Intern

by Sandeep Jauhar

  “Can’t we still make him DNR?” I asked. I had read somewhere that two physicians could issue a DNR order against a family’s wishes if they thought further resuscitation attempts were going to be futile.

  “It isn’t easy,” Morales said gravely.

  “There are very strict criteria.”

  “What about taking him to court?”

  Morales replied that the courts, with their adversarial approach, were not the right place to resolve these kinds of disputes. “Call Dr. Batton and see what she has to say,” he suggested.

  Some primary care doctors regularly came to the ICU to see their patients, but Dr. Batton wasn’t one of them. When I called her, she said she had tried talking with Williams’s brother on many occasions, but he had been equally intransigent with her. When I asked her about issuing a DNR order over the brother’s objections, she suggested I speak with the hospital’s legal department.

  When I called that department, a staff member told me that two physicians could issue a DNR on the basis of futility, but that the definition of futility was very narrow. Two physicians had to agree that even if the patient were resuscitated, he would still die imminently. “In our experience, it’s hard to get two physicians to agree to that,” she said.

  She added that the only way to withdraw medical care from a patient without decision-making capacity was at the behest of the patient’s health care proxy—and then only if there were clear evidence of the patient’s prior wishes. There was no way to withdraw care on “moral grounds”—for example, on the argument that a patient has no quality of life. “The department is very concerned about imposing medical judgments against a family’s wishes,” she said.

  Over the next couple of days, Williams made no spontaneous movements. He remained unresponsive to painful stimuli. He made no spontaneous respiratory efforts. He had no gag or corneal reflex. His deep tendon reflexes were completely absent. A couple of nights later, he had another cardiac arrest when I wasn’t in the hospital. This time, an intern nearly got stuck with a needle during the resuscitation. The next day, I heard Morales talking on the phone with the legal department. “This patient is a high exposure risk,” he said, seething with frustration. “We can’t keep resuscitating him. Someone is going to get stuck with HIV.”

  Because Williams was still in a coma, Morales decided to perform an apnea test. In this test, the ventilator would be disconnected to see if Williams made any effort to breathe on his own. If not, he could be declared brain-dead and be removed from life support. When Morales placed a call to Williams’s brother to explain the purpose of the test, the brother hung up.

  The following afternoon, Williams was hyperventilated for ten minutes and the ventilator was disconnected. After a few minutes, a blood gas measurement showed a precipitous rise in the carbon dioxide level, signifying severe acid buildup. Despite this powerful respiratory stimulant, Williams did not take any spontaneous breaths. After several minutes, the ventilator was reconnected and the test was repeated, with the same result. Morales tried calling the brother to inform him of the results, but the line was busy. When he asked an operator to intervene, he was told that the phone was off the hook. An emergency telegram was sent.

  Now we could act, but Morales wanted to move cautiously. He asked for a note from Patient Services ratifying the decision to withdraw life support. A representative from that department came by and wrote that it was “clinically inappropriate and disrespectful” to continue to resuscitate Williams. Morales himself wrote that Williams’s condition was “hopeless” and that further cardiopulmonary resuscitation would be “futile.” Morales even called a neurologist to perform a confirmatory apnea test. Nigel Caldwell had a crisp British accent and a sharp, decisive manner. In the ICU, he was known as the executioner. After evaluating Williams, he wrote: “The patient has failed the apnea test. He has had three cardiac arrests. It is inappropriate to resuscitate a patient who has failed test #1 it goes against the natural course of illness.”

  He performed another test anyway. This time, Williams’s carbon dioxide level rose to ninety, more than twice normal. After ten minutes, he had still made no attempt to breathe. The doctors watched for an awakening, but there was none. At seven-fifteen in the evening, he was finally declared dead. His brother declined an opportunity to view the body.

  ON MY LAST WEEKEND in the ICU, I rounded with Isaac Sweeney. Dr. Sweeney was a portly, avuncular attending physician with a mischievous grin. Despite the miseries of the ICU, he always maintained a relentlessly upbeat manner.

  It was a brilliantly sunny day, perfect weather for sailing. Midway through long, protracted rounds, Sweeney called us over to a window. He pointed down at a sailboat on the river. A man was standing on the deck, looking up at the hospital. He looked like he was about Sweeney’s age, though fit and tan. He was holding a drink, and a party was going on onboard. “See that guy?” Sweeney said. “Do you know what he’s thinking?”

  No one ventured a guess.

  “He’s thinking, ‘I should have been a doctor.’ ”

  Before I left, I surveyed the unit one last time. I had seen so much over the past month; things I had never seen before, that I had never expected to see. I had changed. And yet I was leaving the place essentially as I had found it.

  CHAPTER TWENTY

  gentle surprises

  The most essential part of a student’s instruction is obtained, as I believe, not in the lecture room, but at the bedside.

  —OLIVER WENDELL HOLMES

  The monthlong rotation in the ICU was a turning point. Like a phase transition, the transformation was almost imperceptible, yet the results were striking. When I got back to the wards I discovered a level of comfort I could never have imagined as an intern, or even early on in my second year. I was actually looking forward to going to the hospital each morning—devising a plan for my patients, conferring with attending physicians, “running the list” with my interns, holding teaching rounds with medical students (“That’s your differential? Major depression? What about autoimmune disease, vasculitis, tuberculosis, lymphoma . . . ?”). New admissions no longer generated armpit-drenching anxiety. Palpitations and dizziness? No problem. Altered mental status in the setting of prostate cancer? I could handle it. Of course, I was following established protocols, but it was becoming clear to me that clinical medicine wasn’t just cookbook algorithms, as I had once imagined. There was a discretionary element to it that could not be captured in a flow chart or a decision tree. It was a bit like chess: the openings had long been worked out, but you could still improvise. As a doctor, how you talked to your patients, guided them, advocated for them, was up to you. That was how your personality could be expressed.

  Ward rounds in the morning were a mad dash with my interns and students in tow. With usually twenty or more patients to see, the visits were mostly flybys during which I would interrogate patients about their symptoms and overnight course while my interns scribbled down tasks for the day: “consult Psychiatry,” “curbside Renal,” “check sodium at 4:00 p.m.,” “inject urokinase into loculated pleural effusion.” We got adept at getting in and out of patients’ rooms quickly, efficiently, not making them feel like we were dismissing their complaints but really saying and doing very little at the same time. Each case had a teaching point, so most mornings I had my medical students prepare a topic to discuss on rounds: lupus pneumonitis, lithium toxicity, cortisol stimulation testing, respiratory stuff. After almost a year and a half of residency, I no longer felt insecure about the gaps that remained in my knowledge base. The set of unknowns was shrinking, and the fact that there was still so much to learn actually energized me. Ignorance was no longer the bugaboo it had once been. It now served the opposite function: it gave me hope.

  There was that time in the early evening when patients were settling into bed, watching television, when I felt the most comfortable; that was when I felt the hospital was a village, and I most enjoyed making my rounds. The lights were on; pa
tients were fed, getting ready to turn in for the night. It was the best time to visit, the time in the day when you were least likely to encounter rancor or resistance. Patients had accepted their stay in the hospital—and so had I.

  At the same time, I felt more relaxed with my resident colleagues, chatting with them in the corridors or commiserating with them over bagels and coffee at morning report. “Six-hitter last night,” someone might say, and I would grin and empathize, proud to be a member of a clique that knew exactly what those words meant. (Admitting six patients in one night was quite a feat.) The struggles of ward life forged bonds—not friendships always, but a kind of intimacy that was accelerated by the daily grind. Finally, after so many years, I was beginning to feel connected—to the same people from whom I had previously felt so estranged.

  I was also beginning to participate more in the social life of the hospital. Something as simple as running to the coffee stand with my interns after rounds became an activity I looked forward to intensely. One morning, Lane, a stocky Australian intern with long sideburns and a Captain America haircut, said to me: “This is the first time I’ve worked with people that I like. You’re the first person above me that I haven’t feared.” Some nights I’d lay awake, smiling at a joke someone had made on rounds or recounting to Sonia the antics of a member of my team, like the medical student who did a great impersonation of a fat man with abdominal pain. At first I disapproved, but he was hilarious, and in the end I succumbed to the humor like everyone else. Doctors make fun of patients for many reasons. Sometimes as a defense mechanism, and sometimes just because they can. Though I was lapsing into some of the same behaviors I had once found objectionable, I rationalized it by telling myself that the job would suck if you didn’t have fun with the people you work with.

  One week, I was assigned to work the night shift in an emergency room in the South Bronx. The hospital, affiliated with New York Hospital, was in a neighborhood not far from where Son of Sam, the serial killer, started his murderous spree in 1976. Some nights when I was sipping coffee in the ambulance bay during my break, I could hear the rat-a-tat-tat of gunshots. In the emergency room, it was not uncommon to encounter drunks swinging at nurses, drug addicts shouting, and handcuffed prisoners under armed escort.

  It was my job to try to drain excess fluid from the belly of a young woman with alcoholic cirrhosis. I hadn’t done an abdominal paracentesis in over a year; the last time was on 10-North, when the catheter had fallen out of the patient with AIDS and I had almost stuck myself. This time, I set up my instruments carefully: catheter-tipped needle, rubber tubing, plastic buckets. When I was ready, I cleaned the woman’s belly with iodine soap. She shivered; it was cold. Then I pierced her abdominal wall with the catheter and started filling the buckets. Midway through the third bucket, I got paged. “Whatever you do, don’t move,” I said to my patient, whose breath still smelled of alcohol. “I’ll be right back.” If the catheter comes out, I told her, I wasn’t going to put it back in. She nodded. I left the room and stopped by the nursing station. “Just keep an eye on her while I’m gone,” I told a nurse.

  I was away for only a couple of minutes. When I returned, the buckets were upturned and puddles of liquid were all over the floor. The catheter was out, and the drain tube was coiled uselessly on the tiles. “I told you not to move,” I said angrily, tiptoeing across the mess.

  “I didn’t,” my patient replied unconvincingly. “A man came in here and had a seizure on the buckets.”

  Exasperated, I stalked out to the nursing station. “I thought I asked you to keep an eye on her,” I said to the nurse.

  “I did,” she replied, “but then a man wandered into the room and had a grand mal seizure on the buckets.”

  Another night I was assigned to the midnight–4:00 a.m. shift in the “salon de asthma,” a treatment room in the back of the ER. The hospital opened it in response to the mysterious rise in asthma in the Bronx, where the prevalence once was eight times as high as the national average. (Today it has declined, probably because of more vigilant monitoring and treatment.) Patients could walk in right off the street and get treated without unnecessary delay. The largest influx occurred at dusk when teenagers started filing out of neighborhood playgrounds and basketball courts and sought help for asthma attacks brought on by exercise.

  In the large room, patients were sitting on purple chairs of cracking vinyl, inhaling a mist of albuterol, a drug to open airways, from plastic pipes connected to oxygen outlets in the wall. A nurse was there, administering medications and checking vital signs. “In the asthma room, the patients don’t fight,” she told me during a lull in the activity. “The tough guys are outside, the drunks. They always want to bite us, to cut us. Here it’s different. Here everybody gets along.”

  The atmosphere actually was more like a party. At 3:00 a.m., two middle-aged men—one having his first asthma attack in twelve years, the other a “frequent flyer”—were in rapt conversation. A young woman—not wheezing, just “a little tight”—was walking in and out of the room, talking on her cell phone. Near the entrance, one of the patients, a fifty-two-year-old man, started doing a stand-up routine.

  Dressed in jeans, a plaid shirt, and white sneakers, he delivered his lines in Spanish with Seinfeldian exasperation. His audience wheezed its approval. Between laughs, the patients translated for me. He was telling them about the time he was riding on the train, chewing gum. When he tried to spit the gum out the window, out flew his false teeth.

  A sixty-four-year-old homemaker from the Bronx, a regular visitor to the asthma room, gasped for breath. “I can’t believe it, he makes me laugh,” she said, pausing to inhale after every few syllables. She tried to explain the story to me but the laughter overcame her. “I’m not used to it,” she said, before putting the pipe back in her mouth. “I’m a serious person. I never joke.”

  Two seats away, a sixty-year-old man from Venezuela leaned forward in his chair and wiped away a tear. “When he got home, he covered his mouth,” he translated. “When his wife finally noticed, she asked him, ‘What happened to your teeth?’ ” Then the whole group laughed and coughed in unison.

  I watched in quiet amazement. The ways people cope with illness always produce gentle surprises.

  IN THE FALL I rotated through the geriatrics ward. One of the attending physicians was an irritating woman whose idea of the Socratic method was pimping you with really vague questions, then acting like she had already thought of whatever answers you gave and that you were only telling her what she already knew. The other attending was a throwback to “the days of the giants,” when pneumococcal pneumonia was diagnosed by injecting sputum into mice and antibiotics for urinary tract infections were tested on agar plates. One morning, one of my interns presented a case to him of an elderly man who had been hospitalized with fever and a cough producing green sputum. “He has pneumonia,” she proclaimed confidently. “Take a look at this chest X-ray.” She pulled up a digital image on a computer screen showing a distinct pneumonic streak. The senior physician waved it off. “First tell me about your lung exam,” he said.

  It was a common scenario on the wards: young doctor ignoring physical examination to the chagrin of an older and wiser counterpart. At one time, keen observation and the judicious laying on of hands were virtually the only diagnostic tools available to a doctor. Now, on the wards, they seemed almost obsolete. Technology—ultrafast CAT scans, nuclear imaging studies, and the like—ruled the day, permitting diagnosis at a distance. Some doctors didn’t even carry a stethoscope.

  There was a growing disconnect between the older and younger generations of physicians on this issue. While residents were apt to regard physical examination as an arcane curiosity, like an old aunt you’ve been told to respect, a few physicians proselytized on its behalf, claiming for it a power it probably no longer has. These anachronisms wanted to hear about whispered pectoriloquy or some such esoteric finding of the lung exam before letting you describe the results of a
chest X-ray. Our apathy seemed to fuel their fervor, increasing their fear that exam skills would atrophy and die.

  “Medical students don’t know how to listen for breath sounds,” our attending complained. “It’s not that they’re bad students; it’s just that no one is teaching them. When I was a resident, you had to know physical diagnosis because we didn’t have any other tools. CAT scans were just coming out. You had to cut someone open to figure out what was wrong with them.”

  One morning I shared one of my favorite medical stories with my team. We had just finished examining an elderly woman with a cardiac rhythm disturbance when I mentioned that Karel Wenckebach, a Dutch physician at the turn of the twentieth century, discovered the arrhythmia later named after him by timing a patient’s arterial and venous pulsations. Wenckebach’s discovery preceded the advent of the EKG and still stands as one of the most astute clinical observations in the history of medicine. Isn’t it amazing, I asked my team, what doctors were once able to do?

  “Today we’d get an EKG,” an intern shrugged. “It’s more accurate anyway.”

  “Who has the time to stare at a patient’s neck?” another said. “They’d think you were crazy!”

  It is true that teaching hospitals are busier than ever, and residents probably have less time to spend examining patients. And it is true that physical examination is often inaccurate. But these facts only partly explain its apparent demise.

  The major reason for it, I have come to believe, is that doctors today are uncomfortable with uncertainty. If a physical exam can diagnose a slipped spinal disk with only 90 percent probability, then there is an almost irresistible urge to get a thousand-dollar MRI to close the gap. Fear of lawsuits is partly to blame, but the major culprit, I think, is fear of subjective observation. Doctors today shy away from making educated guesses on the basis of what they see and hear. So much more is known and knowable than ever before that doctors and patients alike seem to view medicine as an absolute science, final and comprehensible. If postmodernism teaches that there are many truths, or perhaps no truths at all, postmodern medicine teaches quite the opposite: that there is an objective truth that will explain a patient’s symptoms, discoverable provided we look for it with the right tools.