Intern (35 page)

The ICU, more than any other place in the hospital, was where sickness and tragedy converged. Of course, lives were saved, but most days it was suffused with death, family politics, and pain. In Robert Zussman's 1992 book
Intensive Care: Medical Care and the Medical Profession
, an ICU intern reported a dream. In it, he finds penguins in a basement. The birds need to be in a cold environment or they will die, so to save one, he takes it, puts it into a blender with some ice and turns the blender on. The penguin is suddenly floating in a slushy pool of blood. The intern wakes up. The dream's interpretation is clear enough: in the ICU, sometimes the cure is worse than the disease.

After rounds, we went back to the conference room to finalize patient assignments and delegate tasks. By the luck of the draw, I was assigned to be on call the first night.

IN THE EARLY AFTERNOON,
I was paged. A man with HIV was in the ER after vomiting blood. I went down to see him. He was middle-aged, of slight build, with wide-set eyes and blotchy, old-man skin. His family was sitting with him. About three days earlier, they told me, he had developed a “sticking sensation” in his throat while eating solid foods. For the past two days, he had been retching frequently, vomiting about a cupful of blood at a time. Over the past twenty-four hours, despite several transfusions, his blood counts had continued to drop, raising
concern that he was still bleeding internally. I pulled down one of his eyelids; the inside was almost gray, reflecting severe anemia.

The management of acute gastrointestinal bleeding is straightforward: two IVs, in case blood has to be transfused rapidly; a blood count every few hours; drugs to quench stomach acidity; and watchful waiting. Earlier in the day, an upper endoscopy, in which a flexible camera-fitted tube is passed through the mouth and into the stomach, had revealed several shallow gastric ulcers. One was “necrotic and friable,” according to the report, and even though it was no longer bleeding, it had been cauterized for good measure. “If his condition remains stable,” I told his family, “he can probably go home tomorrow.” I told them to go have lunch while I arranged for a bed in the ICU.

Sitting down at the doctors' station, I stared at the code beeper on my waist. I knew it could go off at any moment. I averted my gaze, worrying that it might start ringing just by my looking at it. I glimpsed my reflection in a sliding glass door. Painted on my face was a sort of anxious half smile. Feathery black curls winged upward over my ears. (I needed a haircut.) Cold droplets periodically splattered against the side of my rib cage. A sensation of heightened alertness and unease coursed through me. I did not want to carry this responsibility.

I was still writing up my admission note when I heard the shouts. I saw residents running; then I heard more shouts. I stopped at the doorway of my patient's room as if I had hit a brick wall. My patient was bleeding, like a coffee-colored fountain, out of his nose and mouth. He was unconscious. A nurse was trying to sit him up to keep the fluid out of his lungs, but his head kept flopping backward. Blood dripped onto the floor. “Call a code,” someone shouted.

People rushed in past me. His heart was beating, but he had no pulse. Someone started chest compressions. A nurse put an oxygen mask on him but it wouldn't seal properly, and every time she squeezed the bag to which it was attached, it made an ineffective grunt. “Who's running the code here?” someone asked.

“I am,” I replied softly.

Someone asked me for my stethoscope. I stared at him blankly; his gloved hand swiped it off my neck, smearing blood on my green scrubs. Someone started putting in a central intravenous line without my instructions to do so. “He's HIV!” a nurse shouted, dispensing gloves and masks. An intubation tray appeared, and then someone was prying open my patient's mouth with a metal laryngoscope, trying to visualize the vocal cords while a nurse assisted him by suctioning blood clots to clear the field. Periodically their heads would lurch backward, like a boxer ducking a jab, as chocolate-colored mist splattered their face shields.

People were holding bags of saline over their heads and squeezing them into his veins. Nurses were getting orders to give drugs—epinephrine, atropine, sodium bicarbonate—but not from me. My code was running like clockwork. Without me. I felt like the host of a dinner party with nothing to say.

I tried to push myself, bark orders, do something—but the tip of my tongue quivered uselessly. A breeze was blowing through my mind, which had been expunged of all thought except for the belief that everyone was watching me, cataloging my every deficiency. As the code wore on, my disconnection from it became more complete, as I was forced, with the rest of the onlookers, to the periphery of the room. People in front of me were yelling out, “How much epi has he gotten?” “Which atropine is this?” “Did he get the bicarb push?” A nurse threw up her hands. “Who's running this code?” she cried. I remained silent.

Bags of blood arrived, and doctors in the pit discussed whether it would transfuse quicker through an IV or a central line. I didn't know the answer, but I found myself thinking about the conductance of fluid-filled tubes. My patient's nostrils were trickling like a faucet, leaking blood much faster than it could possibly go in. His heartbeat was slowing down: seventy . . . sixty . . . fifty . . . Blood was everywhere—on stethoscopes, socks, scrubs. I worried that someone would slip on the floor.

After thirty minutes, his heart stopped beating entirely. A surgeon
proposed cutting open his chest and performing direct cardiac massage. No one said anything except for a surgical intern, who clapped his hands with glee.

Then, suddenly, I found my voice. “It's time to call it,” I murmured.

“What was that?” the surgeon demanded, turning around.

I was surprised anyone had heard me. “I said it's time to call it,” I repeated, forcing the words out a little louder.

“Let's just do it for the practice!” the surgical intern cried, his eyes darting back and forth between the surgeon and me.

Emboldened by the attention, I shook my head and said, “It's too much of an exposure risk.” There were murmurs of agreement.

“You're the code leader,” the surgeon said, stripping off his gloves, and just like that, people stopped what they were doing and started filing from the room.

The first and only decision I made in my first code was to stop it.

Afterward, I surveyed the damage: bloody gowns, test tubes, syringes, blood-soaked gauze, central-line kits and procedure trays torn open and discarded, towels, masks, gloves, needles, my stethoscope coated with blood—and a dead body. The blood on the floor had clotted. Custodians arrived to clean up before the family returned. I went to the bathroom to wash up, not sure what was making me feel worse: that the patient had died or that I had looked like such an incompetent in front of my colleagues.

When the family showed up about a half hour later, a social worker intercepted them at the double doors and led them to a private room. “Why? What's happening? What happened?” Since I had been the code leader, it was my responsibility to break the bad news. “He started bleeding after you left,” I told his wife, who was perched nervously at the edge of a cracking-vinyl couch. “We did everything we could but we could not save him.” I had been steeling myself for her response, but it was nothing like what I expected. Her wails reverberated through my mind for days.

The important thing is to make the lesson of each case tell on your education.

—
SIR WILLIAM OSLER

 

S
elf-destructiveness is a staple among patients in the ICU. Over the course of my month there, we saw many patients—alcoholics, anorexics, drug abusers—who had treated themselves with such disregard that their bodies were literally falling apart. None more so than the old woman from Ecuador. She answered my questions with a shrug of resignation, as if we were talking about the price of beef or the inevitable loss of youth, not her breast cancer. Her words and body language conveyed a clear message: it was no big deal.

The tumors had sprouted on her left breast like mushrooms in a dank forest: different shapes, sizes, colors. A couple of them were nodular, like little thumbs pushing up against intact skin. One had cracked open, like an overripe plum. Two were covered with pink granulation tissue, a sign of wound repair. The oldest one glistened, reflecting the jaundiced hospital light off its smooth surface. The sight of them eating away at her breast was as ghastly a thing as I had ever seen.

But the old woman didn't seem to mind. As they were mostly on the underside of her breast, she claimed not to notice them, even though they stained her clothes and the crucifix hanging from a chain
around her neck with bloody discharge. She had obviously grown used to their rancid odor.

She would turn over every morning to let me examine them.
What was it she saw when she looked at them?
I wondered. What inside her—fear, ignorance, madness—had allowed this to happen? I thought of the words of the doctor in Aleksandr Solzhenitsyn's
Cancer Ward
: “Why didn't you come earlier? Why come here when you were practically a corpse?”

In the annals of denial, the old woman's history was not so unusual. When she, a former registered nurse, first felt a lump several years earlier, cancer apparently didn't occur to her. The lump grew to the size of a Ping-Pong ball before she showed it to a doctor—and then only because she was already at a clinic accompanying a sick friend. At the time, it was painless and surrounded by healthy tissue. If it had been removed then, in an early stage, and she had received radiation and hormonal treatment, she probably would have had a 50 percent chance of cure. But a biopsy proved inconclusive, she said, and she was all too ready to forget about the problem. She left America soon afterward for her native Ecuador, where her terminally ill husband had wanted to go to die. While there, she claimed, the tumor shrank and disappeared.

When she returned to America two years later, fronds of tumor were beginning to sprout from her breast. Soon they began to ulcerate and give off a foul smell. She went to an herbalist, who prescribed an assortment of creams. For a while the tumors seemed to regress with the application of the ointments, but then they grew quickly, breaking through her skin. Friends and family insisted that she see a doctor, but she ignored them. The tumors discolored her blouses, but she ignored that, too. Several months later she developed severe pain where the cancer had metastasized to her hip. She took ibuprofen for months without relief, still refusing to see a doctor until the pain became unbearable. Then, when she heard the diagnosis of breast cancer, she said she was surprised.

Now the tumors had invaded through blood vessels. Sometimes
when the bandages were removed, arterial blood spurt forth. An oncologist—short, squat, imperious—took one look at the tumors and told the ICU team that there was nothing she could offer besides palliative chemotherapy. The cancer had spread to the bones and lungs; the old woman's breathing was becoming more labored; the end was surely near. “It's very bizarre,” the oncologist told me later. “These women look at their breasts and it's like a shadow comes over their eyes. They don't see what we see.”

All diseases provoke denial, but something about breast cancer drives some women to such extreme denial that when they first see a doctor, tumors are literally growing out of their breasts. The literature on the subject is vast and has been accruing for at least thirty years.

Exactly what provokes this response isn't clear, but studies have shown that fears of disfigurement, dependency, and death play big roles. A study of Nigerian breast cancer patients showed that fear of mastectomy was the most common reason for delays. Studies of American women have shown that a third or more who feel a breast lump do not seek help for at least three months. A family history of breast cancer has been linked to delay in seeking help.

In small doses, denial can have its advantages, mitigating severe anxiety and depression. (I had experienced this myself in the early days of internship, when I had denied my own misgivings about being a doctor until my crisis forced me to confront my true feelings.) But when denial extends more than a few months, it rapidly becomes harmful as tumors grow and spread.

I didn't want to be on call when the old woman finally had a respiratory arrest. How would we perform CPR? Where would we even put our hands? I told her about the option of palliative chemotherapy. It wouldn't be curative, but it might shrink the tumors, help her breathing, ease her pain. But she said she wasn't interested. “I'm not the type to worry because it's all up to God,” she said, fingering her crucifix. “It always was and always will be. So why should I worry?”

But unfortunately for the old woman, there were no miracles in the ICU that month. After a couple of days, the oxygen tension in her blood dropped and she was put on a pressurized ventilation mask. It dug deeply into her face, making her appear even more uncomfortable. One afternoon, I visited her in her room. She was in severe distress. The base of her neck had become a scalloped-out triangle as she hungrily sucked air into her lungs. A miniature Bible with an orange cover was resting on the pillow beside her. She tried to talk but the words were muffled. I handed her a pen and clipboard, and she scrawled on it with her left hand. (Her right, dominant, hand was incapacitated because of a blood clot.)

“How long?” she scribbled. I said that I didn't know.

She signaled for me to remove the mask. I undid the straps around the back of her head, and the sound of leaking oxygen filled the room. “What am I—?” She stopped, unable to continue. I pressed the mask back on her face. She took a few breaths and directed me to take it off again.