I get up quietly and tiptoe to the bathroom. In the mirror I notice I’ve developed a touch of gray. A bracing splash, some bloody nicks, a suitable tie, and I am outside. It is a bright day, nearly cloudless, the skyline marred only by the steam drizzling out of a tower in the distance. I pull out of my building and drive north, past empty playgrounds and cracked brownstones and apartment complexes stacked like Lego blocks. Street sweepers are out in force, ravenously whirling over the grime and debris. I turn onto the FDR Drive. A few joggers are out on that lonely stretch of waterfront. A couple of miles on, I enter the blue-green expanse of the Triborough Bridge. Pigeons flutter off the ramparts. Across the shimmering East River, skyscrapers in Midtown are arrayed like an irregular bed of nails. I press on the gas pedal. The brilliant day is pulling me forward.
I was asked during job interviews how I planned to create a heart failure program. I replied that if you provided good care and vigilant monitoring and were responsive to patients’ needs, community physicians would refer their patients. I had no idea if this was actually true; but it sounded good, and I got the job. I promised to decrease lengths of stay, improve hospital performance measures, improve the discharge process, decrease readmissions, install a computerized database, enroll patients in clinical trials, write emergency room protocols, and start an intravenous infusion clinic. Eventually I wanted to hire a nurse practitioner, a dietitian, a social worker, and a physical therapist. But I had accomplished none of these things as I drove to work that July morning.
It was a few minutes past seven-thirty when I arrived at the hospital, and I was late for morning report. I pulled into the attending physicians’ lot and parked between two cars whose license plates read “BEAN DOC” and “GAS MD.” At the sliding glass doors leading into the lobby, two patients in teal hospital gowns were leaning on their IV poles, sucking hungrily on cigarettes. I skipped down a concrete stairwell to the basement. The corridors were deserted, save for a tardy first-year fellow racing ahead of me.
When I walked into the conference room, a fellow was presenting a case from overnight. About a dozen fellows and a half-dozen faculty members were there. The fellows rotated each month through the various cardiac subspecialties: electrophysiology (which focuses on arrhythmias, or heart rhythm disturbances), echocardiography (cardiac ultrasound), nuclear stress testing (which uses radioactive tracers to noninvasively detect coronary disease in hearts under stress from exercise or certain drugs), cardiac catheterization (Rajiv’s specialty), heart failure, the general consultative service, and the cardiac care unit (where the most critically ill patients of any subspecialty usually ended up). As faculty members we were responsible for teaching the fellows: scrubbing in with them on procedures, going on rounds with them, and instructing them over discussions at morning report or noon seminar. In the conference room, Rajiv and two of his interventional colleagues were sitting together, arms folded, legs crossed, in purple scrubs, like some sort of academic tribunal. My brother looked at me sharply, glanced at a phantom wristwatch, and winked. I quietly took a seat in the back.
The fellow was trying to explain his management of a critically ill patient the previous night. “The patient’s pulmonary artery saturation was in the mid-forties, so I ended up putting him on some dobutamine and gave him a little fluid back,” the fellow said. “He started putting out some urine, and his blood pressure went up. Over the next twelve hours, his oxygenation improved dramatically.”
Dr. Morrison, one of the interventional cardiologists, demanded to know why the fellow had given the patient intravenous fluid.
“At that point his central venous pressure was two,” the fellow said defensively, describing a state of dehydration. “His pulmonary artery diastolic pressure was six, and his wedge pressure was like eight.”
“And you’re sure the transducer was zeroed and level?” Morrison pressed him. “We see this a lot with the residents. They look up at the monitor and quote a pressure, but it’s just garbage.”
The fellow hesitated. “When we first put in the catheter, the wedge pressure was in the thirties—”
“Well, see, that’s what I’m saying,” Morrison interjected, as if the fellow had just made his point. “This guy wasn’t dehydrated! He was in florid heart failure. This is a textbook case of acute heart failure, from the frothy sputum to the missed myocardial infarction.”
“Anyway, good case,” the chief fellow said, trying to move things along.
“What this patient really needs is a doctor,” Dr. Morrison added caustically.
“As opposed to a plumber like us?” Rajiv shot back, coming to the fellow’s defense.
“Exactly,” Morrison replied, laughing. (Interventional cardiologists who relieve coronary obstructions with stents are often disparagingly referred to as plumbers.)
Looking around the room, I reminded myself how lucky I was to be working at a teaching hospital where residents and fellows would be making rounds on my patients and assisting me on cases. LIJ is one of the largest teaching facilities on Long Island, sitting on fifty acres on the Queens–Long Island border, housing nearly eight hundred beds, and employing seven hundred physicians on its full-time faculty. The evidence shows that patients treated for several common medical disorders, including heart failure, heart attack, and stroke, fare better at major teaching hospitals and have better overall survival. One reason may simply be redundancy: residents and fellows may be annoying when you’re reciting the details of your fainting episode for the third time in the middle of the night—“So tell me, did you pass out before or after you hit the floor?”—but so many pairs of eyes on each patient mean things don’t get overlooked. Eighty percent of medical diagnoses can probably be made on the basis of a patient’s history, and the more people asking, the more likely doctors are to get it right. Another factor is the sheer number of patients treated at the average teaching hospital. Patient mortality tends to drop as doctors get more experience. Would you rather have angioplasty performed by a cardiologist who does two hundred a year—or twenty?
Though I’d been hired to start a heart failure program, I’d been informed that for the first year or so I’d also be assuming frequent responsibility for the cardiac care unit (CCU), where I’d be treating not only patients with heart failure but also those with other, more general cardiac problems (myocardial infarctions, arrhythmias, etc.) to help me build up my practice. So after morning report, I headed up to the CCU, where I was substituting for Dr. Vaccaro, the director, who was on vacation that week. Fifty years ago there were only about a hundred “special care” coronary units in the United States. Since then there has been a veritable hailstorm of cardiac advances, including implantable pacemakers, prosthetic heart valves, coronary bypass surgery, and heart transplantation. Today most hospitals with more than a hundred beds have a cardiac care unit.
Chiming alarms reminiscent of a video arcade greeted me when I arrived. The CCU was a refurbished unit with gleaming tile and a distinctly modern feel. The faintly pleasant odors of disinfectant and talcum powder wafted through the corridors. Nurses were weaving in and out of rooms, attending to their patients. Families were loitering in the hallways or sitting at bedsides, keeping vigil. At the front desk an old woman gruffly answered the phone. “CCU, Eva, may I help?”
As I joined the team for rounds that morning, the bleary-eyed postcall fellow was signing out to Ethan, the CCU day fellow. Ethan was a short Jewish guy with glasses that were too big for his face, spiky gelled hair, and a geeky hyperexcitability. Like most fellows, he was eager to make a good impression. He was constantly toeing that fine line between being assertive and kissing ass.
The postcall fellow was telling Ethan about a cardiac arrest from the previous night. “You’re doing things, and you’re doing them because you’ve got to do them, but you’re thinking, Why the hell am I doing this?” he said, shaking his head in resignation.
“Sometimes it’s out of your hands,” Ethan said sympathetically.
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“It wouldn’t have mattered,” Ethan interrupted. “It was a finger in the dike. That patient was destined to die, and that’s all there is to it.”
The postcall fellow nodded appreciatively. After he departed, Ethan turned to me and said matter-of-factly, “We got lucky, Dr. Jauhar. One transfer patient didn’t show up, one patient the private attending decided he didn’t want the consult, and one patient died.”
The team of doctors in the CCU consisted of Ethan, three residents, and three interns, including Paul, a nerdy East Asian who was supposed to quickly present overnight admissions and leave the hospital by 10:00 a.m. to meet the latest work-hour regulations. As an intern I would never have been allowed to leave the hospital before completing all my responsibilities for the day, but times had changed. All week I’d constantly been checking my team’s work, pushing them to do what they were supposed to be doing, nothing extra. Just getting the trainees to do what was expected of them was hard enough. Everyone was casually dressed—oxford shirts but no ties—not what I remembered from my own residency. Huddled around the rolling chart rack in the hallway, we stopped outside the first room.
“Jerry Simons is a forty-nine-year-old man with a history of drug abuse who was admitted to another hospital on Friday after doing cocaine,” Paul narrated. He chuckled before continuing. “He was sitting in his kitchen having dinner when he broke into a sweat. His wife noticed his shirt was drenched, so she got him a towel, and then he changed his clothes, but they got drenched, too—”
“You can just say he was diaphoretic,” I interrupted.
Paul nodded. “He started having chest pain. He described it as a burning, or rather squeezing, pressure, not really sharp, though it had a pins-and-needle—”
“Just show me the electrocardiogram,” I said, trying to hurry him along.
Paul pulled it out of his coat pocket. An electrocardiogram, or EKG, measures the electrical signals coming from the heart. On this one were ST segment elevations, a serious abnormality, indicating an acute attack, or infarction, of the inferior wall of the heart.
“Do you see a Wellens sign?” Ethan asked me, referring to an esoteric EKG finding. I shook my head. The residents stared blankly.
Paul continued, taking no notice of Ethan’s ass-kissing: “So in the ER he reported shortness of breath and light-headedness. He had ST elevations but didn’t spill any cardiac enzymes,” the latter indicating irreversible damage to the heart muscle.
“All right, let’s go see him,” I announced.
Before we walked into the room, Paul quickly added: “By the way, he doesn’t want to talk about his drug use. He already told me he wasn’t going to stop.”
Mr. Simons appeared to be sleeping when we got to the bedside. He was a thin black man with curly gray hair and a grizzled face. The sheets were off, and his gown was pulled up. There was a bloody patch on his right groin where a cardiac catheter had been inserted. He opened his eyes slowly when I started to speak. I introduced the team and asked him how he was feeling.
“I just swallowed some pills,” he said flatly.
“Oh, did you swallow them the wrong way?” I asked.
He gazed indifferently at the roomful of doctors. “Before you came in, the nurse gave me my pills, so when you said how you doing, I said I swallowed my pills.” He threw a blanket over his exposed leg. “That’s all.”
I applied my stethoscope to his chest. His heart was racing, perhaps a sign of drug withdrawal. I explained to him that we would normally start him on a beta-blocker to slow down the rate, but the medication had a potentially harmful interaction with cocaine. Was he planning on using again?
“All you cats love throwing that word ‘cocaine’ around,” he said, his voice rising. “I don’t want to hear that word again.”
“Look, I don’t know whether you regularly use drugs or not,” I said, my jaw tightening. “I just want to know about the future, so I can decide how best to treat you.” Moral reform was not my objective. Getting him on the right medications was.
“You don’t know nothing about me,” he said angrily.
“I know that cocaine is addictive.”
“I’m not addicted!”
“Then why don’t you quit?”
“I did! Yesterday.”
I told him he was going to have to follow up as an outpatient and undergo at least two negative drug screens before I would prescribe him a beta-blocker. “You have to do something,” I lectured him. “You’re on the path to self-destruction.”
He stared at me tensely for a few moments. “I know I’ve got to quit,” he said quietly. “I tell myself I’m going to stop, and then the pipe just appears in my hand. It’s gone in thirty seconds, and I don’t even know what I’ve done.”
The cast of patients in the CCU that morning was similar to Mr. Simons: sick, indigent, on a slow journey to dignity. Arthur Batista in room 6 weighed over 350 pounds. His body resembled a collection of interconnecting spheres: soccer balls for thighs, a bag of tennis balls around his waist, and a beach ball for a rump. He had an unsightly growth of facial hair, a thick, almost absent neck, and the rancid odor of someone who has too much body surface to wash. His heart was functioning at less than half capacity. He was standing with one foot on a banana peel, as a nurse put it.
When we walked into his room, he was lying on his side, trying to generate enough momentum to stand up. There was a large stain on his bed, which explained the musty smell. “Man, this is just crazy!” he cried, pulling on a fluid-filled plastic line. “I’m all tangled up. I have to get up and take a piss!”
Four of us helped him to his feet, rotating an IV pole twice around his body to untangle the line. While we remained assembled around him, he peed into a plastic urinal. Just that bit of exertion made him winded, and he plunked down into a sofa chair.
“How is your breathing today, Arthur?” I asked pleasantly.
“My breathing’s fine,” he said, even though he was panting. He pointed up at the monitor. “I don’t think I even need the oxygen anymore, but they’re going by the numbers up there.” He picked up his face mask. “This thing is broken. I need you to call the respiratory therapist and get me a new one.” I told him we would.
A nurse’s aide barreled in to check his blood sugar. In one seemingly continuous motion, she prepared the lancet, swabbed his fingertip with an alcohol pad, pricked the finger, coaxed a droplet of blood onto a card, and inserted the card into a glucometer. Then she turned and walked out.
“What’s the number?” he roared as she slipped away. “They always walk out before they give you the number!”
The howl brought his nurse in. “What’s the matter, Arthur? You okay?”
“I’m fine!”
“He was all tangled up,” I explained.
“I had to stand up to pee, okay! To do that, I have to take off the oxygen.”
“Not a problem,” the nurse said calmly. “Just ring the buzzer.”
“That’s what I did! Nobody comes.” Scowling, he turned to me. “The first day they’re fine, but after that they ignore you.” He surveyed the group of doctors standing around him. “You guys just keep throwing pills at me. One doctor says one thing; another doctor comes in and says, ‘No, you got a problem with your kidney.’ Now, which one is it, guys? You should get your stories straight.”
I told him that our role as the cardiac team was to focus on his heart condition. Different doctors were managing his kidney problems.
To judge from his groan of frustration, such division of labor did not sit well with him. (There was an inverse relationship, I’d discovered, between patient satisfaction and the number of doctors coming and going through their hospital rooms.) He placed his hand on his scrotum, edematous from the fluid overload of heart failure. “My nuts are starting to go down,” he announced. “So when can I go home, Doc?” I told him that he would likely have to go to a rehabilitation facility first.
“Rehab? What the hell for?”
“To get you stronger.”
“But I’m fine! This doctor”—he pointed at Paul, the intern—“whatever his name is, Chao—”
“Cheung,” Paul corrected him.
“Whatever. He was telling me something else.”
“Well, I’m running the show here,” I said.
“Then let me go home.”
I hesitated. “I’m just covering for the week. I’ll have to speak with Dr. Vaccaro.”
Exasperated, he shook his head. “Well, if I had known that, I would’ve just invited you to sit down and play cards!”
The most tragic case in the unit was Delmore Richardson, a forty-eight-year-old man who had collapsed three weeks prior after coming home from a dinner party. His wife had recounted the event for me. “He walked into the bedroom, but then he kind of stumbled and held on to the doorjamb,” she said. “I watched him fall backward. He bashed his head on the floor. First, I thought he was having a seizure. He kind of went awwgh.” She made a deep, guttural sound. “I yelled for my brother. He came downstairs and started doing chest compressions. I tried to breathe for him. His mouth was open, but every now and then he’d go awwgh.” She stopped, overwhelmed by the memory. “We called 911. They shocked him twice. It was pandemonium. There were so many people working on him, I got pushed into the kitchen.” When I asked where her children were, her lips quivered. “Unfortunately, their bedrooms are right off the living room, so they walked in on it. They saw the whole thing.”
Mr. Richardson had clearly suffered significant brain damage because he had been out so long. That morning, on rounds, his arms and feet were splayed rigidly outward in a position called decorticate posturing, a sign of severe neurological injury. Air bags, inflating and deflating to prevent blood clots, were wrapped around his immobile legs. A bottle of medicated fluid, hanging on a metal pole, dripped into his vein. A plastic tube in his rectum was draining pond green diarrhea, which was decanting into a bag, solids on bottom, clear liquid on top. His head rested on a towel, which caught secretions from the breathing tube taped to his chin. The ventilator recorded the respiratory rate: machine: 11; patient: 11. He wasn’t breathing on his own at all.
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