The Real Doctor Will See You Shortly (25 page)

After my two-week stint of nights with Don—he and I had exhausted hundreds of hypotheticals during our fortnight together—I was shipped uptown to work a monthlong rotation in the intensive care unit of the Allen Hospital. Located near the northern tip of Manhattan, the Allen was a three-hundred-bed community hospital on 220th Street where Columbia interns spent one month learning the art of geriatric medicine and a separate month running the intensive care unit. The structure of supervision was a bit different uptown because in contrast to the Columbia behemoth on 168th Street—a topflight international referral center—patients at the modest, three-story Allen Hospital tended to have less acute, less complex medical conditions. And for that, we were all thankful.

At first blush, the assignment seemed somewhat contradictory. If patients at the Allen weren't that sick, why have an ICU? On an interminable northbound subway ride to 220th Street in early April, I wondered if, like Sam's allegedly light heart attack, I was about to begin work in a light intensive care unit. As the subway approached the hospital I considered how odd it was to think of humans in this way—as medically simple or complex, the chronically ill or the worried well—rather than as funny or kind or annoying. I was struck by how differently my mind worked now than it did just a few years ago. When did I begin to identify people first on the basis of physiology rather than personality? When did that accountant I was caring for become Salmonella Lady or Diarrhea Guy?

After ten months of being an intern, I no longer experienced life like a normal person. I couldn't watch a movie or read a magazine without drifting off to the hospital—to a procedure or an ambiguous diagnosis or a patient encounter—to relive the moment again and again, until something shook me out of the moment. I now found it hard to have a conversation without mentioning something I had seen or done at work. Ordering lunch at a deli, I'd be thinking about the patient who claimed he sat on a jar of Grey Poupon. Checking out at a grocery store, I'd be thinking about the lung blebs.

I now viewed everything through the lens of medicine. It wasn't something I had planned or particularly wanted, it just happened. When I saw someone on the street with a limp, I now fixated on how it might have happened—stroke? fractured bone? muscle-wasting disease?—until I felt confident in my armchair diagnosis. I found myself staring at oddly shaped moles on the subway and at low-set ears in the park. What caused these things? I couldn't let it go until I'd formulated some sort of hypothesis.

I desperately wanted to become a superb doctor, but as the year wore on I also found myself wanting to remember what it was like to not be a physician—to just be a guy going for a stroll with an uncluttered mind and an armful of groceries. A guy who didn't act quickly and decisively, someone who could make eye contact without thinking about ophthalmology. I wanted to be a doctor
and
a normal person. Was that possible? Or were the two mutually exclusive? I hoped I would never have to choose, but in some ways it felt like I already had.

When I stepped into the Allen ICU for that first thirty-hour shift in April, I discovered that my pod would be supervised by just one third-year resident (rather than four second-year residents) and that this resident would be supervised by two attending physicians. This had presumably been explained to me months earlier, during orientation, when intern year had been laid out in a series of presentations, but I had forgotten the details. I had become remarkably nearsighted over the course of the year, focused on what I needed to know to get
through the day, rather than what might take place in the weeks and months ahead.

The entire Allen ICU team was to go home at 8:00
P.M.
, meaning I was left to hold down the fort on my own overnight. I would have backup, of course, in the form of an overnight attending physician who was admitting his or her own patients in another part of the hospital. But once the sun went down, I was essentially alone.

If scheduled toward the end of the academic year, the Allen ICU was said to be the ideal setting for a promising intern to become comfortable making tough decisions in solitude, without the second-guessing and hand-holding of a more senior resident. But it was also a place where mistakes would be amplified; making the wrong diagnosis or selecting an improper medication could inflict real harm rather than just a tongue-lashing from a supervisor. I had heard stories of interns breaking down in tears from the existential terror of presiding over an ICU in solitude. As the sun settled below the Hudson River and I said good-bye to my ICU colleagues on that first night alone, I only had one thought:
Don't fuck up.

Glancing around the ICU—the room was about the size of a Little League infield—I noticed the fluorescent lights weren't as bright as they were at Columbia and the place smelled different, vaguely antiseptic, as if the tiled floor had just been mopped with chlorine and the room had been infused with industrial-strength air freshener. It wasn't better or worse than the hospital on 168th Street, just different, like I had moved into a new apartment—a strange sublet with unfamiliar neighbors and appliances that I'd eventually get used to but for now felt foreign.

Before me in the unit were a dozen unconscious bodies attached to ventilators and large-bore IVs, just like at Columbia. There were bleating blood pressure monitors, energetic nurses, and grieving families,
just like at Columbia. There were familiar stacks of EKGs and day-old bagels, but there was no Baio and there was no Don. It was just me, alone with a group of very sick, very complicated patients. This was not ICU Lite.

I stared at my scut list on that first evening alone and tried to devise a plan of attack. Where would Baio begin? How would Ashley triage this list? There were perhaps two dozen assignments that needed to be completed before sunrise, and I could do them in any order I wanted. I'd be able to do them with ease if the night remained uneventful, but it would be foolish to assume the night would be quiet. Unforeseen developments—fibrillating hearts, profound electrolyte disturbances, intractable vomiting—would undoubtedly keep me busy, not to mention new patients coming up from the ED. I slung my stethoscope around my neck, checked my pager, and made my way to the nearest patient.

The small room was dark and cool, shielded from the ICU's fluorescent lighting by a large beige curtain that ran around the perimeter. An LCD screen that projected ventilator settings faintly illuminated the mottled skin of a chemically sedated, morbidly obese Vietnamese woman with pneumonia and impossibly long fingernails. As I approached the bed, I felt a silent partner at my side. First it was the voice of Ashley, gently reminding me to feel for hidden lymph nodes; then it was Jim O'Connell, reminding me to peek under the fingernails. I introduced myself to this unconscious woman as a formality, knowing she would be unable to respond. But I spoke loudly, just in case a word or phrase might register.

I felt ready for this challenge, but in those first solitary moments at the Allen, I realized how much I relied on others, how often I tugged the sleeve of a colleague and said, “Hey, quick question.” For me, bouncing ideas and treatment plans off of others had become a way of life, a safeguard to prevent a medical mishap. But now, I didn't have that option. I put on a disposable gown and a pair of gloves and lightly pressed my stethoscope to the woman's sweltering chest.

Soon Don was in my head, forcing me to describe the sound of the woman's heart murmur in greater and greater detail. Glancing at her ample belly, I could hear him reminding me of the proper way to perform an abdominal exam.
Look, listen, palpate
. As I scribbled my findings and the voices bounced around my brain, I felt less alone. I knew that if my judgment failed me, memory would not. I had diagnosed and treated pneumonia so many times that I just needed to draw on prior experience to guide me.

During our series of nights together, Don and I had encountered pneumonia at least a dozen times, and with each successive case he had pulled back, giving me more authority to generate the differential diagnosis, order tests, and concoct a treatment plan. I had felt in control, and developed a modicum of comfort making important decisions, although I knew he was my safety net, double-checking my work in the background. And when Don disagreed with me, I no longer felt compelled to say, “I'm not wrong,” even though I might have been. If I had made a real error, I knew he would've caught it.

“Continue broad-spectrum antibiotics for another twenty-four hours,” I said softly, as I exited the Vietnamese woman's room, “and try to get her off the ventilator tomorrow.” I briefly closed my eyes and imagined my erstwhile supervisors gently nodding in agreement. Then I scribbled the plan onto my scut list.

Moving on to the next patient—a frail Italian man with what had been dubbed a fever of unknown origin—I imagined the voice of Lalitha rattling off the uncommon causes of fever.
Don't forget about familial Mediterranean fever, Matty.
Then it was Ariel chiming in, reminding me of the more common causes of fever that might have been missed.
Did you check for tuberculosis, Dr. McCarthy?
So much of my medical knowledge had come from rounds, simply listening as my pod mates dissected hundreds and hundreds of cases. As I quickly jotted down vital signs, I felt the urge to text them:
Wish me luck!
or
Feel free to come back if you're bored at home!

But I didn't text them. In fact, I took my cell phone out of my back
pocket and placed it in the center of the unit, next to a computer keyboard. Service was so spotty in the hospital that doctors rarely communicated via cell phone; the thing would only serve as a distraction, and I wanted to immerse myself in the essence of being alone and unassisted. I knew it would take complete focus to get through the night without making a mistake.

I had seen and done so much since the Gladstone episode, and the pitiful note I'd written for Baio that had so enraged Sothscott. I was always someone who liked a challenge, but the Gladstone incident had transiently suppressed that, turning me into a gun-shy physician who was afraid of screwing up. Now I had finally moved beyond that, receiving enough positive feedback from supervising physicians—for my ability both to perform procedures and to present complex cases concisely during rounds—that being in charge of delivering care was no longer a stomach-churning thought. Now I could look at a patient like Carl Gladstone with unequal pupils and make a long list of things that could be responsible. I could narrow and rearrange that list, creating a hierarchy of probable causes, and from there I could page an expert—a neurologist, neurosurgeon, or ophthalmologist—to confirm or disprove my suspicions. I felt different now because I was different. After nearly a year of being an intern, I knew I was almost a real doctor.
Almost.

After examining the remainder of the patients in the Allen ICU—there were no medical emergencies, just a handful of conversations with distraught, confused family members—another voice drifted into my head.
When you can eat, eat.
As I wandered over to a box of chocolate donuts in the center of the unit, the ward clerk handed me a telephone and said, “It's the emergency room.” Here we go.

An ER physician named Dr. Brickow quickly introduced himself.
“Just examined a twenty-five-year-old guy named Dan Masterson,” he said. “Guy's in rough shape, gonna need an ICU. I take it you have beds?”

I remembered the back-and-forth between Baio and Don, trying to find an ICU bed for Benny, as I scarfed down a donut. “We do.” Masterson would be the first new patient I cared for alone. That responsibility no longer felt like a burden; it was something I wanted. “What's his deal?” I asked.

“It's a weird story,” Brickow went on. “Wife gets pregnant with their second kid, so he switches jobs to pay the bills. Had to get a health clearance to start work and out of nowhere he tests positive for hep C.”

I grabbed a plastic chair and took a seat. “Huh.”

“Happened a few months ago.”

“So what happened? Why's he here?” I started to create an illness narrative for this new patient. It was something I had learned from Don. It was his way of transforming a two-dimensional story about a set of discrete symptoms into a three-dimensional image of a human being grappling with a disease. It was often helpful, but it occasionally led me to jump to premature, unfounded conclusions.

The narrative started to come together in my mind: I imagined Dan Masterson's unkempt body stumbling into the Allen emergency room with belly pain. Or cirrhosis. He had prematurely aged—Dan was probably a young old man—and he'd initially chalked up his symptoms to stress. Trouble at work, having another kid, something like that. He'd ignored some warning signs—weight loss, shortness of breath—and now he was with us, clinging to life. I wondered if he was frail. I wondered what he was wearing. I wanted to know when he had contracted the virus and how his wife had reacted.

I took a sip from a can of soda and glanced around for a Styrofoam cup, wondering if I might need it for later. How sick was this guy? And would I know what to do? Suddenly, I wasn't feeling so eager to get a
new patient. I hoped I wouldn't see a new medical condition tonight. I wanted something routine, something I could handle. I wasn't looking for a teachable moment, especially since there was no one around to teach me.

“Here's the strange part,” Dr. Brickow said, the pitch of his voice rising slightly. “The guy walks in here from work a few hours ago—walking, talking, totally normal guy—and tells me he thinks he's gonna die.”

I again recalled the terror I had experienced after the needle stick. I had felt that way more than a few times and I hadn't been
that
sick. “Yeah.”

“And he tells me he's been doing some experimental treatment. Inhaled nitric oxide therapy.”