How We Do Harm (15 page)

Yet, because Cedric is so well-spoken, the nurse finally takes him seriously and puts him on a monitor in the cardiac room.
Later, she tells me that she nearly fainted when she saw the rhythm: classic ventricular tachycardia.

The nurse calls me immediately.
My attending, who is down the hall, knows Cedric.
She is busy and tells me to handle it: “He needs cardioversion.
He’ll tell you how he wants it done.”

I examine Cedric quickly, as a nurse inserts an IV in his arm.

“I am still a little afraid of the pain of being shocked,” Cedric says apologetically.

I promise that I will put him under.

“Could you give me two hundred joules of electricity?
That’s what I usually need.”
Also, Cedric says that he wants 15 mg of Versed, a Valium-like drug with a short half-life.

Now, 15 mg is a whole lot of Versed.
“That’s at least five times the dose I am used to giving,” I object.
I explain that this much drug could cause respiratory depression, which is doctor-speak for cessation of breathing.

He nods.
He knows.

“If that happens, we would have to breathe for you with the Ambu bag for a while,” I keep objecting.
An Ambu bag is a self-inflating bag used in resuscitation.

Cedric assures me that we will not have to.
He knows the dose that works.
He begs me to make sure that he is out when I shock him because two hundred joules will hurt so bad.
He is literally crying, pleading to be out.
He has been hurt before.
I promise him that I will make sure he is out.

I don’t get around to telling him that two hundred is a lot of joules.
Usually, you start with one hundred, or even fifty.
You go up only if that doesn’t work.
But the attending was clear: “Cedric will tell you what to do.”

Three nurses are in the room.
One of them starts pushing the Versed into IV tubing, which has half-normal saline running at 120 cc per minute.
Another starts shaving hair off his chest for the paddles.
I continue talking back and forth with Cedric as he begs me to make sure he will be out.

I hear him, but I stop the nurse at 10 mg and assess the situation.
Cedric is still talking.
I give the nurse the go-ahead to give more as I worry about the dose.
Cedric stops talking and seems to fall asleep.

I feel his pulse.
It is still strong.
I can see his heartbeat.
It is V-taching at a rate of 140 per minute.
One nurse has an Ambu bag as we all watch his chest move.
We count every breath.

I charge the machine to two hundred joules, per Cedric’s instructions.

I place one paddle on the anterior chest and the other on the side of the left chest under the armpit.

I call out,
“Clear!”
I look to make sure the nurses aren’t touching the steel hospital bed.
I press the trigger, firing two hundred joules into Cedric’s body.

As his body absorbs the massive shock, Cedric emits a scream, a loud, long, shrieking scream:
“Nigger!!!!!”

Startled, I look at Cedric, then at the nurses.
I feel uneasy, but I am clearly less distressed than these three white women.
The intensity of Cedric’s scream has startled me, not the word he screamed.
(Sure, it’s wrong for a white to call a black by that name, but Cedric is black.
So, it’s okay, almost.
In my childhood neighborhood, we called each other nigger as a form of endearment.
I haven’t encountered an occasion to let this word roll off my tongue over a couple of decades, which doesn’t necessarily mean that I never will.)
I am sure Cedric didn’t intend the word as a term of endearment.
Horrific pain was his evidence that I disregarded his specific instructions and skimped on the elephant dose of Versed he needed.

I compose myself enough to make certain that the procedure was successful.
Cedric is in normal sinus rhythm.
I watch his respiration.

After about ten minutes, Cedric wakes up.
Will he remember the pain or the scream?
One beautiful thing about massive doses of benzodiazepines is their ability to cause amnesia.

“How are you feeling?”
I ask calmly.

Mercifully, Cedric doesn’t remember the pain of the electric shock.
He tells me that I am cool.
“Never had a black doctor do a cardioversion.”
He is back to his old well-spoken, pleasant self.

We admit him overnight and discharge him from a monitored bed the next day.
He comes by the ER on the way home to say thanks to the nurses and me, as he does after every visit.

Cedric needs the same implantable defibrillator that Saul has.
Saul qualifies for Medicare, which paid for the device.
Cedric has no insurance and no hope.
Indeed, if Cedric tries to get private insurance, he will be rejected as uninsurable due to a preexisting condition.
He gets his care from the ER, and the hospital never collects any money for the care it provides.
All the insured patients who come to the hospital subsidize his care, which would be less expensive if he had a regular doctor and gets the defibrillator he needs.

I hear about Cedric’s subsequent trips to the ER for the remaining two years I am in Cleveland, but I never learn what happened to him after I left.
I hope he got one of those newer, low-voltage implantable defibrillators, but I know that it’s more likely that he died hoping for one.

Untimely death isn’t even the most horrifying aspect of the story of Saul and Cedric.
Scarier still is that in this story, medical technology is the only thing that has changed.
The disparities between the insured and the uninsured remain.
Likely, they increase as technology improves.

Chapter 9

Palpitation

I ENCOUNTER NORMA SHEVCHENKO
at an ER examination room at the University Hospitals Case Medical Center in October 1986.
The triage nurse places Norma in the cardiac section, and my job is to determine whether she is having a heart attack.

According to the forms Norma Shevchenko fills out to be admitted, she is fifty-six.
She has not changed into an examination gown either because the nurse had forgotten to tell her to or because she missed or disregarded the instructions.
This is an inconvenience—much of the physical exam will have to wait—but seeing her in street clothes gives me some clues about what ails Norma.
I see that the hour notwithstanding—it’s after 2:00 a.m.—Norma has taken a special effort to pull herself together.

She is wearing a blue dress with a white lace collar, the sort you might see on an older woman at a church service.
I note a large cameo brooch; it’s ivory, old-world.
She has applied eye shadow and a generous daub of perfume.
Her thinning hair is dyed uniform raven-black, with no variation from root to tip.
As a second-year resident, I know that such observations are important.

Norma is sitting on the examining bench, knees over the edge, forearms on top of the legs.
The shoulders are slouchy.
The palms are up, with one palm cradled in the other.
This, too, is important.

“How are you, Mrs.
Shevchenko?”
I say.

The name is the most important part of the question.
An ER is a chaotic place.
Papers get dropped on the floor, things get mixed up, clipboards get placed on the wrong racks.
You can’t take it for granted that you are talking with the right patient.
If the woman in front of me is someone other than Mrs.
Shevchenko, this is her opportunity to let me know.

I take the absence of an objection as a sign that I have the right patient.
So far, so good.

“I am Otis Brawley, I am one of the doctors here.”
I extend my hand.

Her handshake is weak.
I pause, leaving space for Norma to talk.
She doesn’t, so I prompt her: “How can I help you?”

“I can feel my heart beating,” she says slowly.
That’s what I see in her chief complaint, but I want to hear it from her directly.

“How bad?”

“Bad.”

“Do you have any shortness of breath?”

“Maybe a little.”

“Do you have any chest pains?”

She nods.
“Some.”

Irritation sets in.
I am impatient at her slow answers.
This can’t be helped because Norma and I are machines that run at different speeds.
Otis Brawley has to knock out three to four cases an hour, and Norma Shevchenko has all the time in the world.

“Have you had any ankle swelling?”

“Not like last time I came here,” she says.

“You’ve been here before?
When?”

“In May, I think.”

I note that she was here six months ago—a frequent flier.
“What did we tell you then?”

“A young woman doctor told me to use less salt.”

“Do you have family history of heart disease?”

“Yes, my husband.
Never found out whether it was a stroke or a heart attack.”

When we ask about family history, we mean the patient’s blood relatives.
The goal is to pin down hereditary risk factors, and a husband’s history doesn’t help.
In this case, I realize that I learn something more useful, something about environmental exposures.
Her husband’s diet—also, presumably, her diet—could have contributed to his death.
This is all I need for now; time is short.

I have Norma roll up a sleeve and check her blood pressure.
It’s slightly elevated, 157 over 92.
You would expect that in someone mildly obese, someone like Norma.
I look at the forms and see that she is not diabetic.
Not yet.

“How long has it been going on?”

“What?”

“Your feeling the heartbeat.”

“I don’t know.”

“Have you ever experienced this palpitation before?”

“What?”

“The flutter you describe.
Have you had it before?”

“I think so.
Two weeks ago I just couldn’t get out of bed all day.”

“Is there anything you can do to make it worse?”

“Why?”

“Does it get worse when you walk faster?”

“No.”

“Can you walk across the floor?”

Norma gets off the bench tentatively and looks back at me for approval.

“Are you able to walk up steps?”

She nods.

“How many flights of steps can you walk up?”

“Three,” she says after a pause.
“Then my hip starts hurting.
My right hip.”

“What drugs are you taking?”

“Nothing, except for when my hip hurts.”

“Have you had any surgery?”

“I had a women’s procedure.”

“A hysterectomy?”

She nods.

“When?”

“About ten years ago.”

I ask Norma whether she has been drinking caffeinated drinks: coffee, tea, Coke, Pepsi.
She hasn’t.
I ask about less obviously caffeinated drinks: cream soda, Mountain Dew.

“Do you smoke?”

“Never have.”

“Did Mr.
Shevchenko?”

“Three packs a day.”

I am fishing.
I have no idea what to do with this information.
Of course, I suspect that living for decades with a three-pack-a-day smoker can’t be good for your heart and lungs, but I don’t know this.
In 1986, no one does; the studies confirming health hazards for passive smokers would come years later.

“Do you have children, grandchildren?”

“No.”

“Do you go to work?”

She shakes her head from side to side.
No.

“Do you belong to a church, a Ukrainian church, maybe?”
Ordinarily, this would be none of my business, but Shevchenko is an obviously Ukrainian name, and the Ukrainian community in Cleveland likely provides social support for its members.

“No, I am not Ukrainian.
John was.”

“Well, Mrs.
Shevchenko,” I say, getting out of the chair, “I’ll be back in a few minutes.
Meanwhile, a nurse will have you change and take your EKG.
Then we’ll know more about what’s wrong with you.”

*

AS
a first year-resident at Case Western Reserve University (CWRU) in 1985, I got to pull ER rotations in a sustained manner: twelve hours a day, six days a week.
On those rotations, I encountered a legion of patients like Norma Shevchenko.
Everything I see in Norma tells me what’s wrong with her physically: absolutely nothing.

It’s possible that she experienced heart palpitation, but that she dressed up for a visit to the ER—the lace collar, the cameo brooch—tells me that in the middle of the night Norma was overcome with excruciating loneliness and desire to be seen, touched, cared for.
Thirsting for social interaction, she went to the nearest emergency room and ended up in my care.

In doctor-speak, patients like Norma are known under the nickname
gomer,
short for “get out of my emergency room.”
The term became ubiquitous after 1978, when it appeared in a novel called
The House of God,
an account of an internship at Beth Israel Medical Center.
The novel, by Harvard professor Steve Bergman, writing under the pseudonym Samuel Shem, is about a young man’s headfirst dive into the absurdity of real-world medicine.
The novel burrows so deep into your consciousness that it starts to fuse with reality, infecting it with crazed lingo.
I don’t know whether this was the case of life imitating art, but almost all male doctors of my generation claim that their internship was exactly like
The House of God.
Mine was
almost
exactly like that—minus the promiscuous nurses.

In
The House of God,
a gomer is someone who “has lost—often through age—what goes into being a human being.”

In the novel, the gomers were demented residents of nursing homes whose bodies wouldn’t die.
My experience at Case Western showed me other categories of gomers as well.
These people were not demented—just starved for companionship and the human touch.
About three-quarters of these were female.
Women who came to the ER for these reasons were rarely thin.
They were almost always widowed.
They presented with depressed affect, and they dressed up to see the doctor, even in the middle of the night.
The few of them who were thin seemed hyperactive, and when they showed up in the ER, I made a point of sending out their blood to check for thyroid function.

Another category of gomers were little old ladies in their seventies whose chief complaint was constipation.
Their physical exam was totally normal, which left you wondering whether they had your garden-variety constipation that a quart of prune juice could clear up, or whether you were dealing with an obstruction from previously undiagnosed colon cancer or a buildup of scar tissue from a C-section performed forty-five years ago.