by Robin Cook
The nurse was still waiting on the line.
"Has the patient had surgery?" I asked.
"Yes, this morning. A hernia repair," she replied. "And he's not in good shape. The breathing difficulty has been going on for several hours."
"All right, I'll be over to see him in a few minutes. Meanwhile, have a portable X-ray machine brought to the room and get a chest film. And get me some blood for a complete blood count, and be sure there's a positive-pressure breathing machine and an EKG machine on the floor."
I didn't want to wait the rest of the night for that stuff. Maybe I wouldn't need it, but all the better if it was there anyway. When I got out of bed, Karen didn't budge. Not that it mattered. As I put on my clothes, I thought again what a convenience she was. Her apartment was just across the street from the hospital, even closer than my room in the quarters. It held all the creature comforts—television set, record player, a refrigerator well supplied with beer and cold cuts.
Karen and I had started seeing one another four months earlier, just after I had looked at her unusual pelvic X-ray the night she fell down the hospital stairs. Right after that she had been moved to a day shift, where we met again and started having coffee breaks together. One thing led to another, and going to her apartment became a habit—just about the time Joyce stopped being one.
Joyce, who'd been switched to the day shift, too, began wanting to play the tourist, make all the night spots. With that came some pressure to meet her parents and an increasing distaste for those surreptitious leave-takings in the early-morning hours. I tried to go along with her, but her roommate, the TV addict, was still there, and our relationship, which hadn't been very healthy to begin with, finally went completely sour. In any case, Joyce and I decided to cool it a while, to give ourselves a chance to think.
Karen did have another boyfriend, who continued to puzzle me. She saw him every now and again, perhaps two or three times a week, when they would go to a movie or even to a night club. She said that this fellow wanted to marry her, but she couldn't make up her mind. I didn't know him, or much about him, although we had talked once, briefly and quite by accident, when he phoned Karen's place. On the whole, I was not inclined to imperil a good thing by further investigation.
On my way over to see Supercharger's patient, I noticed that the night was unusually quiet, with almost no wind, although a low bank of clouds hung over the island, obscuring the sky. It had been raining hard all week. As I walked around to the west end of the hospital I glanced over into the ER, and the memory of my blind, exhausted bustle there came rushing back. I could see the usual clumps of activity, with people waiting and nurses appearing for fleeting moments in a seemingly disorganized jumble. It looked a little busier than usual for a Tuesday night, and I hoped that it would stay quiet enough not to require my presence. Whenever I got a night call from the ER, it usually meant an admission—probably surgery, and that could be bad.
The hall of the ward was deathly quiet and dark except for the little night lights that peeked out of the rooms as I walked briskly past them toward the nurses' station. The nurses' station was at the far end of the ward, and as I approached the light gradually grew brighter. It was a familiar sensation to me by now, walking down those dark corridors, the silence broken only by an undercurrent of hospital sounds— the light tinkle of an IV pole, an occasional sleepy moan—sounds that always made me feel I was alone in the world. Other doctors have told me of similar feelings. Actually, I had stopped analyzing the hospital and its effects on me as much as I used to, having become, in a sense, blind to my surroundings. Like a blind man, I took for granted the landmarks, the various doors and turns, and often reached my destination without noting my route or my thoughts along the way.
Some months ago the operator had called me in the early-morning hours for a cardiac arrest. I had gotten up, dressed, and run all the way over to the hospital before I realized that she had forgotten to tell me where the patient was, in which ward. Fortunately, I had guessed right about the location— through some sixth sense, you reached the point of being so routinized that when you were awakened you automatically plugged in the right information without being told.
This had its occasional disadvantages—as, for instance, on one of the frequent night calls to see a patient who had fallen out of bed. I made the automatic, insensate run to the ward and found him there, in good shape, of course. After calling his doctor, I left an order for an injection of Seconal, to be sure he'd sleep, and then plodded back to bed. All without ever coming fully awake. The same nurse called just a little later to say that the patient had fallen again, this time down a flight of stairs. So I got up again, plugged in the ward, and started off. In the middle of the journey, while climbing a flight of stairs, I stumbled across an inert mass lying on the landing. Standing there, dazed, I took fully ten seconds to reprogram myself to the fact that lying before me was the patient I had come to see. He should have been on the floor above! But, of course, he was where he was because he had fallen downstairs. Being totally limp during the fall, he hadn't hurt himself a bit. It turned out that all his shots—the painkiller, his antihistamine, his muscle relaxant, and my Seconal order—had been given simultaneously by the nurse and had taken effect at the same time, just as he took the first downward step.
I didn't always walk around in a fog. I simply developed an uncanny ability to continue sleeping while on the way to do some stupid job in the middle of the night. It was different when I got called for something serious, or when I was angry. But since our hospital suffered from an epidemic of patients who habitually fell out of bed, I learned to carry out that mission only half-awake.
The nurses' station seemed as bright as a television studio after that long walk in the dark. The nurse was effusively glad to see me and ticked off what she had done. The blood had been sent up and the X ray taken, and the EKG and positive-pressure breathing machines were both standing ready in the patient's room. I took the chart from her hand and scanned the work-up, which, of course, had been done by a fellow intern. A box of chocolates beckoned from the nearby desk, and I popped a couple in my mouth. Temperature was normal. Blood pressure was up and pulse very high. The rum-cherry centers were particularly good. I could find nothing to explain the breathing trouble. All seemed more or less normal for a recent hernia operation.
I turned back down the hall and retraced my steps almost to the end. Entering the room, I snapped on the light, illuminating a pale-looking man propped up in bed and forcibly inhaling with each breath. As I got closer I could see that he was quite diaphoretic, with beads of perspiration glistening on his forehead. He glanced at me for a second and then looked off, as if he had to concentrate on his breathing. Squinting, I realized I could see the apartment building next door, and Karen's window, the second from the right on the third floor. I wondered if she knew I was gone.
With my stethoscope in my ears, I pushed the patient forward and listened to his lung fields. The breath sounds were clear—no popping, no crackles, no rhonchi, no wheezing. Nothing there. Perhaps his lung fields sounded a little high; that seemed to go along with the fact that his abdomen was swollen and rather firm. It was not tender, however. Listening to his abdomen, I heard the familiar, reassuring gurgles. The heart sounds were normal; he had no signs of cardiac failure. About all that remained was to see if his stomach was full of air. Gastric dilatation was a frequent problem after general anesthesia. I told the nurse to get a nasogastric tube, and meanwhile I hooked up the EKG machine. These EKG contraptions were a source of irritation to me whenever I tried to use one at night, with no technicians around to help. Since I could never seem to get a good electrical ground, the tracing would wander all over the page. But I got this one going okay by hooking the ground wire to the drainpipe of the sink, and I took a tracing while the patient lay there still puffing hard. The nurse had returned with the nasogastric tube before I finished with the EKG. As I greased the tube, I couldn't help thinking of that doctor sleeping away at home while
I was putting in his NG tube.
One thing had stayed with me, even grown stronger, over the past ten months—the satisfaction in achieving a quick, desired result—and I felt relieved when I evacuated a large quantity of fluid and air from the patient's stomach. My relief was minimal, however, compared to his. He was still having some troubles, but his breathing was much easier. When he thanked me very much, it took him two breaths to get the phrase out. I listened to his lungs again, just to make sure that there wasn't any fluid in them. They were clear. His legs were normal, too, showing neither edema nor any suggestion of thrombophlebitis. Peeking under the dressing, I thought his incision looked fine, without excessive drainage. I told the nurse to get a suction machine for the NG tube and hook it up, while I went back to the nurses' station with the EKG.
I was still pretty shaky at reading EKG's, but his looked okay to me. At least, there were no arrhythmias. Possibly there was some slight suggestion of right heart strain with the S wave, but nothing drastic. As a precautionary measure, I decided to call the medical resident for support on the EKG reading. After a rather awkward minute or so during which I explained the situation and the resident listened, he finally said he wouldn't come down to see the EKG because it involved a private surgical patient.
I could understand his reluctance. It resembled mine when the medical intern on duty called me at night for help with a cutdown or something else on a private medical patient. Had the attendings made us feel it was a matter of reciprocal co-operation, each fellow holding up his end, those nasty little jobs would have been easier to take. But in American medicine, much of the difference between an intern and a full-fledged doctor is literally the difference between night and day. They would let us do virtually anything at all after the sun went down, when teaching was nonexistent, but nothing during the day, when we might learn something. As always, a few pleasant exceptions proved the rule—but damn few.
Early in my internship, I had been rather naïve about this master-slave relationship, knowing nothing of my rights. Until it wore me out, I tried to see every patient, private or charity, on the teaching service or not, no matter how minor the complaint. Finally, however, it was a question of my survival. Nowadays, whenever I got called at night for some routine matter concerning a private patient—a temperature elevation, for instance—I always asked the name of the doctor. If he was on the wrong side of the answer—and most of them were—I told the nurse to call him back and say that interns are not required to see private cases except in emergencies. This was not true, of course, for private cases on the teaching service. Then I had to go no matter who the doctor was.
Doctors of middle age or older were fond of making invidious comparisons between our supposedly soft life and their Spartan days way back when. To hear them tell it, thirty years ago an intern lived well below the poverty line. Our sumptuous salaries, which I reckoned to be about half what was paid to a plumber's assistant, simply enraged them. What is the world coming to? they would say. Why, we had to do workups on every patient, no matter what his status, and we never slept, and we didn't have all these fancy machines, and so forth and so on. Their attitude toward us was a simple matter of venom: they had suffered, and so would we. Thus does medical education in this enlightened time creep from generation to generation; each takes its sweet revenge.
Where was the patient in all this? Caught right in the middle—a most uncomfortable place, with the shells and bombs of medical warfare landing all around him.
Curiously, most of the legislation corning out of Washington was only making the situation worse. The thrust was very strongly toward providing more and more private care at government expense, but without any attempt either to control the quality of the medical care or to educate the potential patient. Suddenly armed with dollar power, previously indigent patients were being thrust on the medical market with no notion whatsoever of how to choose a doctor, and somehow, as if by mischievous grand design, they seemed to flock toward those marginally competent M.D.'s whose practice depended on volume, not quality. The immediate result was that the kinds of patients whom the interns and residents used to care for were now appearing on the private floors under the tender care of doctors who, like the Supercharger, did not know how to treat, let alone teach. Even old Roso had appeared again, for some minor complaint, under the care of a. private physician who didn't want the house staff nosing in the chart. Left stranded by the tide of money, the interns were forced into the clutches of these archaic doctors in order to gain experience in dealing with certain types of cases. Everybody suffered. In years past, when these patients were admitted on the staff service, they were taken care of with the help of the best specialists around. It would turn out, logically, that the most capable and knowledgeable attendings were also on the staff teaching service, because the hospital teaching committee and the house staff selected the best they could get. And the attendings who were most interested in teaching were almost invariably the most knowledgeable. If ever I was called at night to see one of their patients, I went, no matter what the reason.
But now, instead of being admitted on the staff service, where they were invaluable for teaching purposes and at the same time got better medical attention than anybody else in the hospital, these former staff patients were all flocking to the Neanderthals. How could something as vital as medical education and care get so screwed up? It seemed especially scary to me in respect to surgery, and it certainly made the English, the Swedes, and the Germans seem enlightened. They allow only specialists to operate in their hospitals. In the United States, any screwball with a medical diploma can perform any kind of surgery he wants to, as long as the hospital allows it. I knew how inadequate my medical-school training had been with respect to patient care; yet I also knew that I could get a license to practice medicine and surgery in any of the fifty states. What is it in the American psyche that allows us to spend billions policing the globe and yet makes us willing to put up with a criminally backward medical system? Like every other important question during my internship, this one was finally pushed aside by exhaustion. I began to accept the situation as if there were no alternative. In fact, there is no alternative at present. Now the problem only popped into my head when trouble was brewing, and I knew I would have plenty of trouble with the Supercharger over those X rays and other tests I had ordered on his hernia repair. I wondered again why I didn't go into research.
Before I called Supercharger and woke him up, I wanted a look at the X ray that had been taken on the portable machine. He'd probably explode when he found out about it in the morning, but I couldn't have cared less.
The hall got darker and darker as I retraced my steps and plodded through the hospital labyrinth on my way to X-ray. It was so silent and dark when I got there that I could not find the technician. Finally, in desperation, I picked up a telephone and dialed one of the numbers of the X-ray department. All around me, about a dozen phones came to life. Someplace, somebody answered one, silencing the others. I told the speaker that I was in his department and wanted to see a portable he had taken only an hour or so ago, whereupon he appeared through a door not ten feet away, blinking and tucking in his shirt. I followed him to a bunch of view boxes, waiting while he sifted through a stack of negatives.
One thing about the X-ray department—it never seemed to know where anything was. This X ray was less than an hour old, and still he couldn't find it. He said he couldn't understand it. They always said that, and I had to agree with them. The secretaries during the day were good at finding the blasted things, but they were the only ones. As the technician went through one stack of film after another, I leaned back against the counter and waited. It was like watching an endless replay of an incomplete pass. Finally he pulled one film from a bunch that were supposed to have already been read. Flicking it up into the X-ray view box, he turned on the light, which blinked a couple of times and then stayed on. The film was on backwards, so I turned it around.
It was a mess—
the X ray, not the patient. Portable films were not, in fact, very good at all, and I was sure the radiologist would tell me that it had been ridiculous to order portables when the patient could have been sent upstairs to get a good film. I never tried to explain that a portable was justified because I could order it by phone from my room and then have it—provided it wasn't lost—by the time I reached the patient. Otherwise I would end up sitting on my ass for an hour in the middle of the night waiting while the patient had a regular shot. This type of reasoning didn't make much sense to someone—a radiologist, say—who slept all night long.
The X ray looked normal for a portable, which is to say that it was a blurred smudge except for the gas in the stomach and the fact that the diaphragm appeared elevated. Even that was misleading, because with the guy lying in bed you could never be sure from what angle the X-ray technician had taken the shot. Anyway, it looked all right.
Next I got the lab technician on the telephone and asked for the blood-count results. The blood lab was pretty good; usually they found test results right away. But tonight the technician there wanted my identification, because the hospital was not allowed to give out such information to unauthorized people. What a ridiculous question! Who else would be calling up about a stat blood count at three o'clock in the morning? I identified myself as Ringo Starr, which seemed to satisfy the girl. The blood count was normal, too.
Armed with all this information, I dialed the Supercharger. The sound of the phone ringing on the other end was a delight to my ears. Four, five, six times it rang. Supercharger, true to his reputation, was a deep sleeper. Finally he answered.