by Pamela Grim
I thought she was asleep, but she opened her eyes when I walked up to the bed.
“What's the matter with me?” she asked.
“You take too many pills,” I told her.
“But my doctor prescribes them.”
“I know,” I said. “It doesn't matter.”
She started crying, great tears tinted gray with mascara. “I tried to hurt myself,” she said sobbing, shoulders shaking. “But I don't want to die. It's not that. It's just that I don't want to be alive.”
“Have you thought about a drug treatment program?” I asked her gently.
She looked up at me, too shocked to keep crying. “What do you mean? What are you saying?” she sputtered. “I'm not some kind of,” she spit it out, “drug addict.”
The husband signaled me for another talk outside the room. He stood in the hallway, arms folded, glaring angrily toward the nurses' station. “All she does anymore is take those pills. I've tried to get her to see a real doctor, a psychiatrist, anybody, but that quack has her strung out on so many pills she doesn't have any idea what's she's doing. She lives for those damn pills.” He took a deep breath and then asked the obvious. “Why don't they prosecute that man?”
I shook my head. Dr. Daiquiri was one very smart guy. He knew what he could prescribe and how to do it so that he stayed on this side of the law. And he knew how to defend himself. He had threatened several doctors with legal action after they complained to the hospital administrators that he was prescribing too many narcotics. He was very slick.
But I was sure that there was more to this story than just Dr. Daiquiri.
“And you?” I said, looking at him.
He looked away. “I'm moving out,” he said. “I want a divorce.” He cleared his throat. “That's why she's doing this.” He looked back down at me, frowning deeply. “I can't take this life. I can't take all the pills. She can let them ruin her life, but I'm not going to let them ruin mine.”
I could see his wife from where we were standing. She was gazing off into the distance, one hand on her chest, clutching at her hospital gown. The hand was twitching, trembling, and then it scraped, claw-like across her chest. Her head was bent back and the twitching extended up her arms and shoulders. It took another heartbeat before I realized what was happening. “She's seizing,” I shouted.
I rushed to the head of the bed. My first thought was: Good God, what's next? I looked down at her face and as I did I saw the charcoal bubbling from her mouth. She's aspirating, I told myself in horror. She was vomiting up some of the charcoal with the seizure. Now she would breathe it down her trachea, into her lungs. She probably was doing so right now. This was a disaster, perhaps a deadly disaster.
She's aspirated, you fool, I shouted to myself. Why didn't you see this was coming? One half of me stood there frozen, hands to my face, horrified. The other half, though, the professional half, smoothly took over. I hit the intercom button. “I need some help in here and call Respiratory.” Then I broke the plastic lock off the intubation cabinet and grabbed at the equipment there. The laryngoscope came first, a flat metal blade with a light attached to a large handle, and an endotracheal tube—ET tube—which goes down through the larynx into the trachea, so that we can breathe for the patient. You don't always need to intubate seizure patients; it's rare for a seizure to last long enough to cause a significant lack of oxygen. But this woman had a gut full of charcoal. She was only going to aspirate and aspirate more. I had to protect her airway, protect her lungs from more charcoal.
On the outside, my professional half smoothly assembled the intubation equipment. The horrified half hadn't disappeared, though. Inside I was seething, arguing back and forth with myself.
If I had known she was going to aspirate, I should have intubated her before I gave her the charcoal.
Still, how many overdose patients had I seen who were as compromised as Marilyn but had never seized?
Hundreds.
Charcoal-stained mucus bubbled up through Marilyn's nose. “Set up suction,” I told the respiratory therapist who had just arrived. The room was beginning to fill with people.
I tried to open the patient's mouth but couldn't. The seizure had clamped it shut tight. We needed to stop the seizure before I could even try to intubate her.
“We need Valium over here,” I told Alisa. The respiratory therapist got the Ambu bag ready and was fumbling with the suction. Pam, the other nurse, put the pulse oximeter on the patient's finger. This measures the amount of oxygen in the blood: 96–100 percent is normal. Anything below 90 is not good, below 80 is very bad. Marilyn's reading was 90 percent.
Alisa was back with a syringe and some Valium. She drew up 5 mg, injected it and flushed the line. We all stood watching. Nothing. Arms and legs jerking. Jaw clamped tight. Marilyn was still seizing. Charcoal still bubbled through her nose.
Her pulse oxymetry reading: 87 percent.
“More Valium,” I told Alisa, who drew up the other 5 mg from the vial.
She injected it. We all stared down at the patient. She had stopped being Marilyn. She was now the enemy: the patient gone bad.
Nothing. Still seizing. Jaw clamped shut.
85 percent.
“What now?” Alisa asked. Clearly Valium was not going to stop the seizure.
84 percent. 83 percent.
I had a choice. I could try to go through the nose with the tube, pass it down into the larynx blindly and see if I could get the tube into the trachea (not easy). Or I could paralyze her, and when she stopped seizing do the somewhat easier standard intubation.
Which one? Either or. Decide now.
83 percent. 82.
“Get the sux,” I told Alisa. “Sux” is short for succinylcholine, a drug that blocks all muscular activity. It produces total paralysis, making it easier to intubate, that is, get the tube down into the trachea. However, if I couldn't get her intubated, she wouldn't be able to breathe on her own. I would be stuck, or rather Marilyn would be stuck. Paralyzed, without an airway, about to die.
82 percent…82 and holding.
When you run a code, everyone moves as if they are running through water. Time dilates and what only takes a minute seems like hours. All that time. Alisa finally returned bearing the bottle of sux aloft.
“A hundred milligrams,” I told her. The problem with sux is that it causes the stomach muscles to contract. More aspiration. There were ways to prevent this, but they all took time.
81…80.
The patient was still seizing, head thrown back, face contorted, arms jerking. Charcoal was everywhere.
Sux in. Pulse ox 80 percent, an oxygen level low enough to cause brain damage.
80 percent and holding.
Slowly, slowly, slowly, the jerking became more pronounced but less frequent. Finally, after one last spasm, Marilyn lay still.
Her jaw moved easily in my hand.
Now I had to get the tube through the larynx, past the voice box and through to the trachea. To do this, I used the blade of the laryngoscope to lift the tongue and part of the voice box out of the way to see the narrow tube, the trachea, and, within it, the twin shutters of the vocal cords.
“I need suction,” I said. The respiratory therapist handed me the Yankhauer. I tried to vacuum up the charcoal as best I could, but even so, as I pulled the tongue out of the way with the laryngoscope, I still couldn't see the larynx. I readjusted the blade. Nothing. No vocal cords. The only thing to do was to poke the ET tube in the general direction of the larynx, and hope for the best. I did this. Again. Nothing. The ET tube was hanging up somewhere. I couldn't get it in.
76…75.
I threw the tube on the floor. “Get me a smaller one,” I shouted.
Somebody scrambled for one. We bagged the patient as best we could, but the pulse ox stayed at 75 percent. She was not going to last long here.
I looked again. More charcoal. Please, dear God, I prayed. Just this once. (I know I always say, Just this once.) Someone handed me
a narrower tube. I flexed it, inserted the long wire stylet and bent over once again to pass the tube into the dim, charcoal-coated reaches of Marilyn's pharynx.
“You in?” Alisa asked breathlessly as I straightened up.
“I don't know.” I pulled out the stylet and attached the Ambu bag. The respiratory therapist gave her a breath. Her stomach rose and fell, not her chest. I was in the esophagus. No good. I pulled the tube out. “No,” I said.
I looked down her throat again with the laryngoscope. I could see only the tip of the epiglottis—the sentinel of the larynx. I made another pass, roughly where I had passed it before.
Once again I pulled out the stylet. We reattached the Ambu bag. One breath, two. The chest rose and fell this time, a good sign. I managed to find my stethoscope to listen for breath sounds as the respiratory therapist bagged madly.
Breath sounds. Good breath sounds. We were in.
As I straightened up, I realized that my back was killing me. I clasped my hands together; they were trembling.
We all looked down at the patient, at Marilyn. The respiratory therapist was in the process of wrapping tape around the endotracheal tube to hold it in place. What next? I thought wearily, looking around the room. What fresh disaster awaired me now?
Marilyn's fate was sealed anyway. Destination: ICU. Diagnosis: overdose, seizure, aspiration. I called the medicine service down. Two internal medicine residents arrived, glanced at the patient and then huddled for twenty minutes with the lab reports. Great, I thought, they get to take hours to go over a decision I had to make in seconds.
The senior resident came over to me.
“You know,” he said, trying to look casual, “you probably should have intubated her before you gave her the charcoal.”
“I know that now,” I said. “But there was no way to predict when she came in that she was going to seize. I can't intubate every overdose I see. Most aspirin overdoses do okay.” You idiot, I thought.
The resident shrugged and gave me a look that said, if he had been here…
I turned my back on him, wondering. Should I have known? Did I miss some clue, something somebody else would have easily seen? I wasn't sure, and the uncertainty made me feel sick inside.
An hour later Marilyn finally went up to the ICU. Afterward I stood in the empty room for a moment bathing in a transient sense of relief. She was now someone else's problem. I looked around the acute room. It was a disaster. Charcoal everywhere, blood on the floor, ET tubes, plastic stuffing, packaging material scattered all over, a garbage bin turned on its side. I stooped down, uprighted the garbage bin and began stuffing trash into it. I didn't think I could handle a task more complicated.
I could hear the recrimination already: the Monday morning quarterbacks, doctors whose specialty is second-guessing any decision involving a patient that goes sour. It's an occupational hazard of the emergency room doctor. This case was particularly bad. After all, I had been one of the doctors who complained about Dr. Daiquiri's prescribing habits. He had already complained to the ER director about me. He was gunning for me in a major way, and I had just handed him a whole boxload of bullets.
But nobody ever said a word to me. Perhaps it was the nature of the case, or that long list of medications on the face sheet of the chart. Other ER shifts intervened and I went on to fresh disasters. Marilyn's and my brief therapeutic relationship was over—or so I thought.
Not quite. My life touched Marilyn one more time and that, surprisingly enough, was in the Medical Records Department. Well, perhaps not so surprisingly. The ghosts that haunt doctors are all housed in medical records. They haunt us because every day minions from Medical Records comb through these charts looking for “incompletes.” Signatures not entered, procure notes absent, discharge summaries never dictated. All these missing pieces are tagged for doctors to complete, to sign or dictate—which, of course, the doctor never wants to do because the only thing more boring than signing charts is dictating them. Some doctors will be in arrears with over a hundred charts at any one time. You find scores of them in the Medical Records Department, a heart-stopping pile of records in front of them. They are only there signing charts now because the hospital has suspended their admitting privileges.
It's as if some kind of giant medical mom has told her kids they are grounded.
One night, though, I sat alone in the department. I was working my way through a stack of charts when I found myself opening Marilyn's. It had been six months since everything happened, and I had entirely forgotten her. Now, though, I felt that old rush of nausea. The charcoal, the charcoal, I thought again. Should I have known she was going to aspirate? Then the nausea subsided and I grew curious about what had happened to her. I started paging slowly through the chart.
She arrived in the ICU and immediately went into ARDS—adult respiratory distress syndrome, a toxic reaction involving the lungs. Then she became septic—bigtime septic—the medicine service thought so, anyway. She was started on three different antibiotics but kept spiking fevers through them. Nobody knew why. Then one of the antibiotics damaged her kidneys so much they almost completely shut down. She was on renal dialysis for weeks.
It occurred to me, as I paged through this chart, that Marilyn had come perilously close to getting what she wanted. She didn't want to die, she had told us, but she didn't want to be alive either.
At last things evened out. Her kidney function returned. Her lungs cleared up. The team transferred her out of the ICU to the floor six weeks after she was admitted. There was another setback, though, a small stroke. She ended up in the hospital rehabilitation unit and had been discharged only a few days ago. Hence her chart was here for my signature.
The weird thing, though, was that after my initial ER dictation, nowhere in the chart did anyone say anything about Marilyn's drug problem. The suicide attempt was taken care of by having a psychiatrist visit her once for twenty minutes. His consult note said she was no longer suicidal; she was depressed secondary to problems in her marriage and would benefit from marital counseling. Nothing about all the drugs. Nothing about the massive amount of painkillers and sedatives Marilyn required during her stay. The doctors had saved Marilyn's lungs, her kidneys, her guts and her brain, but they ignored her addiction, the problem that had brought her here to begin with.
The last progress note in the chart stated that Marilyn was now off dialysis, tolerating an advanced diet and able to ambulate without assistance. Vital signs stable.
Patient discharged in good condition. Referred back to her primary doctor.
Patient to follow up with: Dr. Daiquiri.
9
HOW TO BURN OUT
YOU NEVER KNOW you're burned out. When the stress of the job starts destroying mental software, the capacity for personal insight is the first to go. At the onset of your great burnout season, the scorched-earth years of your life, the only thing you really notice is that just about anything that happens gets on your nerves. The other symptoms: the hair-trigger temper and ferocious mood swings, the trembling hands and the uninterrupted string of hangovers; none of that really registers. You just go on as you always have, pushing through too many shifts, too many patients, too many sleepless nights and harrowing days. Meanwhile, your marriage goes to pot, your kids get screwed up and that nagging back pain gets so bad you start prescribing yourself painkillers for it. A few T#3s can take the edge off any bad day. Face it, though, how can you complain? What are your little tragedies compared to the carnage of bad luck you see at work every day?
Finally, though, one day, you see that you are falling, falling—but you have no idea why. Even now, after you have moved to a sleepier life, there are still moments when, say, some particular song comes on the radio. Or a smell, or the distant sound of an ambulance siren, lonesome as a train whistle. Then, suddenly, there you are again: Icarus.
Why should this ever come as a surprise? On the first day of your internship, the surgeon who ran the Trauma Department told you and your
fellow interns that by the time you all finished your residency, “The divorce rate in your class will be a hundred and fifty percent. That's because some of you will get divorced, remarry and get divorced again.” The surgeon was proud of that. And from that first day on, you went to work in terra incognita. A land unlike any place you had ever seen.
During the worst years it was like getting up in the morning and going into war. Things happened in that small clutch of examining rooms that no one else had ever seen. And if you tried to talk about it, to your spouse or your few friends who did not work in ER, you would get the fisheye—a look of suspicion and disbelief. They didn't really want to know; they certainly didn't want to believe and you couldn't blame them. Even if they were interested, they didn't have the right mind-set to understand what all of you working in the pit relearned every shift. The dead end of rage, the sordid stupidity of drunks and addicts; the awesome destructive power of bad luck. Everyone in that other world, the “real” world, lived in a cocoon of safety. You didn't want to be the one to tell them how much of an illusion that cocoon is.
Only cops seem to know these things. There is a secret fraternal order of people on the front lines. Members include the ambulance drivers who scrape up pedestrian victims smeared across a roadway by hit-and-run drivers; orderlies who wheel the dead bodies down to the morgue late at night; strung-out, exhausted nurses; the even more strung-out ER doctors on the tenth shift in a row. Only insiders could take for granted the casual lunacy of, for example, the patient you saw last night. He was a seventeen-year-old kid—acutely, horribly psychotic—but no drugs, no alcohol—just out there on his own personal pathway to destruction. The police took him into custody after he had set the garage on fire and then tried to stab his little sister. This loopy kid was brought to your Bedlam and, amidst all the other chaos, everyone had to stop what they were doing to get him tied down. As you did, the kid fought back like mad, and all the while he barked— barked like a dog. Not just random barking, either. He was barking, of all things, “Frère Jacques.” Bark, bark, bark, bark, bark, bark, bark, bark. Nothing would shut him up. You tried sedating him, then you stuck him in a side room with the lights turned out. Nothing worked. He just kept barking, barking, barking, until, finally, the boys from the state psychiatric institute arrived to cart him away. By then you were ready to go with them.