BY STEPHEN YOUNG
This is the first of a two-part story. Come back tomorrow to read the conclusion. Copyright is held by the author.
THE THREE of us are in a dimly lit den, each sunken into block-shaped chairs and they do not seem to notice me. Thomas offhandedly comments, “I was disoriented, struggling, we were lost in the clouds and I called into the air traffic controller . . .”and then he trails off before adding, “Catherine, I asked you,” nodding toward her, “to . . . to start praying.”
“And I did. But, the last thing I remember is a large, dark shadow crossing in front of me.”
He replies, “A shadow. That was me. I released my seat belt and thrust myself in front of you, trying to shield you from the impact.”
Catherine lifts her head and calmly states, “I understand that at the site there were no bodies, only tissue, the two of us, Thomas, blended together and they placed an equal allotment into each casket.”
I stand and walk hurriedly down a hallway and fling open a door. The sky is blue and a flock of birds are flying together to and fro, a cluster darting randomly from one point to another.
I awaken from this dream about my deceased older brother and younger sister with a headache, a tightness across my forehead. Then, in the distance, a low throb in the right temple and, although the severity is modest, I sense an escalation. I am nauseated and slowly arise. I brush my teeth, shave, shower and then dress. After placing on each article of clothing — underwear, trousers, shirt, socks, shoes and tie — I sit on the bed, spent by the effort. From the drawer of a nightstand I retrieve a sealed and wrinkled plastic bag and itemize the contents — five aspirin 325 mg, four Fioricet, two ear plugs and rosary beads. I roll this bag up tightly and thrust it into my left front pants pocket. In the kitchen, I microwave a blueberry muffin, laden a cup of coffee with cream and sugar and sit at a table with the Seattle Times. My housemate, Jack, is leaning back against a kitchen counter, hunched forward and attacking a bowl of cereal. I flinch each time his spoon strikes the ceramic bowl.
I weary of this affliction which began several months ago and agonize over whether or not to take one of my pain medicines. They will probably diminish the headache and allow me to work yet, if I take the aspirin or Fioricet — a combination including caffeine and a barbiturate — too often, the intensity and frequency of my headaches might paradoxically increase. I live from one headache to another, weighing short-term versus long-term.
While sitting, I remove the plastic bag and, after unfurling, shakily retrieve a single Fioricet, then another, and swallow them with a sip of coffee and silently pray, “Help me to feel better, give me the stamina I need and guide me as I provide care to my patients and instruction to my interns and students.” After crossing myself I whisper my mantra, “pace and posture, pace and posture.” That is, don’t rush and don’t bend over, remain erect. I drive to the hospital armed with sunglasses although, at this early hour, the only hint of the sunrise is a pale orange smudge on the eastern horizon. I stay at the speed limit in the right-hand lane, no jockeying for position, NPR at low volume, vice-presidential candidate Geraldine Ferraro to visit Spokane. I pat my left leg and panic when, for a few seconds, I’m unable to feel the outline of my medicines and Rosary beads.
Walking across the hospital lawn from the parking garage, I give the groundskeepers, with their buzzing string trimmers, a wide berth. Once in the corridors, I avoid the tortuous low-pitched rumble of rolling food carts by either taking an alternate route or by walking slightly slower or faster. I am a senior Internal Medicine resident entering the final week of a rigorous four-week inpatient rotation and meet my team daily at 7:00 AM for work rounds in our designated conference room on the sixth floor.
Under my charge are two interns, Sarah and Ron, and they, in turn, each have a third-year medical student, Maurice and Liv, respectively. Only Ron is in the conference room and when I glance at my wrist watch and then at him he shrugs. Ron, crisply attired and clean-shaven, standoffish, is only twenty-four years old as he completed a college and medical school tract compressed into six rather than the traditional eight years. Sarah bursts through the doorway and is closely followed by Maurice and Liv who are both beaming.
Sarah is in her late 20s and worked in a low-income faith-based clinic in San Antonio as a medical technician for two years prior to medical school. She states, “Sorry, Lewis. The phlebotomist was unable to draw blood on two of our folks.” Then, jabbing her index finger at the students, she continues, “So, I took these guys with me and showed each of them how to use a butterfly.”
“No problem. Let’s start alphabetically,” I reply. We then discuss each of the patients on our service and, by the completion of these work rounds, my headache has begun to dissipate. With the lessening of the pain I’m left numb and sedated yet also, mildly euphoric.
Ron abruptly stands and walks out of the room.
Maurice looks puzzled and Liv explains, “If we have time before attending rounds he takes a few to grab a smoke, usually up on the observatory deck.”
“OK,” I comment, “We do have about fifteen minutes. Sarah, can you go ahead and start Connie’s discharge summary? She’s leaving later today. Maurice? Liv? You have time to pull the X Rays and CT scans on your patients. I’ll ask Dr. Guttierez if we can begin attending rounds in the Radiology reading room rather than here on the floor. Also, Liv, let Ron know, will you?”
After telephoning Dr. Guttierez I lean back in my chair and recall an evening during the first week of the rotation when Ron and I were on call together. We were paged to the emergency department to admit an elderly man with alcoholism, anemia and pneumonia. Given a history of tuberculosis he was in an isolation room with the worst possible scenario being that he now had a strain of TB resistant to the typical antibiotics. After donning masks and gloves we entered the patient’s room.
He was curled up on the gurney, clad in grimy clothes, white stubble on his creviced face and a frequent wet-sounding cough. He stank. Largely somnolent, he would arouse to our questions to mutter an unintelligible response then drift off once again. I motioned for Ron to take the lead as we began to examine him. He placed his stethoscope on the patient’s T shirt and frowned when I asked him to lift up the shirt to better auscultate the heart and lungs. Upon my request, the assigned ED nurse helped us remove our patient’s trousers, pull down his yellow-stained and baggy briefs, roll him onto his side and pull up his knees so we could perform a rectal exam and check his stool for blood.
“You’re up, Ron.” With an expression blending resignation with revulsion he extended his right index finger to be lubricated.
Afterward, we discarded our protective gear and I led us into a small workroom off the ED where we could sit by ourselves, discuss the patient’s medical difficulties and decide which tests and treatments to order.
“So, what do you think?” I began.
“He might have TB again. A gomer like him probably didn’t take his —”
“Wait a minute,” I interrupted him, hold up my left hand, “You mean ‘gomer’ as in ‘get out of my emergency room’?”
“Well, yeah,” he said sarcastically.
I felt an expanding warmth and realized that it wasn’t so much Ron’s dehumanization of the patient that bothered me. Interns often brandished cynicism as they coped with brutal hours and feeling impotent as they witnessed unremitting suffering. What really bothered me was Ron’s dismissive tone toward me. So, I replied, “Ron, tone it down a bit.”
“Why should I? I heard that when you were an intern you paid an addict 10 bucks to leave this emergency department. To sign out against medical advice.”
I cringe and admit, “Yeah, you’re right, Ron. I did do that. But it was wrong. Look, we’re going to be together for several weeks,” I said with restraint, “and I know how unpleasant it can be to take care of patients like this. They’re uncooperative, unkempt, they cough or spit on you and their trousers are wet with urine but when that happens you need to just ‘play it by the book.’ No derogatory terms. You don’t have to empathize but be respectful and don’t cut any corners. That’s what I mean by ‘playing it by the book’.”
He retorted, “Lewis, is this where you tell me I have a decision to make? Am I going to take this path or that one? And then, after taking the higher road, I deify you?” I felt a rush as he, while gesturing with his thumb back over his shoulder, sneered, “He’s just another drunk. You’re still a resident, I’d a thought you’d understand, that you wouldn’t be such a pussy —”
I kicked the door shut and then, grabbing Ron by the lapels of his white jacket, jerked him up and slammed him against the wall, knocking over a chair, and pressed my bulk into his thin frame. Inches from his face, I exclaimed, “If you ever speak to me that way again I’ll drag you onto the sidewalk and kick your ass.”
With his face reddened and lower jaw jutted out, Ron squirmed futilely and I could feel his heart banging away against my forearm. Then, suddenly exhausted, I limply dropped my arms and stepped back. My hands were trembling wildly so I clasped them together. Quietly, I asked, “Ron?”
Subdued, looking away from me, he answered, “Yeah?”
“Have a seat here at the desk. We need to write the admission orders.”
The following morning immediately after work rounds, Ron, as usual, quickly stood and walked out of the conference room into the hallway. I scooted around the others, milling about, and jogged to catch up with him.
He stopped and pivoted, his brow furrowed, as I came upon him and offered my right hand. After a long pause, with his fists clenched, Ron strode away leaving me with my arm extended, frozen like a mime. Over the next few days I anxiously awaited a page from the residency program director’s office. None. Ron didn’t take it any higher.
During the four weeks since then, Ron has offered meticulous medical care to his patients and has masterfully orchestrated their work-ups. Yet, at the bedside with his patients, he’s kept his distance. During door to door attending rounds each morning Dr. Guttierez peppers us with probing questions. Increasingly challenging, edgy yet rarely malignant. We call this being pimped. He begins with the students and when they are baffled he zeroes in on the interns and then, lastly, myself. During these Socratic sessions Ron has displayed an astonishing understanding of the pathophysiology of illnesses. Unlike the other interns and many of my peers, he subscribes to the leading Internal Medicine periodicals and regularly reads about his patients in medical textbooks.
In contrast, Sarah, with a modest yet expanding fund of knowledge, has a kind smile and labors late. Many of the families of our patients travel in at the end of their work day and they rely upon her evening rounds to keep them abreast. She has become an emissary for her patients and they identify her as their doctor.
For Liv and Maurice this has been the first rotation of their third year in medical school and they’ve been punctual and attentive. They wear short white jackets and, in the beginning of the rotation, were always on the periphery yet they now mix comfortably. Maurice, assigned to Sarah, has begun to emulate her bedside mannerisms and, all in all, feels involved and valued. Liv, on the other hand, has tried to attach herself to Ron but he’s made minimal effort to include her. On a couple of occasions, I’ve reminded Ron of his teaching obligations and he makes an effort for a day or so before disengaging.
On this Monday morning of the final week of the rotation, after viewing the radiographs of our patients, Dr. Guttierez glances at his watch and looks to me, “Where do we start?”
“Eighth floor. Then work our way down.”
Our first patient, Mr. Davis, is a 58-year-old gentleman with end-stage liver disease and he looks like a pumpkin as he is orangish yellow with a rounded and protuberant belly. At age 18 he’d survived the Battle of the Chosin Reservoir in Korea. Upon return to the states he married and he and his wife had a daughter and a son. He drank heavily and, after becoming entangled in the distribution of stolen cars, spent three years in a federal penitentiary. During this incarceration, his wife divorced him and remarried and he lost touch with his children. Following his release, he drank himself into oblivion and his liver failed. A hospital social worker helped him obtain Medicaid and admission to an assisted-living facility. Although he now has nearly three months of sobriety and AA meetings under his belt he has continued to have setbacks — bleeding, infections and now, worsening confusion.
Mr. Davis, cared for by Ron, is asleep and lying supine in bed. In response to Dr. Guttierrez’s greeting he briefly arouses to utter, “Morning.”
“Sir, I’m going to be talking about you as I examine you,” Dr. Guttierez states as he motions for Maurice and Liv to stand directly opposite of him on the left side of the bed. He then elegantly points out on our patient all the stigmata of advanced liver failure — the rose-colored palms, jaundiced sclera, tiny varicosities on the upper chest, enlarged breasts, fluid within the abdomen, dilated veins around the umbilicus and swelling of the legs. Although Mr. Davis cannot hold up his arms with hands extended, as requested, he is able to protrude his tongue which begins to flicker.
“Thank you, sir, I have another question for you.” Mr. Davis opens his eyes and Dr. Guttierez asks, “Can you please recite the months of the year backwards.”
“Yes, backwards, beginning with December.”
“December, December . . . November . . . August . . . September” and then he’s asleep once more.
“OK, thank you.”
Back into the hallway, we clump together and Dr. Guttierez turns to Ron.
“Your thoughts, Ron. Where do we go from here?”
“He has Childs C liver dysfunction and his obtundation likely reflects the build-up of ammonia and other toxins which would ordinarily be cleared by the liver. There’s no obvious precipitant. We tapped his belly and the fluid’s negative for infection. There’s no blood in the stool. No sedating medications. With the lactulose by mouth, he’s having three loose bowel movements each day. He remains confused despite this medicine being optimized.”
“So, what’s your plan?”
“I don’t think he’s going to make it.”
“What about a transplant? A new —”
“No, he’s not eligible for a transplant. First, he hasn’t accrued the necessary six months of recovery and second, he has no social support. Plus, livers are expensive and scarce.”
Sarah, usually quiet on rounds, says, “But, Ron, he’s in AA. Maybe for only a few months, but he’s been sober. And perhaps the assisted-living support will be acceptable in lieu of having a family.”
Ron shakes his head and states, “The guidelines are strict.”
I stand impassively during this exchange and remember the vivid dream of my siblings from last night. How I’d learned that, before the plane crash, Catherine had begun to pray. To pray that they’d be safe.
Then, I’m abruptly back as Sarah, affable and amiable, frowns as she sternly asks, “Ron, who are you to pass judgement?” Maurice and Liv, unaccustomed to such intensity from Sarah, exchange glances and take a step back.
Then, Dr. Guttierez, a Chilean who trained in the UK, locks his gaze on Ron as he reaches into the side pocket of his long white jacket and pulls out five copies of an essay. He hands one to each of us and our heads drop to the title.
“This is from the most recent issue of the New England Journal, ‘The Doctor’s Master’ by Dr. Norman Levinsky. He’s Chair, Department of Medicine at Boston University. As you will read, Dr. Levinsky laments the intrusion of social and cost considerations into our care of patients. He concedes that rationing may be needed — at a regulatory or public policy level – yet never at the bedside by the patient’s physician. The physician’s sole obligation is to advocate for their patient regardless of costs or other factors.”
“So, what are you saying, Dr. Guttierez?” Ron asks defiantly, his chin up.
“What am I saying, Ron? Call the patient’s children, his AA sponsor and his pastor, whoever and then emphasize his ‘social support’ and sobriety to the Liver Transplant Team. Pretend you’re Dr. Levinsky.”
Thomas and Catherine died despite her prayers.
The mood is somber and tense as we continue our rounds. We stop in the hallway outside the room of each of our patients and either the student or intern offers a synopsis as to how that patient is faring to Dr. Guttierez. If he or she has been recently admitted, will soon be discharged or is unstable then we’ll then enter the room to see them at the bedside.
Connie, 18-year-old African-American girl with sickle cell disease is sitting in a window-side reclining chair and is wearing a light blue hospital gown. Her hair is tightly braided into cornrows with red, green and yellow beads. A lunch tray sits in front of her. Despite recurrent pain crises over the years, and, most recently, a stroke, she offers a crooked smile as we traipse into her room. Although her left arm and leg are weak, Connie is able to feed herself, brush her hair and, with one person assisting her, move from bed to chair.
Sarah steps up to her and, with a backward sweep of her hand, says, “Connie, I’m back and I have everyone with me.”
Connie rolls her eyes but continues smiling as she mumbles a response which I don’t understand. Sarah, however, replies, “Thanks, I will,” as she sits on the side of the bed, now eye level with Connie, and reaches out to touch her hand. “We’re here to say good-bye. You’re going to be transferred later today to the rehab center next door.”
Connie closes her eyes and nods and I am uncertain if it is with sadness or relief. At that moment, her father, a huskily built gentleman in a tan windbreaker, button-down white shirt and maroon tie, enters the room carrying a Subway sandwich wrapped in plastic and a 12-ounce Pepsi. Our semi-circle breaks apart allowing him to make his way to the window and stand beside Connie. He places one hand on her shoulder and reaches over to shake hands with Sarah with the other. He is the sales manager for a nearby tire dealership and had recently been divorced from Connie’s mother. Connie, along with her two younger brothers, live with their mom yet their dad stops by their home most evenings to assist with homework and he frequently accompanied Connie to doctor appointments.
“Will you all still be taking care of her once she’s been transferred?” he asks.
Dr. Guttierez replies, “No sir. Fortunately, Connie,” glancing at her, “is faring well enough such that the primary focus from here forward will be upon her getting stronger, doing for herself. The physiatry doctors — that is, the rehabilitation doctors — will be directing her care.” Then, looking at Connie, he continues by saying, “But, we’ll still visit from time to time.” Dr. Guttierez and I soberly shake hands with both Connie and her dad. As we all move to the doorway I look back over my shoulder to see Sarah, lingering behind, lean over to embrace Connie.
Our team is on call that evening through 10:00 PM and I feel uneasy by late afternoon as the earlier discomfort has returned and, although mild, is gaining momentum. The frequency of my headaches is such that it seems like I don’t have discrete headaches but a single permanent one which momentarily abates with medication. In a bathroom stall, I unfurl the plastic bag and fish out three aspirin. I pause, put them back and then pick out a single Fioricet. After tightly rolling up the bag and slipping it back into my pocket I leave the bathroom and walk to the nearest nursing station. There, from a refrigerator, I remove a small canister of grape juice from the patients’ supply. With my back to others I toss the capsule into my mouth and quickly drink the juice. Immediately, I feel hopeful that I’ll soon feel well enough to continue working for the next several hours. At 6:00 PM I gather the interns and students to meet for supper. As we eat off our trays in a patio off the cafeteria, leaning forward, we quickly run our list of patients — how each is faring, test results, possible and planned discharges. Afterward, we slouch back into our chairs. Ron, not on-call that evening, makes a movement to shoulder his backpack and then over the intercom:
CODE BLUE ROOM 431 CODE BLUE ROOM 431 CODE BLUE 431
We dash from the patio into the crowded cafeteria toward a stairwell and I lead as we zig zag between the tables with our white jackets billowing as though we were schooners tacking into a storm.
I am winded as I push my way into Room 431 and find Connie lying supine with her gown askew. A nurse in scrubs is positioned over her performing chest compressions and an anesthesia resident is inserting a tube into her airway. Another nurse is applying EKG leads to her chest while an intern places a catheter — an intravenous tube — into the femoral vein of her right groin. Another resident, Jay, a friend, is standing by Connie’s left side with a gloved hand on her groin to assess whether or not a femoral artery pulse is palpable. Unlike many codes where there’s shouting and panic the room is relatively quiet as Jay, with a calm and confident timbre, directs the others. After a moment he commands, “Stop compressions.”
The nurse performing CPR appears exhausted and I instruct Sarah to take her place during this interruption. Then, I line up Ron, Liv and Maurice behind her and order them to spell each other every one to two minutes.
Jay reports, “There’s a rhythm on the monitor but she still doesn’t have a pulse. Resume compressions and give her an amp of epinephrine.”
End of part one. Come back tomorrow to read the conclusion.