The Real Doctor Will See You Shortly (4 page)

“New patient looks okay,” Baio said of Gladstone a few minutes later as he grabbed two chairs and led me to the back of the unit. “His wife is coming in shortly. Needs to wake up a bit, so I stopped the sedatives.”

“Got it, I'll put in the order.”

“I already took care of it. Okay, let's play a game.”

Our last conversation had ended with a shit-stained scrub top landing in my face; I shuddered to think how a “game” could turn out.

“A year from now, you're going to be in charge of running a cardiac arrest. Dozens of doctors, crammed in a room, looking at you while a lifeless patient lies in the middle. This year you get off easy—you just do chest compressions or draw blood or put in an IV. But next year you're the conductor.”

“Fantastic,” I deadpanned. Running a cardiac arrest was not a scenario that had been covered much in medical school. And perhaps with good reason—the mere thought of it would have given many of us nightmares. We had been more focused on learning and perfecting the basics of listening to patients and examining them.

“I'm going to throw scenarios at you and I want you to tell me how you'd handle them. Ready?”

I laughed. “I think we both know the answer is no. But…yes.”

“Okay, it's six
A.M.
, you show up for work and start checking on your patients. You enter a room and the patient is unresponsive. Twenty-four-year-old black girl. Go.”

He pointed at me, and I slowly exhaled. Beeping ventilators and vital signs monitors were momentarily ignored. “Unresponsive?”

“Unconscious, unresponsive. Whatever. She doesn't move when you shake her. Go.”

“I suppose…I suppose I'd start with the ABCs.”

“Fine. She has a patent airway, but she's not breathing and her heart's not beating.”

I smiled, trying to buy time. “We should fix that.” My mind was in overdrive, desperately trying to draw on the events of the one cardiac arrest I'd witnessed at Massachusetts General.

“Indeed.”

“I would intubate her,” I said, “and start chest compressions.”

“Good, and can you do both of those things?”

“No. Not at the same time.”

“So…” he said, jutting his chin forward.

“I'd get help. I'd yell for help.”

“Excellent!” Baio patted my arm. “In this case, your inclination to react like a small child is correct. Everything in medicine is based around teamwork. Never forget that. So, what else?”

“I'm not sure.”

“You've started CPR, you're giving her oxygen. But why would a young girl's heart stop?” His green eyes narrowed slightly, focusing on me intently.

It shouldn't, I thought. “Congenital something or other?” I offered.

“I said she was a twenty-something black girl. Does that help?”

“Maybe she overdosed?”

“Easy”—he laughed, leaning away from me—“not all black kids are on drugs.”

I was aghast. “No, no, no, I just—”

“I'm kidding—drugs are a reasonable thought. What would you do about it?”

“I could give something maybe to reverse the drugs.”

“Yes. Narcan. It's incredible. Turns someone from a stuporous zombie to agitated and annoying in seconds. What if I told you she had a fistula on her arm?”

“She could have a kidney disease.”

“Go on…”

“Maybe she missed dialysis or maybe her electrolytes are off. I'd ask someone to draw labs. Maybe the potassium…”

He shook his head. “The woman's heart isn't beating. Do you have any idea how long it would take our lab to process her blood and tell us about the potassium?”

“No.”

“She'd be in the morgue before you had your answer.”

I rubbed my forehead. “Shit.” I had reached for the textbook again and the patient was dead. So when was I supposed to reach for the textbook? How could I know what to do if I didn't know what to do?

“You have to be one step ahead,” said Baio. “Treat empirically. Assume her potassium is off and treat it. You have to be comfortable flying blind. And please stop grinding your teeth.”

“I'm trying.”

“Let's do another. You enter the room, and this time it's a banker that's unresponsive.”

“What kind of banker?”

“I don't know,” he said, waving his hand, “a banker. Shuffles paper around, makes a lot of money. A banker.”

“Let's see,” I said, looking at the ceiling, “could be…cocaine?”

“Everyone's on drugs with you,” he said, smiling, as he reached for a small carton of apple juice. “I like it. Keep going.”

As he took a large sip, a nurse sprinted in our direction. Her heavy footfall broke my concentration, and we both looked up as she reached us.

“It's Ms. Franklin!” she said.

Baio stood up and reactively tugged on my sleeve. “Let's do this,” he said, beaming, and started to sprint down the hallway. I followed
him as quickly as I could. As we ran, he said over his shoulder, “Do everything I say. Everything.”

We quickly arrived at the bedside of an elderly woman on a ventilator. She was so frail and thin that you could make out the individual muscle fibers in her neck.

“What happened?” Baio asked a nurse standing at the bedside. Before she could answer, Baio turned to me. “Matt, disconnect her from the ventilator.”

A team of nurses went to work on the woman. “She just flatlined,” one of them said.

I looked at the breathing machine and my stomach turned. I suddenly had an overwhelming urge to move my bowels. Disconnecting a patient from a ventilator was a scenario I had only read about in medical ethics textbooks. Terri Schiavo came to mind.

“Disconnect,” Baio repeated calmly while reaching a hand under her gown and onto her groin, searching for a pulse.

I tugged the breathing tube away from the ventilator, but nothing happened. I tried again but still nothing. A nurse half my size lunged in front of me and pulled the breathing tube off of the ventilator in one quick motion as Baio rattled off a series of questions while assigning each nurse a specific role in the resuscitation. Someone began squeezing a bag of oxygen into her throat as I rapidly glanced back and forth at the flurry of activity, looking for something to do. Baio briefly closed his eyes while again feeling under the gown. “No pulse. Matt, start chest compressions.”

I positioned myself on the left side of the bed and placed one hand over the other. I had performed CPR dozens of times on Janet, the Mass General crash test dummy, but never on a human before. A moment of terror shot through me as I pondered the implications of my 190-pound body descending upon this 87-pound woman.

Baio sensed my hesitation. “Just accept that you're going to break her ribs. Just do it. She's dead. Let's go.”

With the first thrust, ribs cracked as easily as uncooked spaghetti.
“Aah,” I muttered. With my second compression, more ribs cracked. By the third compression, her chest cavity had become soft and I could feel the sharp edges of broken ribs under her skin.

To the nurse beside him, Baio said, “I will need one round of epinephrine and one round of atropine.” Placing his hands in sterile gloves, he reached for a large needle and again mashed on her groin, searching for a pulse. “Slow down, Matt, you're pumping too fast. One hundred beats a minute.”

He began to insert a large tube into her pelvis.

“Staying alive,” he said.

“Yeah, she is…” I said, becoming short of breath.

“No, she is dead. But the song ‘Stayin' Alive,' remember? Do compressions to that beat.”

I didn't remember because I'd been in the restroom earlier that day while the team discussed that chest compressions should be performed roughly one hundred times per minute. In the heat of the moment, it's nearly impossible to keep track of the pace, but the Bee Gees' song “Stayin' Alive,” which happens to play at 103 beats per minute, could be used to help keep the pace.

“Stop chest compressions,” Baio said firmly.

I stopped and caught my breath. The patient's chest was sunken where I'd been pounding away. We looked at the defibrillator monitor. I desperately wanted to do something else, anything. I was not ready to see the second patient I'd touched die in front of me after I cracked her body open performing chest compressions.

“The monitor shows a heartbeat,” I said between breaths.

Baio placed his hand on her neck. “No pulse. Resume compressions.”

The heartbeat I'd seen was not really a heartbeat, rather something called pulseless electrical activity. Her heart was spasming as electrical currents raced across cell walls; to the inexperienced eye (mine) it would appear like beats on a heart monitor. But without a pulse there
was not sufficient blood flow to the body. Baio was right: CPR had to continue.

I resumed my assault on her chest cavity as a nurse injected one medication after another into her. The sharp edges of her broken ribs felt like they were about to slice through her skin.

Baio kept his eyes trained on the monitor. “Hold compressions, and Matt, feel for a pulse.”

I placed my hand on her neck and felt nothing. My heart sank. “I don't—”

Baio simultaneously felt the other side.

“Oh, yep”—he smiled—“there's a pulse. Congratulations. You just saved your first life.”

He moved my hand several inches higher, where indeed, there was a vigorous, bounding pulse.

“Holy shit!” I said as we locked eyes.

“Holy shit, indeed. Now, put her back on the ventilator.”

This was it. After years of preparation, I had just helped bring someone back from the dead. My heart raced, and I could feel my own pulse pounding through my neck. This was the sensation I had been seeking, the one that was missing for me in surgery. Granted, I had done exactly what Baio told me to do, and it had involved damaging the patient in ways that seemed to create a new set of problems, but she had pulled through. She was stayin' alive, and would live to see another day with her spouse, kids, whomever. Medicine was messy, but it was fucking incredible. As we stood together at the bedside, I looked over at Baio with a measure of pride. He seemed to sense this.

“You know,” he said, patting me on the back, “there is nothing more rewarding than bringing a ninety-five-year-old demented woman with widely metastatic lung cancer back to life. Well done.”

I spent the next few hours peering over Baio's shoulder as he put out one fire after another. It was like being in the front row of a small concert, mesmerized by an undiscovered band on the cusp of stardom, thinking, Why didn't I ever learn to play the guitar? On each of my trips to the cafeteria to retrieve snacks, I filled my notebook with terms and phrases to look up. It was three in the morning before I knew it, and twenty-one hours of my shift had elapsed in the blink of an eye.

Or had it? I had seen and done more in this one night than I had in entire months of medical school. A beating heart had stopped and I'd restarted it with the thumps of my palms. I'd broken ribs, mashed on groins, adjusted ventilators, and administered medications that were so new they didn't appear in textbooks. Sure it was fun to delicately suture a facial laceration, but there was something unique, something otherworldly about critical care medicine. The patients were so sick, so close to death; there were no imaginary numbers in the cardiac care unit. The operating room seemed almost mundane by comparison. Axel would surely laugh at the suggestion, but he was missing out. Surgery had come to seem narrow to me; this was complex decision making that involved processing dozens of inputs at once.

Back at the nurses' station, Baio emphatically struck a letter on the keyboard and spun in my direction. “All right, I'm wired and I'm happy. Time for some teaching. Let's go over some EKGs. I will assume you are absolutely horrible at reading these,” he said, fighting back a smile.

I grabbed my pen and wheeled my chair closer to him. “That is an excellent assumption.”

“Let's start with your new patient, Gladstone,” he said, holding up the EKG that hours earlier had set so many wheels in motion. “Everything we do in medicine has to be systematic.”

Systematic,
I said to myself, ready to make it a mantra.

“Otherwise, things get missed and bad shit happens.”

“Understood.”

“When I look at an EKG, I say the same thing to myself every time: rate, rhythm, axis, interval. I start with the rate. Do you know why I start there?”

I shook my head.

“If the rate is wildly abnormal—say a hundred and ninety beats per minute…or twenty-five beats per minute—you need to drop the EKG and go evaluate the patient. Got it?”

I scribbled,
wildly abnormal rate, drop ekg
. “Yes, yes. Got it. Consider it a brain tattoo.”

“You remind me”—he chuckled—“you remind me a little bit of that dude from
Memento
.”

I considered the movie's handsome star for a moment and said, “Thanks.”

“Not a compliment. Next, I examine rhythm. If the rhythm is anything other than normal sinus rhythm, we could have an issue.”

Over the next two and a half hours, Baio showed me how to read an EKG, interpret an arterial blood gas report, and process the deluge of data that was generated on each patient every few hours. I wished I'd been doing this from day one of medical school. Countless anatomy or pharmacology lectures had armed me with volumes of critical information and yet no way to translate it into the actual practice of being a doctor. Dealing with life-or-death situations required knowing not just body chemistry and physical science but how to assess a patient's condition correctly and make quick decisions. And without a framework for organizing all the knowledge in my head for quick application, I
was certain to flounder. What Baio was doing in the CCU, I realized, was providing a way of merging the knowledge in my head with the reality of my patients' symptoms.

Around 5:30
A.M.
, physicians, including my three cointerns, began to file into the CCU. I had been assigned at random to spend the entirety of my three-year residency training with the same three women: Ariel, Lalitha, and Meghan. We would take turns working thirty-hour shifts every fourth day for the majority of the year. But our time together was somewhat limited in the CCU because we'd each been paired up with second-year physicians—in my case Baio—to learn the ropes. Every four weeks for the entire year, the four of us would move to a new rotation—infectious diseases, general medicine, geriatrics, medical intensive care, oncology, et cetera. In our second year, we would repeat the cycle while supervising an intern each, essentially becoming Baio, an idea that was mercifully remote. I couldn't quite tell you what third-year residents did, other than apply for jobs or subspecialty fellowships.

“Breakfast!” Ariel said, handing me a brown paper bag and a coffee. She had frizzy red hair and green designer scrubs with a blue racing stripe.

Baio grabbed the bag and examined its contents. Dissatisfied with the options, he looked up. “How is your pod?” he asked, which was what the hospital called each team of interns.

“They seem nice. Great, actually.”

“Better hope you get along. You don't see much of them now, but you will. You've got eighty hours a week, every week, for the next three years.”

“Hard to believe.”

“Personality conflicts,” he said with a mischievous grin, “can make for a bumpy ride.”

The interpersonal dynamics of working closely with three other interns for three years in a high-stakes environment were not yet clear
to me. But it appeared that these trial-by-fire friendships would emerge in small bursts, and would be based wholly on trust. If my colleagues couldn't rely on me, if they couldn't be sure that I would take care of their patients as well as they could, our group would be dysfunctional. No amount of kindness or humor or empathy could overcome that. Without a shared sense of trust, we would have nothing.

I spent the next hour reviewing my patients and preparing for rounds. At 7:00
A.M.
a new set of nurses arrived.

“Give them some space,” Baio said. “Let's talk.”

I walked with him to a corner of the unit.

“Our attending is going to be here soon,” he said, referring to the board-certified cardiologist supervising us all. “He's a total badass. Cardiologist to the stars. He's brilliant but tough. Doesn't like his time to be wasted. So make your presentations short. Get to the point. Tell him what he needs to know about the patient and move on. Got it?”

Thirty minutes later, rounds started. Eleven of us gathered in a white-coat-clad horseshoe around Dr. Badass: four interns, four residents, a medical student, a pharmacist, and a cardiology fellow named Diego, who was originally from Argentina. Diego had completed his residency training at Columbia and was now in the prestigious three-year cardiology fellowship, learning to become the Badass much like I was learning to become Baio. He had a perpetual squint and reminded me of Axel when I first met him—tired, curt, and wholly unimpressed with me.

Our group stood in silence, waiting for the Badass to speak. I had been up for twenty-six hours, and delirium was setting in. At twelve hours, I had been tired. At sixteen, a second wind had kicked in. But by twenty-four hours, basic faculties started failing, and now I felt about three hours away from needing to be admitted myself. The endurance marathon of the thirty-hour shift confused me. How could I be responsible for my patients if I was in worse shape than they were?

Slowly, heads turned in my direction and the Badass said, “Well?”

Baio nudged me and whispered, “You're on, dude.”

It has been said that if you look around a poker table and can't immediately spot the sucker, it's you. I feared I might now be in the midst of something similar. I squeezed my notes and brought them up to my face. The word
Gladstone
popped out along with
anisocoria,
and in a margin, I had apparently scrawled
solo synchronized swimming—an Olympic sport?,
something I didn't remember writing.

“Carl Gladstone is a fifty-eight-year-old man with no significant past medical history who developed chest pain at work yesterday,” I began, reading from my notes. “Collapsed and was brought to our ER.”

I had everyone's attention, with the exception of Baio, who was whispering in a nurse's ear. When I was finished, we entered the room and collectively examined my patient. I spoke for a few minutes more as Diego stared at the tile floor, gently shaking his head, before the Badass interrupted.

“Fine. Next patient. The thing about the pupil is strange. Scan his head.”

Bleary-eyed and stammering away, I proceeded to present the events of each patient as we moved around the unit. Most of it I got right, some of it I got wrong. Fortunately, my well-rested team was there to step in if I misinterpreted an EKG finding or misstated a lab value. As we approached Benny's room, the Badass softly said, “Next,” and we continued past. Mercifully, I was dismissed after rounds and asked Baio if he wanted to head to the subway with me.

“Nah,” he said, “I'm gonna stick around for a bit.” He picked up a stack of EKGs and yawned. “By the way, nice work last night.”

With the gait of someone about to fail a sobriety test, I walked to the elevator and out of the hospital into the warm summer sun. It was just after noon and I had been awake for more than thirty hours—a new personal best. Crossing the street, I saw a large red banner draped down the side of a hospital overpass.

Amazing Things Are Happening Here!

The words made me smile. How could I possibly describe the things I'd just seen and done?
Amazing
seemed as good an adjective as any. A few minutes later I plopped into an empty seat on a southbound subway car and drifted off to sleep.