Doctored (7 page)

“You know what I think,” he said to me. “I think they're just throwing everything at this, and maybe they'll find something, and then what? They got an MRI, and they're still not satisfied!”

I explained that the doctors were being cautious.

“Hey, I'll sit here with antibiotics going into me, no problem,” he replied. “But doing a procedure that could cause a stroke? That's getting a little scary.”

I pulled out my stethoscope so I could listen to his lungs. What if he refused the angiogram? he asked, leaning forward. Couldn't he have the operation anyway?

I told him that the surgeon would probably not operate without the angiogram, a hunch confirmed the following day.

“But what if I sign a paper accepting the risk?”

The outlines of a memory started to form in my mind. “I doubt that's going to change anyone's mind,” I said. I told him that if he felt strongly enough, I could arrange for him to be transferred to another hospital.

He did not want to do that. “Oh well, it is what it is,” he said, looking resigned. “They're going to get what they want. It's a losing battle.”

Though I agreed with the neurologist that an angiogram was needed before surgery, given the risks of even a tiny aneurysm bleeding during the operation, I felt uncomfortable about forcing Eric to have it. He had made it clear that he wanted to proceed with surgery without delay or additional testing. He was willing to accept the risks of this approach. But his doctors refused to honor this request.

How should such disputes be resolved? It isn't always clear. In 1991 a Minnesota court ruled that the family of Helga Wanglie, an eighty-six-year-old woman in a coma, had the right to demand intensive medical treatment for her, even though her physicians wanted to stop life support because they believed it was futile. In that judgment, patient (or surrogate) autonomy trumped professional integrity. However, in most cases of medical futility, doctors have been allowed to exercise conscientious objection.

In part because of my own experience with Sonia and the baby, I have come to believe that doctors should deny treatment requests judiciously—and rarely. A surgeon might understandably refuse to operate on someone whose religious beliefs proscribe blood transfusions on the ground that he would not want to be forced into medical malpractice. But in cases with reasonable differences of opinion, in which the competing risks are at least debatable, it seems unfair and unwise to me to deny a patient's choice. (If patient autonomy means anything, then patients have the right to make bad decisions, too.) Was Sonia's anesthesiologist being virtuous or knavish? I'm still not sure. Professional integrity can indeed be a double-edged sword.

In the end, we flew to the world-famous Cleveland Clinic, where a young surgeon agreed to perform the operation we wanted. The brushed marble columns and labyrinthine corridors of the hospital lent an air of competence and credibility that we were desperately seeking. At our first appointment, a nurse with a Midwestern twang and a midwife's manner came out to greet us. She shuttled Sonia through a quick triage and obtained her medical history. The surgeon came by around 11:00 a.m. I told him about our experience in New York. “If the patient says no, you have to listen to the patient,” he said kindly. “You have to be suspicious when a doctor is so dogmatic.”

We slept fitfully in the hospital the night before the surgery. Nurses came by every few hours to check blood pressure and vital signs. In the middle of the night, Sonia wanted me to take her for a walk. We wandered down mostly empty corridors to the chapel, a long and narrow chamber with stained-glass windows and a prominently displayed leather prayer book. Pro forma, I whispered a prayer. I hadn't prayed in years, but at this point I would have done anything to stack the odds in our favor. After wandering into an adjoining room, I came back to find that Sonia was gone. I went outside, but I could not find her. I called her name, but she did not respond. I was about to leave when I saw her praying quietly in a pew at the front of the chapel. In the prayer book she had written: “Dear Lord, lead me the way to a complete cure.”

The chief of high-risk obstetrics came by in the morning, while I was in the cafeteria getting breakfast. With a fellow, she quickly performed a fetal ultrasound. She asked Sonia if she wanted to know the gender of the baby. Sonia said she preferred to wait until I returned. She asked the obstetrician to come back later to talk to both of us.

Back in the room, we waited nervously for a transporter. We still didn't know the sex, but Sonia assured me: “We're going to be all right. Our baby boy is my guardian angel, so don't worry.”

At the surgical unit I was handed a pager and told that someone would call me when the operation was over. About an hour later, as I was pacing nervously in the family waiting area, the device buzzed. I hurried over to the front desk, where a nurse in blue scrubs and bonnet told me that the procedure had gone smoothly and that Sonia was already in the postanesthesia care unit. I rushed to her bedside. Though she was still groggy, she gripped my hand tightly, obviously elated. While waiting for her to fully wake up, I went to a hospital phone and paged the obstetrician. I introduced myself and asked her if she could tell me the sex of the baby. “You don't want to wait for your wife?” she teased. I told her that Sonia was in recovery and that I would inform her later.

“It's a bit early to tell for sure,” she hedged, “and we didn't get the best pictures, but it looks like you're having a girl!” A girl? Stunned, I said nothing, so sure had both of us been that it was a boy.

I thanked the obstetrician and wandered into a gift shop, where I bought a tiny figurine. In the recovery unit I gave it to Sonia. “Why pink?” she asked, still dazed. I told her what the obstetrician had told me. Smiling, Sonia said, “She is going to be my beauty, my tennis partner.”

In fact, the chief of obstetrics at the Cleveland Clinic turned out to have been wrong. We were actually having a boy, which was confirmed by an ultrasound two weeks later, after we had returned to New York. “Are you absolutely sure?” I pressed Mary, our flower-child, friendship-braceleted sonographer. I mentioned what we had been told in Cleveland.

“Oh, I'm pretty sure,” she said, “but let me check again.” She twisted the probe, trying to get clearer images. “Yes, see that? It's definitely a boy.” She took a picture, which we put into a metal frame on the windowsill in our bedroom. I couldn't help but laugh. The little boy in the elevator, the homeless guy on Seventy-seventh Street, and Clement, the Rastafarian, had all gotten it right. But not the chief of maternal-fetal medicine at the world-famous Cleveland Clinic with the aid of ultrasound!

We became addicted to monitoring our baby. Just for kicks, we'd sneak into the echo lab at NYU, where Sonia would lie on an exam table and I, a senior cardiology fellow, would gently press the cardiac ultrasound probe to her belly. Her eyes would twinkle, and I would smile, too, quietly overjoyed at the melding of my personal and professional lives. We spent hours watching a video I made of our baby throwing up his arms, startled. We couldn't pull ourselves away from him.

Then, in the thirty-fourth week of the pregnancy, with everything finally going smoothly, Dr. Edwards called Sonia at home and told her to schedule a caesarean section. She said she wanted to avoid any risk of further complications.

“I told her that I needed to discuss it with you,” Sonia said when I returned from the hospital that night, just after I had started my new job at LIJ. “It was like she wanted me to agree with her right on the spot because she said for the umpteenth time, totally well-meaning, I'm sure, ‘I don't want you to feel antagonistic, I'm on your side,' and in the most polite way possible I was, like, ‘Dr. E, I'm just asking questions.' I'm sure she's used to her patients just agreeing with her. Anyway, she's available to see us tomorrow. She wants us to decide this week.”

We met at her office on East Seventy-second Street the following afternoon. Sitting across a desk from us, she explained her reasoning. The baby was mature. He should be delivered under the most controlled circumstances. Waiting until the baby was full-term would only invite further problems. I mentioned data I'd found nervously scouring the obstetrical literature suggesting that a vaginal delivery might be safer because it caused fewer alterations in maternal blood flow. But Edwards replied that this evidence was based on small studies that were not clearly applicable to our case. One problem with clinical research is that the profile of subjects rarely matches that of the patient in front of you. In the end, she made a convincing case and we reluctantly acquiesced, though it obviously wasn't what we had hoped for.

The weekend before the scheduled C-section, I took my first call as a new attending. It was a busy weekend. I had to see patients at both LIJ and its sister institution, North Shore University Hospital, in Manhasset. On Saturday morning an elderly woman actually had an acute stroke while I was making my rounds. When I first visited her, she was speaking normally, asking to go home. Twenty minutes later a nurse paged me to say the patient was insensate, aphasic, and frothing at the mouth. She was totally mute when I ran upstairs to see her, her mouth drooping to one side, a look of alarm on her face. After rushing to the nurses' station, I directed an intern to order an emergent CT scan of the brain and to page the neurologist on call. Unbelievably, the intern refused, saying that she was at the end of a twenty-four-hour shift and was going home. In fact, her insubordination had been legislated in 2003, the year prior, in rigid work-hour restrictions limiting residents to twenty-four hours on call, with three additional hours to hand off their patients. The caps were supposed to improve the learning environment by providing medical trainees with more opportunities to rest, but they seemed to have had the opposite effect, encouraging a kind of shiftwork mentality. Having done my own residency without strict work-hour limits, I believed that you had to see a patient's illness through its course—observe the arc—to get a grip on the dynamics of the disease. I worried that the current crop of interns, mandated to leave the hospital after a long shift, was missing out on valuable lessons and was learning a mentality of moderation that is incompatible with the highest ideals of doctoring. As a resident I would never have insisted on leaving the hospital during an emergency involving one of my patients. However, I didn't argue with this intern, and I ordered the scan and made the calls myself. The CT scan confirmed what I suspected, a huge stroke involving the left middle cerebral artery, and the patient was transferred immediately to the intensive care unit under the care of the neurology team.

All weekend Sonia and I had second thoughts about the scheduled C-section, so we kept calling each other to talk it over and be reassured. At lunchtime, sitting in a conference room with a pile of four hundred EKGs and a turkey sandwich, I found myself stupidly calling the Cleveland Clinic, anonymously asking the obstetrician on call whether a two-week preterm delivery could result in any long-term impairment. At the computer in my office on Sunday afternoon, I obsessively looked up obstetrical abstracts on outcomes for elective C-section. But despite the anxiety, in the end we decided to stick with Dr. Edwards's plan. On Sunday night, after I got home, amid the new crib we were still assembling and the new changing table and the boxes of diapers and baby paraphernalia, we quickly packed our bags to go to the hospital the following morning.

The operating room on the afternoon of Monday, August 9, 2004, was reassuringly abuzz: alongside Dr. Edwards were two obstetrics fellows, an anesthesiologist, a neonatologist, several nurses, and, of course, Sonia, swathed in blankets, staring anxiously up at the ceiling. Her father had told Edwards that delivering the baby before two-thirty in the afternoon would be especially auspicious, according to a Hindu guru he'd consulted, so it was a silly race against the clock, which added a sense of tension that we didn't really need but was vaguely exciting nevertheless.

It took about thirty minutes for the anesthetic to reach the level of Sonia's belly. The wisecracking anesthesiologist kept testing her thighs and abdomen with a sharp needle, leaving tiny bleeding marks on her skin. When the anesthetic finally reached the level of her chest, the operation could begin.

I stole peeks into the operating field. Tiny yellow globules of fat glistened as the Bovie knife broke the skin. Soon amniotic fluid spilled forth, to be slurped up quickly by a suction catheter. I watched as Edwards tugged on the uterus with red-soaked gauze and a metal retractor. Blood spilled on the white tile floor. Then suddenly our baby was out, tethered by an umbilical cord. A couple of gentle taps and he started wailing; the room broke into applause.

I swooned, and for a moment I thought I was going to black out. Weeks, months, years of worry melted away in an instant. Edwards clamped the umbilical cord and cut it, and then started sewing up the uterus with big black stitches. Our newborn was placed into the arms of a neonatology fellow and rushed over to a warming table. Someone called out to me to take a picture. I breathed an enormous sigh of relief—fertility injections, the trip to Anguilla, the reluctant anesthesiologist, and the Cleveland Clinic all flashed in rapid succession through my mind—and another one the following day when Sonia went to the postpartum unit to breast-feed our healthy baby boy.

 

THREE

Learning Curve

The art of medicine, like that of war, is murderous and conjectural.

—Voltaire

On Friday, three days after the delivery and about six weeks after I'd started working at LIJ, I pulled up on the cobblestone roundabout behind New York Hospital to pick up Sonia and our newborn baby, Mohan, and drive them to Sonia's parents' home in Edison, New Jersey. Meanwhile, my parents and my sister, Suneeta, went to Long Island to stay with my brother. My parents stayed with Rajiv whenever they visited New York, a deference they naturally extended to their greatest asset and biggest investment.