A nurse slipped a thin plastic catheter down the breathing tube. With her thumb covering a hole in the vacuum line, she suctioned out thick yellow secretions, which pooled into a bucket. With her help, I hauled him onto his side and listened to his back, which was slippery with ointment. On his tailbone was gauze dressing, which I pulled aside to inspect the bedsore underneath, a pink crater about the size of a small saucer but less than half the depth. Inside it were tiny black flecks, perhaps dead tissue. I picked up his swollen arm. An allergy band was eating into the wrist, leaving a deep furrow. I let the arm go and it dropped with a thud. I used a pen to stroke up on the soles of his feet, unwittingly peeling up dead skin. Both big toes went up, a primitive reflex seen in newborns, a sign in adults of neurological devastation.
Emma, his wife, had been keeping vigil for three weeks, spending most days (and some nights) on a small flower-patterned couch by the window. She was a pretty, muscular woman who, despite the tragedy unfolding before her, still managed to maintain a brave front embellished with lip gloss and eye shadow. “He is going to pull out of this,” she had told me adamantly. “I have hope he is going to walk out of here.”
But by then there was virtually no hope for any sort of meaningful recovery. His blood pressure was starting to fluctuate. He had unexplained fevers. He was entering the downward spiral of the terminally ill, where competing problems grow in significance, where a solution to one problem causes another.
“Did he ever express any wishes about intensive care?” I’d asked her. “About being on a respirator or life support?”
“No, we never had that conversation,” she answered, shaking her head sadly. “We joked once about a close friend who was sick, how we wanted to keep him alive, but that was just joking.”
Without a do-not-resuscitate (DNR) order, we were going to have to try to revive him if he had another cardiac arrest, a possibility we all dreaded. “I know you want him to get better,” I told his wife that morning on rounds, trying to convince her again to sign the paper. “It is only human to want to see improvement, but the chances of him going back to the way he was are basically nil.” It sounded harsh, even to me, and I was sorry I had to say it. I reminded her that he would soon require a tracheostomy, during which a breathing tube would have to be inserted externally into an incision in his throat just below his Adam’s apple. We couldn’t leave him with an oral breathing tube much longer without inviting serious complications.
“Well, I am not agreeing to that right now,” she said, waving off the suggestion. “And I am not going to make him DNR either. He just needs more time. All these medicines and antibiotics are making it harder for him to breathe—”
“If we stop the antibiotics, he will die,” I said sharply. “And he has been off sedatives for at least a week.”
“It’s only been six days,” she replied. “Last Sunday it looked like he was ready to go home with me.”
I had encountered such resistance many times in my career, when loved ones see only what they want to see. As in those cases, it was obvious to me that our efforts here were futile and that they were only going to make him end his life more miserably. “So you would want us to do CPR if his heart stopped?” I said, no longer trying to hide my disapproval.
“Yes, of course,” she replied, as though it were the most obvious thing in the world. “Give him the best possible chance to wake up, even if it’s just to say goodbye.”
A nurse was seated in front of a computer monitor outside the room. “She would never do this if she had to pay for it,” she snapped when I came outside. And though I cringed at her flippancy, she was probably right. Some of the wastefulness in hospitals, I’d learned, especially in intensive care units, is driven by families unable to let go. I sat down to pen a note while the team moved on. The nurse turned to me. “She doesn’t understand his brain is mush and where he is going from here. We keep telling her, but she just looks at you with this blank stare.” She turned back to the monitor and clicked the mouse. “God, I hate buying used cars!” she cried.
Rounds lasted about three hours. By the time we were finished, there was a plan in place for all the patients. After leaving the unit to go to my office, I stopped by the cath lab to add a patient’s name to the board. The cath suite, like most procedure rooms at the hospital, was shiny and new. Fluorescent lights created a zigzagging stream on the polished tile. Rajiv was sitting at a console in one of the control rooms, finishing up a report. Tapping on the keyboard, he spoke fawningly on the phone with a referring physician. “No, sir … yes, sir … okay, ji … yes, boss … no, Plavix is for six months only, boss … okay, boss … okay, boss … thank you, boss … thanks, boss.”
No doctor I’d ever met took the business of medicine more seriously than Rajiv. He was the ultimate rainmaker, taking referrals 24-7 from his vast network of physician friends. He viewed medicine on Long Island as a ruthless competition in which only the most adaptable and socially savvy would survive. He boasted that his success derived from the three A’s: availability, accessibility, and affability (virtues, he claimed, that he’d learned from private practitioners and applied to his salaried hospital practice). He always carried his beeper, even when he wasn’t on call. People could (and would) reach him at all hours. He even attended the notoriously dull Indian doctor parties. “I’m a prostitute,” he once crowed. “I’m not ashamed; hell, I bring Vandana. I make her socialize with all the Indian ladies.” His wife had smiled, a knowing, resigned smile. “I ask him, ‘Just this weekend, can we have family time? Do we have to go to another party?’ But he says it’s good for business.”
After Rajiv hung up the phone, I gave him a quick update on his patients in the CCU. Ms. Wink had acute kidney injury, so we had decided to do a pharmacological stress test instead of a catheterization with potentially kidney-toxic dye. Mr. Lawner was whacked-out and noncompliant, plus, his family was loopy, so I had decided he should get no further testing. Ms. Sankar was a new patient with unstable angina. She needed to be catheterized that afternoon …
Before I could finish, Rajiv put his arm around me in an unexpected show of affection and gave the back of my neck a hard squeeze. “It’s great seeing you every day,” he said, beaming as I winced in pain. “I still can’t believe you’re here.”
* * *
That afternoon, on 7-North, the cardiac ward, I quickly saw three CCU outliers, patients who had been stabilized and no longer required intensive monitoring. When I sat down to write my notes, it was almost 3:30 p.m. How limited our interactions with patients, I thought. We see them for a few minutes, then pen a quick summary and leave directions for the nurses to follow. To whom are we speaking in these inky chart drizzles? Doctors, patients, a phantom lawyer (“I spoke with the patient at length, but he is still refusing…”)? Or perhaps we are just talking to ourselves, regurgitating the patient’s history to create a tidy narrative. The audience shifts, patient to patient, note to note, even sentence to sentence.
At four o’clock, while I was finishing up my last note, Ethan, the CCU fellow, paged me. “Mr. Richardson just dropped his pressure,” he said nervously about the brain-damaged patient in the CCU. “I tried going up on the Levophed and the Neo-Sinephrine, but it didn’t work. When I turned on vasopressin, his pressure dropped even more.”
I thought for a moment. This was the kind of situation I’d feared most as an attending, when I had to respond almost reflexively. (And how hard should I try to save a severely brain-damaged patient anyway?) All the medications Ethan had mentioned had half-lives, so it was hard to know how to interpret the results. “I would back off on the vaso,” I said carefully. “Just start some dobutamine at 2.5 micrograms per kilogram per minute. I’ll be there in a couple of minutes. Did you call the wife?”
“I got through to her a few minutes ago,” he replied. “I told her to come right away.”
When I arrived back in the CCU, the code had already begun. A group of doctors and nurses were at the bedside. The rhy
thm on the monitor was ventricular fibrillation, random electrical oscillations. An intern was doing chest compressions. Saline was running wide open through an IV. Defibrillator pads adhered to Richardson’s hairy chest. His body jerked up and down with every administered shock. Because his heart had effectively stopped, his lungs had filled up with pink, frothy liquid, mostly blood plasma, like beaten-up Jell-O, which came up through his breathing tube. The compressions sent the nurses scrambling for face masks and yellow gowns to protect themselves from the red spray.
“This is a conspiracy to prevent me from getting my afternoon coffee,” quipped a doctor who had shown up to help. I chuckled at the wry shoptalk.
After a couple of adrenaline injections, Mr. Richardson regained a pulse; but it immediately started to die down, and within a few minutes it disappeared. It seemed his body had finally given up. The sequence continued: shocks, chest compressions, and drugs. He got four doses of adrenaline at 1 milligram each, then 5 milligrams, then 10, but the pulse did not return. He received several ampoules of sodium bicarbonate. By then he was blue in the face, a sickening color, like an old hematoma. We continued CPR while I called for an echo machine, which takes ultrasound pictures of the heart. “Let’s take a quick peek before we call it,” I said. When the machine was wheeled in, I pulled the window shades closed and applied the ultrasound probe to his chest. The heart was in standstill, hazy clots filling the ventricles. I pressed a button to take a picture. The room was quiet as I pronounced him dead.
Gowns and masks were stuffed into a trash bin, and people started filing out of the room. Then a strange thing happened. My gloved fingertips, soaked with blood on his pulseless groin, started to vibrate. Wait, I ordered the group.
In the Bible, Lazarus is raised from the dead by Jesus. In medicine, Lazarus is the patient who, believed dead, spontaneously starts to circulate blood.
About forty cases of the Lazarus phenomenon, a number that experts believe is too small to be valid, have been reported in the medical literature. (I have seen at least three cases in my own career.) Though most patients died soon after the event, in eight cases they left the hospital, neurological functions intact. The cases share a kind of morbidity: A man, eighty, is pronounced dead after thirty minutes of CPR. His doctor showers and returns five minutes later to find his patient has a pulse. A man, eighty-four, goes into cardiac arrest while biking. After fifteen minutes of CPR he is pronounced dead and taken to a mortuary, where attendants see him breathing. A woman, sixty-eight, suffers a heart attack and goes into prolonged cardiac arrest. Removed from her ventilator, she is taken to a separate room, where about twenty minutes later a nurse notes she is breathing and moving under the sheet. She is discharged from the hospital and dies three months later in her sleep.
Why are certain deaths “reversible”? The phenomenon remains a mystery. Some have speculated that cessation of CPR decreases pressure in the chest cavity, allowing blood to return to the heart. In 1993 a doctor described the Lazarus phenomenon in a seventy-five-year-old man with a lung hemorrhage. “How [increased blood return] would stimulate the completely quiescent myocardium … is not readily apparent,” he wrote. “There had been no electrical cardiac activity … for several minutes at the time the efforts were terminated. This situation spontaneously reversed.”
There is even a kind of Lazarus phenomenon that has been described in brain-dead patients who make spontaneous movements after they are disconnected from ventilators. Patients have been observed to develop goose bumps on their arms and trunk, raise and flex their arms rapidly, and display complex finger movements. A doctor described one patient raising his arms off the bed and extending his elbows, as if performing a benediction, and another crossing his hands in front of his neck, as if grasping for his breathing tube. These movements sometimes occur despite no measurable blood flow to the brain. Some doctors speculate they are generated in the spinal cord.
However, as with most Lazarus patients, Mr. Richardson’s awakening was short-lived. After about five minutes his pulse disappeared, and despite a few more doses of adrenaline, it never returned. He was pronounced dead a second time after about ten minutes.
I found his wife sitting in the waiting room. She looked up when I walked in. “Is it over?” she asked.
“Yes,” I replied.
“Did he die?”
I put my arm around her. She began to cry. “I’m sorry,” I said.
As I drove home that night around eight, Long Island Sound was pitch-black, apart from the glimmering reflection of light poles. Fat rain droplets, like little eggs, started to splatter on my windshield, smearing with each sway of the wipers. In the distance the fractured skyline of the city stood out like shards of glass. Though I was physically exhausted, my mind was filled with the heady, mysterious events of the day. What had restarted Mr. Richardson’s heart? Was it the delayed action of adrenaline? Was it the bicarbonate? Was it something else?
In Harlem the roads shimmered shiny black. Red taillights winked at me through the watery haze. Police sirens were sounding out loudly. On 116th Street, dented low riders slinked by, windows open, music blaring. My headlights caught a lonely figure under the elevated train tracks.
I called Sonia to tell her that I was almost home. “How did Lamaze go?” I asked. Regrettably, I had missed it again this week. There was silence. “Honey?” I heard sobs.
“We need to talk,” she finally said, composing herself. “Dr. Edwards just called. She thinks the baby is in danger. She says I need a C-section before she goes on vacation next week.”
TWO
Odd Conceptions
Patients’ decisions about their care must be paramount, as long as those decisions are in keeping with ethical practice and do not lead to demands for inappropriate care.
—Physicians’ charter
Sonia and I’d had a hard time conceiving, but not because of a lack of diligence. We tried everything: ovulation sensors, Kokopelli figurines, yoga, meditation, Clomid, Pergonal, intrauterine injections, in vitro fertilization (IVF), even mystical appeals to a Hindu guru (who confidently predicted we would have two boys). Nothing worked. The failures left us feeling tense and frustrated.
In early 2003, at the midway point of my fellowship and shortly after our third unsuccessful attempt at IVF, we went on vacation to the Caribbean island of Anguilla. We both needed a break. We had been trying to get pregnant for over two years—Sonia was now thirty-two, and I was thirty-four—and we were quietly panicking that our efforts had become futile. One afternoon shortly after we arrived, I went for a walk alone on the sun-swept beach, where I met a shirtless loafer named Clement Clemons. He was tall and handsome, with brown dreadlocks emanating from his red bandanna and a quiet, dignified island air. We got to talking, and by and by he invited me to his “tavern,” a tourist attraction just up the road, where he said we could get “happy together.” With Sonia relaxing by the pool at the hotel, I accepted his proposition. After hopping about two hundred yards on the scorching white sand, we arrived at the back entrance to a bamboo shack, where a group of Americans were lounging on cheap rattan furniture, taking hits from a water pipe. Tiny lamps dangling from wooden beams bathed the room in a chocolaty orange. I sat down, and almost immediately the rim of a water bong was sealed around my lips and thick white smoke was gurgling through a purple curlicue shaft. The giggling tourists egged me on. It was a scene right out of the dorms at Berkeley.
Soon towering speakers were piping out joyful Dead tunes, and I was tripping heavily in a hallucinatory mix of speed and calm. Out on the deck, I gazed at a stunning palm-fringed tableau. It felt as if I were in a movie, a contrived visual narrative of an unsuspecting traveler stoned to oblivion in a foreign land. My mind was moving randomly through an array of interconnecting circles. Why is there space? How did it arise? Why are there jeans and tile floors and chairs of different material? So much we don’t understand!
Clement joined me on the terrace. His bandanna gave the illusion of s
treaming the colors of the rainbow. “This is the strongest shit I’ve ever smoked,” I told him, feeling dizzy. He just laughed.
The late-afternoon sun cast long shadows across the wooden deck. The sky was painted in swirls of pastel mixed with bubbly streaks of white. It reminded me of springtime in Berkeley, and thus of Lisa, my college girlfriend. What had happened to her? Where was she now? The last time we’d spoken was before I got married, when she recalled the scooter rides in the Berkeley Hills in those carefree early days. So strange that I didn’t still think about her every day: those brown curls and milky white skin; the raffish grin. At one time all paths of thought had converged on her. I used to obsess about her, her disease—lupus—and the miscarriages doctors predicted she’d have. I remembered that birthday eve when my father asked me, “Don’t you want children?” and my anguish for her gave way to my own desires. In the end, I abandoned her because I didn’t have the courage to cope with her illness. I gave her up to avoid the terrible fate of being without her.
I suddenly became aware that Clement was talking to me. “Why you so serious?” he said.
I shook my head and continued to gaze at the beach.
“Somethin’ is botherin’ you,” he said. I glanced at him. Fervidness was radiating from his dirty yellow sclera. I mentioned the problems that Sonia and I were having.
“You are injurin’ yourself,” he intoned. “And you are hurtin’ her, too.”
I nodded, staring at the turquoise water.
“Don’t worry,” he said. “You will have a boy.”
I turned to him. His face was vibrating. “A boy?” I said.
He nodded confidently. “A son.”
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