles paper around, makes a lot of money. A banker.”
“Let’s see,” I said, looking at the ceiling, “could be…cocaine?”
“Everyone’s on drugs with you,” he said, smiling, as he reached for a small carton of apple juice. “I like it. Keep going.”
As he took a large sip, a nurse sprinted in our direction. Her heavy footfall broke my concentration, and we both looked up as she reached us.
“It’s Ms. Franklin!” she said.
Baio stood up and reactively tugged on my sleeve. “Let’s do this,” he said, beaming, and started to sprint down the hallway. I followed him as quickly as I could. As we ran, he said over his shoulder, “Do everything I say. Everything.”
We quickly arrived at the bedside of an elderly woman on a ventilator. She was so frail and thin that you could make out the individual muscle fibers in her neck.
“What happened?” Baio asked a nurse standing at the bedside. Before she could answer, Baio turned to me. “Matt, disconnect her from the ventilator.”
A team of nurses went to work on the woman. “She just flatlined,” one of them said.
I looked at the breathing machine and my stomach turned. I suddenly had an overwhelming urge to move my bowels. Disconnecting a patient from a ventilator was a scenario I had only read about in medical ethics textbooks. Terri Schiavo came to mind.
“Disconnect,” Baio repeated calmly while reaching a hand under her gown and onto her groin, searching for a pulse.
I tugged the breathing tube away from the ventilator, but nothing happened. I tried again but still nothing. A nurse half my size lunged in front of me and pulled the breathing tube off of the ventilator in one quick motion as Baio rattled off a series of questions while assigning each nurse a specific role in the resuscitation. Someone began squeezing a bag of oxygen into her throat as I rapidly glanced back and forth at the flurry of activity, looking for something to do. Baio briefly closed his eyes while again feeling under the gown. “No pulse. Matt, start chest compressions.”
The Real Doctor Will See You Shortly Page 3