Intern (12 page)

“Let me give it a shot,” Steve finally said. I was hoping he'd miss, at least once, but he hit the artery on his first attempt. When he removed the syringe, blood spurted out the hub of the needle, splattering red dollops onto the table and the tile floor.

“Okay, hand me the wire,” he said. My hands were shaking so badly that the wire, which resembled a guitar string, kept flopping about wildly. Perspiration was trickling down my face. He inserted the wire through the bore of the needle and into the artery. Then he pulled out the needle, leaving the wire inside the vessel. With a scalpel, he made a deep nick in the arm, and forced a stiff plastic catheter, a dilator, through the soft tissue to create a track for the catheter that was going to follow. The patient groaned but did not move. Blood started gushing. Steve slipped the catheter over the wire and tried pushing it into the artery, but it buckled. He tried again but it still wouldn't go. I looked on nervously as the wire protruded unnaturally out of the man's forearm, like a nail askew in a thick plank. “It's probably bent,” Steve said. He turned to the nurse who was with us and politely asked her to bring him another wire. Then, with his finger pressed on the wound, he casually turned to me, like a man waiting for a train. “Never let go of the wire,” he said, and I nodded nervously. I couldn't believe that even at that moment, Steve was still trying to teach me something.

The nurse returned with a new wire and Steve quickly inserted it into the artery. The catheter passed over it easily. He pulled out the wire and connected the catheter to a manometer. Soon a blood-pressure waveform was prominently displayed on the monitor above the bed. “Okay, sew it in,” Steve said. While I made stitches, he gathered up the needles, discarding them into a sharps box, threw away the procedure tray, and stripped off his gown. “Congratulations,” he said. “You just put in your first arterial line.”

“You did it,” I replied, not wanting to be patronized.

“Yes, but you'll do it next time,” he said encouragingly. “See one, do one, teach one.”

That night I wrote in my diary:

Next to Steve, I feel lame, effete, like a shell of a resident. He has a feel for the hospital that I don't have. They say I'll develop it, but I cannot imagine a time when he was as confused as me.

I know I can learn a lot from him. He is truly a wonder to behold. The only thing I would fault him on is his tendency to denigrate patients in conversations with other doctors. But that's hardly unique to him.

 

ONE AFTERNOON IN THE CCU
a few days later, an Australian man was returned to his room after an electrophysiology procedure. Within an hour his blood pressure plummeted. His eyes darted back and forth, like a scared child's, even as he insisted that he was fine. The consensus among doctors in the room was that he was in cardiac tamponade, where fluid rapidly accumulates in the sac around the heart, hindering its ability to fill with blood. The only effective treatment is to drain the fluid. “Page your brother!” someone shouted to me.

When Rajiv came barreling through the double doors, I breathlessly told him that I had paged him 911. “Don't ever fucking do that,” he barked, marching past me. In the room, a technician was performing an echocardiogram, which confirmed that a massive amount of blood had accumulated in the pericardial sac, compressing the heart with every beat. Suddenly Rajiv was in a sterile gown, and I was being asked to step outside. A nurse threw a blanket over the patient. Rajiv tore open a pericardiocentesis kit. Everyone, including attending physicians, watched raptly as he drew lidocaine into a syringe. He seemed to relish the attention, chatting comfortably with the nurse who was assisting him. “Can you move the table over, please?” he asked politely. This was not the brother I knew from childhood, the one who was easily intimidated, who feared dirt-biking in the hills behind our house. I had always been the fearless one, doing cross-outs and tabletops while he adopted a more conservative style. Now I was the one perched on top of the Islander Hill on my Univega bicycle, fearfully looking down.

Rajiv had always been good with his hands, much better than me.
Growing up, he had been the tinkerer and I had been the thinker. It was disheartening to realize how useless my skills were now.

The patient had stopped moving under the drape. He was either being extremely cooperative or was sinking into cardiogenic shock. Rajiv stood on a step stool. After numbing the skin below the breastbone, he pierced it with a six-inch-long needle, directing the tip, with the aid of ultrasound, toward the left shoulder, directly at the heart. I stepped away; I couldn't watch. I could hardly believe what was happening. Wasn't there someone better equipped to do this than my older brother?

I had always been in Rajiv's shadow, and never more so than in the CCU. Dr. Carmen and the others expected me to do well because of Rajiv. I couldn't just worry about myself; I had to worry about his reputation, too. “I don't want to mess this up for you,” I had told him the night before starting the rotation. “You can't,” he replied confidently.

A few minutes later, while I was sitting at a computer checking labs, the mood of the crowd suddenly changed. People started filing away. When I went back into the room, the drape was off, the patient had regained his color, and his blood pressure was almost normal. Bloody fluid was draining into a plastic bag. I found Rajiv chatting with some fellows by the nursing station. People were walking up and patting him on the back. When he saw me, he snapped his fingers loudly. “Did you see it?”

“I missed the last part,” I replied.

“Well, it was fucking awesome!”

“How did you know where to go with the needle?”

“I didn't. I just pushed and prayed.” Then he broke into a cackle that usually meant he was pulling your leg, but you could never be sure.

I stared at him, incredulous. In twenty-nine years, I had never wanted to be like my brother more than at that moment. He was so calm, cool, and collected. He seemed to view hospital dramas as some sort of Vedantic play in which he was merely another actor.

“It's an amazing feeling,” Rajiv said. “Here this guy goes from being in shock to actually talking.”

“What did he say to you?”

“Ah, that was the best part. He apologized.”

“Apologized?”

“Yeah, the first thing he said when he woke up was, ‘I'm sorry for not being a good patient.' ”

“What did you say?”

“I said, ‘Shut the fuck up.' ” Then he broke into another full-throated cackle.

As he was walking away, he stopped. “Don't ever page me 911. I thought something bad had happened.” I started to say something: “Wasn't this—?” He cut me off. “You know what I mean. Like with the family. Like something had happened to Dad.”

MRS. WILLIAMS NEEDED A CAT SCAN
.
She was on a stretcher, in a tangle of wires and tubes, a woman of about seventy with thinning gray hair and a churchgoing face. A nurse was giving me instructions for the road trip. “Just keep the monitor on her at all times,” she barked, like a quarterback calling out a play. She picked up a section of clear plastic tubing. “This is your arterial line. And this here is your central venous pressure. I'm going to disconnect it; you don't need it. This is the heparin. This is the nitroglycerin.” She pointed to the bulky yellow monitor at the foot of the bed. “The yellow line is your oxygen saturation. That's your heartbeat and that's your blood pressure.” She reached underneath the stretcher, where a green metal canister was lying on its side. “That's your oxygen. It should last about thirty minutes.”

She paused to take a deep breath. “This is your code box,” she said, holding up a sealed gray box that looked like a mechanic's tool kit. Inside it were drugs—epinephrine, atropine, lidocaine—that I had never used. “Just break it open if you need it. Of course, if she arrests, you're going to use the paddles.” I nodded; I had never used defibrillator paddles before. “You charge it like this, see.” She turned the knob back and forth quickly. “One hundred joules, two hundred joules, three
hundred joules, see.” My face must have betrayed terror because the nurse offered an almost sympathetic smile. “Don't worry,” she said. “If you need to, you can always call a code.”

The middle-of-the-night road trip is an intern rite of passage. Steve and the other residents had done it, and there was no reason to think that I couldn't do it, too.

A young black man in dreadlocks and lime green scrubs showed up. He was my escort. Without a word, he grabbed hold of the back of the stretcher with one hand and a metal IV pole with the other and maneuvered it to the double doors. Then he punched a plate on the wall, the doors flung open, and we were off.

Coming out of the CCU, with me holding on to a side rail, we tried turning left, but the stretcher went crashing into the far wall. “Oh my!” Mrs. Williams exclaimed. She had few teeth, hollow cheeks, and kind of gummed her words when she spoke. I didn't know much about her, except that she had been admitted to the CCU with chest pains. That was pretty much all Amanda had signed out.

We rolled the stretcher down the checkerboard-tile floor, toward the freight elevator.

Even at this late hour, I could see white-coated men sitting on stools in the satellite pharmacy, sorting pills. Their presence was both creepy and oddly reassuring. More banging, but we managed to steer the stretcher onto the corrugated metal floor of the freight elevator. With each bump I checked to make sure the IVs were still connected. An EKG sticker had come off her chest, dangling uselessly on a wire, making the heartbeat tracing temporarily go flatline before I pressed it back on. We rode up to the sixth floor in silence, except for the reassuring
blip-blip-blip
from the monitor.

Coming out of the elevator, we made a left and rolled up a ramp and down a hallway, past the pediatric oncology wing. Suddenly we were in an old part of the hospital. The corridors were lined with beat-up chairs and rusting file cabinets below peeling paint. We stopped at an intersection. I looked up from the monitor nervously. “I hope you
know where you're going, because I don't.” My escort's flat, somber expression did not change. “I've only been here two weeks,” I tried to explain.

Without a word, he turned left. A couple of turns later, we entered a darkened hallway. It had a faintly chemical smell, like that of a darkroom. “This is it,” he mumbled, disappearing into a room. From the corridor I could see a doughnut-shaped CT scanner sitting on a metal gantry that looked like it could use a good scrubbing. After a couple of minutes, the escort came out and started walking back in the direction of the main hospital. “Hey!” I called out. “Where are you going?”

“Call me when you're done,” he said without turning around.

“What's your number?” I shouted, but he was already gone.

A burly technician with tattooed arms came out of the room. “Okay, Doc, bring her in,” he said.

I rolled the stretcher up to the radiology table. Mrs. Williams was now even more tangled up in wires and tubes. Her rumpled gown was slipping off her shoulders, exposing her breasts. The pulse oximeter had long since come off her finger. One of her IV lines had somehow made its way between the side rails. I disconnected it, looped it back over the railing, and quickly reattached it before any of the medicated fluid dripped onto the floor. The technician pumped on a pedal below the stretcher, raising it to the same level as the scanner. Then I pulled on a latch and lowered the side rail. “Give me your hand, Mrs. Williams,” I said, reaching across the gantry.

“Hold on, Doc,” the tech said. “We've got to give this line some slack or her IV is going to come right out.” He pulled the metal pole in closer, but it didn't look like the tubing was going to be long enough. He stared at it for a few seconds. “Can we stop the drip?” he asked.

“Sure,” I replied automatically. Which drug couldn't be stopped for just a few minutes?

I disconnected the line and reached again for Mrs. Williams's hand. “Doc, she's going to need some help.” He went and got a white sheet. “Okay, pull her onto her side.” As her face pressed up between the rails, he quickly tucked the sheet under her body and rolled her
onto her back. Then we grabbed the sheet on each side and slid her over onto the scanner table.

“This is only going to take five minutes,” I said, patting her on the hand. The tech and I went into the tiny control room. “Don't you want to be able to see the monitor?” he asked me, taking a seat at the console. “Yes, of course,” I said. I ran in and turned it around.

Digital images of my patient's head soon appeared on a computer screen. “What is the scan for?” the tech inquired, adjusting a knob. After a pause, I said, “I'm not sure.” In all the excitement, I had forgotten to ask.

The first images looked okay. Now it was time for higher-resolution cuts.

“She's got to lie real still for this next scan,” the tech said.

I peeked into the room. Mrs. Williams's head was still in the scanner. “Try not to move, ma'am. We're almost done.”

She groaned loudly. “I don't feels so good. Oh Lordy, I don't feels good.”

“What's the matter?” I asked.

“My chest is hurtin',” she said.

Just my luck. Only one more pass through the scanner and now she was having chest pain? “That's okay,” I said. “Just try to keep still.”

She shifted her weight uncomfortably. “But I'm getting these pains in my heart.”

“We'll take care of it once the scan is finished. You don't want to have to come back here, do you?”

She didn't answer.

“So please just lie still for a couple of minutes so we can finish up.” I was focused on completing the scan, whatever the indication for it was.