by Robin Cook
"This is Dr. Peters at the hospital. I've seen your patient, the hernia who was having trouble breathing."
"Well, how is he?"
"Much better. Doctor. His stomach was badly dilated, and I evacuated almost a pint of fluid and a bunch of gas by putting down a nasogastric tube."
"Yes, I thought that was the trouble."
What a fake, I thought, convinced that Supercharger hadn't had any notion about where the trouble might lie. I went on. "I thought it advisable to check out his other systems, too, so I have the results of a blood count, chest X ray, and EKG. They look acceptable. Everything but the diaphragm, which—"
A blast came through the telephone. "My God, boy, you don't need all those crutches. My patient isn't a millionaire, and this isn't the Mayo Clinic. What the hell are you doing? I could have told you what was wrong by using nothing more than a stethoscope and a little percussion. You kids think the world was made for machines. Back when I was doing your job, we didn't ..." I could imagine his face getting red, the veins standing out on his neck. I sincerely hoped he would have insomnia for the rest of the night.
"And what have you done about the NG tube, Peters?"
"I put it on suction, Doctor, and left it in."
"Don't you know anything? He'll just get pneumonia, with that thing down him. Get it out of there right now."
"But, Doctor, the patient is still short of breath, and I'm afraid his stomach will dilate again right away."
"Don't argue with me. Get it out. None of my hernia patients are to have NG tubes. That's one of my basic rules, Peters, basic." Click. I was holding a dead telephone.
I went back to the ward and pulled the tube out. The patient was still struggling for breath, but not as badly as before. As I was leaving a nurse came in, obviously a little surprised and nervous to see me still there. She held a needle. Somewhat guiltily, she said that the Supercharger had called and ordered more sedative. I was so pissed off I didn't even ask her what it was; I just left.
Now I had to decide where to go, my room or Karen's apartment. The latter didn't make sense, because Karen was surely sound asleep. Besides, none of my shaving stuff was there—a policy we followed to avoid explanations to the other fellow. If I went back to my own room, I could shave when I got up in the morning, a few hours from now. It was after three. So I returned to my quarters and called the night operator to tell her I was not at the other number any more. She said she understood. I wondered how much she understood.
I was hardly down on the pillow when the phone rang again. Sweet Jesus, I thought, probably an ER admission. What a bitch of a Tuesday night! But it was the same nurse saying that the hernia patient was much worse again, and the private doctor wanted me to see him again immediately. I was getting tired of this routine—up, down, up, down, seeing patients for whom my responsibility was so muddled and indistinct that I never knew where I stood. The ironies of the situation were considerable. Here the Supercharger had no sooner finished bawling me out for ordering some laboratory tests and for leaving in the NG tube than he had called the nurse—not me—to give some medication; and now he wanted me to see the patient again. It didn't make any sense until you realized that you were just a convenient means of keeping the doctor up on his sleep. The patient obviously wasn't getting what he was paying for. And I? Well, I was getting less than zero teaching. Someday, if I was lucky, I could look forward to being a doctor like him and not giving a shit about the intern, the patient, or medical care in general.
So, for me, it was down the elevator again, through the long hall, into the dark blue light that enveloped the sleeping hospital, my footsteps making distinct clicking noises, as if in a vacuum. It was peaceful now, but come seven-thirty I would be in poor shape for surgery. I felt like checking myself into the hospital for a good going-over. I had lost fifteen pounds since the first day of internship.
Suddenly, from behind me, the world was shattered by frantic sounds of glass and metal hitting against each other. Turning around, I saw the ER intern coming at a run toward me in the blue light of the hall, clutching his laryngoscope and an endotracheal tube. A nurse behind him pushed the tinkling crash cart.
"Cardiac arrest," he panted, motioning for me to follow. We both ran now, and I wondered if it was the hernia patient.
"Which floor?" I asked.
"The private surgical ward, this floor." He went headlong through the swinging doors. A light shone from the room where I had been before, and we rushed in, filling it up. The patient was on the floor near the sink. He had pulled the IV out of his arm and gotten out of bed. Two nurses were there, one trying to give closed-chest massage. I grabbed the board brought in by the nurse and threw it on the bed to make a firm surface for the massage.
"Put him up here," I yelled, and the four of us lifted him onto the board. There was no pulse, no respiratory effort. His eyes were open, with widely dilated pupils, and his mouth was grotesquely agape. The ER intern slapped the chest very hard; no response. I pinched his nose, sealed my mouth over his, and blew in. There was no resistance, and the chest rose slightly. I breathed into him again and then motioned for the laryngoscope, while the ER intern began to give cardiac massage, getting up on the bed and kneeling beside the patient to do it. Every time he pushed on the chest, the patient's head bounced violently.
"Can you hold the head still?" I asked one of the nurses. She tried, but couldn't really. Between bounces, I slid the laryngoscope through his mouth and down into his throat. The epiglottis alternated in and out of view. Advancing the tip farther, I pulled up, and the 'scope clanked against his teeth. Nothing. I couldn't orient myself in the red folds of mucus membrane. Quickly taking out the 'scope, I blew in a few more breaths between compressions. The ER intern was getting nice sternal excursions; the breastbone was moving in and out about two inches, undoubtedly forcing blood through the heart quite well. I tried with the laryngoscope again, down to the epiglottis, tip of the 'scope up, then in farther, and down. There, I saw the cords for a second.
"The endoctracheal tube." A nurse handed it to me. I didn't take my eyes away from his throat. "Push on his larynx." I motioned to the neck. The nurse pushed. "Harder." Then I saw the cords again and pushed in the tube. "The Ambu bag." I hooked up the Ambu breathing bag and watched his chest as I compressed it. Instead of the chest rising, the stomach bulged a little. "Damn! Missed it." I pulled the tube out, put my mouth over the patient's again, and blew, twice more. Then the laryngoscope again. I had to get it this time. "Push again on his larynx." I pulled up very strongly, and then I could see the cords between each chest compression. "Hold it. Okay, stop the compression." The ER intern interrupted his rhythm for a second while I slid in the tube; then he immediately recommenced the massage. With the Ambu bag attached and compressed, the chest rose nicely. The ER nurse had put in the needle leads for the EKG, and we had a blip on the oscilloscope. It wasn't grounded very well.
“Put the EKG on lead two," the ER intern said. That was better. I was compressing the Ambu when a nurse-anesthetist arrived. She took over the Ambu.
"Medicut." The nurse gave me a catheter, and I put a piece of rubber very tightly around his left upper arm. Medicuts can be tricky, especially when you're in a hurry, but they're much faster than cutdowns, because you put the medicut into the vein by just pushing it through the skin rather than making an incision as with the cutdown. I pushed the medicut into the patient's arm and advanced it until I thought I was in the vein; fortunately blood came back into the syringe—but that was only half the battle. I pushed the plastic catheter forward on the needle, hoping it would remain within the lumen of the vein. Then, by wiggling the needle back and forth, I attempted to advance the catheter still farther into the vein. When I pulled out the needle, some dark brownish-red blood flowed through the catheter over his arm and onto the bed. A nurse was still struggling with the plastic tubing from the IV bottle. I just let the blood flow; it didn't make any difference. After securing the end of the tubing to the cat
heter, I could see the blood disappear from the catheter, running back into the vein as the IV started up. Snapping off the rubber tourniquet, I watched the drip, and opened it all the way until it was running fine. "Tape." I secured the catheter to the arm. The EKG still showed rapid but coarse fibrillation. "Epinephrine," I barked. I thought a heart stimulant might smooth out the fibrillation, before we tried to change it electrically to a regular heartbeat.
"How about directly into the heart?" The ER intern suggested.
"Let’s try just IV first." I wasn't very confident of that intracardiac method. The nurse gave me a syringe and said it was 1:1,000 diluted to 10 cc. I injected it rapidly into the new IV site through a small length of rubber tubing, being careful to compress the distal plastic tubing to keep the epinephrine from going back into the IV bottle. "Bicarbonate," I said to the nurse, holding out my free hand. The nurse gave me a syringe, saying it held 44 milliequivalents. "How are you doing with the pumping?" I asked the ER intern.
"I'm fine," he answered.
I injected the bicarbonate into the same IV site— and pricked my finger in the process by putting the needle all the way through the little rubber section. Sucking my index finger, I watched the EKG. Slowly it began to show stronger fibrillation.
"How about defibrillating now?" the ER intern suggested. The defibrillator was all charged up. A nurse held the paddles, with a smear of conductant on each one. Stopping his pumping, the ER intern took the paddles, placing one over the heart and one to the side of the chest. "Away from the bed!" The nurse-anesthetist let go of the Ambu. Wham! The patient jumped, his arms fluttered, and the EKG blip was gone. When it came back, it was just about the same. A medical resident arrived breathlessly and quickly got oriented.
"Hang up a 5-per-cent bicarbonate on the IV and give me some xylocaine." The nurse gave the medical resident 50 mg. of xylocaine. He handed it to me, and I injected it. We defibrillated him again. In fact, we tried about four times before the fibrillation disappeared. But instead of a normal cardiac rhythm taking over, all evidence of activity in the heart disappeared, as the electronic blip on the EKG screen became perfectly flat.
"Damn! Asystole," said the resident, watching the blip.
Epinephrine, isuprel, atropine, pacemaker: we tried all the stuff we had. Meanwhile, the man's pupils came down to about normal size from the widely dilated state they'd been in when we first started. At least that meant that oxygen was getting to his brain, that our cardiac massage was effective.
Another intern arrived, taking over the massage part so the ER intern could go back to his primary duty, poor fellow. Then I took a turn at the massage. "How about calcium?" the other intern suggested. The resident injected some calcium. I asked for another nasogastric tube, but didn't get to put it down until the intern could relieve me at the massage. There wasn't much in his stomach except some gas, and that was probably just what I had pushed in there earlier by mistake, through the misplaced endotracheal tube. I told the resident that this patient was the one whose EKG I had called him about earlier. I also told him that the portable X ray of the chest was generally clear.
Looking behind me, I was surprised to see the Supercharger standing there quietly watching our feverish activity. I guess the nurses had called him. He didn't say a word. The resident injected the heart several times with intracardiac epinephrine. Still we couldn't break the asystole, and we were running out of options. Pumping and breathing, pumping and breathing, for fifteen minutes more we watched the machine trace a straight line across the oscilloscope.
"All right, that’s enough. Stop now." It was the Supercharger finally speaking, after standing by in silence for almost thirty minutes. His words surprised us and failed to penetrate our routine, so that we didn't stop right away, but kept on pumping and breathing as if he hadn't said anything.
"That’s enough," he repeated. The nurse-anesthetist compressing the Ambu was the first to stop. Then the intern, who happened to be massaging at the time. All of us were tired by then, thinking about getting back to bed, and conscious of the fact that we might have stopped earlier if the man's pupils hadn't reduced so well. Constriction of the pupils is one of the signs of revival; that had kept us going. But clearly this time it had been a false sign. So we stopped, and the man was dead. The Supercharger walked out and disappeared down the corridor toward the nurses' station, where he did the paper-work chores and called the relatives. The nurses unhooked the EKG machine, while I got out a large intracardiac needle.
"How are you at hitting the heart?" I asked the other intern.
"I've hit it one hundred per cent, but only on two tries," he answered.
"I'm only doing about fifty per cent," I confessed. After attaching a 10-cc. syringe to the needle, I walked over to the patient and felt for the transverse ridge called the angle of Louis, about midway down the breastbone. This oriented me with respect to the rib cage. It was then a simple matter to find the fourth interspace on the left. The needle went in quite easily, and when I drew back on the plunger the needle filled with blood. Bull's eye.
"I think my problem has been that I've been using the third interspace," I ventured. I tried it again, this time in the third interspace, and when I withdrew no blood appeared. "That's it. Okay, you have a go." I handed him the syringe, and he got the heart right away.
I pulled the endotracheal tube out of the dead man, wiping the rather thick mucus on the tip off onto the sheet, where it left a gray trail. "This guy was really hard to get an endotracheal tube into. Want to try?" Gingerly holding the tube between my thumb and index finger, I advanced it toward the other intern. I was pretty good at entubating now, because I had made it a point over the last few months to practice whenever we had an unsuccessful resuscitation like this one, which happened pretty often. He took the laryngoscope and slipped it in. He said he couldn't see anything. I looked over his shoulder and could tell he wasn't lifting enough with the point of the blade. "Lift until you think you're going to dislocate his jaw." His arm quivered as he strained. Still something wrong. "Let me try." I pulled up, and then with my right hand I pushed down on his larynx. The cords came into view. "He has a pretty oblique angle there. Try it again, but push a little on the larynx." The nurse stuck her head in, saying she needed the 'scope so she could return the crash car to the ER. With a wave of my hand, I staved her off for a few seconds, while I looked over the other intern's shoulder. A sound of satisfaction came out of him as he finally saw the vocal cords. Then, walking out, he handed the 'scope to the nurse, who clucked in disapproval.
Suddenly I was alone as the activity moved on, like some grim parade, to the living in other parts of the hospital. I wondered again whether to go to Karen's place or mine. It was a lonely time, especially because the man had died. I had been one of the last people to see him alive. But I had done everything I could—we all had—I guessed we had given it a good try. Besides, it was the Supercharger who had made me take the NG tube out and who had given him some sort of drug. So it wasn't my fault, though he probably thought it was. No doubt he would blame it on all those expensive tests. That was one of the troubles with the setup for private patients. I was available to see the patient but had no real responsibility, whereas the attending had the ultimate responsibility but was not on the scene. That made my position ambiguous, to say the least. It was too complicated for 4:00 a.m. Still, I was curious about Supercharger's last injection. The nurse had said it was a sedative. If I went back to look at the chart, I'd have to see the bastard again, and he'd probably have some timely comments about expensive blood counts. But, going up the hall, I decided it was worth the risk.
The Supercharger was gone already. That was a relief; it was also an indication of his interest in teaching. Seconal, the order sheet said. It added nothing to what I knew. Reading through the work-up again, I noted that the man did not have a history of heart trouble. The stomach and kidneys were normal, too. Then I read that the hernia had been a huge, basketball type of problem; yet that
didn't seem to explain his course. Something had made him go into respiratory failure ultimately leading to heart failure. The gastric distention I had relieved must have added to the problem, but it had not caused it. What about the anesthesia? I wondered. Turning to the anesthesia record, I read that it had been pentothal induction, maintenance nitrous oxide, no complications. I vainly struggled to pull in all the loose pieces, but I couldn't work through the maze. I was too exhausted. Better hurry back to bed, I thought cynically, so as to be there when the operator calls to wake me up for the day. Very funny.
But it was a bad, bad Tuesday night. Tuesday nights were generally active, Like Monday nights, since both Monday and Tuesday always had full operating schedules, and that meant a lot of nighttime dressing, pain, and drain problems; still, I usually got some sleep. Not this time; hardly had I put my head against the pillow when the phone rang again. It was the OR; a case was coming up for amputation, and I was needed to assist.
There was something particularly upsetting to me about an amputation, especially of the leg. An appendectomy or a cholecystectomy or any of the other interior operations left the surface of the person intact. But lifting a foot and a lower leg from the table and carrying them away from the person they belonged to was an irreversible act of alteration. No matter how jaded I became, I was never able to look upon the removal of a human limb as just another medical procedure.