The Real Doctor Will See You Shortly (3 page)

“Still asleep,” the nurse said as I drew back the curtain and poked my head into one of the partitioned glass cubes on the unit's perimeter. “He's all yours.”

Behind the nurse, the room's windows opened onto the Hudson River, but the view was obscured by a mountain of medical equipment. In the center of the room a male patient lay sedated in a large bed with guardrails that had been ergonomically designed to prevent bedsores. If too much pressure was applied to one side, sensors would activate and the mattress would inflate to balance the force. Behind the bed stood what appeared to be a stainless-steel coatrack upon which hung nine different plastic bags filled with clear fluid, each about the size of a breast implant. Above these, monitors slightly larger than an iPhone screen displayed the names of the medications in the bags and the rate at which they were being administered. If a bag became empty, an alarm would sound. If someone tampered with the rate, a whistle would blow. The whole setup looked like a cryptic art installation of sirens, machines, buttons, tubes, wires, and blinking lights. I had been given very clear instructions during orientation: aside from the patient, don't touch anything in the room.

I took a deep breath and approached the unconscious patient, a mustachioed man who looked a bit like Teddy Roosevelt. I grabbed a pair of gloves and prepared to examine this mysterious man who had been dropped into our laps by whatever fate had befallen him. I
thought back to medical school and how I was taught to perform a physical examination.

“Start with the hands,” my instructor had advised. “It will put the patient at ease and will reveal how a person lives, how they eat, how they work, if they smoke…”

I put on the gloves and picked up the man's limp right hand. It looked like a normal hand, pink and soft, and without dirt under the nails. No evidence of the small hemorrhages known as Janeway lesions or the lumps known as Osler's nodes, named for physicians of a bygone era and each indicative of an infected heart valve. From the hand I moved up the arm, looking for track marks—signs of IV drug use, which could also predispose the heart to infection. From there I shifted my attention to his head, where I noted a small abrasion on his scalp. Throughout my examination, his chest gently oscillated up and down as the ventilator forced half a liter of air into his lungs every five seconds.

“Mr. Gladstone,” I said.

No response. I was almost relieved, but then I remembered another nugget of medical school wisdom. “You do not want to be the physician who assumed the patient was sleeping,” the instructor had told us, “when in fact he was dead.”

“Mr. Gladstone!” I shouted, too loud.

The patient let out a soft whimper. I moved to his eyes, lifting each lid up with my left hand while using my right to shine a penlight in; both pupils contracted as they should. I waved my finger toward his nose, assessing the ability to focus on a near object, a process called accommodation. His pupils, which easily reacted to light, could not accommodate. Before moving on to the nose, I noted that the left pupil appeared two millimeters smaller than the right.

As I jotted my findings in a small notepad, the ambient noise of the unit faded into the background. It was just the two of us alone in a vacuum. I raised my eyes from my notes and stared at the patient's chest,
watching it quietly heave with every manufactured breath. What was his heart doing under there? Was he recovering or dying? “You're going to get through this,” I whispered, more to myself than to him. I wondered where Carl Gladstone was from and how he spent his days. Did he work? Did he have a family?

ARREST STAT, SIX GARDEN SOUTH!
the intercom blared overhead.
ARREST STAT, SIX GARDEN SOUTH!

I turned away from the patient to see Baio sprinting past the room, grinning, a man utterly in his element. “It's just you, bud!” he said as he pushed the unit doors open. “Hold down the fort!”

And with that, I was alone in the unit, the doors swinging gently on their springed hinges in Baio's wake. I closed my eyes and cursed under my breath. Quickly completing my examination of Carl Gladstone, I typed up a note to reflect my findings. With every sentence, I looked around the room, certain that someone's heart had stopped. I was alone, and filled with an electrifying sense of nowness.

Baio returned after twenty agonizingly long minutes.

“How'd it go?” I asked.

“Just saved a life,” he said, smiling. His jockish pride reminded me of former teammates and my former life. “How is our new patient?”

“Wow, that's great. What happened?”

“Priorities, my friend. Tell me about our new patient first.”

“Sure, sure,” I answered, pulling up my notes. “Fifty-eight-year-old guy had a heart attack. Kinda random. Just went to work, teaching a class, and dropped to the floor.”

“Not random,” Baio said flatly.

I paused, recalling our conversation on rounds a day earlier. Baio had mentioned that cardiovascular functions are influenced by circadian rhythms, and as a result, heart attacks are much more common in the morning hours.

“Right.”

“Go on,” Baio said. “You have my undivided attention.”

“They took him to the cath lab and fixed him.”

His eyes locked onto mine and he wrinkled his brow. “And that's it?”

“He's a little sleepy right now, but yeah, that's it.”

“Anything else you'd like to tell me?”

“I think that's the big picture. On exam he looks pretty good. Still sedated but stable. I'm sure there's more detail in here,” I said, reaching for his chart.

Baio grabbed the cranberry chart before I could and shook his head in frustration. “You have told me almost no useful information.”

I scratched my chin, avoiding eye contact. I hated to disappoint this man. I wanted to be like him. I wanted to
be
him. “One pupil is smaller than the other,” I offered.

Baio looked up. “Well, that
is
interesting. What do you make of it? What's your differential diagnosis?” he asked, referring to the systematic process of elimination in which a clinician considers an array of maladies before arriving at a diagnosis. This was how I had been taught to approach any symptom or clinical finding in medical school. The cause of something simple—a cough, for example—could ultimately be so obscure that we were encouraged to initially think as broadly as possible. This expansive list, which was quickly pared down, was known as the differential diagnosis. Our professors at Harvard had routinely amazed us with the inconceivably long lists they could generate.

I had been pleased with myself for noting the unequal pupils but hadn't really taken the next step and considered the cause. I was the dial-up to Baio's broadband, the MySpace to his Twitter. I thought back to a mnemonic I'd been taught in medical school to generate a differential diagnosis: VINDICATE.

V—Vascular

“He could be having a stroke,” I said. “Maybe there's a vascular process in his brain causing one pupil to constrict.”

I—Infection

“He could have an infection of the pupil—something like herpes of the eyeball.”

N—Neoplasm

“He could have a neoplastic process—a tumor of the eye or brain cancer.”

D—Drugs

“He received a number of painkillers in the ambulance and a sedative before the catheterization. I know narcotics can affect the pupils.”

Baio touched his index finger to my chest, almost sweetly. “I'm impressed.”

“Thank you,” I said, fighting back a smile.

“Now, it's great to rattle off a bunch of possible causes, but what are we actually putting our money on?”

Medical school was for generating a list, I thought. But being a doctor means knowing how to narrow that list. “Well,” I said as my eyes quickly moved back and forth, “I doubt it's cancer, might be a stroke. Less likely infection. It's probably the drugs.”

“Sounds reasonable,” Baio said, closing the chart. “Listen, we need to work on your presentations. I need to know about these patients in far greater detail than you just gave me.”

“Okay.” I reached for my notebook and quickly jotted down
details!

“But first let me tell you about that cardiac arrest.”

“Yeah, that's right. What happened?”

“Whenever I run to an arrest, I whisper ‘ABC, ABC' to remind myself that it's got to start with airway, breathing, circulation.”

I scribbled
ABC.

“Don't write this down, just listen,” he said. “So I get into the room and this dude isn't moving. His eyes are open but nobody's home. Not responding to anything. So imagine you're me. What do you do?”

The thought paralyzed me. “I have no idea.”

“That is not the right answer, Dr. McCarthy. Think.”

“Let's see…”

“But remember, in real time you don't have the luxury of thinking about it.”

“It has to be instinctual,” I said awkwardly.

“What did you say to yourself while sprinting?”

“ABC…” A hint of a smile from Baio. “So,” I went on. “A…airway. I would assess the airway.”

“Bingo.”

“Did the patient have an open airway?”

“I checked his airway and it was blocked. So we intubated him on the spot.”

“Nice.”

“And when the tube went into his throat, all this shit came out.”

Baio removed his white coat, displaying innumerable smudges on his scrub top.

“What do you think it was?” I asked.

“Oh, it was shit. Actual feces.”

I put my hand over my mouth. Holding on to his undershirt with his right hand, Baio pulled the scrub top off with his left and bundled it into a ball.

“But how could—”

Before I could finish the thought, the scrub top hit me in the face.

“We'll talk more about it later,” he said, as he sauntered away to examine Carl Gladstone. “Go introduce yourself to the rest of our guests.”

Looking for a patient with whom I could interact, I elected to begin with the only one who was ambulatory: the large man on the stationary bike.

“Hello,” I said, gently tapping on the glass divider separating the patient's room from the rest of the unit. He stopped pedaling and took off his headphones. A Hispanic man in his early forties, he had a shaved head and a room littered with books, magazines, and scraps of handwritten notes. He was stocky, barrel-chested, and broad-shouldered like an ex-linebacker, and by the looks of things he had been in the unit for quite some time.

“Hi,” I continued as I entered the room, “I'm…”

“One of the new guys.”

“Yes.”

“Benny Santos,” he said, extending a hand. “It's a pleasure.” He spoke softly and deliberately and had a surprisingly smooth hand. Unlike the other patients, he was not in a hospital gown. Instead, he wore a New York Giants T-shirt and jeans.

“I'm one of the new physicians here,” I said, avoiding the word
intern
.

“Welcome.”

Catching sight of a notebook by his bed, I paused and tried to figure out how to ask this rather large, well-appearing man why he was in a critical care unit.

“Why am I here?…Is that what you're wondering?” he said, flashing a smile. His voice was so soft that I found myself leaning in close to catch his words.

“It is.”

“Need a new ticker,” he said, pointing at his chest.

Outside his room, we overheard a senior physician giving an evening tour to a group of medical students. “Many of the patients in this unit,” the guide said, “are among the more than five million Americans living with heart failure—a condition in which the heart is unable to pump sufficient blood to the body.”

“That's me,” Benny said cheerfully, “star attraction.”

“Failing to deliver blood to starving organs,” the guide continued, “fluid gradually backs up into the lungs as the kidneys and liver inevitably fail. At that point, no medication or dietary modification can save them. It's transplant or bust.”

“Been here for several months,” Benny said softly, “just waiting.”

I thought of how I'd spent the past few weeks—graduation parties, move to Manhattan, orientation cocktails. “That's tough,” I offered. On the other hand, his relatively stable condition meant one less patient for me to worry about.

“Just trying to sneak up the UNOS list,” he said. On rounds as a medical student I had been introduced to the United Network for Organ Sharing and its sophisticated algorithm for allocating organs; it varied significantly by city, but the median wait time for a new heart was expected to be just over 150 days. Benny, however, was on his way to becoming an unfortunate outlier.

“What are you listening to?” I asked. This was a mistake. I wanted to make a connection, but discussing music was a huge weak spot for me. In college I'd once been laughed out of a dorm room for saying that I felt like the Goo Goo Dolls were playing the sound track to my life.

“A little Babyface,” he said. “You a fan?”

“I can't say that I am.”

“Okay, okay. That's cool.”

“Judge Judy, on the other hand,” I added, motioning toward the television, “huge fan.”

He smiled, and we looked up at the television. “Yeah, she's great. Very wise.”

My teeth grinding came to a halt and I took a seat on the edge of his bed. “They call her the White Oprah,” I said.

Benny wrinkled his brow as Judy banged her gavel. “Who calls her that?”

“Didn't someone call her that?”

“I don't think so,” he said. “Definitely not.”

Benny looked out of the window, onto the Henry Hudson Parkway, where traffic was backed up for miles. “I really appreciate you guys coming in here, checking on me periodically, shooting the shit and whatnot.”

“Of course.”

“You know, one of your colleagues used to come in here, spent fifteen or twenty minutes with me every single day. Talk about Scripture, talk about music, anything.”

“That's great.”

“One day we were both here on a holiday. I was down, and she could tell I wasn't my normal, charming self. So we're looking out the window just like this and she says, you know, more traffic accidents happen on holidays. Drunk drivers, more people on the roads, stuff like that.”

I nodded.

“And she smiles and says, ‘Every drunk driver, every family coming back from the beach…those could be organ donors.' Every crash brings me closer to a transplant.”

He turned from the window and looked at me.

I wasn't sure what reaction was called for here. “I suppose that's one way of looking at it,” I responded.

He frowned. “That's a horrible way of looking at it!”

“Yes, that is a horrible way of looking at it.”

I blushed, embarrassed by the exchange.

“She meant well,” he said, glancing up with a smile, “but no one would mistake your colleague for White Oprah.”