The Real Doctor Will See You Shortly (21 page)

“Okay,” I said, “I missed the discussion on rounds. Did we decide that Ms. Hansen's chances of recovery are nonexistent?”

“She's dying. She's suffering. No one in the family wants to acknowledge that. They keep saying ‘do everything' because it helps them sleep at night.”

The word
suffering
recalled my conversation with Dr. Phillips. He had left Columbia for another hospital shortly after I'd discharged his patient safely. Word came back that he was going to a nonteaching
hospital where he wouldn't have to deal with interns. “Tough spot,” I said, wondering how I'd handle things if my mother was in the intensive care unit and I had to make decisions on her behalf. I also thought of Benny. If her family decided to withdraw life-prolonging measures, Marlene Hansen would no longer need to be in an ICU. There would be a spot for Benny in our unit and I could go down to the ER to retrieve him myself.

“It's not a tough spot,” Don said. “It's outrageous that the family is doing this to their mother. And our hands are tied.”

“Are they?” I didn't have a solution, but I had learned from Baio to ask more questions when answers were proving elusive. “Can't we just say enough is enough?” I asked. “I mean, who's running the show here?”

“Better go talk to the daughter now,” Don said. “If Hansen becomes comfort measures only then we can send her out of the unit. We'll have room for that second patient in the ER you know.”

Was he hinting at my emotional attachment to Benny? The idea made me uncomfortable. “Everyone definitely agreed on rounds that she should be comfort measures only?”

“Yes. She suffered a massive heart attack, which deprived her brain of oxygen for so long that she's brain-dead. Her kidneys are failing. Soon she'll need dialysis. And the neurologists came by and confirmed there's no brain activity.”

“Huh.”

“We could keep her alive,” Don said, “but to what end?”

“Okay. I've only done a couple of these goals-of-care discussions. How, uh, do you usually go about it?”

“As it stands, if Ms. Hansen's heart stops we're supposed to do CPR. Ribs crack, the whole deal. Just try to convey that scene as clearly and vividly as possible. It's one thing to do it to a thirty-year-old. But this woman is brain-dead.” He put his hand on my shoulder. “There's no right way to have this conversation. Don't tell them what to do; help them figure out what's best.”

I imagined uncooked spaghetti cracking under my palms and again asked myself what I would I do if my mother were in this situation. Could I live with myself if I pulled the plug and there had been even a sliver of a chance of recovery? And would I do it based on the recommendations of an intern? People occasionally recover from a vegetative state, don't they? I was certain that someone at some point in history had recovered. Right?

“Don't look so stressed,” Don said as he scooped a handful of Goldfish crackers into his mouth. “This'll be good practice.”

Was there any other job, I wondered, where practicing involved telling someone she was better off letting her mother die? It sure seemed like the real deal to me. But perhaps I was approaching the conversation the wrong way. Was there a way to offer comfort to Ms. Hansen's daughter while conveying that all hope was lost? I began testing out opening lines, imagining how I wanted the dialogue to play out. This kind of story line never appeared on any sitcom or drama that I was familiar with. I closed the door to the lounge and made the slow walk toward Ms. Hansen's room, vigorously grinding my teeth along the way.

“I'm not a doctor,” Ingrid Hansen said, sitting in an orange plastic chair next to her mother. “I'm still trying to wrap my brain around what happened.” I brought another chair into the room and took a seat. “She was fine a week ago.” Her green eyes darted back and forth as she stared at the floor; Ingrid wore knee-high leather boots and a nose ring and couldn't have been a day over twenty-one. She took a sip from a large cup of coffee and reached for her scarf, which was resting on her purse. From the looks of things, she hadn't slept in days.

I tried to calibrate how close it was appropriate to sit. What was the right way to do this? I slid my chair a few inches closer to Ingrid, and she looked on as I briefly scanned her mother's ventilator settings. “Tell me what your understanding is thus far,” I said, parroting a phrase Don often used with families.

“I don't know,” she said. “Someone found her. She had a heart attack, she had a stroke. She won't wake up.”

As with so many of my patients and their families, I tried to imagine what their home life was like. Was she close with her mother? Did they talk on the phone? Did they fight? Did Ingrid truly understand what her mother would want in this nightmare scenario?

“She had a massive heart attack,” I said, measuring my words. “Blood wasn't able to pump to her brain. We don't know exactly how long she was down.” I fought the urge to look away when Ingrid's lower lip began to tremble, and again I thought of my own mother. “She suffered profound brain damage,” I went on. “There is no brain activity.”

“Oh…God.”

I could feel a part of myself shutting down as Ingrid's eyes welled with tears. It had become a slightly habitual reaction since Dre, when I was faced with such raw suffering, but now, with my health in the clear and my position at the hospital feeling more secure, I knew I needed to break myself of it. I took Ingrid's soft hand in mine and searched for words as ventilator and blood pressure alarms blared in the background. My hand was cold, and I could tell it wasn't providing comfort. She flinched when my palm touched hers and I thought she was going to pull away, but she didn't. Her lower lip continued to tremble. When she closed her eyes, a tear dripped down her cheek. “We have the option to scale back.” I struggled to find the right balance between staying empathetic and not crying myself.

She took a deep breath and dabbed her cheeks with her scarf. “Is she suffering?”

“That is a concern, yes.”

“I don't understand.”

We sat in silence as I considered my words. I wasn't sure I was handling this conversation the right way, but it didn't feel like the wrong way either. I felt my pager buzz and fought the urge to throw it against the wall. “Sometimes there's no rhyme or reason,” I said softly.

“I just don't…How can she be suffering if there's no brain activity?”

I did not have an answer. And then, a moment of terror. What if this was the moment Baio had been talking about—a time when I was instructed to do something that I shouldn't? Something that was wrong. “There are certain things we know,” I said. “We know that—”

As the words trickled out, I became less certain. During rounds, when the team had discussed Marlene Hansen, I had been called away to transport a patient to the MRI scanner. I hadn't been there to hear just how dire her case was. It was clear from reading the notes of other physicians that a consensus had been reached that she no longer needed to be in an ICU, but I was technically relying on secondhand
information. I was basing my conversation with Ingrid on the opinion of Don and experts whom I barely knew—medical consultants who had only met Marlene Hansen a day or two ago. What if they were wrong? What if I deferred this conversation until morning, when the rest of the team was available? What if that caused Benny to remain stuck in the emergency room because no ICU or CCU beds were available?

“I'll do what you want,” Ingrid said softly, removing her hand from mine.

“You shouldn't do what I want. And difficult as it may be, you shouldn't do what you want. You should do what your mother would want. Have you ever discussed what she might want in this situation?”

“No.”

“But you are her healthcare proxy?”

She nodded. “She doesn't have anyone else.”

“There is something called comfort measures only. We won't draw blood, we won't poke her with needles. We'll make her comfortable.”

“I thought she couldn't feel anything.”

“Right.”

“If she gets an infection, would you give her antibiotics?”

I wasn't sure. I hadn't even been present for the discussion on rounds about what was appropriate. Ingrid took her mother's hand and kissed it. “I don't want her to suffer,” she said. “I trust you. Just show me what I need to sign.”

I closed my eyes and bit my lip. I had been sent in to carry out a mission—to get Marlene Hansen out of the ICU—but it was clear that I didn't have all of the necessary information. Maybe in a few hours I would, after I'd reviewed all of the notes from other doctors, but at that moment I wasn't sure about very basic things like whether we'd provide antibiotics.

I mostly believed I was doing the right thing, but I wasn't certain. It was impossible to know everything—I'd never know how to read an
electroencephalogram, I'd never be the one to perform dialysis; those were jobs for experts in neurology and nephrology, and I had to trust them. If they felt Marlene Hansen had no hope of recovery, they were probably right. But what if I'd met Marlene instead of Benny? What if she was the patient trapped in the hospital—the one I visited day after day—the one I felt an emotional attachment to? Would this conversation have played out differently?

I wasn't sure.

A moment later, I returned with the paperwork and handed Ingrid a pen. As she signed her name, I imagined myself taking the pen back, tearing up the papers, and telling Don that Ingrid wasn't entirely sure what her mother would want. That was the truth of it. With space available, it seemed prudent to keep Marlene Hansen in the ICU until Ingrid figured it out. But what purpose would that serve? Was Ingrid going to suddenly recall some distant conversation with her mother about her end-of-life wishes? Was she going to remember that Mom actually wanted to be kept alive at all costs for as long as possible, even if she was brain-dead? The reality was that Don had a better grasp on how to keep the flow of traffic moving in the hospital; allowing emotions to get involved would introduce subjectivity. And subjectivity could screw things up for all of the other patients.

I kept my mouth shut and let her sign the papers.

“Nice work,” Don said as I leaned over a filing cabinet and placed the paperwork into Ms. Hansen's chart. “We'll send her out in a few hours.”

“Few?”

“They got a bed for Benny in the CCU.”

I jolted upright. “What? So Hansen can stay?” I felt like I had been punched in the gut. Don took a bite out of a tuna sandwich and patted
me on the shoulder. “Hospital doesn't function when we're at capacity, Matt. Gotta have a bed available if there's an arrest on the floor. Hansen needs to go. This is a no-brainer.”

“Gotcha,” I said softly.

He inhaled the remainder of his sandwich. “Get something to eat and then let's do a vitals check on the unit. There's more tuna in the lounge.” And with that he headed down the hall, looking like a man who knew much more than I did.

It was approaching 3:00
A.M.
, the witching hour, when my body temperature inexplicably plummeted and the pace of work finally calmed down. Or exploded. We never knew. On a quiet night, it was the ideal time to throw on a sweatshirt and pick a supervisor's brain, catch up on paperwork, or prepare for the firing squad of morning rounds. On a disastrous night—one in which there were simultaneous cardiac arrests or a half dozen new admissions—3:00
A.M.
was the time when you daydreamed about business school or working as a medical consultant for a hedge fund.

The ER sending Benny to the CCU meant we had dodged a bullet. There would be time to talk, time to check labs and vital signs, time to process the matrix of data and tidy up the unit before the rest of our team arrived at dawn. And maybe, if we were lucky, there would be time for Don to impart some wisdom. I attempted to nudge him in that direction.

“I heard about that diagnosis you made,” I said. “Takayasu's arteritis. Very impressive.”

Don grinned. “Attention to detail, my friend.”

“There are so many details.”

“Key is figuring out which ones are important. That's what intern year is about. They call them
vital
signs for a reason.” I noted a hint of swagger in his voice. “I was just heads-up.”

“I'll say.”

He ran his hands through his blond hair. “They asked me to give
a talk about it to the department. Can you believe that? What the hell do I know?”

I shrugged. Beneath Don's glimmer of swagger was vulnerability. I'd seen it when Baio had called him out on the phone. It occurred to me that we were all wrestling with some form of impostor syndrome, unable to internalize and appreciate our own accomplishments. There was always someone more impressive, someone who could make you look foolish if they really wanted to. Underneath the glimmering personas, some of us—including me and the women in my pod—secretly worried that we didn't deserve to be doctors, we didn't deserve to hold life in our hands, we weren't the ones who should be leading complex discussions about comfort measures and vegetative states. The key to residency was figuring out ways to ignore those feelings without turning into a monster.

“On second thought,” Don said, “let's hold off on the vital signs. Get some food and grab a few minutes of sleep if you can. You just know the ED is teeing someone up for us.”

He pulled out his cell phone and showed me several pictures of his son. The kid was crying in every one, but Don was beaming.

“You sure?” I asked. I was wide awake—stress was a remarkable stimulant—but Axel's axiom wafted into my head:
When you can sleep, sleep
.

“Couch is all yours.”

In my six months at Columbia, I had observed two types of interns—those who couldn't sleep on call and those who desperately needed at least a few moments of shut-eye during the thirty-hour shift. I fell into the latter category; just eight minutes of sleep and I felt reasonably refreshed. By contrast, after a sleepless night I looked, as one colleague put it, “like someone vomited on dog shit.”

I had been snoozing for two glorious hours when a brown paper bag dropped on my chest with breakfast. “How was the night?” Lalitha asked, pushing my legs off of the end of the couch. “Lounge is a mess.”

“Not horrible.”

Her appearance meant I'd survived the night.
Hallelujah
. She patted my thigh with an old
Us Weekly
and shook her head. “I can't believe you have a subscription to this.”

I grabbed the magazine from her. “How else am I going to know Candace Cameron just lost twenty-two pounds?”

Lalitha and I made it a point to engage in conversational nonsense for a few minutes every day before the sun rose and the storm of work and morning rounds rolled in. Our lives together were so intense, so structured, so stressful, that it felt good to talk about something other than our critically ill patients.

We all struggled with the weight of our work, but having the occasional dopey conversation was a reminder that we weren't simply using each other to get through the day. We were normal people who could engage in idle chitchat. But because our personal lives were so limited—the rare off day was often spent catching up on sleep—we rarely had normal things to talk about. Celebrity gossip became linguistic currency, something we could bring up when we needed to disengage from medicine. For me, the levity of the tabloids helped balance out the tragedy of watching people die day after day.

Lalitha scanned Candace Cameron's new figure and pulled out a compact and brush from her bag.

“Did anyone ever tell you,” I said, as I watched her groom, “that you look like Rudy from
The Cosby Show
?”

She rolled her eyes. “Did anyone ever tell you that you look like Pat Sajak?”

“Pat's a national treasure.”

“Sajak crossed with ALF crossed with Chandler from
Friends
. When he was on drugs.”

Don entered the lounge, and we sat upright. “At ease, Doctors.”

“What'd you do to Matt overnight?” Lalitha asked. “Looks like a truck hit him.”

I parted my hair, held the magazine over my face with my right hand, and flipped her off with my left. These little moments brought us closer.

Don shook his head. “Gotta say I love working with you two. Get along better than anyone I know.”

“It's because I'm afraid of her,” I deadpanned.

“He is definitely afraid of me.”

“How could I not be?”

The door burst open, and the nurse manager poked her head in and calmly said, “Jones is crashing.”

I dropped the magazine and grabbed Lalitha. This was the scenario Don had prepared me for: Mr. Jones, the man with the unusual lungs, had dropped his blood pressure. I felt a surge of adrenaline. “Let's do this,” I said, feeling momentarily like Baio. The transition from goofball to physician was instantaneous.

“Blebs?” Lalitha asked as we bounded out of the lounge. She was a step quicker than I was. Her ponytail sashayed from side to side like a broom as we blew down the corridor past Ingrid Hansen, who was staring blankly out a window.

As we entered Jones's room, the first thing I noticed was a large window at the head of the bed. A container ship could be seen in the distance, floating south down the Hudson. The room—with its khaki walls, framed Impressionist artwork, and muted television—was oddly quiet. I was accustomed to a cacophony of alarms blaring whenever I encountered a patient in distress, but this room was silent. I imagined myself as the second-year resident, about to lead Lalitha through a resuscitation.

ABC, ABC

A nurse increased the amount of supplemental oxygen as I turned to Lalitha and announced, “Please assess the patient's—”

“Tension pneumothorax,” she said quickly. “We need to decompress.” She reached for two butterfly needles as I felt for a pulse. Mr. Jones's eyes were closed and he was gasping for air.

“Got a pulse,” I said firmly. I stared at the man's heaving chest, relieved that I didn't need to start CPR. His ribs would have snapped with the first thrust of my palms. Jones was suffering from end-stage AIDS and pneumonia; he was emaciated, weighing less than one hundred pounds, and his cheeks were sunken in. His arms were like two Wiffle ball bats, flailing as he gasped for air. As I estimated his heart rate—it was well over one hundred beats per minute—I pictured myself doing chest compressions on this frail man, and I imagined one of the shattered ribs piercing through his heart like a warm knife through butter.

Don hung back and watched. Standing next to him, in what momentarily seemed like a mirage, was Baio. Instead of going home after his night shift, he'd come to the ICU to check on Darryl Jenkins. They both folded their arms. Part of being a strong supervisor is knowing when to let your intern take the lead, and this was apparently one of those times. Mr. Jones's eyes bulged as he squirmed in bed, panting for air. I took a deep breath. Lalitha and I were on our own.

“Have you done one of these before?” she asked as we hovered over the patient. “Needle in the chest?”

“I watched the video last night,” I said, feeling like an actor in a commercial saying, “No, I'm not a doctor, but I did stay in a Holiday Inn Express last night.”

“Good enough.” She felt for the man's left clavicle. “I've done one. Just do what I do.” She tilted her head toward his right clavicle and handed me a needle that had been attached to rubber tubing. Lalitha plunged the needle into Mr. Jones's chest and turned to me. “Go.”

I felt for the landmark on my side and with my left hand thrust the needle deep into the man's meager chest. In my right hand I held the rubber tubing that was attached to the needle. Don and Baio sidled up behind us and peered over my shoulder. I waited for a gust of air, but there was nothing. “I thought a rush of air was supposed to come out,” I said, “if a bleb really burst.”

Lalitha and I looked at each other nonplussed as Mr. Jones continued
to gasp for oxygen. Don and I hadn't discussed a Plan B. I readjusted the needle and waited for something to happen, but nothing did. I waited for Baio to say something encouraging—
you can do this
—but he just stood behind me with his arms folded and his mouth shut.

Beads of sweat gathered above my lip as Mr. Jones writhed in his bed and his blood pressure continued to plummet. Two nurses entered the room; one quickly injected a medication into the man's arm while another checked vital signs. ABC, I said to myself. He had an airway, he was breathing, and he had circulation. What was next? I was watching a man suffocate and I wasn't sure what to do. Intubation? I readjusted the needle a third time. Nothing.

I looked at Lalitha and she looked at Don. We would need to intubate him if things didn't turn around quickly. He'd also need a large IV in his groin if his blood pressure dropped again. After what felt like an eternity but was actually ten or twenty seconds, Baio handed Lalitha and me a small Styrofoam cup filled with water. I was about to take a sip when he grabbed it and said, “No.” I looked at Lalitha, who had placed the tubing into the cup, and I followed her lead. Again, nothing.

I readjusted the needle a fourth time and with Baio's gentle prompting, dropped the plastic tubing into the cup of water. We both peered into my cup, which was now bubbling vigorously, and smiled. “There it is.”

Air rushed out of Mr. Jones's thorax and into my cup. It was a moment straight out of
MacGyver,
not an instructional video. How did Baio come up with this stuff? I felt the muscles in my face relax just slightly. Lalitha nodded and glanced at her watch. Minutes later, Mr. Jones was breathing comfortably.

“Well done, Dr. McCarthy,” Baio said, as he headed toward the exit sign. “Amazing things are indeed happening here.”