Internal Medicine: A Doctor's Stories (11 page)

Which may be why one particular code persists in my memory, long after the event, as the perfect code.

D
AVID
G
ILLET WAS THE
name I got from the medicine admitting officer. I wasn’t sure what to make of the MAO’s story, but I knew I didn’t like it.

The story was an eighty-two-year-old guy with a broken neck. He had apparently fallen in his bathroom that morning, cracking his first and second vertebrae. I had a vague memory from medical school that this wasn’t a good thing—the expression “hangman’s fracture” kept bobbing up from the well of facts I do not use—but I had a much more distinct impression that this was not a case for cardiology.

“And Ortho isn’t taking him because?” I said wearily.

“Because he’s got internal organs, dude.”

I sighed. “So why me?”

“Because they got an EKG.”

The MAO was clearly enjoying himself. I remembered he had recently been accepted to a cardiology fellowship. I braced myself for the punch line.

“And?”

“And there’s ectopy on it.
Ectopy
.” He then made a noise intended to suggest a ghost haunting something.

“Ectopy,” meaning literally “out of place,” refers to a heartbeat generated anywhere in the heart but the little knob in the upper right-hand corner where heartbeats are supposed to start. Such beats appear with an unusual shape and timing on the EKG. They can be caused by any number of things, from too much caffeine to fatigue to an impending heart attack, but in the absence of other warning signs ectopy is not something we generally get excited about. And it sounded to me as though a man with a broken neck had enough reasons for ectopy without sending him to the Cardiology service.

“So?” I said, trying not to sound indignant.

“So he’s also got a history. Angioplasty about ten years ago, no definite history of MI. You can’t really read his EKG because he’s got a left bundle, no old strips so I don’t know if it’s new.”

We were down to business.

“So I rule him out.”

“You rule him out. Ortho says they’ll follow with you.”

“Lovely. And once I rule him out?”

“Ortho says they’ll follow with you.”

I said something unpleasant.

The MAO understood. “Sucks, I know, but there you are.”

And there I was, down in the ER on a Sunday afternoon, turning over the stack of papers that David Gillet had generated over his six hours in the ED. There was a sheaf of EKGs covered with bizarre ectopic beats, through which occasionally emerged a stretch of normal sinus rhythm, enough to see that there was, indeed, a left bundle branch block, and not much else. The heart has several bundles, cables in its internal wiring. When some disease process disrupts a bundle, the result is an EKG too distorted to answer the question we usually ask it: Is this patient having a heart attack? Of course, the bundle itself is not a reassuring sign, and if new it merits an investigation, but plenty of people in their eighties have them and it’s pretty much a so-what. But the ectopy on today’s strips was impressive—if you didn’t know what you were looking at you might think he was suffering some catastrophic event. I read between the lines of the consult note the orthopedic surgeons had left, and it was clear they regarded David Gillet as a time bomb, and didn’t want him on their service.

Which I couldn’t help noting was exactly how I felt about having a patient with a broken neck on my service. But I didn’t get to make decisions like that. Instead I wadded the stack of papers back in their cubby and took a brief glance through the curtains of Bay 12. From my somewhat distorted perspective, most of what I saw of the patient was his feet, which were large, bare, and protruding from the lower end of his ER blankets in a way that suggested he would be tall if I could stand him up. At his side sat a small, iron-haired woman who at that moment was speaking to him, leaning close while she spoke. She wore a faint, affectionate smile on a face that looked otherwise tired. I watched her for a moment, her profile held precisely perpendicular to my line of sight as though posed. For a moment her face took on an almost luminous clarity, the single real object in the pallid blur of the ED, a study in patience, in care—and then it wavered, receding into a small tired woman with gray hair beside a gurney in Bay 12. The patient’s face was obscured by the pink plastic horse collar that immobilized his neck. I watched the woman for a minute. Her expression, the calm progress of their conversation, suggested that nothing too drastic was going on. I took a walk to the radiology reading room to get a look at the neck films.

There were many of these, too. They showed the vulture-neck silhouette all C-spine films share. There were several unusual views, including one that I decided must have been shot straight down the patient’s open mouth: it showed, framed by teeth palisaded with spiky metal, the pale ring of the first vertebra, the massive bone called the atlas, and clear (even to me) on both sides of it were two jagged dark lines angling in on the empty center where the spinal cord had failed to register on film. The break in the second vertebra was harder to make out, but I took the surgeons at their word:
C1/2 fx. Will need immobilization pending installation of halo. Will follow w/you.

I
WAS NOT IN
the best of moods as I made my way back to the ER, grabbed a clipboard, and parted the curtains to Bay 12. I still managed an adequate smile as I introduced myself. “David Gillet?” I said tentatively.

The woman at his shoulder blinked up at me, wearing that same weary smile, brushing an iron-colored lock of hair from her face.

“It’s ‘
Zhee-ay
,’ ” she said, with an odd combination of self-deprecation and something else—perhaps it was warmth?—that made me like her. “It’s French,” she explained. Her smile widened, one of those dazzling white things older people sometimes possess (dentures, I believe), and she welcomed me into Bay 12, which I had been inside of more times than I cared to count, with a curious air of apology, as if concerned about the quality of her housekeeping. I was charmed. This was still relatively early in the day and I was capable of being charmed. I shook myself a little, straightened my back (her posture was perfect), trying to escape some of the lethargy that had been piling on me over the day.

Her husband made a less distinct impression. The cervical stabilization collar tends to have a dampening effect on most people, as would the eight milligrams of morphine he’d absorbed over the past six hours, so it was a bleary and not very articulate history I got from him. His wife filled in the relevant bits. No prior MI. Occasional chest pain, hard to pin down (arthritis in the picture as well, of course). Otherwise a generally healthy, alert, and active man. On the one really critical point—what had caused the fall—Mr. Gillet insisted on giving account. He had
not
fainted. He had not been dizzy or breathless or experienced palpitations or anything of that sort. He had tripped. He had caught his toes on the damned bath mat, and gone down like a stupid ox. As he said the last he shook his head vehemently within the confines of his collar, and I caught my breath: you’re not supposed to do that with a broken neck.

Even so I was partially reassured. The history didn’t suggest a cardiac cause to his fall, and he denied any of the other symptoms that go along with impending doom. The physical exam was similarly reassuring, although hampered by the cervical collar and my dread of doing anything that might disturb his neck. He was a tall, bony man, with a nasty-looking cut across the scalp above his right eye, and dried blood crusted in his bushy eyebrows. The cut had been sutured already, and the blood made it look much worse than it was. Aside from the cut and a large bruise on his right ribs (none broken), he seemed fine. Except for the neck, of course. I stayed another few minutes, making idle chat with the wife, and then excused myself to write my orders.

H
E RULED OUT WITH
the four a.m. blood draw the next morning, which I announced on rounds a few hours later with less pleasure than I would have ordinarily. I knew what was coming.

“So now what?” the attending asked.

“I guess I call Ortho.”

Everybody—from attending to fellow to the other resident on the team and the intern, even the two medical students—started to smile. Then laugh.

“Well, I can call them, can’t I?”

“Go ahead,” the attending said.

There are attendings who will actually fight to make a transfer happen. They will call the attending on the other service and make the case, at least. Usually, when it comes to this, the transfer goes through. Which might be why most attendings are loath to let things get that far. If the patient’s welfare requires it, they’ll make the call (except for those dreadful individuals—and we know who they are—who believe themselves capable of caring for cases far outside their subspecialization). Or if they’re dealing with some critical shortage of space. But if it’s simply a matter of one patient more or less on their census, most attendings will let things be. And this attending was one of the more notoriously laissez-faire, happy enough to let the house staff run the show.

I made the call, and after three or four hours the Ortho resident returned the page. I knew by that time that I was already defeated, but I went ahead and asked the obligatory question, and received the inevitable answer (the Ortho resident having anticipated as well) that the Ortho attending did not feel comfortable taking the case—“and besides, it’s not that bad a break. We’ll follow.”

“How long?” I asked.

“What do you mean?”

“How long does he need to be in the hospital?”

Puzzled. “When will you be done with him?”

“We’ve been done since eight this morning.”

“You mean you’d send him home?”

“Except for the neck thing, yeah.”

“Oh.” This he hadn’t anticipated.

“So what does he need from you?”

“He needs a halo.”

I knew what a halo was. They’re those excruciating-looking devices you may have seen somebody wearing in the mall: a ring of shiny metal that encircles the head (hence the name), supported by a cage that rests on a harness braced on the shoulders. Four large bolts run through the halo and into the patient’s skull, gripping the head rigidly in place like a Christmas tree in its stand. A little crust of blood where the bolts penetrate the skin completes the picture. They look terrible, but patients tell me that after the first day or so they don’t really hurt. Getting one put on, however: that hurts.

“So when does he get it?” I asked. Again, I knew the answer. It was already past noon. I was pretty sure it was Monday.

“Well,” the Ortho resident replied, “it’s already past noon.”

“And you’re in surgery.”

“Yeah.”

“And tomorrow?”

“Clinic. All-day clinic.”

I didn’t say anything. I waited a long time, biting my tongue.

“I guess we could do it tonight.”

“That’d be nice.”

“Unless there’s an emergency, of course.”

“Of course.”

Of course there was. And clinic ran overtime the next day, or so I was told. Their notes on the chart (they came by each morning at five forty-five) ran to five scribbled lines, ending each time with
Plan halo. Will follow
, and a signature and pager number I couldn’t quite decipher. This left me, of course, holding the bag. Not only had I one more unnecessary patient crowding my census, one more patient to see in the morning, round on, and write notes about (this during the month our team set the record for admissions to cardiology), but I also had the unpleasant responsibility of walking into Mr. Gillet’s room on Tuesday and Wednesday morning to find him unhaloed, and making apologies for it.

It would have been unpleasant, at least, but for Mrs. Gillet. Her quiet grace put me in mind of faces I’d seen in old oil paintings, looking off to one side at something beyond the frame, eyes lit by what she saw there, the rest of the scene lost in dark chiaroscuro. All of which only made the situation even more intolerable, driving me to want to
do
something—and the only thing I had to offer lay in the gift of the inaccessible Ortho resident.

Wednesday I was on call again, and had pledged myself, in the brief moments between admissions, to track down the Ortho team and make them come up and put that halo on. Unfortunately, this was the day we admitted fifteen patients, as the failure clinic opened its floodgates and the Cath Lab pumped out case after case. Nobody was any too sick—the ER was blessedly free of chest pain—but the sheer volume of histories to take, physicals to perform, notes and orders to compose was overwhelming. The phone call—with its necessary sequel of waiting for the paged resident to call back—never happened.

Sometime in the late afternoon, however, I looked up from the counter where I had been leaning, trying to absorb the salient features of yet another failure patient’s complex history, and saw through the open door of Mr. Gillet’s room a strange tableau: two tall men in green scrubs wielding socket wrenches around the patient’s head, a tangle of chrome, and the patient’s hands quivering in the air, fingers spread as if calling on the seas to part. Some time later I looked up again and the green scrubs were gone: Mr. Gillet lay propped up in his bed, his head in a halo. From the side, his nose was a hawk’s beak, the rest of his face sunk in drugged sleep, but his mouth still snarled as if it remembered recent pain. I remembered him in the ER, the flash of injured pride he had been able to conjure even through the morphine. That was gone now. He looked like a strange, sad bird in a very small cage.