by Robin Cook
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 misleadin
g, 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.
"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 r
ubber 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 catheter, 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.