by Robin Cook
In any case, there is always a lot to be done on any ward. Although the nurses will normally cope, if a doctor is around he's sure to be kept busy, and I was fading fast. There was only one job I wanted to do before going back to my room — to see Mrs. Takura in intensive care. I hoped that Jan had had enough sense to crawl under the covers before going to sleep. It was well after midnight.
We never called the intensive care unit by its full name, just ICU. Of all the names, initials, abbreviations, and jargon an intern hears, none can make him jump like ICU, because this is where the action is, a room in perpetual crisis. The chances of being called to the ICU at least twice a night were very high, and the chances of not knowing what to do were impossibly higher. That the nurses were efficient and knowledgeable only made it worse. You began to wonder what you had learned during those four expensive years of medical school. Schwartzman reaction, that's what we had learned. Two lectures on that, and no one was even sure it existed. Something's screwy when a doctor knows all about a disease that might not exist, but less than the nurse about any ICU situation. Of course, if the patient happened to have a Schwartzman reaction, I'd be an instant success: I could discourse at length on what the distal convoluted tubule of the kidney would look like under a light microscope, among other things. As for practical measures, however, we hadn't had time in medical school, nor had the pathologist cared, a fact that truly bugged me. The nurses had mostly carried bedpans through their three years of training. That's not fair, I realize, but, still, their training was trivial compared to the stacks of mechanism, enzymes, and Schwartzman reactions we had to memorize. Yet in the ICU I might as well have been carrying the bedpans. I often felt I'd better get the hell out of there before something happened that required an intelligent response.
An intern is supposed to pick up the practical stuff as he goes along, but if he got more of it in medical school he'd be a lot better off and so would the patients. In a working hospital nobody cares what you know about the Schwartzman reaction. The surgeon looks at your knots. "Weak," he says, "awfully weak." The nurse wants to know how much isuprel to put into 500 cc. of dextrose and water. "Well, how much have you been using on this patient?" "Usually 0.5 mg." "Hmmm, that should be okay." You don't have the guts to ask whether isuprel is the same as isoprotemol. Would she like to know about the thalamic radiations of the ventral nuclei of the cerebellum? No, and rightly, for it wouldn't help a single person in the ICU. What a way to live.
These thoughts were very much with me as I walked through the swinging doors of the ICU, as usual hesitating in wonderment at this strange mixture of science fiction and stark reality. Weird instruments hung from the walls and ceiling, adorned with their thousand buttons and switches and oscilloscope screens. Sonarlike beeps mingled symphonically with the rhythmic dick-clack of the respirators and the muffled sobs of a mother hunched over a bed in one corner. Moving and flickering as they stood guard over life, these machines often seemed more alive than the patients, who lay immobile, covered with bulky mummy like dressings and connected by plastic tubes to dusters of bottles that hung from the tops of poles. The mixture formed an alien and mysterious environment.
Nonmedical people react strongly to the ICU. It is the solid, physical incarnation of their fears about death and of the hospital as a place of death. Cancer, for instance, is certainly the most feared disease of our time, but unless you are the victim or a close relative or friend, it hardly exists outside hospitals. In the ICU, cancer hangs in the air like a sickening, primeval smog. If you work there a lot, you can easily forget that the hospital is a place where life begins as well as ends. But babies are not born in this room, and most people, with reason, associate it with the ominous, the unknown, and the final, where life hangs by its fingertips.
Although the normal human being does not enjoy a visit to the hospital, once he is in the ICU it holds him with its magnetic fascination, despite the morbidity, or perhaps because of it. His eyes dart around absorbing the fantasy, building monuments in imagination to the abstract power of medicine. Medicine must be powerful indeed, with all those machines. Otherwise, why have them? An observer, however, always senses the undercurrent of fear that mingles with the visitor's respectful awe, catching him in the conflict of wanting to be there and wanting to flee at the same time.
I felt the same ambivalence, for a different reason. I knew that most of the machines did almost nothing. Some of the smallest ones, though unimpressive to look at, did all the work. Those little green respirators, for insistence, clicking and clacking as they breathed for the people who needed them, were worth all the others put together. The complicated ones, with their screens and electronic blips, were not doing anything unless they were being watched. Medical school had taught me how to read these oscilloscopes. I knew that an upward sweep on the screen indicated millions of sodium ions rushing into the muscle cells of the heart. Then came a bump on the screen as the cells contracted while the cytoplasmic organelles worked like crazy to pump the ions back into the extracellular fluid. Fantastic to think about; but this scientific wizardry was only half the job. On the basis of these curves and sweeps, a doctor still had to make the diagnosis and then a prescription. That’s what pulled me apart, wanting to be there because I could learn a lot in a short time, yet always terrified that I wouldn't know what to do when total responsibility fell on me because I was the only doctor around.
In fact, my fear had already been justified several times — for instance, during my first night on call as an intern, when I was paged to deal with a hemorrhage in the ICU. Rushing upstairs, I had reassured myself with the fact that localized pressure would stop any bleeding. Then, entering the room, I had seen him and stopped in my tracks. Blood was pouring out of both sides of his mouth, drowning him in a red river, a continual bloody gush. It wasn't vomitus; it was pure blood. Terrified, I had just stood there watching, dumfounded, while his eyes pleaded for help. Later I was told that nothing could have been done. The cancer had eaten through the pulmonary vein. But all that mattered to me was that I had been lost, empty-headed, and immobilized. For nights afterward I had relived that scene, and now I had an obsession about being able to do something, even if it wouldn't help the patient.
Mrs. Takura was propped up in a corner bed. She was almost eighty, and her head was wreathed with fine white hair. A Sengstaken tube hung out of her left nostril, firmly held by a piece of sponge rubber that wrinkled and distorted her nose. A few drops of blood had dried in one corner of her mouth. The Sengstaken tube is about a quarter of an inch in diameter, and it is a rough one. Inside this large tube are three smaller ones, called "lumens." Two of the lumens have balloons attached, one inside the tube in a short lumen and one on the end in a long lumen. In order for the Sengstaken tube to work, the patient must swallow all this apparatus, never an easy task, and especially hard when the patient is vomiting blood, as is usually the case. Once the tube is down, the balloon on the bottom of the tube, in the stomach, is inflated to roughly the size of a large orange; this anchors everything in place. About halfway up is the second balloon; when inflated it takes the shape of a hot dog nestling inside the lower esophagus. The third lumen, small but long, simply dangles in the stomach for use in evacuating unwanted fluids, like blood. The point of the whole thing is to stop esophageal bleeding through pressure exerted on the walls of the esophagus by the hot-dog balloon.
Only once before, in medical school, had I treated a patient who needed a Sengstaken tube. His problem was alcoholism, which had caused severe cirrhosis and, eventually, liver failure. Mrs. Takura wasn't an alcoholic, of course — her problem sprang from an earlier case of hepatitis, years before — but their cases had a common aspect. A damaged liver impedes the passage of blood, so that pressure gradually rises in the blood vessels leading to the liver and then backs up, causing the veins to the esophagus to dilate and, in extreme cases, to break. At this point the patient vomits copious amounts of blood. Although I had treated the alcoholic for only
a day or two, I vividly remembered trying to help him swallow those balloons. When he couldn't do it he had been taken to surgery, and he never made it back to the ward.
Portal hypertension with bleeding esophageal varices was a serious affair, but so far we had been able to stabilize Mrs. Takura's by getting the tube down her. And she was scheduled to be operated on in eight hours or so.
She didn't look Oriental, despite her name and her abundant good cheer and inner calm, traits that I was beginning to see in all Orientals. Every time we talked she was lucid and alert, knowing just what was happening and speaking very quietly. I think she would have calmly discussed her geraniums in the middle of a typhoon. When she asked me how I was, as she always did, the answer seemed important to her. We got along well. Besides, I thought she would recover. You get that feeling with some patients, just an irrational hunch. Sometimes it works out.
Once, a few hours after her admission, the doctors had tried to remove the Sengstaken tube, but this had resulted in recurrent heavy bleeding and sent her into shock before the tube could be replaced. Since I had been off duty that night, I missed the blood and drama; she did scare me badly the next morning, however, when her blood pressure suddenly dropped to 80/50 and her pulse shot up to 130 per minute. Somehow, I had been collected enough to order and administer more blood, realizing that the steady bleeding had finally affected her pressure. When the blood pressure came up again nicely, my spirits rose with it Cause, effect, cure. This should have given me a bit of lasting confidence, but, curiously, believing that a right decision lay behind every situation only made me more nervous. To give the blood had been a right decision, but a simple one; next time it might be different.
Tonight, Mrs. Takura was pleasant and calm, as usual. I checked her blood pressure and the balloon pressures, and generally messed around trying to justify my being there, although I really only wanted to talk to her. "So, are you ready for your little operation?" "Yes, Doctor, if you are ready, I'm ready." That was a shocker. I felt sure she meant "you" in the collective sense, the whole surgical service. She couldn't have meant me. I was nowhere near being ready, despite the fact that I did know a good bit about the operation, at least the theory of it. I could talk for twenty minutes on portal-pressure gradients, on the various benefits and disadvantages of the surgical approach by forming a portal-vein-to-inferior-venacava anastomosis, end to end or end to side. I could even remember the diagrams of the splenorenal union — that was end to side. The whole idea was to relieve the blood pressure in the esophagus by connecting the liver venous system, where the pressure had risen and caused the bleeding, to a vein where the pressure was still normal, like the interior vena cava, or the left renal vein. Also lodged in my memory were the comparative mortality figures for these various procedures, but I didn't want to think about that. How can you look at a patient and think 20-per-cent mortality?
"We're ready, Mrs. Takura." I leaned hard on the "we," when in fact I wanted to say "they," for I had never even watched one of these operations, called a portal caval shunt. Theoretically, it was fantastic. Nothing excited the professors so much as talking about those pressure changes and hooking up this with that. Once they got started, they particularly enjoyed rattling on about obscure articles written by Harry Byplane of Umpdydump University (Harry was always a very good friend, of course), which showed that some article by George Littlechump at Dumpdydump University had been wrong in assuming the intralobular hepatic vein pressure gradients with the portal interlobular plexus weren't important. That was it right there, the kind of stuff you got a lot of on medical-school ward rounds. To win the game, you had to quote the most obscure article about some pressure gradient (they especially liked pressure or pH gradients) saying that Bobble Jones had shown conclusively (any doubt was disaster) that in a series of seventy-seven patients (an exact number, even if fictional, was necessary), all seventy-seven died if they went to the hospital. It didn't much matter what you said at the end as long as you got in enough numbers and gradients and personal references to the author; then you were golden, and rocketed to the front of the class. That was the big leagues: "Well, Peters, you've really done it now." What about Mrs. Takura? Forget the patient, man, we're talking about hydrogen ions in the blood, that's pH, with a little p and a big H.
I can remember a time we were all clustered around this one bed during medical-school teaching rounds. The short white coats were students, as anyone could tell. The short white coats and white pants marked interns and residents. And then, at the pinnacle, there were those long, heavily starched white coats — a washday dream, they were, so white they made even the bed sheets look gray. Need I say who wore those coats?
Somebody had mentioned the name of the patient's disease, and we were off and running on an intricate discussion of pH, sodium ions, and glucose pumps, with articles from Houston, California, and Sweden. Names flew back and forth in a kind of academic Ping-Pong game. Who would get in the last name, the latest change? We were nearly breathless with anticipation when someone noticed that we were standing by the wrong bed. The patient in front of us did not have the disease under debate. That had ended the game without a winner, and we had quietly moved on to the next bed. What the hell difference it made I couldn't fathom, since we hadn't had time even to look at the patient. Maybe everybody felt shy about discussing one disease in the presence of another.
"Try to get some sleep, Mrs. Takura. Everything will be all right." I glanced over my shoulder to see if the coast was clear. The nurses hadn't paid much attention to me, mostly because they were busy with a man in the opposite corner. He was wired up to an EKG monitor that showed a very irregular heartbeat.
The woman was still sobbing quietly by the bed of her heavily bandaged teen-age boy. He had a head injury, the result of an auto accident; the poor fellow never regained consciousness. I headed for the door, pulled it open, and went out. Day changed to night. The bright lights, the sound of the machines, the bustle of the nurses were suddenly cut off as the door shut behind me.
I was back in the hushed dark air of the hospital corridor. To my left, a nurse sat at her station, her face silhouetted by the light directly in front of her. Everything else melted off into darkness. I turned into a completely black corridor. All I had to do was turn to the right, go down the stairs, and cross the courtyard to my quarters. There was still time to get some sleep.
Suddenly a light flashed behind me, and a voice shouted, "An arrest, Doctor. There's an arrest. Come quickly!" As I turned around, the light evaporated, leaving scintillating blotches in the center of my visual field. Berlin blockade, Cuban missile crisis, Tonkin Gulf: crisis, all right, but not so close together or close to home. To me, this was a red alert, the type of catastrophe I dreaded most. My first thought was that I would be not only the first doctor to arrive, but also, since it was the middle of the night, perhaps the only one. Given a choice, I would have fled in the opposite direction, not worrying whether I was a coward or a realist. But there I was, running toward the patient, almost a cliche of the young intern dashing down a dark corridor with his stethoscope thrashing wildly in his tightly gripped fingers.
You've seen it all on television and movie screens, and it's thrilling — isn't it? — rather like the bugle call and the cavalry charge in the nick of time. But what is he thinking, this intern? It depends on where he's running. If it's pitch-black, he's trying to get there in one piece. Beyond that, it depends on how long he has been an intern. If not long, just a couple of weeks, then he's running scared — terrified, to be more exact. He doesn't want to be the first person to arrive.
Now he's there, a little out of breath but physically intact. His mind is another thing; what little information he owned appropriate to the situation has suddenly been drained out of his cerebrum by the shock of responsibility. Don't bother to learn drug names or dosages, the pharmacology professors insisted, just learn concepts. How do you tell a nurse to draw up 10 cc. of concept for a dying patient?
As I pushed open the ICU door, the weird world enveloped me again, and of course I found myself the only doctor there, quite alone with two nurses beside the bed of the man with the irregular EKG. While my mouth formed an inaudible obscenity, my fingers involuntarily clutched the side railing of the bed as if using it for support. I was no longer the television intern, but a real one, complete with inexperience and terror. Who would support me if this man died? The nurses? The medical-school professors? The attendings? The hospital? Most important, I had not yet learned to forgive my own mistakes.
Looking back at the door, I hoped against the odds that a resident would suddenly appear; it came home to me why many brilliant and dedicated students go all the way through medical school and then, facing internship, change course and switch to research or some paramedical field. Anything must be better than internship. Something's wrong here. Why can't the intern know something useful when he runs into the ICU during the first couple of weeks? And why don't the attendings back him up? Even the helpful ones are mostly no better than quietly aggressive. They seem to be saying, "We waded through all this shit. Now, goddamn it, you do it, too."
Well, I was doing it, here and now in the ICU, with no chance of any help, but this time I got lucky. The EKG monitor displayed on the oscilloscope showed a wildly erratic electrical impulse, like the scribbles of an irritated child. As its beeping sound rose higher and higher, to an extremely rapid staccato, I realized that the patient had slipped into ventricular fibrillation; his heart muscle was just a quivering, uncoordinated mass. Now I knew what to do; I would "shock" him.
Actually, the decision was not so much mine as the nurses'. Always a step ahead, they had the defibrillator charged up and one of them was holding the greased paddles out to me.