Intern (36 page)

“What am I—going—?” The mask went back on. Tears were streaming down her cheeks.

We tried again. “What am I going—to do—?” she pleaded.

“We can give you chemotherapy,” I said, my heart heavy. “It will shrink the tumors so you will be able to breathe a little—”

She raised her hand, signaling for me to take the mask off again.

“—today!?”

“What are you going to do today?” I said. She nodded, sobbing. My own breath quickened. How could she not have known that it would end this way? “You are going to lie here. You are going to let us give you medicine. The cancer in your lungs is making it hard to breathe, so—”

She shook her head, her face contorted by grief. The mountain of denial was collapsing in a landslide. “What am I going to do—today?” she pleaded again.

I had nothing left to say. I sat with her awhile but soon I had to go.
She signed a DNR form later that afternoon. A couple of days later, she had a respiratory arrest. No code was called.

“
DO YOU WANT TO KEEP EATING,
even if it means dying of pneumonia?” That was the question I posed to Mr. Caner as he consumed the rest of his lunch. “Yes,” he replied without hesitation.

A wizened seventy-seven-year-old with fiery eyes, he had been admitted to the hospital short of breath. Initially it wasn't clear why. Except for a stable manic-depressive condition for which he was being treated, he seemed healthy. He did not smoke and had no cough. Though his breath sounds were coarse, there was nothing suggesting asthma, pneumonia, congestive heart failure, or other common causes of breathlessness.

His chest X-ray gave it away. Littering both lung bases were opaque speckles that looked like shards of glass. It turned out to be barium, a metal used to expose internal organs on X-rays.

But why was it in his lungs? He said he had undergone a barium-swallowing test a few months earlier when doctors suspected he was aspirating food into his lungs. To rule out esophageal narrowing, a common cause of swallowing difficulties, he ingested barium and had X-rays. Some of it accidentally went down his lungs, and stayed there.

His breathing trouble, I suspected, was caused by intermittent aspiration of barium, food, or whatever else. I told him he should strictly regulate his diet, avoiding thin liquids that are easily aspirated. He would have to eat sitting up, and in small bites. But he said he had already found such a diet too burdensome.

When a person swallows, both voluntary and involuntary mechanisms ensure the food ends up in the stomach and not the lungs. First, the tongue pushes the chewed-up food to the back of the throat, where sensory receptors cause muscles in the pharynx to contract. As the muscles tighten, the epiglottis, a flap of cartilage, flexes protectively into place over the larynx, preventing food from entering the windpipe. The food is propelled into the esophagus, where contractions
usher it down to the lower esophageal sphincter, which allows entry into the stomach.

Several things can disrupt this reflex. Cancer or blockages can narrow the opening so that food does not pass easily to the stomach but backs up in the pharynx, where it can be aspirated into the lungs. Muscular dystrophy and other muscle disorders can paralyze the pharyngeal muscles. Neurological dysfunction, too, from nerve diseases like polio and Lou Gehrig's disease, or brain disorders like Alzheimer's dementia or strokes, can disrupt the complex signaling.

The reason for Mr. Caner's swallowing trouble wasn't obvious. A brain scan revealed no strokes. There was no esophageal constriction. Nerve studies were normal. In the end, we were faced with a condition we could neither explain nor treat very effectively. The safest treatment was to stop him from eating and insert a feeding tube. It seemed the only surefire way to prevent him from aspirating and getting repeated pneumonia and developing respiratory failure. But he so loved to eat—it was one of the few remaining pleasures in his life. He even raved about the hospital food. I presented the option of a feeding tube to him. He said he wasn't interested. It was too high a price to pay, even for a longer life.

One night a nurse called to tell me that Mr. Caner had choked on his dinner. When I saw him, his breathing was labored and he looked miserable. A chest X-ray showed a new “infiltrate” in the right lung, where the pea soup, sliding down his windpipe, had finally come to rest. I ordered IV antibiotics, supplemental oxygen, and a dose of steroids, and in a few hours his breathing and blood gas concentrations had improved. But I knew that it was only a matter of time before he aspirated again.

After discussing it on rounds the next morning, the team decided to make him NPO—“nil per os,” or nothing by mouth—and schedule the insertion of a feeding tube. I felt conflicted about this. It was our duty to protect him—perhaps even from himself—but there seemed something barbaric about not allowing him to eat. He had no family, few friends, and no hobbies. Some mornings his only complaint was
not being able to eat fast enough. In medicine, I had learned, there is often a fine line between the barbaric and the compassionate.

The following night, a nurse paged me to tell me that Mr. Caner had aspirated again. Somehow, even though his diet orders had been rescinded, he had obtained a dinner tray, and while gulping whipped potatoes, he had become acutely short of breath. When I saw him he was wheezing again and his blood oxygen tension was dangerously low. His chest X-ray showed yet another infiltrate—it even looked like a smear of mashed potatoes—at the base of the right lung.

Security was tightened. Signs were posted reminding the staff of his NPO status. Food delivery people were given strict instructions not to enter the room. At first Mr. Caner appeared to take the restrictions in stride, but after a few days of emulsified feeds through a nasogastric tube, he became mute and distant. “Why are you here?” he'd say when we made rounds, curling up in a fetal posture, pulling the blanket up to his chin.

On the morning the feeding tube was supposed to be inserted, I snuck into his room. I brought a couple of small juice cups with me. “Drink this,” I urged, handing him a six-ounce carton. Without a word, he took a sip. “Try again,” I said, ready to slap the cup out of his hand if he started choking. This time he drained the carton. Giddy, I handed him a piece of bread. He chewed it to extinction without coughing. Elated, I offered him other foods, all swallowed successfully. His swallowing trouble had somehow abated! Perhaps he had willed himself to get better, and just in time, too; transporters were on the way to take him to the operating room. That morning I wrote in the chart that Mr. Caner had passed a swallowing evaluation. It was supposed to have been conducted by a trained occupational therapist, but I had just done it myself. I had risked his getting aspiration pneumonia—risked his life, really—out of pity, sentiment, but the outcome seemed to have been worth it. I wrote an order to start an aspiration-type diet. I called the gastroenterology team and canceled the feeding tube. No one objected. By then I think everyone realized that a feeding tube was going to kill him a lot faster than aspiration ever would.

THE DAYS IN THE ICU ROLLED ON.
“We changed the artificial tears from twice a day to three times a day,” an intern quipped on rounds one morning, describing the treatment plan for a comatose patient. I perfected my technique for inserting central lines, even supervising the interns on a few. One afternoon I performed a lung tap with the ICU fellow. The patient was a frail elderly man with bad, cyst-ridden lungs. I knew what had happened as soon as I pulled back on the syringe and got nothing but air: a partial collapse of the lung. The patient had to have a tube inserted through his ribs to evacuate the air. I felt bad; I probably shouldn't have done the tap. There was no reason for me to do it; the fellow could have done it much better than me. But I had to learn.

Most of the patients we had started the month with were gone. The paralyzed Russian man with the raccoon eyes was transferred to a rehabilitation facility. A young woman with severe brain damage developed sepsis and died. The plastic surgery fellow had tended to her bedsore, slicing away dead tissue like a butcher, deeper and deeper, until white bone was visible, but eventually it got infected, leaking bacteria into her bloodstream and causing her demise. Even the woman with terminal leukemia finally had her ventilator turned off. For weeks her family had maintained steady pressure on her estranged husband. “I respectfully request you to stop life support,” her father wrote in an appeal placed in the chart. “My daughter trusts her family to act in her behalf to do what she would want. She would not want her body maintained with life support. I am asking that she be allowed to go in peace.”

Her brother added: “We had an uncle that died in the hospital when we were young children. We talked about how he looked on that machine, and we said that we would never want to look like that. I've known my sister for many, many years. She did not like having to ask for assistance but was always there to assist. If she knew she was being supported this way, she would be extremely unhappy.”

In the end, her husband relented. “I now doubt that my wife will be able to sustain the meaningful life which she always lived,” he wrote in a note that was cosigned by a notary public. One afternoon, she was put on a morphine drip and her breathing tube was removed. At first her breaths were rapid and shallow, but they quickly turned deep and sonorous, a sign of imminent death. About fifteen minutes later, they stopped altogether.

But one patient lingered on. Curtis Williams had as torturous a medical history as any patient I had ever encountered: AIDS, syphilis, hepatitis C, pneumonia, infective endocarditis, kidney failure, and cirrhosis. He was also blind, deaf, and brain-damaged from a bout of meningitis. He had been hospitalized with a blood infection, likely from an infected dialysis catheter, and despite intravenous antibiotics, his condition had deteriorated. He eventually developed respiratory failure requiring the insertion of a tracheotomy tube in his throat. On rounds, when nurses changed his bedsheets, the ravages of his many life-threatening diseases appeared in excruciating view. Mouth wide open in an impossibly wasted face, he looked like he was emitting one long, continuous wail.

He had a cardiac arrest on the one call day I happened to be fifteen minutes late to work. “Cardiac team, 5-South . . . Cardiac team, 5-South . . .” the intercom blared.
Goddammit!
I shouted in my head. What were the chances of a code occurring between seven and seven-fifteen? I raced down the corridor, spilling my coffee into a brown paper bag, which got warmer and wetter with every stride.

It was the moment I had been waiting for since the debacle of my first code in the ER that first day on call. I had practiced for it, committing the resuscitation protocol to memory. At night in bed I had envisioned various code situations: ventricular fibrillation, bradyasystolic arrest, pulseless electrical activity. I had mastered everything else as an ICU resident. I had gotten the hang of inserting Swan-Ganz catheters and interpreting hemodynamic data. I felt comfortable managing a ventilator. I could even intubate on occasion. I was doing a competent job supervising interns and medical students. But running a code was
a skill that eluded me. It was a rite of passage, seemingly the last major hurdle in my education. I had to prove to myself that I could master it before moving on.

When I arrived in the room, the code team was in its usual positions. An intern was squeezing oxygen from a balloon into the tracheotomy tube, while another was performing chest compressions. “He needs a central line,” Paulie, a third-year resident, called out, and almost immediately a resident pulled open a triple-lumen catheter kit and started pouring brown antiseptic soap onto the groin. “Glad you could make it,” Paulie said when he saw me. He was a wise guy from the Bronx with an affected macho bravura. People called him a code monkey because he liked coming to codes, even when he wasn't on the code team, which he wasn't that morning.

I stared at the monitor. Tiny squiggles were meandering across the screen. Ventricular fibrillation. “How many shocks has he gotten?” I asked. “Just one,” someone said. Defibrillator pads were affixed to his chest, charged up and ready to go. “All clear,” an intern announced. Everyone took a step backward, she pressed a red button and Williams's whole body hiccupped. I looked at the monitor. Still fibrillation. “Push a round of epi and lidocaine,” I said to no one in particular.

“God, are we really going to do this?” a nurse said, shaking her head in disgust. I did not respond. This was my code, and I had something to prove.

The rhythm briefly normalized, but after a minute it degenerated once again into ventricular fibrillation. “All right,” I called out. “Epi, lido, amiodarone. Epi first.”

“I think I blew the line,” someone said, holding a giant syringe of sodium bicarbonate.

“So put in another one,” I commanded, surprised at how easy it was to issue the order.

Then Paulie spoke up. “You, Manetta”—she was still doing chest compressions—“tell us when you need a break, and you”—he pointed to an intern who was standing and watching—“take over. You”—he pointed to another intern—“continue bagging. You finish getting that
line in. What's taking so long? You over there, help him. I want everyone who doesn't need to be here to leave,” he announced like a drill sergeant. “And keep it down. I can't hear myself think.” His tone was crisp and forceful. The coup was smooth and bloodless. I did not resist it.

Paulie ordered injections of calcium gluconate, sodium bicarbonate, and epinephrine. The EKG continued to show disorganized electrical activity. “He's still fibbing,” Paulie bellowed. “Charge the machine.” Williams's whole body jumped as electrical current discharged into his chest.

Someone said he thought he felt a pulse but he couldn't be sure. “Check the blood pressure,” Paulie shouted. An intern wrapped a cuff around the arm and placed the bell of a stethoscope at the crook of the arm. “I'm not getting it,” he said nervously.