Internal Medicine: A Doctor's Stories (7 page)

“When can he come home?”

T
WO DAYS LATER.
Mr. Jenkins, his cancer thoroughly staged and determined beyond any hope of cure, sits peacefully in the recliner in his room. He is dressed in street clothes. Sunlight is streaming in over his shoulder, he’s breathing comfortably, and the television set is tuned to one of the two hospital channels, which is showing a locally produced documentary about dialysis. When I go in to see him one last time, Mr. Jenkins is watching, rapt. I realize I’m almost looking forward to introducing myself again, if only to say goodbye. And for a moment I watch him, and find myself equally rapt at the sight of him: sick, dying, and eternally unaware. For a moment I am almost envious.

The feeling passes, replaced by a kind of nostalgia. He’ll forget me again as soon as I’m gone. I’ll never learn from his account of me what kind of doctor I am. But that’s not it: I am tantalized by the sense that I’ve missed something here. I thought I was giving him bad news. The bad news wasn’t his, but mine.

Out at the nursing station, I pick out of the general hubbub a nurse’s voice speaking my name and the words “over there,” and through the doorway see a man looking my way.

The family resemblance is strong. “I’m Charles Jenkins,” the man says. He looks past me into the room. At my back I hear a sudden cry.

The reunion is a happy one. I leave them there, edging out of the room as I’ve edged out of so many, leaving the family to gather up the plastic bags of personal belongings, medications, paperwork with discharge instructions. My last memory of Thomas Jenkins is of him looking up from the chair, sunlight surrounding him, his face alight in the recognition of one of the few faces in the world he can still remember.

I like to think of him that way. That way, and no other. I only wish I could hold myself so finally aloof from time.

D
URING MY FIRST MONTH AS WARD RESIDENT
, I was assigned to the oncology service. I hated it. Any service on which patients routinely die during morning rounds upsets me. And there were always too many patients, most of them being treated for some terminal process with drugs that made them sick to just this side of death and not infrequently beyond. Some doctors enjoy this kind of challenge; I’m not one of them. It scared me. I was twenty years older than the rest of the residents in the hospital, and it shook me in some way I wasn’t able even to name. As if some vulnerability within me were waiting to declare itself. Something that, like cancer, I would discover only after it was too late.

Which may have been why, that month at least, I tended to leave the routine business of the service to my competent intern, Mike, and on the weekends didn’t mind looking after my orphan. “Orphan” is the name given to any intern admitting patients when her own resident isn’t around; on weekends when I was admitting, one of my responsibilities was to supervise the orphan also admitting that day.

The current orphan’s name was Virginia; she went by Virgie, and she was assigned to the gastrointestinal, or GI, service. This is another subspecialty the house staff tends to regard with distaste, but compared to oncology it seemed to me a clean, well-lighted place. True, the patients include a fair number of GI bleeders, who require close watching but never quite buy the transfer to, say, a surgical bed that would get them off your census. You usually also have two or three patients in the final stages of liver failure, who are generally delirious, capable of taking sudden nasty turns, and infected with viruses you don’t want to bring home to your family. Add to that the pancreatitis patients (unstable alcoholics who withdraw under your care), the inflammatory bowel patients (unhappy), and the occasional fecal impaction (don’t ask), and you can understand why, when Virgie returned my page that morning, she sounded a little harried.

“Just checking in,” I said. “How’s your day going?”

“It’s horrible,” she cried. “We just finished rounding and I’ve got three discharges to get out and a float down in the ER I haven’t even seen yet.”

As problems go, I thought, this wasn’t bad. Discharges were a good thing. And the patient in the ER was probably stable. But for the sake of form I asked.

“I think so,” Virgie said. “Some bogus abdominal pain thing. But I don’t know when I’m going to see her. Could you go? I’ll get there as soon as I can.”

“Take your time,” I said soothingly. “Happy to help out.”

“Thank you thank you thank you,” she cried, and hung up.

I was happy, I realized as I made my way down the quiet back stairs to the basement. Somebody else’s patient to see. Already worked up. Probably not dying. More of a social visit than anything else.

Ten-thirty on a Saturday morning, and the emergency department was already busy. Most of the bays were occupied, and the noise was enough to make ordinary conversation difficult; there were shouts coming from one of the trauma bays on my right. I ran my eye over the bank of monitors suspended above the front desk, checking the list of patients for anything that looked like it might be coming my way. The one good thing about oncology was that it tended to get its admissions from clinic, and the clinic wasn’t open on weekends. But sicklers, intractable pain, clotting problems of various sorts, and the occasional blast crisis could come in at any time. And once the other services filled up, we would be in line for whatever needed admitting. But the board seemed clear for now, so I looked for the name Virgie had given me. I found her on the first screen, Bay 7:
Crawley, A.
, her name in pink to indicate her sex. Her time of arrival the night before (10:42) was highlighted in orange, a token of the emergency department’s outrage at her continued presence here. This probably accounted for some of Virginia’s urgency about her pending discharges: she was undoubtedly getting pressure from bed control to free up space for incoming admissions.

I pulled the chart for Bay 7. This is a bed at the front of the ER, where they like to keep the unstable ones. I wasn’t sure what there was about Crawley that merited this. I registered this question, like most questions in the hospital, as a pang, a surge of doubt that distracted me as I thumbed through the untidy stack of papers on the clipboard.

A. Crawley was a float—a patient worked up by the night shift and handed over to an intern the next morning for ongoing care. Floats are notoriously iffy: the system has too many cracks where orders, lab results, sometimes entire patients can get lost; and the workup, conducted by a resident whose internal clock is even more messed up than usual, can vary from merely sketchy to outright delusional. It had been drummed into me early in my training: always eyeball the float.

The admission note told me little. This was a twenty-two-year-old female who had come in with a one-day history of nausea, vomiting, and abdominal pain. No significant medical history, no drug allergies, no sick exposures except to a dog known (how, I could not begin to guess) to harbor parvovirus B19. It was clear this was a red herring included in the history in a display of mere thoroughness: factual, obscure, irrelevant. Ms. Crawley had endured her nausea, vomiting, and abdominal pain for approximately twelve hours, at which point she had attempted to treat it with a few Tylenol Sinus tablets. When those failed to bring relief, she came in to the ED.

As stories went, it sounded odd. Twelve hours of a bellyache don’t usually bring otherwise healthy young people to the hospital. I was left with a familiar mix of annoyance (this was wasting my time), relief (nothing horrible was going to happen), and dread (what was I missing?). According to this script, the lady shouldn’t have come in. But she had. And they’d put her up front in Bay 7 where they could keep an eye on her. Why?

I scanned the rest of the note. The review of systems—that laundry list of symptoms with which we catechize admissions (“Anyfeverschillsnightsweatsweightlosschestpaincoughorchangeinthecolorofyourstools?”)—added nothing to the history. Physical exam ditto: mild abdominal tenderness. Meaningless. The labs and X-rays seemed to rule out any specifically abdominal pathology. But there were two false notes that got my attention. Her white count was slightly elevated, indicating a possible infection. And her serum lactate was high. This was the one that made me stop and look up for a moment.

An elevated lactate accompanied by a high white count explained why they had lodged her in the front of the ED rather than stashing her in the back room with the sore throats and bladder infections. Lactic acid is a by-product of cellular metabolism gone astray. In company with a high white count, it signals sepsis: infection at large in the circulation, and a patient hours away from the ICU.

None of which fit the innocuous history of A. Crawley.

I scanned the admission note again, wondering if there was anything I’d overlooked. But there was nothing there; the only other lab value remotely notable was the serum Tylenol level. We check Tylenol levels pretty frequently: it’s at once an extremely common and potentially a very nasty drug. Toxicity can occur at less then twice the recommended dose. And when somebody, in a suicidal gesture or simple confusion, downs an entire bottle, there isn’t much time to get help. If the antidote isn’t started within twelve hours of ingestion, the patient is basically dead (although the dying can go on for weeks). But given Crawley’s history and the time they had drawn the sample, the level they had gotten wasn’t worrying: it was consistent with a reasonable dose taken at the time she had reported, about four or five hours before she came to the ER. But they had thought to check: that was interesting.

The history didn’t do much for me except to rouse vague fears of doom—and what day in the hospital doesn’t do that? Abdominal pain and infection: the possible causes of such a pairing make a long list, and some of them can be serious trouble. Fortunately for my orphan, the common ones—appendicitis, gallbladder disease—are surgical issues. And until A. Crawley developed signs or symptoms of needing transfer to surgery, there wasn’t much for Virgie to do. Time would tell. We would watch her, and wait (as the saying goes) for her to declare.

That should have been all. But I thought again about the Tylenol, and I saw that the ED had been thinking about it too. They had started her on N-acetylcysteine, the specific antidote for Tylenol, around six a.m
.
Her levels didn’t warrant it, but it’s an innocuous drug (except for the taste), so I could see their logic. Not knowing what to treat, they had treated what they could.

When I look back at those years in the hospital, I can see that this kind of nervous second-guessing might seem, to anyone on the outside, hysterical. At the time, however, for me and I think for most of the house staff, it was simply a way of life. During those years, I always felt that I knew nothing. And no matter how much you did know, there was always more you didn’t. In that vast desert of ignorance always lurked that one detail waiting to kill somebody. Which was bad enough if you were prone to worrying about such things. What made it worse was that you were required—by the patient, the family, the intern—to look as if you knew what you were doing. You couldn’t turn and ask someone else. And you couldn’t count on second chances. I’d learned that years before.

So it must have been an irrationally optimistic impulse that made me look around again, hoping to find somebody who could tell me anything else about A. Crawley. But there was nobody. The nurse said only, “She’s a flake. When are you going to get her out of here?”

I knocked on the door, pausing briefly before pushing through. The room was dim. The bed occupied the back half. Curled up in it was a slender, pretty young woman under a cotton ER blanket and a tangle of sheets. She wore a hospital gown. The inevitable bag of saline hung over her, dripping through an angiocath taped to her left forearm. In the far corner, the usual pile of clothing, shoes, and purse lay heaped on a chair. The patient was already awake, watching me. In the corner behind the door, a long male figure sprawled half out of a chair, stirring as I entered.