Intern (37 page)

“Get me a Doppler probe,” Paulie cried. “We need a blood pressure.” He waited for about three seconds. “Hello! I need a Doppler probe in here!”

“We need to run and get it,” a nurse said, looking annoyed. Paulie made a face. “Is the bicarb in? Hello! Is it in?”

The person who was pushing medications into the central line said, “I just pushed it. We need a flush.”

“You heard the man, get him a flush!” Paulie shouted. “Watch the needles, guys. There are too many hands in the field.” He grabbed an errant needle and plunged it into the mattress. It was the sort of impetuous, decisive behavior I seemed incapable of. A thought passed through my mind like an evanescent gust:
Will this mattress be reused?

More drugs went in as I silently looked on. I resented Paulie for usurping my authority, but at the same time I felt relieved. At one point Williams regained a weak pulse, but it quickly disappeared. “Want another round of epinephrine and atropine?” I asked softly. Paulie looked at me askance. He didn't want suggestions; he wanted people to do as they were told. With fluid running into several IVs, he ordered escalating doses of epinephrine. Soon people started murmuring, “How long has it been? When did we start?”

“Hold compressions,” I finally said, staring at the monitor. Wide electrical complexes raced across the screen. “Ventricular tachycardia,” I said. “Get the paddles ready.”

“That's not ventricular tachycardia,” Paulie cried, squinting at the screen. “That's electromechanical dissociation!”

The squiggles looked like a sine wave with plenty of noise. “It's VT,” I murmured.

“No it's not,” Paulie shouted. “It's EMD. That is not a shockable rhythm!”

An intern was standing tiptoe on a step stool, waiting for the order to shock or not. Doubt started creeping into my mind. What was EMD? How were you supposed to distinguish it from slow VT? How was it treated? Atropine? Epinephrine? The confidence was draining out of me quickly. I found myself wondering what people in the room were thinking. What kind of impression was I making in my second attempt as code leader?

Then I turned to Paulie. “Who's running this code?” I snapped. I turned back to the intern. “Give him the shock.” She hesitated. “Give the shock,” I insisted. An alarm sounded, and Williams's body jumped up and down as the defibrillator discharged into his chest. On the monitor, the blips narrowed. Sinus tachycardia. A picket fence. A normal rhythm.

A resident had his hand wedged into the groin. “Pulse . . . pulse . . . pulse,” he yelled out. A trembling relief washed over me. This time, the pulse did not go away.

Before the code team dispersed, Paulie went on a rant. “This was the worst code I've ever seen,” he bellowed. “You guys are shocking EMD! You're not doing proper chest compressions.” He put one hand over the other and pumped up and down to demonstrate how it should be done. “This poor guy will be lucky if he doesn't lose the two neurons he has left.” I glared at him but did not say anything. Williams was alive, after all. I had made the right call, and I had done my job.

After ordering an intern to ventilate Williams with an oxygen bag,
I went out to the nurses' station to call Williams's brother. I had never met him. In fact, I had never even spoken with him.

When he answered the phone, I told him that his brother had had another cardiac arrest. I explained that the high potassium level in his blood, a consequence of kidney failure, had probably been the cause. “We revived him but he is obviously in critical condition,” I said. “Will you be coming to the hospital to see him?”

“I can't come today,” he replied.

“Well, when you do come in, would you please ask a nurse to page me? I'd like to talk with you about your brother's long-term plan.”

“What plan?” he asked suspiciously.

“I'd like to talk face-to-face, if possible.”

“Let's talk now.”

“All right, if you prefer—” I hesitated. “I just wanted to know . . . Has anyone talked to you about DNR?” I knew the subject had been brought up, but I couldn't think of a better way to get the conversation started.

“We're not talking about that again!” he said fiercely.

“I'm sorry, sir, but we need to talk about it because your brother just had a cardiac arrest.”

“I told the doctors before; I want everything done to keep him alive.”

“That's fine; we can do that, but—” I decided to try a line I had heard Dr. Morales himself once use. “Some people think that when the heart stops beating, it's like the person is already dead. I'm not saying we won't treat him. I'm just talking about not trying to revive him again if his heart were to stop or if—”

“Who do you think you're talking to?” he interrupted angrily. “You're trying to bullshit a bullshitter.”

“I'm not trying to bullshit you,” I replied. “Your brother is terminally ill. Continuing to resuscitate him won't prevent his death. It's just torturing him for no good purpose.”

“You guys have been trying to make me kill my brother for years.
Curtis wanted to live for as long as possible. ‘Don't let me die,' he told me. Now how am I supposed to go against his wishes?”

“Do you think he'd still feel that way if he could express himself now?”

“It doesn't matter,” he snapped. “It's what he told me. Look how many times you guys thought he was gone and then he turned the corner. He'll surprise you. I'll count him out when they pull the sheet over his head.”

“Sir—”

“Put him on a heart-lung machine if you have to. I don't want his blood on my hands.” Then he hung up.

That afternoon, I found Dr. Morales at the nurses' station writing notes. I told him about my conversation with Williams's brother. I asked him if we were going to have to resuscitate Williams again in the event of another cardiac arrest. I did not want to be involved in another code on him.

“He's Dr. Batton's patient,” Morales said defensively. “She should have made him DNR years ago. Now we're at the mercy of that nut brother.”

“Can't we still make him DNR?” I asked. I had read somewhere that two physicians could issue a DNR order against a family's wishes if they thought further resuscitation attempts were going to be futile.

“It isn't easy,” Morales said gravely.

“There are very strict criteria.”

“What about taking him to court?”

Morales replied that the courts, with their adversarial approach, were not the right place to resolve these kinds of disputes. “Call Dr. Batton and see what she has to say,” he suggested.

Some primary care doctors regularly came to the ICU to see their patients, but Dr. Batton wasn't one of them. When I called her, she said she had tried talking with Williams's brother on many occasions, but he had been equally intransigent with her. When I asked her about issuing a DNR order over the brother's objections, she suggested I speak with the hospital's legal department.

When I called that department, a staff member told me that two physicians could issue a DNR on the basis of futility, but that the definition of futility was very narrow. Two physicians had to agree that even if the patient were resuscitated, he would still die imminently. “In our experience, it's hard to get two physicians to agree to that,” she said.

She added that the only way to withdraw medical care from a patient without decision-making capacity was at the behest of the patient's health care proxy—and then only if there were clear evidence of the patient's prior wishes. There was no way to withdraw care on “moral grounds”—for example, on the argument that a patient has no quality of life. “The department is very concerned about imposing medical judgments against a family's wishes,” she said.

Over the next couple of days, Williams made no spontaneous movements. He remained unresponsive to painful stimuli. He made no spontaneous respiratory efforts. He had no gag or corneal reflex. His deep tendon reflexes were completely absent. A couple of nights later, he had another cardiac arrest when I wasn't in the hospital. This time, an intern nearly got stuck with a needle during the resuscitation. The next day, I heard Morales talking on the phone with the legal department. “This patient is a high exposure risk,” he said, seething with frustration. “We can't keep resuscitating him. Someone is going to get stuck with HIV.”

Because Williams was still in a coma, Morales decided to perform an apnea test. In this test, the ventilator would be disconnected to see if Williams made any effort to breathe on his own. If not, he could be declared brain-dead and be removed from life support. When Morales placed a call to Williams's brother to explain the purpose of the test, the brother hung up.

The following afternoon, Williams was hyperventilated for ten minutes and the ventilator was disconnected. After a few minutes, a blood gas measurement showed a precipitous rise in the carbon dioxide level, signifying severe acid buildup. Despite this powerful respiratory stimulant, Williams did not take any spontaneous breaths. After
several minutes, the ventilator was reconnected and the test was repeated, with the same result. Morales tried calling the brother to inform him of the results, but the line was busy. When he asked an operator to intervene, he was told that the phone was off the hook. An emergency telegram was sent.

Now we could act, but Morales wanted to move cautiously. He asked for a note from Patient Services ratifying the decision to withdraw life support. A representative from that department came by and wrote that it was “clinically inappropriate and disrespectful” to continue to resuscitate Williams. Morales himself wrote that Williams's condition was “hopeless” and that further cardiopulmonary resuscitation would be “futile.” Morales even called a neurologist to perform a confirmatory apnea test. Nigel Caldwell had a crisp British accent and a sharp, decisive manner. In the ICU, he was known as the executioner. After evaluating Williams, he wrote: “The patient has failed the apnea test. He has had three cardiac arrests. It is inappropriate to resuscitate a patient who has failed test #1 it goes against the natural course of illness.”

He performed another test anyway. This time, Williams's carbon dioxide level rose to ninety, more than twice normal. After ten minutes, he had still made no attempt to breathe. The doctors watched for an awakening, but there was none. At seven-fifteen in the evening, he was finally declared dead. His brother declined an opportunity to view the body.

ON MY LAST WEEKEND
in the ICU, I rounded with Isaac Sweeney. Dr. Sweeney was a portly, avuncular attending physician with a mischievous grin. Despite the miseries of the ICU, he always maintained a relentlessly upbeat manner.

It was a brilliantly sunny day, perfect weather for sailing. Midway through long, protracted rounds, Sweeney called us over to a window. He pointed down at a sailboat on the river. A man was standing on the deck, looking up at the hospital. He looked like he was about
Sweeney's age, though fit and tan. He was holding a drink, and a party was going on onboard. “See that guy?” Sweeney said. “Do you know what he's thinking?”

No one ventured a guess.

“He's thinking, ‘I should have been a doctor.' ”

Before I left, I surveyed the unit one last time. I had seen so much over the past month; things I had never seen before, that I had never expected to see. I had changed. And yet I was leaving the place essentially as I had found it.

The most essential part of a student's instruction is obtained, as I believe, not in the lecture room, but at the bedside.

—
OLIVER WENDELL HOLMES

 

T
he monthlong rotation in the ICU was a turning point. Like a phase transition, the transformation was almost imperceptible, yet the results were striking. When I got back to the wards I discovered a level of comfort I could never have imagined as an intern, or even early on in my second year. I was actually looking forward to going to the hospital each morning—devising a plan for my patients, conferring with attending physicians, “running the list” with my interns, holding teaching rounds with medical students (“That's your differential? Major depression? What about autoimmune disease, vasculitis, tuberculosis, lymphoma . . . ?”). New admissions no longer generated armpit-drenching anxiety. Palpitations and dizziness? No problem. Altered mental status in the setting of prostate cancer? I could handle it. Of course, I was following established protocols, but it was becoming clear to me that clinical medicine wasn't just cookbook algorithms, as I had once imagined. There was a discretionary element to it that could not be captured in a flow chart or a decision tree. It was a bit like chess: the openings had long been worked out, but you could still improvise. As a doctor, how you talked to your patients, guided them,
advocated for them, was up to you. That was how your personality could be expressed.

Ward rounds in the morning were a mad dash with my interns and students in tow. With usually twenty or more patients to see, the visits were mostly flybys during which I would interrogate patients about their symptoms and overnight course while my interns scribbled down tasks for the day: “consult Psychiatry,” “curbside Renal,” “check sodium at 4:00 p.m.,” “inject urokinase into loculated pleural effusion.” We got adept at getting in and out of patients' rooms quickly, efficiently, not making them feel like we were dismissing their complaints but really saying and doing very little at the same time. Each case had a teaching point, so most mornings I had my medical students prepare a topic to discuss on rounds: lupus pneumonitis, lithium toxicity, cortisol stimulation testing, respiratory stuff. After almost a year and a half of residency, I no longer felt insecure about the gaps that remained in my knowledge base. The set of unknowns was shrinking, and the fact that there was still so much to learn actually energized me. Ignorance was no longer the bugaboo it had once been. It now served the opposite function: it gave me hope.