Weekends at Bellevue (31 page)

A medical student begins compressions, and the chief says, “Real CPR, please,” to the student. It must be a tradition, I think, flashing back to the chaotic scene at the codes when I was a medical student, when doing compressions seemed like the best role to play in a resuscitation. You feel you are being productive, you are doing something physically to help the patient, and it requires a minimum of know-how. But then the person running the code comments on your form, and the critique cuts you down to size, transforming you from the one who is saving the patient to the one who is killing the patient through your incompetence.

This chief has a way of making everyone feel incompetent though, and that’s what he does to me when I make the huge mistake of mentioning to him, as he runs the code, that I had tried to get AES to take the triage and they refused.

“That’s not helpful to me right now,” he says testily, and I know he’s
right. I tell him the patient had two Tylenol 3s at around eleven o’clock, in addition to whatever heroin he injected six hours earlier, and recommend Narcan, an opiate blocker. It’s the only useful piece of information I give him, and he begrudgingly orders Narcan, after making me wait and watch for a moment to see if he’ll gratify me in this way.

One resident is attempting to get a sample of arterial blood from the patient’s arm, another is putting a catheter into his penis, a third is putting an intravenous line into his neck. A nurse is filling syringes, serially—Epinephrine, Narcan, Epinephrine—stating the medication’s name with solemn regard as she hands the needle to the chief.

The patient’s heartbeat comes back after two rounds of “Epi”—a hormone similar to adrenaline—the stuff that is now surging through my veins and making my heart race, as I struggle to keep my hands out of my mouth and appear calm. The compressions cease, and the second-year resident tries for a second time to intubate the patient, craning the patient’s chin toward the ceiling to see down his throat. She can’t visualize the vocal cords, the landmarks to tell her she can proceed with the tube into his windpipe; because of the strangulation, there’s too much swelling. The chief resident finally takes over, the savior, the martyr, to do the intubation like it’s supposed to be done.

The pregnant attending ambles up next to me to watch her protégé run the code; I find it comforting to have her there. I imagine she’s glad he was in my area, and not in hers, when he made the second attempt that day on his miserable, dwindling life.

“His pupils are blown,” the chief tells the crowd. “Let’s call respiratory.”

I know what this means: Jesus Martinez is as good as dead.

He is placed on a respirator and admitted to the MICU, the medical intensive care unit, where they will likely try to contact the next of kin to discuss removing the respirator, assuming that he will stop breathing and die a natural death. Sometimes, however, these patients keep breathing on their own, and then we are left with what we call “a brain stem.” The medulla, a major part of the brain stem—south of the cortex where the real feeling and thinking is orchestrated—is still functioning, reminding the lungs to breathe, instructing the heart to beat. During my neurosurgery rotation in medical school, the bulk of the patients on the inpatient wards were in this state. I would write notes that said VSS, CVSP: vital signs stable, chronic vegetative state persists.
And persists. If they don’t get an infection, “brain stems” can live for a painfully long time, being fed through a tube into their stomachs. We would also sometimes refer to these patients as “rocks,” immobile, immutable. We would come and go as we began and ended our rotations, but they never left the hospital.

I remember the afternoons on the neurosurgery wards, when the visiting families would come. The patients would lie there, dressed in their satiny sweat suits, breathing, blinking, hearts beating. Sometimes their eyes would move, a reflex of the lower brain centers; they seemed to follow their loved ones across the room, but a vegetative state is not fully alive, and the patient is not really “there.” The eye movements often give the families false hope, which can complicate their decision to turn the patients into DNRs. It’s hard for the families to understand that even though the eyes are open and moving, their loved ones are not truly seeing them.

So, Mr. Martinez hasn’t quite killed himself exactly. He has, thanks to our interventions, put himself into a medical purgatory. He’s not alive, but he’s not dead. His brain is functioning just enough to keep his heart beating, and our machines will keep his lungs filling with air, his blood oxygenated, his organs functional.

I come back to CPEP with the information that he is on a respirator in the MICU, which the staff takes as good news, that he has been saved, but they are wrong. He has basically killed himself on my watch, under our care, and it is only a matter of time and semantics separating him from actual death.

And now come the paperwork, the phone calls to the bosses, the questions, the revisions, the muted conversations, and the Monday-morning quarterbacking. I steel myself in preparation for the inevitable days ahead, when I will have to speak with the hospital administrators, the lawyers, my boss, his boss, and the boss above him, and the lawyers, the nursing supervisor, the next of kin, and the lawyers again.

MacKenzie calls me up at the house to ask me what happened, and I tell him everything I can remember. He tells me that on Thursday there will be what the Bellevue Department of Psychiatry calls a “Special Review.” These reviews are supposed to be dispassionate dissections of what occurred, but inevitably they morph into a reaming of one or more parties.

Shortly afterwards, Daniel calls me to strategize for the inquisition.
He is upset when he finds out that I have already spoken to MacKenzie. He has a lot of specific recommendations for how best to answer the questions, and how to frame the situation in general. He jokes that I should cry during the Special Review. He figures if I look frazzled, they’ll go easy on me.

At first I don’t understand why he’s calling to give me any advice. Why should he care if I take a fall? But then it occurs to me that it will reflect badly on him if there is any blame shouldered. He’d prefer the whole CPEP look innocent.

He reminds me to keep my responses to a minimum. I have a habit of overtalking and overanalyzing; in my most awkward situations, I get a case of verbal diarrhea.

When I see the AES chief resident who ran the code at a downtown restaurant a few weeks later, I apologize for doing just that.

“I should’ve just shut up after I gave you the bullet, but I was stressed and I kept talking. I shouldn’t have said that you guys rejected the triage. It was right for you to respond the way you did,” I tell him. Better for me to make peace with him, I figure. I may have to work with him again down the line.

He did, after all, prevent my patient from actually dying, and for that I am thankful. But our patient, he really wanted to die. I am sure of it. He would not be so grateful his plans were thwarted.

D
r. Henderson, the director of inpatient services, pulls me out of the up-wards conference room just before the Special Review begins. He squeezes my shoulder and murmurs, “Julie. No one thinks you did anything wrong. Go easy … go easy.”

I am stymied, and offer no response. Sweltering in my most matronly sweater set, a sickening shade of pale green, I’m finding that it’s only too easy to appear emotionally distraught. Daniel will be pleased that I am taking his advice.

I can’t figure out if Henderson is telling me to relax because I have nothing to worry about, or if he is soothing me because he’s afraid I will make a scene otherwise. I remember the phone conversation between us on that Saturday night, around one in the morning, shortly after the code. I started off on the offensive.

“Dr. Henderson, I know Bellevue,” I began. “I’ve been here long enough to know that in these situations somebody usually takes a fall; someone is always left to twist in the wind. I just want to make it clear, sir, that ‘somebody’ is not going to be me.” Maybe I even said it menacingly. I wanted him to know I wouldn’t take any of this lying down. I wouldn’t go quietly.

Everyone seems to be warning me not to sabotage myself at this meeting. They are all implying that my usual protection, my swagger, is my potential undoing. It certainly hobbled me at my oral boards, and I can’t let that happen again.

The conference room is full of unit chiefs, department directors, and other high-level administrators sitting around a large, rectangular table. I choose my seat carefully, looking for allies. I am afraid for my job and for my reputation, and it’s hard to figure out whom to align myself with. I sit between Daniel and MacKenzie.

Henderson calls the room to order and begins. “This is a very complicated case. And though it seems clear that this patient was marked”—he pauses for dramatic effect—”marked for death, this should not have occurred in our hospital.”

I love that, marked for death. Henderson’s got quite a flair for the dramatic. He asks to hear from the different specialties assembled around the table, and the director of nursing begins.

And we’re off. There is some confusion about how many patients were in the area and how busy we were that night. I look over at Daniel questioningly, with terror on my face, and he does something cryptic but potentially communicative in its symbolism. He begins to draw on my Special Review handout—a schedule of who is to speak and in what order, with Mr. Martinez’s initials and medical record number at the top of the page. Is Daniel writing me a note? No, he draws a tic-tac-toe board and he puts an
X
in the bottom right-hand corner. He slides the paper toward me.

Tic-tac-toe…. Yeah, okay … Huh?

What the hell is he doing?

Dr. MacKenzie is directly to my left and there is no way I want our boss to see us playing a game at the outset of this meeting. Is Daniel trying to get me in trouble? Like making a sibling laugh while getting chewed out by Dad? Or is he trying to show me it’s all a game? That he doesn’t think this meeting is a big deal and neither should I? Or maybe it’s a message I’m supposed to interpret in a different way: The nurses are playing a game and they’ve put the first
X
here. They’re setting up the board and now it’s my turn.

Being a shrink can be a real pain in the ass. I can offer up a slew of interpretations, but when the subject is me, I have to choose one all on my own, and sorting through them all is distracting me from the meeting.

People seem to be maneuvering around, trying to dodge the blame ball. Not only are the nurses giving conflicting accounts about how many patients were in the area, but now there is a discrepancy about
the staffing. I’m almost positive we had fewer workers that night than they’re reporting. What advantage is it for them to overstate the number of staff? At least overestimating the census makes sense to me. We were busy, we didn’t catch him putting a string around his neck. But to say we were heavily staffed instead of understaffed makes us look like buffoons: We should’ve seen this happen if there were extra staff members tripping over one another on the unit.

The thing that makes the least sense is the nurse’s triage paperwork from that night. She must have panicked. She has written not one, but three different responses in the space on the nursing triage sheet where it asks if the patient is currently suicidal. First she wrote “Vague” and then that is crossed out and it says “Denies,” which is also crossed out. The third response says “I want to die.”

When a patient is asked whether he is suicidal, either he says he is, or he isn’t, or he’s vague. Pick one! The nurse probably never got to ask him point-blank if he was suicidal. That’s why she was at a loss for what to write. If she didn’t get to formally interview him, why not just report that? The nurses are allowed up to two hours before they have to triage a patient, and the doctors are allowed up to six hours. Given the time frame of the events, she could’ve written that she hadn’t asked him yet, and that would’ve been fine.

Luckily, Mr. Martinez hadn’t been interviewed by the doctors yet, so the amount of writing I had to do in the chart was limited. I wrote one quick paragraph summing up the entire events of the night, taking the easy way out—the truth. He had been on the unit less than an hour before the suicide attempt.

Dr. MacKenzie asks me, “Dr. Holland, given what you know about the case now, in hindsight, would you have done anything different that night?”

“With hindsight I would’ve done everything differently, in order to prevent this suicide attempt, yes. But given what I knew prospectively, going into the case, I wouldn’t have done anything differently,” I answer as calmly and confidently as I can. I hope they appreciate my good grammar.

“Did you think this patient was high risk?” Dr. Henderson asks me. “All the patients in the detainable area are high risk,” I answer. I know Daniel likes my answer. We had agreed during our earlier phone call
that there was nothing specific about Jesus Martinez that would have separated him out from the other patients we typically see. Nothing that was available to me at the time of his presentation, anyway.

“We see people who have just attempted suicide all the time. He wasn’t particularly special in that way,” I explain.

“In hindsight, everyone is a genius,” Dr. MacKenzie says during the review.
Man, you aren’t kidding
. I did the best I could in the moment. It was like a war zone; there was no time to mull over my options, no room for error. Now, with the luxury of time and speculation, it’s all twenty-twenty vision.

The Special Review is winding down. Now that everyone who has ever treated this guy has come together, I have learned a bit more about Mr. Martinez. One new piece of information is that he had hidden a razor in his mouth on a prior visit, and a staff member saw him retrieve it from under his tongue and place it in his sock. That was one month ago, when he was admitted involuntarily to the upstairs psych unit, then transferred to the medicine floor for a work-up of a fever. He was eventually discharged home from the medical ward, instead of being transferred back to the psychiatry ward, because the psychiatrist on the consulting service said that he wouldn’t benefit from an inpatient stay.