Internal Medicine: A Doctor's Stories Read online

  Despite being no secret to anyone, the code still holds its mysteries. I’m not sure, still, just what I have learned by running to so many codes. But the experience haunts me, long after the fact. As if, somewhere in the tangle of tubes and wires, knotted sheets, Betadine, and blood, I lost track of something important. Listen.

  IN THE HOSPITAL WHERE I work, codes go something like this. A nurse finds a patient slumped over in bed. The nurse calls her name. No answer. The nurse shakes her. No answer. Harder. Still no answer. The nurse steps to the door and calls, in tones that rise at each syllable, “I need some help here.” The rest of the nurses on the floor converge. Within a minute, every bystander within hearing is gathered at the door.

  In the basement of the hospital, a hospital operator listens intently to her headset. She flips a switch, and a faint click opens the hospital to the microphone on her console. “Adult Code 100, 6 South. Adult Code 100, 6 South.” The message goes out on the hospital PA system, her bodiless voice filling the hallways. It also goes out to a system of antique voice pagers, from which the operator’s measured words emerge as inarticulate squealing. The pagers are largely backup, in case some member of the team is, say, in the bathroom, or otherwise out of reach of the PA system.

  The team consists of eight or nine people: respiratory techs, anesthesiologists, pharmacists, and the residents on call for the cardiac ICU. On hearing the summons, the residents drop whatever they are doing and sprint. People running full-tilt in a hospital is unavoidably a spectacle. In their voluminous white coats, from whose pockets fall stethoscopes, penlights, reflex hammers, EKG calipers, tuning forks, ballpoint pens (these clatter across the floors, to be scooped up by the medical student who follows behind), the medical team’s passing is a curious combination of high drama and burlesque.

  The medical team arrives on a scene of Bedlam. The room is so crowded with nurses, CNAs, janitors, and miscellaneous onlookers that it can be physically impossible to enter. Shouldering your way through the mob at the door, you are stopped by a crowd around the bed; the crash cart, a rolling red metal Sears Roebuck toolchest, is also in the way, its open drawers a menace to knees and elbows. There are wires draped from the crash cart, and tubing everywhere.

  At the center of all this lies the patient, the only one in the room who isn’t shouting. She doesn’t move at all. This time it is an elderly woman, frail to the point of wasting; her ribs arch above her hollow belly. Her eyes are half open, her jaw is slack, pink tongue protruding slightly. Her gown and the bedding are tangled in a mass at the foot of the bed; at a glance you take in the old mastectomy scar, the scaphoid abdomen, the gray tuft between her legs. At the head of the bed, a nurse is pressing a mask over her face, squeezing oxygen through a large bag; the woman’s cheeks puff out with each squeeze, which isn’t right. Another nurse is compressing the chest, not hard enough. You shoulder her aside and press two fingers under the angle of the jaw. Nothing. A quick listen at her chest: only the hubbub in the room, dulled by silent flesh. Pile the heels of both hands over her breastbone and start to push: the bed rolls away. Falling half onto the patient, you holler above the commotion, “Somebody please lock the bed.” Alternate this with, “Does anyone have the chart?”

  A nurse near the door hoists a thick brown binder, passing it over the heads jamming the room. “Code status,” you bawl out. “Full code,” the nurse bawls back. You reposition your hands and push down on her breastbone. “Why’s she here?” There is a palpable crunch as her ribs separate from her sternum. “Metastatic breast cancer,” the nurse calls, flipping pages in the chart. “Admitted for pain control.” You lighten up the pressure and continue to push, rhythmically, fast. You look around, trying to pick out from the mass of excited bystanders the people who belong; the background is a weird frieze of faces and limbs reaching, pointing, gesticulating, mouths open. The noise is immense. On the opposite side of the bed you see one of the respiratory techs has arrived. “Airway,” you shout, and the tech nods: she has already seen the puffing cheeks. She takes the mask and bag from the nurse and adjusts the patient’s neck. The patient’s chest starts to rise and fall beneath your hands.

  “What’s she getting for pain?”

  “Morphine PCA.”

  “What rate?”

  The question sets off a flurry of activity among some nurses, one of whom stoops to examine the IV pump at the patient’s bedside. “Two per hour, one q fifteen on the lockout.”

  “Narcan,” you order.

  By this time the pharmacist has arrived, which is fortunate because you can’t remember the dose of opiate-blocker. You doubt this is overdose here, but it’s the first thing to try. Out of the corner of your eye you see the pharmacist load a clear ampule into a syringe and pass it to a nurse.

  Meanwhile, on your left, the other resident and the intern are plunging large needles into both groins, probing for the femoral vein. The intern strikes blood first, removes the syringe, throws it onto the sheets. “Send that off for labs,” you shout. Blood dribbles from the needle’s hub as the intern threads a long, coiled wire through it into the vein. The other resident stops jabbing and watches the intern’s progress. With a free hand she feels for the femoral pulse, but the bed is bouncing. You stop compressing. The resident focuses, shakes her head. Start compressing again.

  A nurse reaches around you on the right, trying to fit a pair of metallic adhesive pads onto the patient’s chest. You shake your head. “Paddles,” you shout. “Get me the paddles.” Then, into the general roar, “Somebody take that syringe and send it off for labs.” A hand grabs the syringe and whisks it off. “You,” you shout at the med student, who is hanging by the resident’s elbow. “Get a gas.” The resident throws a package from the crash cart, then steps back to give the student access to the patient’s groin. The student fits the needle—it’s a sixteen-guage, two inches long—to the blood gas syringe, feels for the pulse your compressions are making in the groin, and stabs it home: blood, dark purple, fills the barrel. The student looks worried; he may have missed the artery. It doesn’t matter. The student passes it around the foot of the bed to another hand and it vanishes.

  The nurse at your elbow is still there, holding the defibrillator paddles. She stands as though she has been holding these out to you for some time. Clap the paddles on the patient’s chest. Over your shoulder on the tiny screen of the defibrillator a wavy line of green light scrawls horizontally onward. You look back at the other resident. “Anything?” you both say at once, and both of you shake your heads. The intern has finished with the femoral catheter, very fast. He holds up one of the access ports. “Amp of epi,” you say, but there’s no response. Louder: “I need an amp of epi.” Finally someone shoves a big blunt-nosed syringe into your hand. Without stopping to verify that it’s what you asked for, you lean over and fit it to the port and push the plunger. Another look at the screen. Still nothing. “Atropine,” you call out, and this time a nurse has it ready. “Push it,” you say, and she does. Stop compressions, check the screen.

  Suddenly the wavery tracing leaps into life, a jagged irregular line, teeth of a painful saw. “V fib,” the other resident calls out, annoying you for a moment. You clamp the paddles down on the patient’s ribs. “Everyone clear?” Everyone has moved back two feet from the bed. You check your own legs, arch your back: “Clear?” You push the button. The patient spasms, then lies limp again. The pattern on the screen is unchanged. The other resident shakes her head. You call over your shoulder, “Three hundred,” and shock again. The body twitches again. An unpleasant smell rises from the bed.

  The pattern on the screen subsides, back to the long lazy wave. Still no pulse. You start compressing again. “Epi,” you call out. “Atropine.” There is another flutter of activity on the screen, but before you can shock, it goes flat again, almost flat, perhaps there is a suggestion of a ragged rhythm there, fine sawteeth. “Clear,” you call again, and everybody draws back. “Three-sixty,” you remember to say over your shoulder
, and when the answering call comes back you shock again, knowing this is futile. But the patient is dead and there is no harm in trying. As the body slumps again, there is a palpable slackening of the noise level in the room, and even though you go on another ten minutes, pushing on the chest until your shoulders are burning and your breath is short, and a total of ten milligrams of epinephrine have gone in, there is nothing more on the monitor that looks remotely shockable.

  Finally, you straighten up, and find the clock on the wall. “I’m calling it,” you say. Against the wall, a nurse with a clipboard makes a note. “Time?” she says. You tell her.

  There is more. Picking up, writing notes, a phone call or two. There is a family member in the hallway, sitting stricken on a bench beside a nurse or volunteer holding a hand. You need to speak to her, but before you do you have to find out the patient’s name. Or you don’t. And then you go back to whatever you were doing before the code went out over the PA.

  WHAT I’M THINKING, USUALLY, as we trickle out at the end, is this: What a mess.

  There is a great deal of mess in hospital medicine, literal and figurative, and the code bunches it all up into a dense mass that on some days seems to represent everything wrong with the world. The haste, the turmoil, the anonymity, the smell, the futility: all of it brought to bear on a single body, the body inert at the center of the mess, as if at the center of all wrong it remains somehow inviolate, beyond help or harm; as if to point a moral I would understand better if I only had time to stop and contemplate it. Which I don’t, not that day. We’re admitting and there are three patients, two on the floor and one down in the ER, waiting to be seen. There is no time to read the fine print on anything, least of all the mortal contract just executed on the anonymous woman lying back in that room. I can barely make out the large block letters at the top: Our Patients Die. And very often they do so in the middle of a scene with all the dignity of a food fight in a high school cafeteria. We can’t cure everybody, but I think most of us treasure as a small consolation that at least we can afford people some kind of dignity at the end, something quiet and solemn in which whatever meaning resides in all of this may be—if we watch and listen carefully—perceptible.

  Which may be why one particular code persists in my memory, long after the event, as the perfect code.

  DAVID GILLET WAS THE name I got from the medicine admitting officer. I wasn’t sure what to make of the MAO’s story, but I knew I didn’t like it.

  The story was an eighty-two-year-old guy with a broken neck. He had apparently fallen in his bathroom that morning, cracking his first and second vertebrae. I had a vague memory from medical school that this wasn’t a good thing—the expression “hangman’s fracture” kept bobbing up from the well of facts I do not use—but I had a much more distinct impression that this was not a case for cardiology.

  “And Ortho isn’t taking him because?” I said wearily.

  “Because he’s got internal organs, dude.”

  I sighed. “So why me?”

  “Because they got an EKG.”

  The MAO was clearly enjoying himself. I remembered he had recently been accepted to a cardiology fellowship. I braced myself for the punch line.

  “And?”

  “And there’s ectopy on it. Ectopy.” He then made a noise intended to suggest a ghost haunting something.

  “Ectopy,” meaning literally “out of place,” refers to a heartbeat generated anywhere in the heart but the little knob in the upper right-hand corner where heartbeats are supposed to start. Such beats appear with an unusual shape and timing on the EKG. They can be caused by any number of things, from too much caffeine to fatigue to an impending heart attack, but in the absence of other warning signs ectopy is not something we generally get excited about. And it sounded to me as though a man with a broken neck had enough reasons for ectopy without sending him to the Cardiology service.

  “So?” I said, trying not to sound indignant.

  “So he’s also got a history. Angioplasty about ten years ago, no definite history of MI. You can’t really read his EKG because he’s got a left bundle, no old strips so I don’t know if it’s new.”

  We were down to business.

  “So I rule him out.”

  “You rule him out. Ortho says they’ll follow with you.”

  “Lovely. And once I rule him out?”

  “Ortho says they’ll follow with you.”

  I said something unpleasant.

  The MAO understood. “Sucks, I know, but there you are.”

  And there I was, down in the ER on a Sunday afternoon, turning over the stack of papers that David Gillet had generated over his six hours in the ED. There was a sheaf of EKGs covered with bizarre ectopic beats, through which occasionally emerged a stretch of normal sinus rhythm, enough to see that there was, indeed, a left bundle branch block, and not much else. The heart has several bundles, cables in its internal wiring. When some disease process disrupts a bundle, the result is an EKG too distorted to answer the question we usually ask it: Is this patient having a heart attack? Of course, the bundle itself is not a reassuring sign, and if new it merits an investigation, but plenty of people in their eighties have them and it’s pretty much a so-what. But the ectopy on today’s strips was impressive—if you didn’t know what you were looking at you might think he was suffering some catastrophic event. I read between the lines of the consult note the orthopedic surgeons had left, and it was clear they regarded David Gillet as a time bomb, and didn’t want him on their service.

  Which I couldn’t help noting was exactly how I felt about having a patient with a broken neck on my service. But I didn’t get to make decisions like that. Instead I wadded the stack of papers back in their cubby and took a brief glance through the curtains of Bay 12. From my somewhat distorted perspective, most of what I saw of the patient was his feet, which were large, bare, and protruding from the lower end of his ER blankets in a way that suggested he would be tall if I could stand him up. At his side sat a small, iron-haired woman who at that moment was speaking to him, leaning close while she spoke. She wore a faint, affectionate smile on a face that looked otherwise tired. I watched her for a moment, her profile held precisely perpendicular to my line of sight as though posed. For a moment her face took on an almost luminous clarity, the single real object in the pallid blur of the ED, a study in patience, in care—and then it wavered, receding into a small tired woman with gray hair beside a gurney in Bay 12. The patient’s face was obscured by the pink plastic horse collar that immobilized his neck. I watched the woman for a minute. Her expression, the calm progress of their conversation, suggested that nothing too drastic was going on. I took a walk to the radiology reading room to get a look at the neck films.

  There were many of these, too. They showed the vulture-neck silhouette all C-spine films share. There were several unusual views, including one that I decided must have been shot straight down the patient’s open mouth: it showed, framed by teeth palisaded with spiky metal, the pale ring of the first vertebra, the massive bone called the atlas, and clear (even to me) on both sides of it were two jagged dark lines angling in on the empty center where the spinal cord had failed to register on film. The break in the second vertebra was harder to make out, but I took the surgeons at their word: C1/2 fx. Will need immobilization pending installation of halo. Will follow w/you.

  I WAS NOT IN the best of moods as I made my way back to the ER, grabbed a clipboard, and parted the curtains to Bay 12. I still managed an adequate smile as I introduced myself. “David Gillet?” I said tentatively.

  The woman at his shoulder blinked up at me, wearing that same weary smile, brushing an iron-colored lock of hair from her face.

  “It’s ‘Zhee-ay,’ ” she said, with an odd combination of self-deprecation and something else—perhaps it was warmth?—that made me like her. “It’s French,” she explained. Her smile widened, one of those dazzling white things older people sometimes possess (dentures, I believe), and she welcom
ed me into Bay 12, which I had been inside of more times than I cared to count, with a curious air of apology, as if concerned about the quality of her housekeeping. I was charmed. This was still relatively early in the day and I was capable of being charmed. I shook myself a little, straightened my back (her posture was perfect), trying to escape some of the lethargy that had been piling on me over the day.

  Her husband made a less distinct impression. The cervical stabilization collar tends to have a dampening effect on most people, as would the eight milligrams of morphine he’d absorbed over the past six hours, so it was a bleary and not very articulate history I got from him. His wife filled in the relevant bits. No prior MI. Occasional chest pain, hard to pin down (arthritis in the picture as well, of course). Otherwise a generally healthy, alert, and active man. On the one really critical point—what had caused the fall—Mr. Gillet insisted on giving account. He had not fainted. He had not been dizzy or breathless or experienced palpitations or anything of that sort. He had tripped. He had caught his toes on the damned bath mat, and gone down like a stupid ox. As he said the last he shook his head vehemently within the confines of his collar, and I caught my breath: you’re not supposed to do that with a broken neck.

  Even so I was partially reassured. The history didn’t suggest a cardiac cause to his fall, and he denied any of the other symptoms that go along with impending doom. The physical exam was similarly reassuring, although hampered by the cervical collar and my dread of doing anything that might disturb his neck. He was a tall, bony man, with a nasty-looking cut across the scalp above his right eye, and dried blood crusted in his bushy eyebrows. The cut had been sutured already, and the blood made it look much worse than it was. Aside from the cut and a large bruise on his right ribs (none broken), he seemed fine. Except for the neck, of course. I stayed another few minutes, making idle chat with the wife, and then excused myself to write my orders.