The Real Doctor Will See You Shortly (20 page)

During rounds, I had quietly counted the minutes until Employee Health opened and sprinted toward Banderas's office the moment I could excuse myself. I had nearly knocked Benny over when I turned a corner and bumped into him in the lobby.

Sitting in Benny's room on that cold night in December, I wanted to tell him about all of this, I wanted to tell him how I'd imagined Banderas rolling into work, checking his email, pulling up my test results, perhaps putting a hand to his face, wondering if he could break the bad news to me over the phone or if I needed to be told in person. I wanted to tell Benny that I could have checked the results on the computer myself but I was afraid to. I wanted to recount every moment in painstaking detail just as I'd lived it.

But when I looked into Benny's eyes, I chose not to say any of this. A man who'd been on the receiving end of so much bad news in his life didn't need a dramatic reenactment of my good news.

“Things worked out,” I said.

“Oh.” A smile emerged over his face. “Oh, that's wonderful. I'm so relieved for you. Whatever it was.” He stood up to hug me, but the IV kept him tethered to the metal pole, so he waved me toward him. As I leaned in and extended my arms, as if on cue, my pager went off and I was summoned to the intensive care unit for an orientation session.

The first night on call of my rotation in the intensive care unit occurred in mid-January, as a gentle snowfall blanketed Washington Heights. I was lying on a black leather couch in the doctors' lounge, reviewing a stack of EKGs, when the door flung open.

“Nap time's over,” a voice said as I pushed a banana peel off my chest and flung myself upright. “Looks like we've got some more business.”

The voice belonged to my blond, floppy-haired supervisor, Don, a second-year resident who had taken over for Baio and Ashley as my medical swag coach. Among the many disorienting aspects of intern year was the constant shuffling of supervisors. Just when I became comfortable with one resident's style, I was pawned off on a new resident with a new system. The carousel of bosses meant I was exposed to all kinds of teaching philosophies, and as the year wore on, I realized just how special Baio had been. Others were excellent in their own ways—some were nimble with needles, others were master negotiators—but no one quite brought the incredible immediacy of medicine to life the way Baio had.

I had heard of Don before I had ever spoken with him. He was a bit of a cornball—a milquetoast midwesterner who loved to show cell phone pictures of his eight-month-old son—but more recently he was known around the hospital as the guy who had picked up a congenital blood vessel abnormality in a young woman after noticing a subtle difference in blood pressure readings in her arms. Word of his careful eye
had spread quickly, and Don was now regarded as a master diagnostician. I suspected that he, like Baio, was someone special, and I couldn't wait to work with him. Don reinforced my belief that professional reputations could be created or destroyed with a single patient.

“New admission from the emergency room,” Don said, gliding across the linoleum. His face was pinched—as if his features were rallying around the scar from his surgically repaired cleft palate—and I wasn't yet sure if he was one of those guys who would lord his sterling reputation over me. He picked up the black plastic phone and put it on speaker.

“Fellas,” the voice on the other end said. It was Baio.

“My man,” Don replied. “I'm here with Matt McCarthy. What you got for us?”

“Kindly give Dr. McCarthy my regards.”

I moved toward the phone, took a seat in an orange plastic chair, and said, “Hey!”

“Got a young guy down here in the ED,” Baio said quickly. “Nineteen-year-old morbidly obese kid with asthma coming in acutely short of breath. Labs look like shit. Chest X-ray looks like shit. I'm thinking it's…”

“Influenza?” Don asked.

“Oh, Don,” Baio said, not nearly as impressed with Don's powers of deduction.

“Sorry, sorry,” Don said, picking up a marker, “I'll shut up now.”

“We're thinking viral infection with superimposed bacterial pneumonia. Probably triggered an asthma exacerbation. We might have to tube him.”

“Yikes,” I said softly. I hadn't heard of someone so young requiring a ventilator.

“Well, send him on up,” Don said. “He'll take our last bed. ICU's full.”

The conversation abruptly ended, and Don stood up and moved to a small white marker board. “Stupid mistake,” he said. “Never hone in
on a diagnosis so quickly. Let's make a list of the things this kid could have
other
than infection. Go.”

Life in the medical intensive care unit was wildly unpredictable. Some nights we admitted up to a half dozen new, exceedingly sick, exceedingly complex patients. Working in the ICU required an advanced grasp of physiology and the ability to remain calm yet assertive while dealing with complex, terrifyingly sick patients. It was the perfect fit for a guy like Baio, but not so much for me. Patients in the ICU are often too sick to describe the events that led up to their admission, and the aim is not to cure a condition but rather to stabilize it. There isn't much red meat there for doctors who find meaning through personal connection.

Fortunately, tonight was looking relatively quiet. Our unit was nearly full and Don had put out most of the fires earlier in the evening, so we had some time to talk. He and I spent the next half hour creating a preposterously long list of what might be wrong with our new patient, until a nurse knocked on the door, poked her head in, and said, “New admission, Darryl Jenkins, is being wheeled in now.”

Don dropped the marker. “Showtime.”

I watched closely as Don examined Darryl, who was clutching his chest while gasping for air. Darryl's huge body took up the entire hospital bed. He must've weighed three hundred pounds, and yet his face was childlike—he looked like a boy trapped in a body far too large for him. And he looked like a wreck. I could hear him wheeze from across the room. Large beads of sweat dripped from his forehead down the side of his face as a nurse placed an oxygen mask on Darryl's face, and a nebulizer treatment was administered to open up his asthmatic lungs. It was jarring to see someone so young who was so sick. Don stood off to the side, fixated on Darryl's fingernails. I pulled my stethoscope out of my white coat and cleaned it off with an alcohol swab, wondering what Don was doing.

“Just going to take a quick listen,” I said to Darryl as I tapped his upper back. “Need to listen to your lungs.” He closed his eyes, failing to acknowledge my comment.

As I leaned in, Don said, “Stop.” He was holding Darryl's left hand, shining a penlight onto the middle fingernail. “Look at this, Matt. What do you see?”

I withdrew the stethoscope and inched toward the outstretched arm. “What?” I asked.

“What do you see?” Don asked again. “Describe it to me.”

It looked like a normal fingernail, perhaps slightly shorter than average. “Looks a little short,” I said. “Maybe he was biting it?” I looked
up at Darryl's round face; his eyes were still closed, and he was generating quick, shallow breaths. “Understandable, considering the circumstances.” Two more nurses entered the room and administered more nebulizer treatments.

Don shook his head. “No.” He brought the limp hand up toward his eyeballs. “Look here.”

I stretched my neck and closely studied the nail. “I'm not sure I see anything.” As I took the hand and held it in my own, Darryl began a vigorous coughing spell and pulled away.

“Look at the curvature of the nail bed,” Don said. “It's called clubbing.”

“I've heard of it,” I said, enthusiastically recalling a patient on the infectious disease service who'd had the condition as a result of chronic lung disease. “I've actually seen it before. But I didn't see it here.”

“It's subtle,” Don said, “but it's there.”

“Huh.” Not only did I miss it but I wouldn't have thought to look for it.

“The question is why.”

Before I could answer, Don moved to Darryl's feet, pulling off his socks to examine his toes. From there, he went behind the bed to inspect Darryl's scalp. Then he plunged his hands into Darryl's vast armpits. Last, after he'd examined every possible inch of our new patient, he listened to Darryl's lungs. His approach to the physical exam recalled the way Baio had taught me to read a chest X-ray, starting from the periphery. “He's gonna need a ventilator,” Don said. “Let's go put in some orders.”

After the orders were in, Don called in a team of anesthesiologists, and I looked on as they tunneled a breathing tube into Darryl's throat. After the ventilator was switched on, we retreated to the doctors' lounge.
Don assumed his position at the marker board and said, “Asthma is treated in a stepwise fashion based on pulmonary function. Walk me through those steps.”

I tried to shake the image of Darryl—the flabby arms, the swollen lips forming a seal around the breathing tube, the large IV disappearing somewhere below his enormous belly—and grabbed a can of soda from a miniature refrigerator in the corner of the room. As Don pointed the marker at me, the phone rang.

“Bad news, gentlemen.” Baio's voice emanated through the speakerphone. “Looks like I got another one down here for you.”

Baio was working a twelve-hour overnight shift in the emergency room, assigning patients to various floors and medical teams. We all had to spend two weeks working as ER physicians to see how the other half lived, and most of my colleagues loathed the experience. Quickly triaging an endless stream of patients in the emergency room was remarkably different from what we usually did, which was to care for a confined panel of about a dozen patients within the hospital.

“Sorry,” Don said, still standing, “you know we don't have any beds. The ICU is full.”

“It's a frequent flier,” Baio replied, referring to oft-hospitalized patients. “Honestly should go to the CCU, but they're full.”

“We're full, too,” Don said firmly.

“It's this guy Benny Santos. McCarthy knows him.”

I nearly spat out my soda. “What's he doing in the emergency room?” I asked.

“The CCU sent him home a few days ago,” Baio said. “Told him he could just wait for the heart at home. But he looks sick as shit right now.”

“Fuck.” At my last count, Benny had been living in the hospital for seven months; I couldn't believe they'd just sent him home. And without telling me? How did I not know about this? In truth, there was no reason to tell me. I was more his friend than his physician. I was no
longer caring for him in the CCU, and there was no reason to send out a press release, no need to inform an intern like me. His cardiologists must have decided that Benny had fallen so low on the waiting list that he could simply wait at home. Or perhaps his heart had regained some strength. Maybe he didn't
need
to be hospitalized anymore. Maybe he didn't even need a transplant.

I shook my head. There were many things I was unsure of, but I knew he needed the transplant. I'd seen just how quickly illness could strike him. One afternoon we'd be watching Judge Judy admonish a man for failing to pay child support and the next Benny would be intubated, made chemically numb by anesthetics so a breathing tube could keep him alive. He could flash at any moment and should've died a dozen times. Or more.

I wondered what it had been like for Benny to be dismissed so suddenly, to unexpectedly walk outside and breathe fresh air. Perhaps it didn't feel so sudden for him. I thought of a wrongly convicted inmate being set free. They really just sent Benny home? Why didn't he tell me?

We had often joked about grabbing lunch someday “on the outside,” somewhere far, far away from Columbia—somewhere that served normal food and had real utensils. I never thought that day would come, but it now appeared it had come and gone. Benny had been released and now he was back, sitting in our emergency room. And based on Baio's judgment, he was very sick and needed to be in an intensive care unit. Contemplating what Benny must have gone through—the relief of being discharged, the pain of realizing it was only temporary—was dizzying.

“No room,” Don said loudly. “We can't take him. I'm sorry. The ICU is full.”

“Make room,” Baio said.

I stared at the phone, waiting for Don to say something. Baio knew how tenuous Benny's health was. Did Don? There was tremendous
pressure on the emergency room physicians to quickly triage their sickest patients. Baio was expected to see a new patient every twenty minutes during his ER stint; one train wreck of a patient with no place to go could lead to a bottleneck and a preposterously long wait for others.

“Look,” Baio said, “I know how it works up there. There's gotta be somebody you can bump.”

Intensive care residents like Don were under similar pressure. ICU beds were at a premium, and patients on the mend were transitioned out of the unit and to the general hospital ward the moment they were ready. But sending someone out prematurely could lead to a bounce-back, a dreaded situation in which the patient returned to the ICU less than twenty-four hours after discharge. Don put his hand over the speaker and whispered to me, “We could put Santos in the corner pocket.”

I shook my head. “No!” I whispered back.

There was one room in the ICU, in the near right corner, where patients reportedly went to die. Don told me he'd never seen someone make it out of the corner pocket alive. Everyone knew it was just a coincidence, but practicing medicine had made some of us, including my pod mates, increasingly superstitious. There was no way we were putting Benny there.

“We'll see what we can do,” Don said. “We won't leave you hanging.”

“Like I said, still trying to get Santos to the CCU,” Baio said. “I'll talk to Diego and let you know. Later, fellas.”

Don looked up from the phone and took a deep breath. “Looks like we're in for a wild night. Let's run the list before shit gets crazy.”

My mind was lingering on something Baio had said about Benny:
McCarthy knows him.
How did he know that? Did he remember that we'd cared for Benny together months ago, or was this part of my reputation? Did people know that I popped in to chat with him? Was Don the master diagnostician while I was just Benny's buddy?

I pulled out my list, scanned the dozen ICU patients, and prepared
to take down my marching orders. My eyes were heavy, and the night was only in its infancy. “Let's divide and conquer,” Don said. “First up, Mr. Jones, forty-one-year-old with HIV here with PCP pneumonia. Did you review his chest X-ray?”

I barely heard him. My thoughts were still with Benny in the emergency room, presumably gasping for air or clutching his chest. I needed to be professional. I needed to focus on the patients in the ICU, and Benny was in good hands with Baio. I couldn't play favorites. I needed to be a utilitarian, providing the greatest benefit for the greatest number of patients, and that meant focusing on the task at hand, not the guy in the emergency room. I tried to remove the mental image of Benny from my mind. But how?

“Matt,” Don said loudly, “did you review the X-ray?”

“Yes. Yes, I did.” Lung tissue had been replaced by air bubbles called blebs that looked like tiny, innumerable blisters. “Never seen anything like it.”

“We have to be prepared for the worst,” Don said. “What are you going to do if Mr. Jones's blood pressure suddenly tanks tonight?”

“Fluids,” I said, recalling Baio's introductory lesson on shock. It was as vivid now as it had been months ago. “Probably sepsis.”

“Maybe,” Don said, “or…?”

I had gotten better at these little give-and-takes; Don was good at them, and I hoped I would be, too, someday. “Heart failure?” I offered.

“His lungs! They're filled with blebs that are just waiting to burst. And if one does, he's screwed.”

“Right,” I said, tossing my empty soda can into the trash. “The blebs.”

“So, Dr. McCarthy, a bleb bursts at three
A.M.
and I'm taking a piss. What are you going to do about it?”

This is precisely what made intern year so difficult. Just when you developed some confidence, just when you thought you'd mastered a critical mass of knowledge, you were thrown a curveball. Something you've never seen before that set everything back to square one. It
wasn't my fault—it was impossible to see every medical condition in the first six months—but it bothered me. Another piece of the canvas of my mind was about to be splattered with paint. “I'm not sure.”

Don put his arm around me. “It's okay, big guy, that's why I'm here.” He stood up at the marker board. “Tension pneumothorax. His chest will fill up with air but he can't breathe any of it. He'll suffocate in minutes. Or less.”

I started scribbling. In medical school I had read about blebs and tension pneumothorax, and I had memorized the ways to treat it. But this was different. Every time I moved to a new floor, I had to familiarize myself not only with new supervisors and nurses but also with new equipment. Even if I knew
how
to treat tension pneumothorax, I might not know where to find the equipment on my own. Every floor had a different supply room and a different way of arranging its inventory.

“Your job,” Don said as he ran his hands through his hair, “should you choose to accept it, is to stick a needle in Mr. Jones's chest, just a few inches below the collarbone, to let the air out.”

“Got it,” I said, recalling the instructional video on
The New England Journal of Medicine
website. It was a tricky procedure to perform, and I hoped I'd be able to do it properly. I wondered if these medical maneuvers would ever become second nature, if my pulse would eventually cease to race at the thought of inserting a needle into another human. I hoped not. I thought of the Asian doctor I'd seen many months ago, submerging a large needle into the lining of someone's heart. These outlandish, lifesaving interventions were unnatural, and the day they became mundane would be the day I lost a bit of my humanity.

“Yes. It's a shame,” Don said. “This all could've been prevented if Mr. Jones had just taken his HIV meds.” I closed my eyes and thought:
Not as easy as you think
.

“Bed ten, Ms. Hansen, is a potential bump,” Don said.

“Is she the one from Canada?” I asked. At times it was difficult to differentiate the ICU patients; most were sedated and intubated,
draped under gowns or special machinery to augment their core body temperature. I hated to admit it, but a lot of the patients in the intensive care unit looked alike.

“Yeah,” Don said, jotting something on his hand. “A few days ago she was found unconscious in her living room by a neighbor. The guys in the ER couldn't get a central line into her femoral vein so they went straight into her shin.” We both winced; the interosseous approach was preposterously painful, but there had been no other option for giving her a rapid infusion of medications. “She's still full code, but her healthcare proxy just arrived. I think it's her daughter. See if you can get her to change to comfort measures only.”

Comfort measures only
meant we were effectively throwing in the towel; aggressive attempts at resuscitation would be over and life-prolonging interventions like dialysis would be withdrawn. Most people hadn't thought about what medical interventions they'd want if the unthinkable happened, and even fewer had assigned someone to carry out their wishes. Family members were often left to confront these decisions for the first time when a loved one landed in the ICU. Overwhelmed with heartbreaking decisions, many healthcare proxies simply asked that we “do everything.” But this wasn't always in the best interests of the patients. It could lead to expensive, futile procedures and merely prolong the inevitable. Conveying this with tact was a skill. With no textbook to provide guidance, interns were left to figure out how to lead these discussions in much the way we learned anything—through observation, practice, and occasional failure.