How We Do Harm (19 page)

She reiterates her desire that everything be done.
Claren asks whether she means that she wants us to do everything reasonable to keep him comfortable.
No, she says, that’s not what the family wants.
We are to treat all illnesses.

The next day, the CT of the chest shows the extent of Huzjak’s tumor bilaterally.
There’s lots of it and with lymphangitic spread.
The air exchange surfaces are thickened by tumor.

Still, we are in a chicken-and-egg situation.
Does the pneumonia cause him to be obtunded or does obtundation lead to the pneumonia?
We see disease in the liver.
There is still some pleural effusion, some pericardial effusion.

At this point, Wild Dave Johnson takes Huzjak to the bronch suite and, with his resident, bronchs him.
I send the students so they can watch.
Someone should witness this travesty.
Later, they tell me that Johnson used no anaesthesia.
He was concerned that pain control could cause Huzjak to stop breathing.

They go through the nose, passing the throat, into the larynx, and on into the bronchus.
They examine both sides, seeing tumor in the bronchial tubes—roughened, yellowish-red surfaces in the bronchial tubes on both sides, extensive cancer involving both lungs.
They see near-obstruction and pus in the left main-stem bronchus and get a sample for culture.
This means it’s likely a postobstructive pneumonia; things that are blocked or partially blocked get infected.
The bronch also produces pictures of the partially obstructed bronchus with pus and pictures of the cancer in the bronchial tubes.

Wild Dave withdraws the scope and observes Huzjak for an hour to make sure he is okay.
Even he realizes that old men don’t take trauma like this well.
He returns the patient to the room and leaves a note with pictures.

Huzjak stays in the hospital for the next three days.
He is quietly there, out of everyone’s way.
The nurses turn him frequently, to keep him from getting bedsores.
His blood cultures grow gram positive cocci, a bug sensitive to ampicillin and gentamicin.

He is surviving and seems to be doing well, except he is not waking up.
He is not running a fever, but he may still have bugs the antibiotics haven’t killed.
And slowly but steadily he is losing blood pressure.

We have to worry about nutrition.
I have Beth pass a Dobhoff tube into him.
This thin tube with a weight at the bottom goes up the nose and down through the throat, esophagus, and stomach, stopping in the first part of the small bowel.
The nurses hang a bag of white, milky-looking nutrients and drip in twelve hundred calories a day.
This provides some nutrition and some hydration.

Eventually, we convert his IV to a central line.
We place it in the subclavian vein, another procedure for Beth and one of the students.
The X-ray shows no damage to the lung and perfect positioning of the catheter near the atrium of the heart.
The X-ray also shows pneumonia.
It could have been there all along, when he was dry.
Now that he has been hydrated, or, as we say in the language of distancing, “watered,” wet bacteria and wet pus have been rendered visible.

*

APART
from procedures, Huzjak requires less and less attention.
We check his labs daily, but he becomes a nursing problem, not a doctor’s problem.
The nurses complain a bit, asking about
placement.
The phrase means they think he should be discharged to a nursing home or a hospice.

Yet, Huzjak remains in the hospital.
He needs to be on antibiotics for two weeks without running a fever before the meds going into his central line can be stopped.

After he has been in the hospital for nearly three weeks, Claren calls a family meeting.
I see another desperate attempt to make the younger Huzjaks come to their senses.

This time Claren brings in another doctor, someone white, with a blue-collar upbringing—David Ginn.
Ginn comes from a long line of white Arkansas sharecroppers.
His father is an auto mechanic.
Ginn is tall, lanky, crusty, sometimes macabre, the sort of guy who finds it an ordeal to wear a tie.

As Ginn comes over to provide a second opinion, I sit in with the interns and students.
Claren introduces us all to the family and once more explains what’s happening to Huzjak, with the latest updates and information we have.
He says that we need to talk about limitations of care and asks Ginn for his thoughts.

“I’ve seen Mr.
Huzjak’s X-rays and labs, and I’ve examined him,” Ginn begins.
He knows what he is up against, so he puts on a performance.
He comes up to an X-ray view box and turns it on.

First, he puts on a bone scan.
“This is a normal bone scan.”
He leaves it in place and puts on another bone scan.
“And this is your father’s bone scan.”
The difference is obvious.
Huzjak’s scan is shocking, lit up with metastases.
“It ain’t normal.”

Ginn takes down the scans and clips a chest X-ray onto the light box.
“This is a normal chest X-ray.”
He places another X-ray next to it.
“And this is your father’s chest X-ray.
It ain’t normal.”

He keeps going.
“This is a normal liver on CT scan, and this is your father’s CT.
It ain’t normal.”
Next, he does the same for bronchoscopy.
“The red and irregular yellow areas are cancer,” he points out.
“Your father has a disease that medical science cannot treat.
He has widely metastatic, widely spread lung cancer.
There are no good treatments, and he has had the only reasonable treatment, which is not very good, and it did not help him.”

Ginn is readying for the finale, and it’s a good one:
“God is calling, and who are we to say no?”

The family doesn’t budge.

*

ON
my last day on service, Huzjak spikes a fever to 103°.
We examine him, culture his blood and urine, and get a portable chest X-ray.
We can’t find a reason for the fever.
We call the daughter to report the change in status.

Over the next several hours we change his antibiotics to ceftazidime and clindamycin in an effort to cover what we might be missing.
He has some diarrhea, likely due to the tube feeding.
We send it off for study.
Pseudomembranous colitis caused by
C. difficile
growing as a result of the antibiotics could explain the fever.

His respiratory rate and heart rate increase suddenly.
The blood pressure starts to drop.
I hate using ICU beds for someone who is dying anyway, but I have no choice.
The ICU is in the building next door.
Huzjak is wheeled over by Beth and the two students, with two nurses from the floor.
The daughter and a son walk along.

Huzjak stabilizes in the ICU.
Ironically, I get transferred to ICU the same night, replacing the resident who checked Huzjak in.
We have fourteen beds, and nine of them are occupied.
We have some sick people in the unit.
Four are on ventilators and six are on pressors.
Pressors are medicines such as dopamine or Levophed, given intravenously to keep a patient’s blood pressure consistent with life.
We have people with infections, people with respiratory issues, especially COPD bronchitis, and emphysema.
The worst is a twenty-four-year-old girl with herpes meningitis.

The next morning, I realize that I am weirdly delighted to find Huzjak alive.
Perhaps it’s because he has turned into a fixture in my life.
I worry about him often, realizing how close he is to death to begin with, worrying even more about bringing him to its brink.
Yet here he is still, resilient, surviving.

He hasn’t changed much since I sent him to the unit.
He actually seems more comfortable, or maybe more obtunded.
Whatever the reason, he seems to be in less discomfort.

His family is keeping a vigil.
In the old days, I would only see the daughter.
Now I also see her brothers, their wives, even some grandkids.
I greet them, but they are guarded, minimally polite.

I do my work on all the patients and get three new admissions.
As we are working up new admits, the nurse responsible for Huzjak quietly asks me to come over.
He is throwing a lot of ectopic, abnormal heartbeats.
His blood pressure is lower than it was last time we measured it.
I ask for an EKG and go on to care for the other patients.

The EKG shows the extra abnormal beats, but also shows T waves across the anterior of the heart.
I was taught to call this pattern the tombstone Ts—they indicate a myocardial infarction.
He is having a heart attack, likely a big one, and there isn’t a thing we can do to slow it down.

Drugs aren’t an option.
We just got clot-busting drugs in the past year, but a metastatic cancer patient is not a candidate.
These drugs are more likely to kill him than help him.

I call Claren and ask what he would like me to do.

“Let it evolve if necessary,” he says.
“Give him some nitroglycerin if his blood pressure will allow it.”
I dare to give Huzjak a couple of inches of nitropaste to the skin.
We can wipe it off if his already low blood pressure becomes a problem.

After three hours, at almost exactly midnight, he develops bradycardia, a slow heart rate of about thirty.
He almost certainly has infarcted part of the Purkinje system, a group of nerve fibers in the heart that regulates heart rate.
His blood pressure is dropping, too.

The nurses usher his son out.
I get the endotracheal cart open as a nurse breaths for him with an Ambu bag.
The intern notes that his pulse is only thirty to forty per minute.
I open his mouth and slide a light and a blade into his mouth.
I see the vocal cords and slide an endotracheal tube into his trachea.
I inflate the balloon that holds it in place and connect the Ambu bag.
We continue to breathe for him as Sarah, the ICU intern, listens to his lungs for breath sounds.
The next few seconds are tense.

“Yes.”
Sarah nods.
This means I had placed the tube into the lungs and not into the esophagus.
With some relief, I listen to assure myself that I got the tube in the right place.
I even listen over his stomach, to make sure I am not pumping air into his stomach instead of his lungs.

Next, we quickly put a wire through his triple lumen.
We use a wire with a catheter capable of pacing his heart.
We use this to stimulate his heart to beat at eighty beats per minute.
His blood pressure is still eighty systolic, which is low.
As it starts to go lower, I order a dopamine drip to support his blood pressure.

We seem to have taken over his entire body, taking control of all of its functions.
Chest compression is the only procedure left that we had not yet done.
I wonder if I will have the guts to order the nurses and interns to pump on this guy’s chest in a code, and Huzjak is considerate enough not to put me in that position.

His body temperature at night swings from fever at 103°, to cold at 96°.
We conclude that he has also had an infarct in his thalamus, a part of the brain that controls the body temperature.
The nurses put a water blanket on him.
To even out his body temperature, we circulate water of whatever temperature we see fit.
We give him a diuretic when we decide that it’s time for him to pee.

By 6:00 a.m.
I am sitting at the foot of Huzjak’s bed.
I feel like shit about all the pain I caused while using his body to teach LPs, central lines, and thoracentesis to the interns and medical students.
Here he is, the guy whose family frustrated the hell out of me.
He is just lying here quietly.
I know that he is trying to die, and his family and the rest of us won’t let him.

I sit there with him on a ventilator, with a pacer, on pressors, under a temperature blanket.
This black kid from Detroit whose credentials, competence, and education the Huzjak family has questioned can now decide his vital signs for the day.
I can set his respiratory rate and his respiratory volume.
Also, his heart rate, blood pressure, and body temperature.

Around 8:00 a.m.
the next morning, Huzjak goes into ventricular fibrillation and loses his blood pressure, possibly due to another heart attack.
We usher out his family—his daughter, a son, and a grandchild.

Six or seven of us are in the room—doctors, nurses, students.
There is nothing to do, so we stand somberly, silently, with our heads down, some of us praying, others tearing up watching him go into cardiac arrest.
It would have been so much more humane if the Huzjaks had been there instead of us, but that was the choice they made.

We turn the blower and the pacer off and tell the family that we are sorry, but Mr.
Huzjak died at 8:20 a.m.
“We were unable to resuscitate him from the second heart attack,” we tell them.

They take it well.

I call Claren and let him know that it’s finally over.
He expresses his gratitude to the interns, nurses—and me.
He asks how I’m feeling.
A decent guy, he knows how difficult “saving” Huzjak was.

PART III

More Is Better

Chapter 12

Ole Boys’ Club
BY THE MIDDLE
of my second year of residency I realize that I want to be in a subspecialty where I will be working with patients who are genuinely and demonstrably ill.
In October 1986, I call John Ultmann, a professor and friend at the University of Chicago.

“Dr.
Ultmann, I have been thinking about what I want to do in medicine, and I want to do oncology.”

“Ott-i-ss,” says Ultmann with the Austrian accent that is remarkably thick for someone who came to New York at age thirteen.
“I have been waiting for this call.”

*

ULTMANN
had a deeper appreciation of ethics—and failure thereof—than your average doctor.
Born in Vienna in 1925, he deeply understood the power of a bad idea.
He watched fascism take root in the city of his birth, and it was about him.
The ideology was built on the idea that people like John—the Jews—were not fully human.

His understanding of cancer was deeply rooted, too.
His mother died of it when he was ten.

After graduating from the Bronx High School of Science, Ultmann returned to Europe wearing a GI’s uniform.
He fought in Italy, then returned to Austria, where his job was to identify and interrogate Nazi criminals and gather information for the war-crimes trials at Nuremberg.
He attended Brooklyn and Oberlin Colleges and then the College of Physicians and Surgeons at Columbia University.