The Real Doctor Will See You Shortly (8 page)

I walked into Denise Lundquist's room and found her husband, Peter, seated next to her, gently stroking her hand with his own. Denise was asleep, and Peter, wearing a charcoal gray mock turtleneck and a pair of green jeans, had a legal pad in his lap. He was a young guy, probably in his early thirties, and he stood up quickly as I entered the room. I could tell he was flustered.

“Are you the attending?” he asked.

“No,” I said, shaking his hand. “I'm the intern, Matt. I work with the attending.”

I took a seat next to him, and he nodded, interlocking Denise's limp fingers with his. Something about his gentleness touched me. He was a solid, well-built man, but his voice was soft, almost a whisper, as if he were afraid he might wake his wife up.

“I have a bunch of questions,” he said, touching the yellow pad. “Do you have a few minutes?”

“Of course, fire away.”

I was conscious of my naturally somber demeanor and tried to lighten the mood with a large smile, but I wasn't entirely sure what I was smiling at. Denise was improving, but in rough shape. The hue of her skin still did not look human; it looked like it had been peeled from a mannequin. The situation didn't exactly call for confetti. Was there a proper physician's facial expression, I wondered, for a cautiously hopeful moment? Something that conveyed guarded optimism? I'd have to start watching Baio and the Badass for this.

Peter reached for his reading glasses on a small nightstand but, realizing he would have to let go of Denise to put them on, decided against using them. I motioned toward the bifocals, but he waved me away and cleared his throat.

“Today someone mentioned a possible heart transplant. Does she need a new heart?”

I stared at the young woman and squinted. Despite her terrible color, Denise was gradually improving, and on rounds we'd discussed transitioning her to a general cardiology floor in the coming days. Had Peter heard us talking about someone else?

“I'm not sure,” I said. “I don't recall anyone mentioning a heart transplant for your wife. But I don't want to give you bad information.”

“Understood.” He checked off the first question and took a deep breath.

I leaned close to him and saw that he had written down thirteen questions. Instinctively I guessed that I'd be able to answer four, maybe five of them at best. I felt bound to disappoint Peter, or worse, leave him more confused, like I had Sam. As my jaw tightened for another round of teeth grinding, I suddenly became aware that I was moving almost imperceptibly away from Peter, toward the door. I had unconsciously sat back in my chair and could feel my legs tense, ready to rise; my body was beating an involuntary retreat. So this is what Benny meant, I thought. Looking at Peter looking at me, I could imagine what Benny saw: a doctor shutting down and going through the motions. A doctor who maybe didn't care enough. A doctor who was so afraid he might be wrong that he couldn't properly care for his patients. I caught myself and leaned forward, looking Peter in the eyes.

“I will obviously find out for you whether any heart procedure is being discussed,” I said. “But I don't think there is.”

Peter nodded. He stared down at the words he'd written on the legal pad but didn't speak. He simply stroked his wife's hand and watched her breathe. She made a faint gargle, and he parted his lips expectantly. I tilted my head to look at the questions, hoping I could
read and answer them on my own. Squinting, I could just make out the next one.

Why did God let this happen?

Nope. I moved to the next one. Scanning down the sheet, I saw that he'd scribbled a heart and inside it written

Denise + Peter

I looked at this grief-stricken husband and then back at the sheet. In the bottom corner, he'd drawn a smaller, broken heart without names in it. Raising my eyes up from the drawing, I looked on as Peter wiped the bangs away from Denise's eyes.

And then, I burst into tears.

Not “eyes welled up” tears but genuine, blubbering, sloppy tears, heaving breaths, quivering shoulders. Perhaps it was the fear of what was being discussed that very moment at M and M, or perhaps it was being in the presence of such profound love and heartache. Maybe it was the lack of sleep. But the act of being there for Peter, of facing his pain and need, was simply too much. I had taken it all on myself and it flattened me like a pancake.

Peter led me by the shoulder to the corner of the room, gentle but urgent. “Matt,” he said quickly, “is she…dying?”

I struggled to pull myself together. “No,” I said through sobs. “Peter, she's doing amazing. Amazingly well.”

He struggled to read my face. “Well then, what is it?”

My thoughts were with this grieving man, but they were also somewhere else. I ached to know what was being discussed at the Morbidity and Mortality conference. How many heads were shaking? Who was cursing my name?

“Denise is expected to make a full recovery.” As the words exited my mouth, I wanted to snatch them back. I wasn't sure I was supposed to present such a rosy picture. On rounds, we agreed that Denise was improving, but she was still critically ill.

“Oh, thank God,” he said, taking a step back. “Thank God.”

“Yes.”

My words belied my emotional state. Peter was very confused.

“You love your wife,” I wanted to say.

I turned my blurry eyes in the direction of Denise and said, “It all got to me just now. I'm sorry.”

He patted me on the shoulder. “We've all been through a lot.”

I laughed the way one does through tears at a funeral. Here was another tip they'd omitted at medical school: when you can't comfort the patient, make the patient comfort you. Peter and I sat back down, and he once again took Denise's hand.

“Can we just sit?” he asked as he put the legal pad on her bed. “Just the three of us?”

“Yes, of course.”

I was unaccustomed to such wild emotional swings; I wondered if I was developing a mood disorder. How did senior physicians build up enough emotional calluses to avoid bawling without becoming automatons?

“You know,” Peter said, “it kills me to know I played a role in this.” He touched the lobe of her ear with the back of his hand and frowned. “That I'm the one who told her about her brother. I keep replaying the scene in my mind, thinking I should've done it differently.”

I wiped my eyes on my white coat as more tears trickled down my cheeks. I was a fucking mess. Everyone breaks, Baio had said. I just never guessed that I'd break so soon.

When I reconvened with Baio an hour later, I carefully watched his eyes for any sign that I had been the subject of M and M. But he never mentioned what was discussed at the conference and I never asked. I was too scared to. Its uneventful passing came to seem an absolution. We talked about our new patients, and that was it. Gradually, as the hours ticked by, Sothscott receded from the forefront of my consciousness.

“Listen,” Baio said a few days later, “I got another person for you to rectalize. Room sixteen.”

“Sure thing,” I said and popped out of my chair. In those intervening days, I became increasingly proficient in a half dozen skills around the unit. Placing an IV was now a breeze, and I'd finally gotten the feel for dropping a nasogastric tube into a patient's stomach. “I can probably get it done before rounds.” A modicum of proficiency in this task left me feeling exuberant. I pulled out the guaiac card and developer and shuffled toward room 16.

Baio's lips were pursed when I returned.

“What's up?” I asked. I caught the Badass out of the corner of my eye; rounds were about to start.

“That was fast,” he scoffed.

I smiled. “No bleeding.”

“You know you didn't even ask why you were doing that rectal.”

“Check for bleeding,” I replied. “And you asked me to.” At this point, the job description seemed quite clear: carry out the will of the
supervisor. Considering my relative ignorance, following his instructions to the letter was the safest course for my patients and for me.

“Right.” We stood in silence, and he folded his arms. “And?”

I wasn't sure where this was going. “You ask me to do dozens of things.”

“I do.”

“And I try to do them as quickly and efficiently as possible.”

Baio half-grimaced. “Enthusiasm is appreciated. But you're not thinking. You're doing.”

“Yeah, lots of doing. Don't think. Do.”

“Look, Matt, you're gonna spend the entire year being told what to do. A good intern will perform every task quickly and accurately.”

“I'm certainly trying.”

“But a great intern will pause and ask, ‘Do these orders make sense?' ”

“What do you mean?”

“Is it even necessary to guaiac someone before starting a blood thinner?” he asked.

I looked around the room. “Seems to be the standard practice in the unit.”

“Are there any established guidelines that recommend it?” he asked disapprovingly.

It seemed like a reasonable thing to do, but I wasn't certain. I had learned a lot about advanced cardiac care in the unit, but I was no expert. “I'm not sure.”

“Of course you're not. The point is that at some stage, you're going to be instructed to do something you shouldn't be doing.”

What was he talking about? It was a frightening thought. What if all of my supervisors weren't as sharp as Baio? They were just one year ahead of me, and still in training. What if they struggled to perform procedures or were paralyzed by indecision? The implications were terrifying.

He patted me on the back and smiled. “I pray that you'll be able to identify those moments.”

Rounds started a few minutes later. Ariel, the post-call intern, who'd been awake for twenty-seven hours, began by detailing the unusual condition that had brought the first of five new admissions to the unit. “Forty-one-year-old woman with nonischemic dilated cardiomyopathy and bipolar disorder on lithium was admitted to the CCU at four o'clock this morning.”

Ariel had worked in consulting before applying to medical school, making the career switch in her mid-twenties. She was a star on rounds; her presentations were crisp, without a single wasted word. I imagined her in her previous life, standing before a boardroom in a pantsuit, telling executives that their company needed to cut out middle management and use less paper.

I sidled up to Lalitha's jet-black ponytail. “Hey,” I whispered. “How's it going?” We'd been so busy paired off with our respective second-year physician-supervisors that there hadn't been much time for chitchat.

Lalitha stared ahead at Ariel and out of the side of her mouth whispered, “Barf.” With her accent—was it Cockney?—the word sounded more like
boff,
which was slang for sex, and I bit my bottom lip so I wouldn't giggle. I, too, kept my eyes on Ariel—she was saying something about peaked T-waves found on the EKG—and wondered what Lalitha meant. What was “barf”? Was she feeling ill? Or was she referring to our jobs? Out of the corner of my eye the expression on her face was indecipherable. Was I barf? I was taking everything personally. Had I inadvertently done something to upset her? I glanced at Baio and thought about his “bumpy ride” comment.

I scribbled
What's barf?
in my notebook and placed it under her eyes.

“Everything,” she whispered, her gaze still fixed on Ariel, who was trying in vain to place her tangle of red hair into a bun. “Has anyone considered,” Lalitha said, now addressing the entire group, “that this is all lithium toxicity? It would tie everything together.”

I certainly hadn't; it was a situation I'd only read about. Rarely did a day pass where I didn't find myself marveling at the brainpower around me. The hospital was filled with people with such different types of intelligence. Some appeared to have photographic memories, others were facile with logic and numbers. The interns and residents at Columbia were people who could do anything in life and they'd chosen medicine, working longer hours for lower pay, because it was important to them. It felt good to be surrounded by these people.

“Seems rather straightforward,” Lalitha concluded.

Turning to me, she whispered, “Yesterday my resident had me draw blood on four people. Not cool.” Doctors at other top hospitals weren't expected to carry out this time-consuming task, but at Columbia we were.

“Totally.” I still couldn't reliably draw blood; Lalitha could do it in her sleep. She had gone to a medical school where students learned phlebotomy. I had not.

“And what do you think, Matt?” Dr. Badass bellowed. “Do you concur?”

I scratched my chin, unsure, but hoping to appear deep in thought. “I think,” I said, “I think it would be a mistake to draw any conclusions before we finish hearing all of the details of this case.”

Lalitha rolled her eyes.

“But,” I said, “I'm tempted to concur.”

Lalitha scribbled something on her scut list, then tilted it toward me and cracked a smile. I looked down to see the word
politician
with an arrow pointing at me. Perhaps she was right. Maybe I was just trying to give vague answers on rounds that couldn't later be used against me.

We stood in silence as Ariel presented the complex matrix of clinical information, repeatedly sweeping the frizzy red hair out of her eyes
as the Badass pressed her to interpret the results of a transthoracic echocardiogram. Her sleepless composure was admirable; I knew I looked like shit after a night on call.

“All right, Dr. McCarthy,” the Badass said at the conclusion of her presentation, “you have heard the entire case. What is your diagnosis?”

“Everything I've heard,” I said as heads turned toward me, “points to lithium toxicity. Excess lithium led to kidney failure. Which in turn caused volume overload. Fluid overwhelmed the heart and lungs and she became—”

“Hypoxic,” he said. “Very good. I agree. Next patient.”

But I wasn't ready to move on. My mind had been churning Baio's advice—essentially to question everything—and as we prepared to move on to the next patient, I couldn't shake something that was nagging me about Ariel's case.

“But why?” I asked. Bodies froze mid-stride. I felt for a moment like a character in a network crime procedural. “It doesn't quite make sense,” I added, looking from colleague to colleague. “Why was there too much lithium to begin with?”

“Overdose,” said a pert, strawberry-blond medical student with a freckle on the tip of her nose.

Meghan, my third pod mate, shook her head. She had a kind, open face, with penetrating blue eyes. Like me, she had done laboratory research as a medical student, and at orientation we'd spoken briefly about becoming hematologists someday. She was from Dallas and had a well-concealed twang, which appeared only after she'd been awake for more than a day. “The patient has been on the same dose of lithium for twelve years,” she said as she ran a hand through her butter-blond hair, “and has never had an issue.”

“Suicide attempt,” Diego, the brooding cardiology fellow, offered. “A call for help. Something like that.”

“I spoke to her husband,” Ariel said. “She's been in good spirits. Got a promotion at work. Looking forward to a vacation in Tuscany later this summer. I don't see her trying to kill herself.”

“It's a good question,” the Badass said. “And I agree, some aspects of the case elude explanation. Dr. McCarthy, I invite you to investigate it further after rounds. But in the interest of time we should move on.”

Later I would realize his ruthless pragmatism was the only thing keeping rounds under four hours.

“Yes, sir. Will do,” I said and scribbled
Lithium WTF!?!?

After rounds, we gathered on the black leather couches and divvied up the day's remaining work. Diego and the Badass gave us this time to ourselves, to recover from rounds and to quickly eat lunch.

“Lalitha, I need you to draw a set of blood cultures on twelve,” Baio said as he stared at the scut list he'd constructed over the past three hours. “And, Matt, transport the patient in four to CAT scan. Meghan, we need a central line on—”

“Why the CT?” I asked. I was on a roll.

He looked up from his sheet. “That was the plan we came up with on rounds. CT to rule out pulmonary embolus. Is that okay with you, Doctor?”

The other physicians and the medical student slowly turned toward me. I'd spent most of rounds surreptitiously reading about the diagnosis and treatment of pulmonary emboli in preparation for this moment. “The patient has all the classic symptoms of an embolus,” I said timidly. “In critically ill patients, it's recommended to start treatment before the CT scan. Why are we waiting? Seems like we're wasting precious time.”

Baio smiled; his style was disarming. “Good stuff, Dr. McCarthy. Anyone care to respond?”

No one spoke.

“Or is everyone here just mindlessly following directions?” he asked.

I glanced around the room; heads were down, fixated on impending scut. My face felt hot. I hadn't intended to implicate my cointerns as ill-informed automatons.

“When Matt heard ‘pulmonary embolus,' he did the right thing,”
Baio said, clapping his hands. “He looked up the essentials of diagnosis and treatment. Well done. He looked in a textbook and attempted to make a clinical decision.” It was strange to have our didactic sessions play out in front of others. I felt a creeping pride. “But he made a crucial mistake. He didn't then take into account the particulars of the patient.”

My jaw clenched; I nearly bit my tongue. Baio was always one step ahead of me.
Don't run to the library when a patient is having a heart attack.

“In this case,” Baio went on, “if Matt had gone through the chart he'd've seen that this patient recently had a gastrointestinal bleed that almost killed her.”

“Oh,” I muttered.

He leaned over and patted me on the back. “Conventional therapy for a pulmonary embolus would likely kill this patient.”

“Shit.”

“But thank you for inquiring, Doctor.”

Baio spun to the medical student. “Remember, medicine is not one-size-fits-all.”

The student closed her eyes and said, “Of course.”