“I’m just a float,” the nurse replied, referring to the fact that she worked per diem shifts. “I’m meeting him for the first time, too.”
At the nursing station, I answered the page. A patient’s heparin drip needed to be renewed. I told the caller that I’d come by as soon as possible to write the order. Sitting down, I perused Schroeder’s chart. Caitlin had written an “event note” that afternoon, but it didn’t say much more than what she had already told me. When I called Schroeder’s family, hoping they could clarify his baseline mental status, his daughter told me in fluent English that he had a history of alcoholism but had never behaved anything like what I was describing. “He had an MRI of his brain this afternoon,” she said. Caitlin had neglected to mention that. “Can you tell me what it showed?”
Beep . . . beep . . . beep. Another page.
“I’m going to have to get back to you,” I said.
“When will that be?” she demanded. Beep . . . beep . . . beep. Fourth page in ten minutes.
“Listen, I’m sorry but I’m covering eighty patients right now,” I blurted out. “I will have to call you back.”
“It’s just that I live in Westchester and it takes me a half hour to—” she started saying before I hung up.
When I got off the phone, an attending physician in the nursing station took me aside. It was Jim Krank, a clinical trialist who specialized in acute leukemia and the withering stare. He was a chubby man with a brown, bushy toothbrush mustache. I had taken care of one of his patients recently, an elderly man with drug-resistant leukemia and fungal pneumonia. When the end was near, his son had tried to put restrictions on blood draws. “I know my father, and he didn’t want to live this way,” he had said. “The one thing he always prayed for was that he would go in his sleep.” But we quickly discovered that it was almost impossible not to draw blood from a cancer patient. Some reason or another always came up. Eventually his family instructed us to provide “comfort care,” which meant no needle sticks and a steady infusion of morphine. For a while, his condition seemed to improve, making Dr. Krank grumble thickly, “It always happens this way. Patients do better when we leave them alone.” It was the most devastating critique I had heard of the profession, and though I knew it was made flippantly, it still made me think: What is the point of all this? All the protocols, the chemotherapy, the transplants—what was the point of it if, in the end, the sickest patients, the ones we were beholden to help, or at least not to harm, were better off without us? My first instinct when the old man started getting better was to turn off the morphine drip, but Krank dialed it up even further. I was afraid he might stop breathing, but of course that was the whole point. It was called the law of double effect. It was okay for us to hasten his death in the service of treating pain and discomfort.
“The daughter doesn’t need to know how many patients you’re taking care of,” Krank said quietly, facing me down in the nursing station. I tried to explain but he cut me off. “The only patient she cares about is her father. So go check on that MRI.”
I instructed the nurse to administer another dose of Haldol and ran downstairs to the radiology department, which was deserted at this hour. “Nice lives these radiologists lead,” I thought bitterly. A resident was sitting in a darkened room in front of a workstation with a thick pile of radiographs. I asked him if he would look at Schroeder’s MRI with me.
“What’s the story?” he snapped, obviously annoyed by the interruption.
“Sixty-four, colon CA, delirious.”
“Liver mets?”
“Not that I’m aware of.”
“Any mets at all?”
“I don’t know.”
“Why’s he in the hospital?”
“Now? I don’t know.”
He looked disdainfully over his shoulder. “Look, I’m just covering for the night,” I protested.
“So am I,” he replied coldly. Another float.
The MRI showed an abnormal marking in the right cerebellum. Could it be a metastasis? “It’s nonspecific, but I guess you have to assume it is,” the resident said.
“So what should I tell the family?”
“Tell them the MRI was read by a floating second-year,” he replied, chuckling.
By the time I got back to the twelfth floor, Schroeder was fast asleep. “What should I do if he wakes up?” the nurse asked.
“Give him some more Haldol,” I replied. I had learned my lesson last month with Mrs. MacDougal. Best to have the drugs in the body before the shit hits the fan.
I called Schroeder’s daughter and told her that a preliminary reading of her father’s MRI showed a vaguely abnormal speck in the brain. Bracing myself, I informed her that the scan wouldn’t be officially read until tomorrow. To my utter surprise, she accepted this delay without objection.
On night float, you don’t stay in one place for very long. Pretty soon my beeper was in status epilepticus. There were orders interns had forgotten to renew: IV fluids, antibiotics, nutritional supplements. Patients on blood thinners needed to have their clotting times checked. Some patients required blood tests every six hours to monitor for “tumor lysis syndrome,” in which cancer cells rapidly die and flood the bloodstream with dangerous levels of potassium, phosphorus, and uric acid. At eight o’clock, I got called about fever spikes, which meant more patients to examine, chest X-rays to order, and blood and urine cultures to draw. As I pored over charts, my neck started to ache terribly, so I went to the call room and put my cervical collar back on. I furiously scribbled down tasks: type and cross-match blood, transfuse platelets, order MUGA scan, change antibiotics, replete potassium, add Bactrim, start fluconazole. The tiny boxes were proliferating on my sheets like the pox. By the time I got around to seeing my third febrile patient, my task list had doubled, more pages were coming in, and I had given up trying to examine every single patient I was being called about.
I did manage to see a few. I went up to the bone-marrow transplant ward on the twelfth floor. The first successful bone-marrow transplant was performed in 1968 to treat aplastic anemia, a kind of leukemia. Since then, the therapy has been used to treat many cancers and immunological conditions. Success has been tempered by complications, horrific problems in their own right: graft rejection, graft-versus-host disease (where the graft rejects the host), cirrhosis, infections, death. After these transplants, patients are often at risk for life-threatening infections. Many of them are “neutropenic,” with vanishing numbers of infection-fighting white blood cells, and some have “neutropenic fevers,” requiring long courses of intravenous antibiotics.
Bruce Diner had recurrent pulmonary infections, bronchiolar widening, and liver failure—complications of a bone-marrow transplant. He was sitting up straight, appearing anxious and short of breath. A pressurized oxygen mask was digging into his chubby cheeks, its oppressive whooshing sound barely modulated by the loud rock music coming out of his headphones. He needed a new liver and a new pair of lungs and was waiting to hear if his name was going to be added to yet another transplant list. Lara Rand needed platelets. Red, raw skin was peeling away from her neck, a consequence of graft-versus-host disease. No one knew why her platelet count was so low, but preparations were being made to remove her spleen in case the platelets were being sequestered there. Jane Glass’s skin was tightening in a scleroderma-like reaction, another consequence of graft-versus-host disease. Her face was like a mask. “I’m so confused,” she sobbed when I went to see her. “Yesterday they told me I’m dying; today that I’m getting better.”
Around 9:30 p.m., I went to the Department of Medicine library, where it was quiet, to answer another flurry of pages. A Mediport catheter had just blown and the nurse and the IV team had been unable to draw labs, which meant that I was going to have to do it. I was steeling myself for the patient’s likely reaction to another hospital worker showing up at his bedside with a needle. “They should really teach us about this tumor-lysis stuff,” I said angrily to the other night-float
intern, a stocky Korean who was watching Ally McBeal. I couldn’t believe he wasn’t running around madly like me.
“It was in the packet,” he said, gazing at the TV. “Yeah, it went through everything you need to know, how you’re not supposed to give calcium, when to draw labs, et cetera, et cetera.”
I shrugged, annoyed. “They should still teach us about it. Not everyone has time to go through the packet.”
There were two kinds of interns at Memorial: those who were planning on specializing in oncology and those who couldn’t tolerate the subject for even a month. My fellow night-float intern, it turned out, was in the latter camp. He was planning on specializing in infectious diseases and was eager to get back to New York Hospital.
“Everyone around here is enrolled in a research trial, but have you seen the way they get informed consent?” he said at the commercial. “The fellows are walking up to patients who are encephalopathic, and they’re handing them a sheet of paper and saying, ‘This is the protocol that we talked about. Now sign here.’
“They gave a Jehovah’s Witness a bone-marrow transplant across the street,” he went on incredulously. “She said that there were absolutely no circumstances under which she would accept blood transfusions. Now tell me, how could they in good conscience do that? She’s saying, ‘Under no circumstances will I accept a blood transfusion.’ They should be telling her that there is a 99.9 percent chance that you will need a blood transfusion. I mean, have you ever seen a transplant patient who didn’t get a blood transfusion? They’re giving that 0.1 percent chance and presenting that as a reality, and what is a desperate patient supposed to say? ‘Yeah, I believe in God, I’m going to be in that 0.1 percent group.’ They should have told her, ‘If we give you this treatment, there’s a 90 percent chance that we will shorten your already short life span by three months.’ ”
He went on to tell me about an elderly woman with pancreatic cancer that had grown into her bile duct and metastasized through her GI tract. She had been through several rounds of chemotherapy without success and was ready to quit treatment but was afraid to tell her oncologist. “She told me, ‘I don’t want him to think I’m giving up.’ Can you believe it? She didn’t want to let him down! The last thing she needed to feel guilty about was wanting to die at home. So I told her, ‘Why don’t you have a talk with your oncologist?’ But she couldn’t do it. So when it came time for a biliary stent procedure, which everyone knew was going to be futile, I called the interventional radiologist and said, ‘She has a couple of months to live. Tell you the truth, I’m not even sure of that, and she doesn’t want the procedure, and neither does her daughter, but they’re not able to tell their oncologist.’ I presented it like, If she dies, they’re going to come after you, and I got the response I wanted, which was, ‘It doesn’t sound like such a good idea. Sounds like the risk is too high.’ If I had presented it a different way, I probably would have gotten a different response.
“So then I went to the oncologist and told him what the radiologist said and he said, ‘Fine, send her to hospice.’ I think he knew I was putting up roadblocks, trying to prevent him from doing what he wanted, but at least I prevented him from giving her any more chemo.
“She died two weeks later at home. One day this woman comes up to me on the ward. She had been the woman’s hospice aide. She told me that the patient made her promise that the day she died, she would come find me and tell me. She said my patient wanted to thank me for encouraging her to die the way she wanted to.”
A short while later I was called to the room of a middle-aged man with colon cancer who had started bleeding profusely from somewhere in his intestinal tract. His wife, grim-faced, was at his bedside. Large gobs of tarry stool were sitting in a bedpan. The muscle had eroded from his upper body, making his neck appear unusually long, like a swan’s. He eyed my cervical collar with an affected curiosity. “Looks like you need a doctor,” he said, forcing a smile. Cancer had cast its long shadow over everything in the room except him.
Unable to localize the site of the bleeding, doctors had been giving him radiation therapy to his entire gut. In the dim, yellow light his wife started asking me questions, but I knew so little of his complicated case that there wasn’t much I could tell her. The results of a recent CT scan, the most likely sites of the bleeding, when he might go for further radiation therapy—all that information was deep in his chart, and in the mind of his sleeping resident.
Then I went to see a patient with intractable hiccups. Several months before being hospitalized, he had begun vomiting after meals. An upper endoscopy revealed esophageal cancer. Walking into his room, I felt almost relieved. After what I had been dealing with so far that night, hiccups seemed almost laughably unserious. But as with everything at Memorial, these were no ordinary hiccups. They had been going on for over twenty-four hours, leaving the patient sleepless and utterly demoralized. “These hiccups are killing me dead, night and day,” he said.
I didn’t know what caused hiccups, let alone how to treat them. When I asked a nurse, she mentioned that a drug called chlorpromazine was sometimes used, so I wrote an order for it. Walking through the nurses’ station, I casually checked the patient’s chart. There, amid his papers, was a brief note. He had once suffered a severe reaction to chlorpromazine. It wasn’t documented as an allergy but was scribbled in a progress note. I immediately canceled the order, relieved that I had caught the mistake in time but alarmed at how easily it might have slipped through the system. (Later, I realized that if the hiccups would have yielded to such a simple solution, it would have been attempted already.)
That was the thing about night float. You were taking care of patients about whom you knew next to nothing. Night float was like walking along a narrow mountainous ledge. As long as you looked straight ahead, oblivious to the height, you were okay. But every now and then, you had to look down.
Patients, too, hated the night shift. They wanted answers; it didn’t matter to them that you were just covering for the night. I went to see an elderly woman. “The doctor told me that I needed surgery next week,” she said. (Actually, it was a bronchoscopy, where a flexible tube is inserted to inspect the trachea, but in her mind there was no distinction.) “Do you know anything about it?”
I said I didn’t.
“They say they see this mass on my chest X-ray and want to evaluate it. I’ve had this mass for years and now they want to do surgery? Why?”
I told her I didn’t know but that she could bring it up with her doctor when he returned in the morning. “I tried already, but he wouldn’t say,” she replied. I tried to leave but she stopped me. “See, I just want to know, why would a doctor come in and tell me what none of my doctors ever mentioned before? It doesn’t make sense.” I nodded. “Can you explain it?” I said I couldn’t. “But why would he say it?” she persisted.
“If you don’t want the surgery, you don’t have to have it,” I said. “Remember, it’s your body.”
“Yes, that’s right,” she said, settling back into bed. “Thank you.”
I could only imagine how disruptive my ill-informed remark had been the following morning.
Later that night I was paged because a leukemia patient wanted to ask me a question. When I finally got around to seeing him, it was almost 2:00 a.m. He was an obstetrician from New Jersey who had been admitted to the hospital because of a leukemia flare, an acute “blast crisis,” where the bone marrow starts to churn out leukemic cells (myeloblasts) at a prodigious rate. He had received the usual chemotherapy cocktail, until he became short of breath and doctors discovered a large collection of malignant fluid in the space around his heart. Surgeons had drained the fluid with a needle. Now he was awaiting a CT scan to see if the pericardial membrane needed to be stripped away to prevent further fluid accumulation.
But it hadn’t been signed out to me that he needed the CT scan tonight. He was sitting in a chair, wearing flannel pajamas and a gray T-shirt. His temples were wasted, imparting a
forlorn look. The sign on the door read CONTACT ISOLATION. I stepped inside the room, being careful not to touch anything.
“I’m supposed to be going for a CAT scan—” he began.
“It’s not going to happen tonight,” I interrupted.
“Why not? Is the scanner being used?”
“No, at least . . . I don’t know, but they don’t do nonemergent scans in the middle of the night.”
“Then why do they keep telling me I’m going for this test? They keep telling me that they need to rule out constrictive pericarditis. They’re talking about pleurodesis. Doesn’t that qualify as an emergency?”
“I’m not your regular doctor so I can’t say,” I replied lamely. “It wasn’t signed out to me to have it done tonight so it’s going to have to wait until the morning.”
“God, I’m going to have a nervous breakdown if I don’t get out of here. I’ve been here since July.”
Beep . . . beep . . . beep. “I’m sorry, sir,” I said, holding up my pager.
“It doesn’t matter to them that you’re a doctor. You’d think it would make a difference, being an insider, but it doesn’t. You’re still at their mercy.”
“I’m sorry but—”
“This is a fine institution,” he went on, undeterred. “I’ve been fortunate to be here, but there is no coordination—”
“I’m sorry, sir, but I have to go,” I said, and left.
On night float, things sometimes happened in clusters. That night at Memorial was the night of the falls. First, I got called about Mr. Gurvitch, whom the nurses found kneeling on the floor next to his bed. He said that he had been walking to the bathroom when his knees buckled. “Does he need a CAT scan?” a nurse inquired. The patient insisted that his head hadn’t touched the floor, so I told the nurse that a CAT scan wasn’t necessary. I ordered the patient to remain in bed for the rest of the night.
A half hour later, he face-planted into the windowsill. Back in his room, I found him sitting in a chair, dabbing dark droplets of blood from his nostrils. Apparently he had again tried going to the bathroom but had again gotten dizzy. I was pretty sure his nose was broken. Now, there was no question that he needed some sort of imaging study. I phoned the radiology department. No answer. I tried again, this time letting the phone ring for several minutes. Someone finally picked up. “I need a complete facial series stat!” I cried.
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