Internal Medicine: A Doctor's Stories

  INTERNAL

  MEDICINE

  A Doctor’s Stories

  Terrence Holt

  LIVERIGHT PUBLISHING CORPORATION

  A DIVISION OF W. W. NORTON & COMPANY

  NEW YORK LONDON

  To William E. Holt, MD

  Obiit 16 Jan 1994

  Curse, bless, me now with your fierce tears, I pray.

  CONTENTS

  Author’s Introduction

  A SIGN OF WEAKNESS

  GIVING BAD NEWS

  ORPHAN

  THE PERFECT CODE

  WHEN I WAS WRONG

  HEART FAILURE

  THE SURGICAL MASK

  IRON MAIDEN

  THE GRAND INQUISITOR

  AUTHOR’S INTRODUCTION

  Did you ask me why a surgeon writes?

  I think it is because I wish to be a doctor.

  RICHARD SELZER, 1976

  THIS BOOK IS THE STORY OF A RESIDENCY IN internal medicine. I wrote it over a period of ten years, beginning just after my own residency ended. The chapters appear here in an order that follows the trajectory of residency, from the first night on call to another call night some forty months later, by which time the narrator, no longer a resident, is out on his own, practicing as a hospitalist in a small town in the Midwest. I wrote this book primarily in an attempt to make sense of the process of becoming a doctor.

  I first realized how much I wanted to tell this story on a day in March of my intern year, sometime between three and four in the afternoon. I’m at a nursing station, where three medical teams—each with its resident, interns, attending physician, medical students—and two or three consult teams of similar size and composition, along with nurses, CNAs, physical therapists, occupational therapists, speech therapists, the chaplains, transport workers, dieticians, social workers, case managers, maintenance workers, and probably others I’ve forgotten are all busy with the different things they do. Everyone is talking at once. At any given moment, two or three of them are trying to talk to me.

  I’m standing in the middle of this roar and babble. My pager is going off more or less continuously. The phones are ringing, the unit clerk is crying out names (one of which, if I could only hear him, might be mine) to come and take a call. There are visitors, family members, and patients leaning over the counters, each with some question, need, or piece of information. From time to time the hospital PA system adds to the din.

  I’m worried about one patient who might be hemorrhaging, another who could be going septic, and still another who simply isn’t getting better for reasons no one understands. I’m worried that there may be yet one more on my list that I should be worrying about, but try as I might I can’t recall which one that would be. It’s unlikely I’ve eaten since five that morning. My feet probably hurt. I know I’m tired. Details blur.

  Still, I remember very clearly one day when I looked out over this scene and said to myself: This is not narratable.

  This was probably not the most useful thing I could have been thinking at that moment. It was, however, true. What I glimpsed that day was that the hospital is too manifold, too layered, too many damn things happening one on top of the other ever to get it down in its entirety. If there was any way of doing justice to it, it would have to be through some kind of condensation: by transforming it into a parable that could somehow imply the whole. I wasn’t sure that was possible, either.

  I realized only later how much I wanted it to be possible. I needed to understand how those years in the hospital had transformed me. This collection is not called Internal Medicine for nothing.

  FORWARD A COUPLE OF YEARS. It’s July, the month when everything changes: new residents arrive, others advance to another year, still others graduate, as I did this particular July. My memory of the transition is hazy. I celebrated the first several weeks by falling asleep wherever I sat down.

  That month I also started writing these stories. There was no premeditation in this, and certainly no intention of producing the book you’re holding. That moment in which I had recognized the non-narratibility of the hospital had produced, in a kind of delayed reflex, these attempts to get down some different kind of account of what it had been like. Not a record that accurately captured every relevant detail: I knew it was not possible to capture the meaning of residency that way. What I found myself writing instead was those parables I had imagined before, using them to identify what remained mysterious, and often troubling, about the process of becoming a doctor.

  I understand that anyone picking up this book is probably hoping to learn something about what goes on in residency. The hunger to get behind the scenes of institutions that keep their inner workings hidden is powerful; this is especially so around medicine. I also wrote this book to satisfy that hunger, to give a truthful account of residency and the hospital. There are barriers, however, to giving such an account, limits on what a doctor is allowed to reveal. Patients have a right to privacy, of course. But there is something more than privacy at stake. You might change a few details: a name here, a hair color there, add a few years or drop a few pounds, give that one a different diagnosis and the other an Irish accent, and that’s enough to conceal your patient’s identity from the world at large. But that’s not enough to respect the patient. As long as there’s an actual, unique individual beneath that disguise, you’re making a spectacle of somebody’s suffering, and that’s a line no one should cross. It’s bad for the patient. It’s not good for the writer, either.

  This poses a challenge to a writer trying to offer a factual account of residency. Medicine without patients isn’t a very useful story. This is why the patients in this book aren’t based on specific individuals, no matter how disguised. They aren’t “facts.” They are at most assemblages drawn from a variety of sources, compiled from multiple cases, transformed according to the logic not of journalism but of parable, seeking to capture the essence of something too complex to be understood any other way.

  In writing these stories I have drawn on what I thought and felt and generally did as a resident, but in re-creating experience as parable I have watched the narrator of these pieces evolve into someone else. He dealt with patients different from the ones I cared for, and did so, necessarily, in ways I never did. The mistakes he makes were not mine. He sometimes thinks and feels things, or fails to, in ways he would not be proud of were they generally known. But I like to think he does a pretty good job in spite of it all. He struggles with issues I struggled with, and with which every doctor struggles. He struggles differently from the way I did, but in the end he learns things that it took me much longer to figure out. In portraying his inner conflicts I have tried to get at what the hospital teaches us. I have tried, more than anything else, to be faithful to the inner life of medicine.

  As to the externalities, the bits and pieces of special knowledge that constitute much of the appeal of medical accounts: I have tried to be accurate here as well, combining multiple hospitals into one that never existed, but in which, I hope, you will recognize the next hospital you enter.

  While pressing life into story, I have tried to keep other agendas from creeping in. I don’t think I have reshaped events simply to generate drama. Nothing happens in these pages that doesn’t happen every day in a variety of ways in hospitals everywhere. I have had to simplify what defied narrative form, and alter or suppress whatever might have compromised the respect patients deserve. But in making sense of residency within the constraints of narrative form and human decency, I have hewed as closely as possible to the lived reality of the hospital.

  Chapel Hill

  November 2013

  A

  SIGN

  OF


  WEAKNESS

  MY FIRST CALL NIGHT AS AN INTERN, I RAN into Dr. M, one of the senior attendings, whom I had known for several years. “How’s it going?” he asked me. I told him I was on call. “First call?” He smiled. “I remember my first call. About ten o’clock that night, my resident said to me, ‘I’m going to be just behind that door. Call me if you need me. But remember—it’s a sign of weakness.’”

  I don’t recall my response: I don’t think I even had time to consider the story until evening, when the frantic milling about that makes up an intern’s day had started to wind down. That day, we filled up early—three opportunistic pneumonias from the HIV clinic; a prison inmate transferred from Raleigh with hemoptysis, presumably TB, and a fever-of-unknown-origin.

  Keith, the resident, whose job it was to direct me in my labors, felt this was a good day—his work was essentially done by five, as together we wrote admission orders starting the workup of the mysterious fever. He said to me, “I’m heading off to read. Call me if you need anything.”

  “But it’s a sign of weakness, right?” I said, remembering Dr. M’s story.

  Keith laughed. “Right.” And sauntered off down the hall.

  Later, I was on the eighth floor, getting sign-out from one of the interns on the pulmonary service. It was almost seven—this was early in the residency year, and nobody was getting out before dinner. This intern was post-call, red-eyed, and barely making sense. Her sign-out list was eleven patients long. I don’t remember any of it except the one: Mrs. B was listed as a DNR/DNI 47yo WF w/scleroderma RD. “RD” meant “respiratory distress.” The little arrow meant this was one possible effect of her scleroderma. I had never seen scleroderma before, and what it was, exactly, I could recall only hazily.

  “She’s a whiner,” the intern explained. “Don’t get too excited about anything she says.” She paused. “I mean, if she looks bad, get a gas or something, but basically she’s a whiner.”

  Whiner, I wrote down in the margin of the list.

  I sat at the workstation for some time after that, running through lab results on the computer—the scheduled seven P.M. draw was still going on, so there was nothing new on the screen, but it calmed me to go through the exercise.

  A nurse stuck her head through the door. “Doctor?”

  I was still unused to people calling me that.

  “Do you know the lady in twenty-six?”

  I fished the sign-out sheets out of my pocket. “What’s her name?” There were too many sheets. The nurse gave me the name and my eye fell on it at the same time. Whiner.

  “What’s her problem?”

  “She says she’s feeling short of breath.”

  “Vitals?” I heard myself ask, marveling at my tone of voice as I did.

  The nurse pulled a card out of her pocket and read off a series of numbers. When she was done I realized I hadn’t heard any of them.

  The nurse read them again. This time, I wrote them down. Then I spent a minute studying them. She was afebrile, I noted. That was good. Her heart rate was 96, a high number I had no idea how to interpret. Her blood pressure was 152 over 84, another highish set of numbers that told me nothing. Her respiratory rate was 26—also high, and vaguely disquieting. Her O2 sat—the oxygen content of her blood—was 92 percent: low, and in the context of that high respiratory rate not a good sign. The nurse was still looking at me. “I hear she’s a whiner,” I said hopefully. The nurse shrugged. “She asked me to call you.”

  The patient was alone in a double room. The light in the room was golden, the late sun of the July evening slanting through the high window. The face that turned to me as I knelt at the bedside was curiously unwrinkled. Her skin had a stretched and polished look, her features strangely immobile, the entire effect disturbingly like a doll’s face. Her chest rose and fell, but her nostrils did not flare. Her mouth was a tight puncture in the center of her face. Only her eyes were mobile, following me as I moved.

  “What seems to be the problem?” My voice had taken on a strange quality: tight, almost strangled.

  “Are you my doctor?”

  “I’m the doctor on call,” I explained.

  “I can’t breathe.”

  I looked at her for a minute.

  “What do you mean?”

  “I can’t . . . catch my breath.”

  I thought, but nothing brilliant came to mind. “Are you feeling dizzy?” I asked.

  “No. Just. Short of breath.”

  I watched, counting. They were quick, shallow breaths, about twenty-eight of them to the minute.

  I bent over her and placed my stethoscope on her back. I heard air moving, in and out, and a faint, light rustling, like clothes brushing together in a darkened closet. “I’ll be right back,” I said, and left the room to find her nurse. A few minutes later the nurse reported back to me. “Eighty-nine percent.”

  “Is she on any oxygen?” I should know this, I thought. I’d just been looking at her.

  The nurse shook her head.

  “Put her on two liters and check again.”

  Ten minutes later the nurse was back. I was in the doctors’ workroom, looking up “scleroderma” on the Web.

  “Ninety-one percent.”

  “That’s better,” I said hopefully.

  The nurse shook her head. “Not on two liters. Not how hard she’s working.”

  “You think she’s working hard?”

  The nurse smiled thinly. “Do you want to check a gas, Doctor?”

  I smiled back, genuinely relieved that someone was willing to tell me what to do. “That’s a great idea,” I said. “Can you do that?”

  “No. But you can. I’ll get the stuff.”

  An arterial blood gas is a basic bedside procedure—the kind of thing third-year medical students are encouraged to learn. It involves sticking a needle into an artery and drawing off three or four ccs of blood. The reason a doctor has to draw it is that arteries lie deeper than veins. Even the relatively superficial radial artery—at the wrist, the one you press when checking a pulse—lies a good half-inch deep in most people, and sticking a needle in it stings more than a bit. I was not at that time very skilled at procedures—the arterial blood gas was about the limit of my expertise—but to my relief I had no trouble getting it: bright red blood flashed into the syringe. The patient bore this without a grimace, although by now I wondered if the skin on her face was capable of expression at all. Her eyes regarded the needle in her wrist.

  “How are you feeling?”

  “A little. Better.”

  I pulled the needle out, held a pad of gauze to her wrist.

  She subsided into the bed. “But still. Short of breath.”

  I watched her. Twenty-six, twenty-eight. Shallow, the muscles at her neck straining with each one.

  “I’ll be back in a bit,” I said, rising with the syringe in my hand. “Call if you need anything.” But it’s a sign of weakness, I echoed to myself. I hurried on down the hall, the echo following.

  While I waited for the lab to process the gas, I skimmed over fifteen pages about scleroderma, a mysterious, untreatable condition in which the skin and organs stiffen. The most feared complications are cardiac and pulmonary. Some victims develop fibrosis of the heart early in the course of the disease and quickly die, as the accumulation of gristle disrupts the heart’s conduction system. In the lungs, collagen invades the membranes where the blood exchanges oxygen and carbon dioxide with air: the lungs stiffen, thicken, and fail.

  It is possible to get an idea of how this would feel. Putting your head in a paper bag is a dim shadow of it; thick quilts piled high come closer. The difference, of course, is that you can’t throw scleroderma off. The bag stays dark; the quilts simply thicken, over years.

  The blood gas was not encouraging. The numbers on the screen told me several things. Her blood was acidic. CO2 trapped in her lungs was mixing with water in her blood to make carbonic acid. The acid was chewing up her stores of bicarbonate, whi
ch meant that her lungs were getting worse faster than her kidneys could compensate. The really bad news was the amount of oxygen dissolved in her blood, which at a partial pressure of fifty-four millimeters was unusually low, especially for someone getting supplementary O2. Taken together, these numbers spoke of lungs that were rapidly losing access to the outside air.

  I remembered a patient I had taken care of during an ER rotation a year earlier, an old lady with pneumonia. I had gotten a gas on her, too, and it had come back essentially normal. The attending had asked me to interpret it. “It’s normal,” I said. “And?” the attending replied, directing my attention to the patient gasping on the gurney. I looked at her for a moment. She was breathing about forty times a minute. “You’re about to tube her,” I said. “Right,” the attending said, and did just that. A normal gas on somebody working hard is a bad sign. A below-normal gas on somebody working hard to breathe on supplementary O2 is a very bad sign, especially if her chart carries the notation DNI. The letters stand for “Do not intubate.” It’s the patient’s order to her doctors and it draws an inviolable line. No breathing tubes, no ventilators, no call to the ICU for help.

  I hurried back down the hall to the room. The sun had set, leaving the sky a dim purple. The room was dimmer still, the patient’s face a sheen on the white pillow, her chest visibly stroking from the door. I stood in the doorway for a minute, watching her, trying not to match her breathing with my own. Her face was turned to me. The eyes glittered.

  “How are you feeling?”

  “Not. So. Hot.”

  “I know,” I said. “I’m going to get you some more oxygen.” I reached for the regulator in the wall and cranked it up to six liters, the maximum you can deliver by nasal cannula.

  The nurse appeared at the door. “Do you want me to call Respiratory?”