Crash (15 page)

36

Residency

The kids were six and eight when I began my residency, nine and eleven when I finished. They went from “Oh, Mom. You’re on call again?” (Translation: You bad mother. You’ve already left us twice this week.) to “Oh, Mom. You’re on call again?” (Translation: Poor Mom isn’t going to get any sleep tonight either.)

On most rotations we were on call every third night. Surgery rotations could be worse. There’s a well-known saying among surgeons: “What’s the worst part of being on call every other night? Missing half the cases.” On our post-call days we rounded on our patients and wrote orders before signing out to our colleagues. Our goal was to finish work by twelve o’clock, attend noon conference, then go home, hoping to catch some sleep before arriving early the next day to pre-round on our patients. Sometimes we didn’t leave until three.

Nowadays the Accreditation Council for Graduate Medical Education regulates resident work hours, the idea being that sleep-deprived doctors make mistakes. I agree with the sentiment, but I wouldn’t trade my long hours of patient care for anything. I only learned about the stages of a woman’s labor and delivery by seeing them, hour by hour. Serial abdominal exams helped me divine the diagnosis of appendicitis when the initial history and physical exam were equivocal. Today many residents sign out after morning rounds, required by their programs to be out the door by 8:00 a.m. But I wanted to write the orders on my own patients, because no one knew them better than I. I wanted to go to morning rounds and present my own patients to the chief, hear his feedback. I learned from my mistakes, but only because I knew I had made them.

There are trade-offs that come with shorter working hours, not only in resident learning but also in patient care. The shorter residents’ hours become, the more sign-outs are required to pass on patient information from one team to the next. As careful as we are to communicate to our colleagues what needs to be done, we’ve all played the game of telephone. Invariably at times messages aren’t heard or information is misinterpreted.

Maybe the ultimate answer is a longer residency program. There seems to be an infinite amount of information to learn but a finite amount of time to learn it in.

Saul brought the kids to see me when I was on call whenever both of our schedules allowed. We’d have supper together in the cafeteria or out on the patio under umbrellaed picnic tables. After dinner the boys had fun rolling down the grassy hill between the edge of the cafeteria lawn and the ambulance bays of the ER. If they were really lucky, they’d get to watch a Med-Flight helicopter land or take off. The boys would stand shoulder to shoulder, heads turned up to the sky, sometimes shading their eyes from the setting sun. The copter’s rotors whipped their in-need-of-a-haircut curls while Saul and I looked on and smiled. This is as close as we would ever come to being “helicopter parents.”

Sometimes on a quiet night they’d come up to the floor with me. We’d watch a video in the call room, or sometimes my kids would play with some like-aged patients in the playroom.

Those were the good times.

Both my parents were admitted to my hospital during my residency.

My father went first. He had not been feeling well for a couple of weeks. His stomach was bloated. The whites of his eyes had begun to muddy. He had gone to his family doctor, who was running some tests. My sister and I went to pick him up and take him to the doctor’s office to get his results. He was weak and tired. Our father, who prided himself on never being sick a day in his life, had aged years since the last time I’d seen him just a few weeks before. He leaned heavily on my mother on his way to the car. When we got to the doctor’s, I went inside to get a wheelchair, afraid he’d never make it across the parking lot.

The news wasn’t good. My father had cancer. At the sound of the word, his shoulders slumped and he exhaled heavily. It sounded like the life was being let out of him right before our eyes, as deflated as a child’s spent balloon.

The doctor outlined his plan. He was hospitalizing my father right then and there. He would hydrate him over the weekend, beef up his nutrition. On Monday they would run more tests to find out where the cancer had started and how far it had spread and formulate a plan for treating it.

My father had stopped listening. He had stopped hearing anything after “the C word,” as his generation called it.

I registered my father in the emergency room at UMass. He was placed in a johnny by nurses I knew, examined by residents in my program, his care supervised by an attending who had supervised me.

I held his tanned hand in mine.

“It’ll be okay, Dad,” I said, words with no faith behind them.

He stared back at me not saying anything, his face blank. I couldn’t blame him for not believing me. I didn’t believe myself. His eyes were vacant. As his eyelids closed, I looked up at his monitor. The neat green blips of his normal rhythm had turned into an erratic lightning strike across the screen.

“Dad!” I screamed, shaking his shoulders.

“Dad!”

I ripped the call bell from the wall. But the team was already pushing their way through the curtain and into his cubicle, alerted to the dangerous rhythm by the telemetry unit at the nurses’ station. The drawers of the red crash cart were flying open before it had even come to a stop.

“Dad.” My voice caught in my throat like a chicken bone.

One of my fellow residents appeared out of nowhere, her gentle hands on my shoulders, leading me, my sister, and mom into the family room. There we waited, huddled and afraid, until they came to tell us what was going on.

The “they” turned out to be Cynthia Adams, one of the more aggressive attendings in the ER. In the pediatric department we used to joke that she wouldn’t know a well child if she tripped over one. She was a large woman, always in scrubs, and walked with a manly swagger. Now she was standing over us, hands on hips.

“Well, he’s stable,” she told us. We let out a collective sigh of relief.

“Yup, we tubed him and thumped him,” she went on.

Now it was my turn to tune out. By “tubed him” the doctor meant that my father had stopped breathing and that the code team had had to insert a tube into his throat and hook it up to a ventilator to breathe for him. By “thumped him” she meant that someone had either literally delivered a decisive fist to his chest to get him out of that dangerous rhythm or, more likely, shocked his heart using electrical defibrillator paddles. Somewhere in the back of my mind I was appalled that Dr. Adams would use this ER cowboy lingo to describe what had happened to my father, but at the time I was sick with worry and fear and anxious to get back to his side.

By now his bedside was crammed with machines and monitors. IV fluid and meds dripped into his skinny arms. A glowing red clip on his finger monitored his oxygen levels. His breathing tube was taped to his slack-jawed face; the ventilator’s bellows whooshing, regular as a metronome. The lightning strike rhythm had evened itself out into orderly green blips again.

I explained what was going on to my family. But as I spoke, his heart went into V-fib again. Again we were herded out of the room while they worked on him. Now an ICU attending was involved, telling us he needed a pericardial window. His heart was filling up with blood and needed to be drained.

My brother arrived. We conferred. Our dad would definitely not want this. Here was our father, healthy as a horse his entire life, now hooked up to medications and machines. Facing a diagnosis that felt like a death sentence to him and a treatment he may in fact have refused.

But I was out of my league here. I was a pediatric resident, not an intensivist or an oncologist or a cardiologist. I wasn’t even an attending. I called the only person I thought could help us—someone who knew my dad and also took care of many sick and elderly patients in the office and on the floor: my father’s family doctor.

I explained the situation.

“He keeps going into V-fib. They keep coding him. Now they’re talking about a pericardial window.”

I wanted to know what to do. I wanted some numbers. I wanted statistics. What were my father’s chances of survival? I knew I was asking his doctor a lot. At this point, he didn’t even know what kind of cancer my father had. But he knew
him
. He knew the man. He had cared for him for over forty years.

“If he has a pericardial effusion, it’s probably metastatic,” he began, waiting for that news to sink in.

“And?”

“Well, Carolyn, I can tell you this much.” He spoke slowly, as if choosing his words very carefully. “No one in that situation—metastatic effusion around the heart, going into runs of V-fib—has ever left the hospital.”

I don’t know where he got that statistic. He didn’t quote a study. Maybe he was just relaying his own experience. But he knew what I was asking, and I think he was telling me what I needed to know.

I conferred with my family, and we all agreed. My dad wouldn’t want what was happening to him to continue unless he could be assured of some good quality years ahead, and his doctor was telling me that wasn’t going to happen.

We signed the DNR papers. Do Not Resuscitate. We got him settled into a bed in the ICU. He was kept comfortable on morphine.

“Is he on the dope?” my mother asked when he didn’t respond to her voice.

“Yeah, Mom, he is, but he can still hear you.”

I honestly didn’t know if that was true, but I knew we always said that to families in the ICU, and it seemed to give everybody comfort to be able to still talk to their loved one. And we talked to my father now.

“I love you, Dad,” I said. My brother and sister followed suit.

But the next time his heart rhythm turned into V-fib, the next time lightning struck, instead of coming in with a crash cart, the nurse just came in. She turned the monitors off. We held Dad’s hands and laid our heads on his chest and waited for his quivering heart to lay quiet in its cage.

My mother’s end was not so quick. Her first stroke happened on my surgery rotation. I was scrubbed in on a routine appendectomy, excited because with these relatively minor routine surgeries, we sometimes got to do more than hold retractors and sew up the wound. Sometimes we got to cut.

When we were in surgery, we left our beepers with the nurse at the front desk, who answered the pages and relayed messages. She usually just called in by phone or over the intercom system. So when she appeared at the door in person and called me by name, I knew something was wrong.

I didn’t get much information initially. Just that my mother was down in the ER. I took the stairs two at a time, found my mother’s name on the board outside Triage, and stepped into her cubicle. She was alone in the room, in a johnny and on a stretcher with the side rails pulled up, but otherwise looking fine. No monitors. No IVs. Her color looked good. I smiled in relief.

“Hi, Mom.”

She turned her head toward me, but just stared. It occurred to me that she might not see me.

“Mom?” I repeated, walking toward her. She seemed to not know who I was. She opened her mouth to speak, but no words came out. My heart plummeted in free fall, crash-landing in the pit of my stomach as I realized what I was watching: my mother’s stroke in evolution.

There was nothing for me to do. There wasn’t the same urgency to her situation as there had been to my father’s. My mother had had rheumatic fever as a child, which left her heart with leaky valves. Her rhythm was chronic atrial fibrillation or A-fib. Though not as lethal as the kind of fibrillation my father had suffered, it did put her at risk for blood clots, which could travel to the brain in the form of a stroke. She was on a blood-thinning medicine to make clotting less likely, but that put her at risk for a different kind of stroke—a hemorrhagic stroke in which the brain, instead of having its blood supply cut off by a clot, is actually flooded with blood with nowhere to go. She was between the proverbial rock and a hard place. We wouldn’t know which kind of stroke she’d had or what her treatment would be until more testing was done.

Meanwhile she was admitted to a medical-surgical floor. I rode up in the elevator with her, holding her hand. I helped the nurses transfer her from stretcher to bed. A neurology resident came by to examine her. He tested her gag reflex, determined it was absent, and ordered a feeding tube. I refused. I spooned tiny amounts of ice chips into her mouth instead. She didn’t choke once. They also ordered a Foley catheter to be placed in her bladder so that she would not be incontinent and suffer skin breakdown. Again I sent the nurse away, turning my mother every two hours and putting her on the bedpan myself. My friend and fellow resident Mike Zackin took my shift that night so I could spend it next to my mom on a foldout recliner, fending off nurses with tubes.