Intern (10 page)

I draped the sheet back over her face. “Yes, she's dead,” I told the nurse outside, as if the whole exercise had been some sort of test.

“You have to write a note, Doctor, and put an order in the computer.”

“Order for what?”

“The order that she is dead.”

The order that she is dead??
My lips curled up into a grin, inviting the nurse to laugh with me at the absurdity of her request, but she just continued to stare at me blank-faced.

“All right,” I finally said.

I sat down and jotted a brief note. “Called by nurse to pronounce death at 5:10 a.m. Patient had no spontaneous respirations. On exam: no breath sounds, no heartbeat, no pulse. Assessment: Death. Plan: No resuscitation, as patient was DNR.”

I entered an order into the computer. Unlike most orders, this one was just one simple click. I filled out the death certificate. Under “cause of death,” I wrote “cardiac arrest.” Under “due to or as a consequence of,” I wrote “heart failure.” “Was an autopsy performed?” I checked “no.” I wasn't about to call the family at this hour to ask for one. The nurse looked over my shoulder.

“You have to change the time of death, Doctor.”

I looked up. “Why?”

“Because I put four o'clock in my note, and there cannot be a discrepancy.” Sure enough, she had written “4 a.m.” on the previous page.

“But when did she die?” I asked, puzzled.

“About an hour ago, Doctor,” the nurse declared, a bit flustered. “I did not want to wake you. You looked tired.”

It was too early to argue, so I wrote another note. The computer wouldn't let me backdate the order, so I left it the way it was.

Back in the call room, Steve was lying awake. “Did you pronounce her?” he asked.

“Yes,” I replied.

“Everything okay?”

“Yes, no problems.”

“Did you call the family?”

“Uh, no.”

“And the attending?”

I knew I had forgotten something. I went back outside and made the calls. Mrs. Piniella's niece seemed relieved when I delivered the news that her aunt had died. The attending physician sounded annoyed for being woken.

It was too late to go back to bed—I didn't think I'd be able to wake up again—so I took a seat in the conference room and looked over the whiteboard. It was divided into a grid, with each square representing a patient's room. Within each square were tiny unfilled boxes denoting tasks that still had to be completed: “CBC Q4,” “blood cultures x2,” “wean vent.” In my mind, I went over the past twenty-four hours, my first day in the CCU. When I arrived yesterday morning at six-thirty, I was met by Amanda and Nancy, my fellow interns in the CCU. Amanda was a soft-spoken woman with large, quiet brown eyes who had gone to Yale as an undergraduate and then to medical school in the South, which left her with a winsome mix of southern drawl and clipped New England patois. As I would soon discover, she always came in early to preround and finish her daily progress notes before the attending physician arrived. Her unassuming, intelligent manner was very appealing. Nancy was a good-looking blonde with a rather severe visage and matching personality who reminded me of the nurse Hot Lips Houlihan from the television show
M*A*S*H
. She had gone to medical school here at Cornell with Vijay, who had warned me that she was competitive, even a bit cutthroat.

Amanda and Nancy had come in early to receive sign-out from the departing intern. They had already divided up the fourteen patients, taking five each and giving me four. “So there's an advantage to coming in late,” I quipped. Nancy forced a smile and handed me a stack of sheets. “You'll need these for rounds,” she said curtly.

The CCU was a rectangle, with most of the rooms arrayed along a long wall running parallel to the East River. There was a central bay with a nursing station and a medication room. At the front entrance were a clerk's desk and a pneumatic tube system for ferrying specimens to the laboratory in the basement. At least once an hour one could hear the
hut-hut-hut
of a test tube containing a blood sample being
whisked away for analysis. Sleek and modern, constantly buzzing, the CCU occupied a world apart from the rest of the hospital, which by comparison was relatively staid. Staff were constantly walking through, wheeling machines. Alarms rang incessantly. Consultants were always around, scribbling notes. That first morning, the nurses were in the middle of their change-of-shift routine. “Bed Two is still constipated,” a nurse announced. “She hasn't had a bowel movement for me in three days. Bed Four got agitated again last night, requiring Xanax, which he's still getting PRN. Seven is status-post a 250 cc bolus of normal saline because he was running tachycardic most of the night. Twelve was suctioned once: large, yellow . . .”

I hurried to see my patients before attending rounds began at eight o'clock. The first of them, Paolo Fellini, was a well-to-do businessman who had been enjoying his retirement for years when he was felled by a massive heart attack. Over the ensuing weeks, he had suffered numerous complications, including respiratory failure requiring a ventilator, blood infections requiring broad-spectrum antibiotics, and a stroke, which incarcerated him in a sort of dementia that left him unable to recognize even his grandchildren, whose get-well cards were pasted all over the walls. On his bedside table was a picture of him standing on a boat, smiling broadly, looking every bit the Connecticut waterman he once was, a stark contrast to the man who lay before me. He was now wearing a diaper—judging by the fetid odor, it was filled with stool—and a hospital gown that was more off his body than on. His mouth was open: a thick crust coated his lips and tongue. His legs were twisted into an unnatural position, a result, no doubt, of his stroke. On his arms were large purplish bruises where attempts had been made to draw blood, and several tears in his paper-thin skin were still oozing. A plastic tracheotomy tube jutted out of his throat, connecting to a blue baffled hose that originated from a spigot in the wall. A bag was attached to his bed railing, filled with Coca Cola–colored urine. At the bedside were a teal blue IV monitor, several oxygen canisters, a ventilation bag, and a bundle of purple tubes which snaked across the floor and fed into inflatable cuffs on his legs. A bag of milky
tube feeds and several bags of clear medicated fluids were hanging on a metal hook suspended from the ceiling. Above his head, connected to a flexible metal crane, was a small television, which was off.

When I got near him, his eyes jiggled apprehensively in their sockets. “Good morning,” I said. “I'm Dr. Jauhar.” His breath faintly smelled of old rice. “What is your name?” He did not respond. “Do you know where you are?” I reached for my stethoscope. On the monitor, his heartbeat quickened and his breathing became more rapid and shallow. The ventilator started wailing. For all the talk of coma, he clearly sensed my presence.

His ribs poked out of his bony chest like spokes on a wheel. So rippled was the topography of his chest that I could not find a flat place to put my stethoscope. I finally wedged it between two ribs. “I'm not going to hurt you,” I said as he grimaced horribly. I had read that patients who make it out of intensive care units often liken the experience to combat. Many suffer chronic anxiety and depression; others develop post-traumatic stress disorder. Drugs like morphine and fentanyl are used not just for pain relief but to keep patients from remembering their suffering.

I tried sitting him up so I could listen to his lungs, but he resisted. I tried pushing him gently onto his side but he would not budge. Tears streamed down his sunken cheeks. I looked around for a nurse to assist me but no one was available. His lungs made deep, guttural groans, like a foghorn, so clogged were they with fluid and muck. I placed my hand on his abdomen and pressed gently. He opened his mouth, as if to emit a blood-curdling howl, but because of the tube in his throat, there was no sound. “I'm sorry, sir,” I kept saying.

Outside the room, I jotted down a few notes. It was already seven forty-five. The encounter had taken almost fifteen minutes. I was going to have to scramble to finish seeing the rest of my patients before eight o'clock.

I hustled to the bedside of Camille Panizzo, an eighteen-year-old with a rare blood disorder requiring frequent blood transfusions. Over the years, the excess iron from the transfused blood had accumulated
in her vital organs, including her heart, which had enlarged and thickened, leading to congestive heart failure. In the CCU she had had numerous runs of ventricular tachycardia, a potentially life-threatening heart arrhythmia. Electrophysiologists were considering implanting a defibrillator in her chest to shock her heart in case it stopped, but in the interim they had decided to treat her with intravenous lidocaine, an anesthetic that suppresses arrhythmias. The infusion had worked—the ventricular tachycardia had subsided—but now she was deeply somnolent, a side effect of the drug.

When I arrived, she could barely open her eyes. She had delicate, appealing features—blond, curly hair, high cheekbones, and a narrow nose. Her jaundiced skin was the color of polenta, probably because of all the iron in her liver. Her eyelids only fluttered when I introduced myself, but I could still make out that she had green eyes, and that they were beautiful. Her mother, also blond and pretty, like a middle-aged flight attendant, was sitting by the window. She asked me if a decision had been made about a defibrillator. I told her that it was my first day but that I would check on it and get back to her. “They have to do something about this medication,” she said wearily. “I can't stand to see her like this.”

The mood next door could not have been more different. Ramón Ojeda, a middle-aged taxi driver, had had angioplasty, where a tiny balloon and a coil of wire called a
stent
was used to open a severely blocked coronary artery. Now, just a day later, he was sitting up in bed, admiring a magnificent view of the sun-soaked East River and the Queensboro Bridge. He was going to be transferred to a regular floor today. When I informed him of this, he feigned disappointment. “Look at me here,” he said, arms outstretched. “I'm king of the world!”

Across the hall, my last patient, Irving Waldheim, was lying on a cardiac recliner, staring at a wall. Waldheim was a wizened man in his late sixties with a shock of wild, professorial hair and gray bushy eyebrows. His skin was pallid and shiny, with a residue of perspiration. Like Mr. Fellini, my first patient, he had suffered numerous complications during his monthlong stay in the CCU, the latest being unremitting
fevers of unknown origin. The workup, including numerous blood cultures and CAT scans looking for occult infections, had been negative. Now his doctors were saying that, ironically, the antibiotics he was on might be causing the fevers.

The room was dark, one of four in the CCU without windows. Next to the wall was a plastic bucket filled with foamy secretions. On the bed was a quilt knitted with a verse from the Twenty-third Psalm: “The Lord is my shepherd. I shall not want. He maketh me to lie down in green pastures.” I asked Mr. Waldheim some questions but he did not respond. Since I was running late, I didn't press. I was about to leave when his son, who was just coming in, asked me if his father could be moved to a room with a view. “I think some light would do him good,” he said. I told him that I would check with the other doctors.

When I finally made it back to the conference room, the team had already assembled at the long table, their white coats draped over the backs of the vinyl chairs. “Jauhar's brother,” someone said as I took a seat. The attending physician, Jonathan Carmen, nodded to acknowledge me. Dr. Carmen was in his late thirties, muscular and square-jawed, with a balding pate and an almost menacing visage. My brother, who knew him well, had described him as smart, savvy, your basic tough kid from Brooklyn who'd made it up the hospital ranks through hustle and hard work. I didn't know how much of his story was myth and how much fact, but it was appealing nevertheless, and I had been looking forward to meeting him. “I've heard a lot about you,” Carmen said, looking me over intensely. “Thank you,” I replied stupidly.

One of the senior residents turned to me. He was tall, with glasses, short brown hair, and handsome features. “I'm Steve,” he said, extending his hand. “We'll be taking call together.”

Carmen quickly went through the logistics of the rotation. There were three intern-resident teams, so call was every third night. Rounds were long, he warned, “so keep your presentations on point. Start with the chief complaint. And don't just tell me what the patient said. Sometimes
I'll hear the chief complaint is, ‘It's cold in here.' ” He drew out each syllable in a high-pitched nasal sneer, like Jackie Gleason on
The Honeymooners
, and we all laughed. “That may be the chief complaint, but that's not the reason the patient is in the hospital.”

On rounds, we huddled around a metal rack bulging with charts, Carmen and the fellow in the center, then the interns, then the residents, who hovered on the periphery, periodically breaking away to answer pages. Outside each room, arms folded in postures of serious purposefulness, everyone listened intently as Amanda, Nancy, or I read off vital signs, medications, ventilator settings, fluid intake, urine output, nutritional data, and lab results from the flow sheets. Carmen and the cardiology fellow interrupted frequently to fill us in on details or to ask questions or to make clarifying comments. One of our patients was a nephrologist with kidney failure who wept inconsolably when we went to see him. It wasn't clear what was wrong, except everything. There was a music school teacher who woke up with chest tightness and went to work, only to go to the ER in the evening and be told that he was having a heart attack. A young man with an artificial heart valve had continued to use heroin and now was hospitalized with another valve infection. “When's the surgery?” he asked defiantly, and Carmen brusquely told him that it was up to the surgeons. When a resident brought up the issue of drug withdrawal, Carmen said, “Just give him what he needs. Let's not worry about detoxing him here.”