“Call me when you’re done,” he said without turning around.
“What’s your number?” I shouted, but he was already gone.
A burly technician with tattooed arms came out of the room. “Okay, Doc, bring her in,” he said.
I rolled the stretcher up to the radiology table. Mrs. Williams was now even more tangled up in wires and tubes. Her rumpled gown was slipping off her shoulders, exposing her breasts. The pulse oximeter had long since come off her finger. One of her IV lines had somehow made its way between the side rails. I disconnected it, looped it back over the railing, and quickly reattached it before any of the medicated fluid dripped onto the floor. The technician pumped on a pedal below the stretcher, raising it to the same level as the scanner. Then I pulled on a latch and lowered the side rail. “Give me your hand, Mrs. Williams,” I said, reaching across the gantry.
“Hold on, Doc,” the tech said. “We’ve got to give this line some slack or her IV is going to come right out.” He pulled the metal pole in closer, but it didn’t look like the tubing was going to be long enough. He stared at it for a few seconds. “Can we stop the drip?” he asked.
“Sure,” I replied automatically. Which drug couldn’t be stopped for just a few minutes?
I disconnected the line and reached again for Mrs. Williams’s hand. “Doc, she’s going to need some help.” He went and got a white sheet. “Okay, pull her onto her side.” As her face pressed up between the rails, he quickly tucked the sheet under her body and rolled her onto her back. Then we grabbed the sheet on each side and slid her over onto the scanner table.
“This is only going to take five minutes,” I said, patting her on the hand. The tech and I went into the tiny control room. “Don’t you want to be able to see the monitor?” he asked me, taking a seat at the console. “Yes, of course,” I said. I ran in and turned it around.
Digital images of my patient’s head soon appeared on a computer screen. “What is the scan for?” the tech inquired, adjusting a knob. After a pause, I said, “I’m not sure.” In all the excitement, I had forgotten to ask.
The first images looked okay. Now it was time for higher-resolution cuts.
“She’s got to lie real still for this next scan,” the tech said.
I peeked into the room. Mrs. Williams’s head was still in the scanner. “Try not to move, ma’am. We’re almost done.”
She groaned loudly. “I don’t feels so good. Oh Lordy, I don’t feels good.”
“What’s the matter?” I asked.
“My chest is hurtin’,” she said.
Just my luck. Only one more pass through the scanner and now she was having chest pain? “That’s okay,” I said. “Just try to keep still.”
She shifted her weight uncomfortably. “But I’m getting these pains in my heart.”
“We’ll take care of it once the scan is finished. You don’t want to have to come back here, do you?”
She didn’t answer.
“So please just lie still for a couple of minutes so we can finish up.” I was focused on completing the scan, whatever the indication for it was.
“Let’s do it,” I said, returning to the control room.
“You sure, Doc?” the tech replied skeptically.
“Yes, I’m sure,” I snapped. The tracings were fine; her heartbeat was regular. Tasks were piling up back in the CCU. I did not want to have to bring her back.
Midway through the final scan, she started moaning. “Oh Lord, oh my!” “Thirty seconds,” the tech said, his eyes peeled to the screen. The mumbling got louder and her feet started shifting from side to side. “Oh Jesus, help me!” she groaned. “All right, Doc,” he said, punching off a lit button. “I think we got what we needed.”
We pulled Mrs. Williams back onto the stretcher. “Oh Lord, oh Jesus, get me out of here!” she wailed. I clenched my teeth to keep from laughing. For a moment the whole situation seemed rather comical. What was I doing here in the middle of the night, in this abandoned corner of the hospital, with this tattooed technician and this helpless old lady? The whole road trip had been so nerve-racking. I was just glad that it was over.
I quickly reconnected the IV line and turned the machine back on. Beep . . . beep . . . beep. I turned the machine off and tried again. More beeps and a red light started to flash. I tried silencing the alarm but it kept ringing. The rotors started whirring in my head. The IV had been delivering nitroglycerin. Nitroglycerin is used to treat angina. I turned the machine off and tried again. Angina means decreased blood flow to the heart. I punched the buttons on the front panel. Decreased blood flow can cause chest pain. I squeezed the bag, trying to get the drip restarted, but all I got were more flashing lights. Then it hit me square in the gut: My patient was having a heart attack!
Her moans and the alarms mixed into a dissonant instrumental. I spun toward the tech. “Do you have any nitroglycerin?” He looked at me like I was a lunatic. I flipped open the code box the nurse had given me. There were vials of lidocaine, epinephrine, atropine, saline. No nitroglycerin. Dammit, I screamed in my head. Steve had told me to carry a bottle with me at all times, but I had ignored the advice.
Now I was in a full-blown panic. “I have to get her back to the unit,” I cried. “Can you call Transport?”
“I already did,” the tech replied, nonplussed. “But he said it would take a few minutes.”
“I can’t wait. Can you help me bring her back?”
He looked at me helplessly. “I can’t leave, Doc. I’m the only one here and there’s another patient on the way.”
I grabbed the IV pole and the back of the stretcher and started racing toward the elevator. “Tell Transport to catch up with me,” I shouted. I swerved, barreling into a chair, backed up, and tried again. If she dies, this is going to be your fault! I screamed in my head. You’ll be fired. Risk management will have to get involved. How did you get yourself into this mess? Why did you insist on finishing the goddamn scan?
“You’re going to be okay, Mrs. Williams,” I said, trying to mollify her as she started to shriek. “The nurses are going to give you some medicine and you’re going to be just fine.”
We got to an intersection. Which way? Earlier we had turned left, so now I had to turn . . . right. Simple calculations were eluding me. For a moment I thought about stopping to call a code. But where was I? It was the middle of the night and I was in the middle of a vacant corridor. How were you supposed to call a code anyway? Who were you supposed to ring? Where were the phones? God, I prayed, if you get me through this, I’ll be a better doctor. I’ll take things more seriously. Please, just let me get through this night.
Back at the freight elevator, I struck the button furiously and the doors opened. On the ride down, her cries were deafening. When the doors opened, I saw the escort. He appeared to be waiting for me. “Oh, thank God,” I cried. “Help me get her back!” Without a word, he took the back of the stretcher and we raced it back to the CCU. On the way there, I tried to explain what had happened. “I stopped the nitroglycerin drip, and she started having chest pain, but then I couldn’t get it restarted.” He didn’t appear to be listening. This was my mess, and he seemed to want no part in it.
When we rolled into the CCU, three nurses materialized immediately. Evidently the tech had called ahead to tell them I was on the way. “We couldn’t get her into the scanner,” I said breathlessly. “I stopped her nitroglycerin. I couldn’t get it restarted. Maybe there’s air in the line. It’s her nitroglycerin. She’s having chest pain.”
“We’ll take care of it,” the nurse who had sent me out forty-five minutes earlier said calmly. I wasn’t prepared for her sympathetic tone, and almost instantaneously tears filled my eyes. I felt guilty, undeserving of her empathy. “I stopped the nitro and she started having angina,” I said again. “I didn’t know what to do, so I brought her back.”
“You did the right thing,” the nurse said. “We’ll take care of her.”
I was so on edge th
at I felt numb. I hovered as the nurses whisked Mrs. Williams back to her room. As they got her into bed, I continued trying to explain my actions from the door. “We finished the scan. I probably shouldn’t have disconnected the IV.”
“It’s okay,” the nurse said. She smiled broadly. “Congratulations. You just made your first road trip.”
When the nurses restarted the nitroglycerin drip, Mrs. Williams’s angina subsided. Before long she was lying in bed comfortably. I was right, there had been a small air bubble in the line, making the machine turn off automatically. For a while I lingered outside the room, peeking through the curtain to check on her. Finally I slipped away. She was in good hands now, much better than mine.
I wanted to run away but there was nowhere to go. Back at the workstation I tried checking labs but I couldn’t concentrate. There were still a slew of tasks to complete. Soon Steve was going to start walking around the unit to make sure everything was done, and after that I was going to have to print up flow sheets and start prerounding. I stared at my reflection in a glass door. The veins were popping out on my glistening temples. The image ricocheted off the glass door behind me, trailing off to infinity.
In semiconductor physics, there is the concept of an electron-hole pair. A hole is the absence of an electron. It is not a real particle, though it behaves like one. It is a shadow particle, a phantom, behaving exactly opposite to an electron. Gazing at my reflection, I was struck that in some fundamental way I had become a hole, a shadow of my former self, behaving antithetical to my true nature. I was a thinker, not a doer. This was too much doing for me. I was beginning to appreciate what it was going to take to make me into a doctor—into a man.
CHAPTER SEVEN
first death
The patient, it seems, is not so well sleeping.
The screams echo off the walls.
—THE VELVET UNDERGROUND, “LADY GODIVA’S OPERATION”
A middle-aged woman wearing navy blue slacks and faux pearls emerged from one of the CCU rooms. “Can someone come take a look at my husband?” she hollered. Since I was on call again, that someone was going to have to be me.
“What’s the matter?” I said, remaining seated at my computer.
“He’s twitching,” she said insistently. I looked over at the telemetry monitor. The tracings looked fine. The pulse oximeter was reading 100 percent. Earlier in the day, there had been a cardiac arrest on the tenth floor, six flights up. When I arrived at the code, one of the residents was up on the rolling stretcher, straddling the dying man, riding him like a jockey, thumping on his chest all the way down to the CCU. During the subsequent code, I briefly performed chest compressions but the patient died anyway. Afterward, my scrubs bloodied, I had to go upstairs to the surgical suites to get a new pair. Now it was late in the afternoon. My progress notes weren’t written, labs weren’t checked, and Amanda and Nancy, my co-interns, were getting ready to sign out. The code had ruined the flow of the day. I didn’t have time to respond to every little twitch.
“I’ll be there in a minute,” I said. I picked up the man’s chart. He had been transferred to New York Hospital from a hospital in Brooklyn. The transfer summary, scribbled in chicken scratch by an intern at the other CCU, indicated that Alexander Jusczak, a fifty-five-year-old resident of Coney Island, had been getting ready to go on vacation when he collapsed on the driveway outside his home. His wife found him unconscious and called 911. When paramedics arrived, they performed CPR and inserted a breathing tube into his airway, reviving him briefly. He was taken to a local hospital, where he apparently had had another cardiac arrest (here the details were vague). Cardiac catheterization revealed a total blockage of the left anterior descending coronary—the so-called widow-maker lesion, often afflicting middle-aged men and often fatal. The entire front portion of his heart wasn’t moving. Cardiologists inserted a special “balloon pump” to assist the heart and transferred him to New York Hospital, known for its cardiac work, for angioplasty.
No mention was made about whether he had ever regained consciousness.
As I was reading all this, his wife came out again. “Isn’t there a doctor who can see my husband?” she cried plaintively. I signaled that I was coming. “Please! He needs help!” I quickly followed her into the room. Her husband was lying naked, unconscious, with catheters in his groin, penis, arms, and neck. His abdomen was mottled and distended. Stubble coated his chubby face. A thin plastic tube filled with green liquid slithered across the bed and up into his nose. At the bedside a special monitor recorded each inflation and deflation of the pump.
“There! Why is he doing that?” she demanded. His left eye winked playfully while his lips quivered. I took out my penlight and shined it into his pupils, but they did not react. I tried shaking him but he did not respond. I placed my hand on his cheek, trying to dampen the fine oscillations, but they persisted.
Her eyes were trained on me. Reflexively, I removed the stethoscope from around my neck and placed the bell on his chest. His lung sounds were coarse, indistinct. The pump in his chest sounded like a piston in a car engine. I stared at the monitor. I wasn’t sure what to make of all the data.
His wife broke the silence. “Why is he shaking?”
“I’m not sure but I think he’s having a seizure,” I replied. I suddenly felt burdened, like I was carrying a secret I had to unload. “Please wait here. I’ll be right back.”
The unit was moving at a languorous pace befitting a late Friday afternoon. Sunlight seeped through the window blinds, reflecting brightly off the hard counters. This was California weather, and memories of my previous life came flooding back. Friday nights in Berkeley, my lab-mates and I would go to the Bison Brewery on Telegraph Avenue and sit around for much of the night sipping wheat beer, playing pool, talking about physics, philosophy, and politics. The goofy guy with the depressed girlfriend who was taking Prozac. The bad-boy physicist from Holland who had a penchant for double espressos and hand-rolled cigarettes. Fridays had always filled me with such a wonderful sense of expectancy. Now I was just dreading another night on call.
At the other end of the unit, Rajiv was gabbing with Joe, a first-year fellow. “I need some help,” I called out. Rajiv raised his forefinger and continued talking. “Now!” I shouted.
Back in his room, Jusczak was still twitching, and momentarily I felt relieved that Rajiv and Joe were there to see it. The tics were like petulant scowls, not unlike a Tourette’s spasm. Joe immediately asked Mrs. Jusczak to step outside. “Is it a seizure?” I asked timidly. Joe nodded, tapping on his forehead. “He probably burned some rubber with the cardiac arrest,” he said.
Uncontrolled seizures can damage the brain within minutes; they must be treated immediately. Joe ordered a nurse to administer fifteen milligrams of Valium. When she did, the seizures subsided. “How long has this been going on?” he demanded.
“A few minutes,” I replied hesitantly.
I went to check the patient’s labs. I scrolled down a computer screen, looking for anything unusual. Then I noticed something highlighted in red. Jusczak’s blood sodium concentration was 153, well above normal. High serum sodium can cause neurological impairment. The brain does not like sitting in salty fluid. Like a celery stalk, it will shrink as water diffuses out of it by reverse osmosis. If this happens quickly enough, seizures can result. With nothing else to go on, I concluded that this was probably what had caused the seizures (though it was hard to be sure).
Back in the conference room, Amanda and Nancy were waiting patiently to sign out. “How did we miss it?” I heard Carmen say when Joe told him the sodium level. Joe shrugged and shook his head. “Nobody checked the labs,” he replied. Of course, checking Jusczak’s labs had been my responsibility, but I had been too busy doing other things. I sat down, saying nothing. Amanda and Nancy started handing off their patients to me. Carmen, who was getting ready to leave for the weekend, told Joe to update him that night.
Most seizures terminate with intravenous sedat
ives, and Jusczak’s did too, for a while. But at midnight they started up again with a vengeance. Now they involved not only Jusczak’s face but his hands and feet, too. His eyelids were clenched shut. I tried prying them open but my fingers slipped on his oily skin. His mouth appeared to be emitting silent screams. The telemetry sirens wailed: ding-ding-ding. We pushed more Valium, then Ativan, then an intravenous load of Dilantin, an antiepileptic. Again the seizures stopped, but they resumed within minutes with seemingly greater force. Joe told a nurse to give free water through the nasogastric tube to dilute the salty blood. We paged a neurology consultant, who came by and suggested phenobarbital, which worked, but only briefly.
I spent most of the night at Jusczak’s bedside with Joe and a nurse. The bright ceiling lamp illuminated his naked body like a spotlight. Sweat drenched my T-shirt; my thighs were sore from standing. Every movement took energy I didn’t have. When Joe went out to call an anesthesiologist, I started pushing drugs on my own. I was amazed at how easily my confidence flowed when it became clear that we were fighting a losing battle.
The convulsions seemed to gain in force and amplitude with the passage of the night. Over several hours, the sedative drips were dialed up well beyond the maximum limits in the textbooks. Eventually his whole body was quivering like a bowl of gelatin. We tried everything: glucose and thiamine, useful for hypoglycemic and alcoholic seizures, which he didn’t have; Versed, a potent benzodiazepine, which paradoxically seemed to fuel the spasms; a cooling blanket, because there was some evidence suggesting that hypothermia could prevent brain damage after cardiac arrest. It was a reach, but we didn’t know what else to do.
An anesthesiologist eventually showed up and put Jusczak on propofol, a milky white anesthetic. The seizures immediately ceased. With the propofol running into his body, they never resumed.
The nurses had put Mrs. Jusczak into an empty patient room. I found her there at four in the morning, sprawled on her stomach, still in her business suit. The room was musty, though with the faintly pleasing odor of perfume. I thought about waking her to give her an update but decided to let her be. Her husband almost certainly had irreversible brain damage at this point, and I did not want to provoke an outburst so early in the morning. I pictured her at his funeral, walking beside his coffin, wearing a black veil. I pictured the pallbearers in their black suits. I shuddered thinking about what had occurred over the past twelve hours.
Intern Page 10