Internal Medicine: A Doctor's Stories Page 5

  I like to think of him that way. That way, and no other. I only wish I could hold myself so finally aloof from time.

  ORPHAN

  DURING MY FIRST MONTH AS WARD RESIDENT, I was assigned to the oncology service. I hated it. Any service on which patients routinely die during morning rounds upsets me. And there were always too many patients, most of them being treated for some terminal process with drugs that made them sick to just this side of death and not infrequently beyond. Some doctors enjoy this kind of challenge; I’m not one of them. It scared me. I was twenty years older than the rest of the residents in the hospital, and it shook me in some way I wasn’t able even to name. As if some vulnerability within me were waiting to declare itself. Something that, like cancer, I would discover only after it was too late.

  Which may have been why, that month at least, I tended to leave the routine business of the service to my competent intern, Mike, and on the weekends didn’t mind looking after my orphan. “Orphan” is the name given to any intern admitting patients when her own resident isn’t around; on weekends when I was admitting, one of my responsibilities was to supervise the orphan also admitting that day.

  The current orphan’s name was Virginia; she went by Virgie, and she was assigned to the gastrointestinal, or GI, service. This is another subspecialty the house staff tends to regard with distaste, but compared to oncology it seemed to me a clean, well-lighted place. True, the patients include a fair number of GI bleeders, who require close watching but never quite buy the transfer to, say, a surgical bed that would get them off your census. You usually also have two or three patients in the final stages of liver failure, who are generally delirious, capable of taking sudden nasty turns, and infected with viruses you don’t want to bring home to your family. Add to that the pancreatitis patients (unstable alcoholics who withdraw under your care), the inflammatory bowel patients (unhappy), and the occasional fecal impaction (don’t ask), and you can understand why, when Virgie returned my page that morning, she sounded a little harried.

  “Just checking in,” I said. “How’s your day going?”

  “It’s horrible,” she cried. “We just finished rounding and I’ve got three discharges to get out and a float down in the ER I haven’t even seen yet.”

  As problems go, I thought, this wasn’t bad. Discharges were a good thing. And the patient in the ER was probably stable. But for the sake of form I asked.

  “I think so,” Virgie said. “Some bogus abdominal pain thing. But I don’t know when I’m going to see her. Could you go? I’ll get there as soon as I can.”

  “Take your time,” I said soothingly. “Happy to help out.”

  “Thank you thank you thank you,” she cried, and hung up.

  I was happy, I realized as I made my way down the quiet back stairs to the basement. Somebody else’s patient to see. Already worked up. Probably not dying. More of a social visit than anything else.

  Ten-thirty on a Saturday morning, and the emergency department was already busy. Most of the bays were occupied, and the noise was enough to make ordinary conversation difficult; there were shouts coming from one of the trauma bays on my right. I ran my eye over the bank of monitors suspended above the front desk, checking the list of patients for anything that looked like it might be coming my way. The one good thing about oncology was that it tended to get its admissions from clinic, and the clinic wasn’t open on weekends. But sicklers, intractable pain, clotting problems of various sorts, and the occasional blast crisis could come in at any time. And once the other services filled up, we would be in line for whatever needed admitting. But the board seemed clear for now, so I looked for the name Virgie had given me. I found her on the first screen, Bay 7: Crawley, A., her name in pink to indicate her sex. Her time of arrival the night before (10:42) was highlighted in orange, a token of the emergency department’s outrage at her continued presence here. This probably accounted for some of Virginia’s urgency about her pending discharges: she was undoubtedly getting pressure from bed control to free up space for incoming admissions.

  I pulled the chart for Bay 7. This is a bed at the front of the ER, where they like to keep the unstable ones. I wasn’t sure what there was about Crawley that merited this. I registered this question, like most questions in the hospital, as a pang, a surge of doubt that distracted me as I thumbed through the untidy stack of papers on the clipboard.

  A. Crawley was a float—a patient worked up by the night shift and handed over to an intern the next morning for ongoing care. Floats are notoriously iffy: the system has too many cracks where orders, lab results, sometimes entire patients can get lost; and the workup, conducted by a resident whose internal clock is even more messed up than usual, can vary from merely sketchy to outright delusional. It had been drummed into me early in my training: always eyeball the float.

  The admission note told me little. This was a twenty-two-year-old female who had come in with a one-day history of nausea, vomiting, and abdominal pain. No significant medical history, no drug allergies, no sick exposures except to a dog known (how, I could not begin to guess) to harbor parvovirus B19. It was clear this was a red herring included in the history in a display of mere thoroughness: factual, obscure, irrelevant. Ms. Crawley had endured her nausea, vomiting, and abdominal pain for approximately twelve hours, at which point she had attempted to treat it with a few Tylenol Sinus tablets. When those failed to bring relief, she came in to the ED.

  As stories went, it sounded odd. Twelve hours of a bellyache don’t usually bring otherwise healthy young people to the hospital. I was left with a familiar mix of annoyance (this was wasting my time), relief (nothing horrible was going to happen), and dread (what was I missing?). According to this script, the lady shouldn’t have come in. But she had. And they’d put her up front in Bay 7 where they could keep an eye on her. Why?

  I scanned the rest of the note. The review of systems—that laundry list of symptoms with which we catechize admissions (“Anyfeverschillsnightsweatsweightlosschestpaincoughorchangeinthecolorofyourstools?”)—added nothing to the history. Physical exam ditto: mild abdominal tenderness. Meaningless. The labs and X-rays seemed to rule out any specifically abdominal pathology. But there were two false notes that got my attention. Her white count was slightly elevated, indicating a possible infection. And her serum lactate was high. This was the one that made me stop and look up for a moment.

  An elevated lactate accompanied by a high white count explained why they had lodged her in the front of the ED rather than stashing her in the back room with the sore throats and bladder infections. Lactic acid is a by-product of cellular metabolism gone astray. In company with a high white count, it signals sepsis: infection at large in the circulation, and a patient hours away from the ICU.

  None of which fit the innocuous history of A. Crawley.

  I scanned the admission note again, wondering if there was anything I’d overlooked. But there was nothing there; the only other lab value remotely notable was the serum Tylenol level. We check Tylenol levels pretty frequently: it’s at once an extremely common and potentially a very nasty drug. Toxicity can occur at less then twice the recommended dose. And when somebody, in a suicidal gesture or simple confusion, downs an entire bottle, there isn’t much time to get help. If the antidote isn’t started within twelve hours of ingestion, the patient is basically dead (although the dying can go on for weeks). But given Crawley’s history and the time they had drawn the sample, the level they had gotten wasn’t worrying: it was consistent with a reasonable dose taken at the time she had reported, about four or five hours before she came to the ER. But they had thought to check: that was interesting.

  The history didn’t do much for me except to rouse vague fears of doom—and what day in the hospital doesn’t do that? Abdominal pain and infection: the possible causes of such a pairing make a long list, and some of them can be serious trouble. Fortunately for my orphan, the common ones—appendicitis, gallbladder disease—are surgical issues. And unti
l A. Crawley developed signs or symptoms of needing transfer to surgery, there wasn’t much for Virgie to do. Time would tell. We would watch her, and wait (as the saying goes) for her to declare.

  That should have been all. But I thought again about the Tylenol, and I saw that the ED had been thinking about it too. They had started her on N-acetylcysteine, the specific antidote for Tylenol, around six a.m. Her levels didn’t warrant it, but it’s an innocuous drug (except for the taste), so I could see their logic. Not knowing what to treat, they had treated what they could.

  When I look back at those years in the hospital, I can see that this kind of nervous second-guessing might seem, to anyone on the outside, hysterical. At the time, however, for me and I think for most of the house staff, it was simply a way of life. During those years, I always felt that I knew nothing. And no matter how much you did know, there was always more you didn’t. In that vast desert of ignorance always lurked that one detail waiting to kill somebody. Which was bad enough if you were prone to worrying about such things. What made it worse was that you were required—by the patient, the family, the intern—to look as if you knew what you were doing. You couldn’t turn and ask someone else. And you couldn’t count on second chances. I’d learned that years before.

  So it must have been an irrationally optimistic impulse that made me look around again, hoping to find somebody who could tell me anything else about A. Crawley. But there was nobody. The nurse said only, “She’s a flake. When are you going to get her out of here?”

  I knocked on the door, pausing briefly before pushing through. The room was dim. The bed occupied the back half. Curled up in it was a slender, pretty young woman under a cotton ER blanket and a tangle of sheets. She wore a hospital gown. The inevitable bag of saline hung over her, dripping through an angiocath taped to her left forearm. In the far corner, the usual pile of clothing, shoes, and purse lay heaped on a chair. The patient was already awake, watching me. In the corner behind the door, a long male figure sprawled half out of a chair, stirring as I entered.

  I introduced myself. A. Crawley stretched carefully, propped herself up on one elbow, and took my offered hand. She didn’t look too sick.

  “I hope you won’t think I’m bad,” she drawled. She said this with a sly half smile, waiting for a reaction.

  It was such an odd thing to say that I paused.

  “Why would I think that?”

  She shrugged, still smiling. “I don’t know.” And slowly she slid back down to the bed. She was still looking at me.

  The oddness of her opening gambit hovered in the room. I didn’t know what to do with it, so I set it aside, plunging into the ritual. How did she feel? Not so good: her stomach hurt. When did that start? This morning—no, it’s yesterday now, isn’t it. She stopped with a giggle, and a girlish movement of the shoulders that made her seem ten years younger than she was, until she caught it with a sudden intake of breath. My thoughts went haring after the abdominal pathologies that might make it painful to move like that. It’s not a short list.

  We plowed on through, and I heard the same story I’d gotten from the admission note, minus the irrelevant dog. The repetition of the history should have been reassuring, but—oddly—it was not. I had been waiting for an inconsistency, something that might account for the strange atmosphere in the room, the opaqueness of her chart—waiting for anything, preferably something psychiatric and therefore harmless. But she wasn’t a nut. Her story was lucid, at least. And yet the strange atmosphere persisted. She giggled at odd moments, went shy at others, and generally carried on like a naughty teen. Something was off here, but I couldn’t figure it. She was a flake, I told myself. Her belly hurt. Watch her declare. I let the exam cement the story: a healthy young woman with normal active bowel sounds, slightly tender in the epigastric region.

  Virgie came in, filling up the rest of the space in the room with her own awkwardness and hurry. I made the introductions, Virgie performed a perfunctory exam, and we excused ourselves.

  Out in the ED it was getting on toward noon, and the noise level had gone up a notch; the hollering from the trauma bays had died down, but from everywhere else came the clamor of people speaking: words laid on words until they formed a resisting medium, a substance you could almost feel parting as you passed through. We retreated behind the counter and lodged against the cubbies, where I reshelved the clipboard.

  “You’ve got to scan her belly,” I shouted over the din.

  “Why?” Virgie spoke petulantly, out of the intern’s settled resistance to adding anything.

  “Belly pain, white count. You’ve got to. And did you see her lactate?”

  Virgie flustered. “She’s got a lactate?”

  Then to cover her omission she started asking me all the questions you run through to find the cause of an elevated lactate. I knew the questions too. I just didn’t know the answers.

  “You need to scan her belly,” I repeated. “Get it started down here.” I flipped through the papers on the board. “She’s written for a floor bed. She should probably be in step-down, but the floor is all we’re going to get.”

  “I can write her for frequent vitals.”

  “Do that.” I handed her the clipboard. “But it’s no substitute for step-down, you know.”

  “I’ll keep an eye on her,” she muttered as she scribbled orders.

  I watched her, her hair astray, white coat grubby, clutching her pen between her teeth as she reached up to grab a new order sheet. There was a slightly wild look about her, an extra millimeter or so of white showing around her irises. The odds of Virgie finding time to keep an eye on A. Crawley struck me as pretty slim.

  CT-abdomen-pelvis-w/contrast, she wrote out. Abd pain & wbc/lactate.

  “Make it stat,” I added as an afterthought. “And tell her nurse.”

  Despite what you may see doctors do on TV, I hardly ever order anything stat. You can get a bad reputation. Everyone knows that what you really mean is, I forgot to order this and I want to go home for dinner. Today it meant something else. Vague fears. Impending doom. Abd pain & wbc/lactate.

  AROUND FOUR THAT AFTERNOON, Mike, my intern, paged me with the news that we had two new admissions waiting in the ER: a young man with sickle-cell disease and joint pain and a chemotherapy patient who had been vomiting uncontrollably for several days. I told him to start on the sickler; sickle-cell pain crises are usually routine, and beyond the need to make sure the patient’s marrow and lungs are still working, management is a matter of ordering IV fluids, narcotics, and the laxative of choice. I went to the nearest workstation to look up the records of the other patient, a young woman with metastatic breast cancer and a recent history of frequent admissions for nausea and vomiting. She had three young children and seemed to do better when someone took care of her for a change. We’d treat her and send her home, she’d take care of her children until she needed to come in again, and it was going to go on like that until one day she wouldn’t go home. Armoring myself dully against the implications of this, I lumbered down to the ER to talk to her, trying not to think about anything but the treatment of nausea.

  I SHOVED THE CLIPBOARD for Bay 11 back into its slot and fished a blank order sheet off the top shelf. The shelf is a bit of a reach for me, and as I stood there, stretched high on tiptoe, I found myself staring at a pair of surgery residents a few feet away. I knew the senior, Sara Barnes, a fifth-year unusual among her kind for a helpful civility with the other house staff. She was in earnest conversation with her intern, a sour-faced young woman who looked ready to quit. They were holding a large dark square of radiography print up to the overhead fluorescents. I recognized the patchwork of a CT scan. Sara gestured to a series of images on the lower third of the print.

  “There,” she was saying. “See it? Where the contrast makes that little V and stops?”

  “Yeah,” said the intern.

  Sara ignored her tone. “It’s classic. They call it arrowhead sign: it’s practically pathognomonic
for appendicitis.”

  “Okay,” said the intern.

  Appendicitis is, by definition, a surgical emergency. I’d actually seen it only twice in my life, during rotations in medical school. As my hand groped along a seemingly empty shelf, I found myself automatically rehearsing what I knew about appendicitis. That little worm at the base of the colon gets blocked off for any number of reasons; infection, inflammation, and swelling set in, along with nausea, and pain so variable in its location as to be notoriously misleading; pretty soon the organ gets so distended it cuts off its own blood supply. Tissue dies.

  And as it dies, it produces lactate.

  “We’ve got to find whoever ordered this,” Sara said, and her eyes started questing around the room.

  My hand by this time had found the order sheet it was looking for, but I was no longer concerned with what my hand had found.

  “Is that Crawley?” I called. “Is that Ariel Crawley’s CT? I ordered that.”

  It took Sara a moment to focus on me. Then the two of them were around me, barking.

  I let them go on, cherishing the growing warmth of my realization that they were talking about taking A. Crawley to the OR tonight. Even though this would ultimately benefit Virgie, not me, I couldn’t help but feel a flush of misplaced pride. Virgie would emerge from her call night with one fewer patient to round on in the morning. Good for Virgie. I was taking care of my orphan.

  Sara and her intern left, busy, satisfied. I placed a page to Virgie to let her know. And then I sat down to order ondansetron and Ativan for the patient I’d just admitted in 11, whom I could still see, through a gap in the curtains, retching in a basin, a mauve turban askew on her hairless skull.

  AROUND EIGHT P.M. I was up on 3 Central, passing through on my way from the ED, where our last two admissions of the day were still having the finishing touches added to their admission orders. I was on my way up to the cancer ward, where the patient in the turban was still vomiting. There was little purpose in my putting in an appearance, having ordered more Ativan for her over the phone, but I felt the obligation. And the ER was making me weary. While admitting our full five patients, I had also helped Virgie with three more. She still had two scheduled transfers, both end-stage livers for transplant evaluation, coming in by plane from elsewhere, and both delayed by weather. I had no idea what weather might be happening outside to delay the air ambulance, but I was glad of it. My own intern had capped. We had survived. All that remained for me to do was to help Mike get his patients settled. Then I could scuttle off to my call room and try to sleep.