Intern (14 page)

I spent most of the night at Jusczak's bedside with Joe and a nurse. The bright ceiling lamp illuminated his naked body like a spotlight. Sweat drenched my T-shirt; my thighs were sore from standing. Every movement took energy I didn't have. When Joe went out to call an
anesthesiologist, I started pushing drugs on my own. I was amazed at how easily my confidence flowed when it became clear that we were fighting a losing battle.

The convulsions seemed to gain in force and amplitude with the passage of the night. Over several hours, the sedative drips were dialed up well beyond the maximum limits in the textbooks. Eventually his whole body was quivering like a bowl of gelatin. We tried everything: glucose and thiamine, useful for hypoglycemic and alcoholic seizures, which he didn't have; Versed, a potent benzodiazepine, which paradoxically seemed to fuel the spasms; a cooling blanket, because there was some evidence suggesting that hypothermia could prevent brain damage after cardiac arrest. It was a reach, but we didn't know what else to do.

An anesthesiologist eventually showed up and put Jusczak on propofol, a milky white anesthetic. The seizures immediately ceased. With the propofol running into his body, they never resumed.

The nurses had put Mrs. Jusczak into an empty patient room. I found her there at four in the morning, sprawled on her stomach, still in her business suit. The room was musty, though with the faintly pleasing odor of perfume. I thought about waking her to give her an update but decided to let her be. Her husband almost certainly had irreversible brain damage at this point, and I did not want to provoke an outburst so early in the morning. I pictured her at his funeral, walking beside his coffin, wearing a black veil. I pictured the pallbearers in their black suits. I shuddered thinking about what had occurred over the past twelve hours.

I lay down in my call room, fatigued beyond words, certainly beyond anything I had ever experienced before. I had stayed up all night only a few times in my life: once in college before a history final, a couple of times in graduate school when I was collecting data, and now seven times over the past three weeks. The thoughts began to flood in, even as I tried hard to hold them back.
Why didn't you check the sodium earlier? Aren't you responsible for what happened?

The following afternoon, after taking a restless nap, I took out my diary and the discontent came pouring out:

Do doctors care? I don't know. I don't see a lot of caring. Maybe I myself don't care, or care selectively, which is hypocrisy, which I despise. No, I don't see much attention to the psychosocial aspects of medicine. There is lip service, but by and large, no one seems to pay it much mind. Like this morning. Steve had no interest in holding Camille's mother's hand, in asking her why she was crying. It was pretty obvious why, but I think she would have appreciated it, if only as a gesture to recognize her pain. I myself didn't make an effort, not because I was uncomfortable but because there was so much to do. I thought it best to spend my time doing what needed to be done.

It's almost criminal the callousness with which we treat some of our patients. Remember Mr. Fellini. Poor man; it was almost comical how he cried out for us to leave him alone, to not hurt him, punish him for his helplessness. This was a man loved by his family, a businessman or banker, perhaps, one who asserted his will on others, and now he is a helpless child. Nature did not wire into us the desire to take care of our aged. Maybe that's why the contempt, the frustration, with gomers. They are heavy, dead evolutionary weight. They sap our resources. We don't want to take care of them. Baby shit doesn't smell. But gomer shit smells the worst.

I should have known that I wouldn't be able to do this. What are we doing, poking and prodding people at two in the morning, drawing blood like vampires? The 2:00 a.m. blood draw is just an exercise, a way to protect yourself from being questioned on rounds for neglecting something. This whole month we never acted on a lab test in the middle of the night. When I asked Matt about it, he said, “This is what we do here. This is the CCU. Here, we should be able to get labs every hour if we want to. The techs should just do our bidding.” Implicit in his remarks is the belief that more is better. I am not convinced.

Sometimes, you have to take a chance, but doctors don't want to take a chance. Sometimes you have to say, “This is the most likely cause; we're not going to do a bunch of tests to rule out every possibility. This is a simple fainting spell, and we're not going to do any further workup.” But doctors
aren't willing to go out on a limb like that, take a chance, not cover themselves; hence all the waste, the unnecessary tests.

Maybe Matt will always be a better resident than me, because he cares at some core level to do all the little things that I find burdensome, like making the call to the lab to reproach the tech for a canceled (or delayed) test, or learning stuff like how to read a chest film and which antibiotics to use and when. When Fred, the third-year resident, was telling me today about the difference between heparin and warfarin, it was sad how little I cared. I'm sure that indifference is contributing to my problem, which is not performing. Perhaps at some level I am just lazy.

Today, when I was walking up Second Avenue, I was thinking: so much of medicine is simply supportive. Nothing is definitive; there are so few things we do that cure: some chemotherapy, I'm told, antibiotics, maybe angioplasty. The therapeutic taps don't work; the fluid reaccumulates. The studies to find lung cancer—so what, death is inevitable. And then it's made worse by the futile interventions at the end.

 

That night I called Rajiv at his apartment. I told him about what had happened to Mr. Jusczak after he left. I didn't want pat consolation, but that was exactly what Rajiv offered, as if I were engaged in some sort of fashionable exercise in self-reproach. He told me that the cardiac arrest had probably lowered Jusczak's seizure threshold. He told me that nothing could have been done to prevent the seizures. He told me to take a more “laissez-faire” approach or I would end up hurting my patients.

“There's just too much going on in the unit,” I blurted out. “It's hard to keep track of it all.” Rajiv suggested keeping three-by-five note cards. “That's not the solution!” I cried. “I'm not sure all this is for me.”

“Shit happens,” Rajiv said, by way of ending the conversation. “I know you love to beat yourself up, but don't do it here.”

I thought about Jusczak all weekend. His face appeared to me in a dream. I was wandering around a run-down hospital, trying to find him. The corridors were decrepit, and the bathrooms were smeared with urine and feces. People were turning on me, accusing me of
things I hadn't done, accusing me of putting them down. It was bizarre. I woke up terrified.

On Monday morning, I went to see Jusczak before rounds. The seizures had stopped, the sedative drips were off; he had settled into a coma. His wife was with him. Her hair was tousled, her makeup streaky; little black speckles dotted the bags under her eyes. She still had on the same suit, except now it was stained. The neurologists had told her over the weekend that her husband's prognosis was dismal. One of them had written in the chart that the chances for any kind of meaningful recovery were essentially nil.

She said, “Good morning.” It caught me unprepared, how she was able to engage in such a simple nicety. I returned the greeting and walked up to the bedside to conduct the requisite exam. A strong odor emanated from the body, an unwashed smell. His head was turned unnaturally to the right. His legs and arms were turned inward, a fetal position aptly called
decorticate posturing,
a sign of severe brain damage. He was intubated, exhibiting no spontaneous breathing “over the vent.” I shined light into his eyes. Jutting out over his eyelids was a thick layer of clear gelatinous material. I rotated his head from side to side. His eyes moved with the motion of his head. This absence of “doll's eyes”—a primitive reflex—was a sign of a damaged brainstem.

“What do you see?” his wife asked, looking on.

“There is damage, but I'm not sure how much,” I lied. The guilt welled up inside me. If only I had checked the sodium when I was supposed to, perhaps this whole tragedy could have been averted. In medical school we had been taught to treat the patient, not the numbers. In this case, the logic seemed to have broken down. In this case, treating the sodium earlier could have been the difference between life and death.

“The neurologist will be coming by soon,” I quietly informed Mrs. Jusczak. “I'm sure he will speak with you.”

He arrived a few minutes later, a lanky Australian fellow with a brisk, impatient clip and the brainy look befitting someone in his profession. He immediately asked Mrs. Jusczak to step outside. I looked
on as he performed his examination. He took a Q-tip and spun a tiny wisp of cotton. Then he lowered an eyelid and lightly brushed the cornea with the cotton, trying to evoke a blink; none came. He tapped on the knees with a hammer; the reflexes were abnormally brisk, further confirmation of brain damage. He took the handle of the hammer and scraped the soles of the feet. The big toes flexed upward—the Babinski sign—confirming that there had been extensive cortical injury. I asked him what the EEG, a brain-wave scan, had shown. “Diffuse slowing,” he replied, “but that doesn't really matter. It's been seventy-two hours and he hasn't woken up. That's a very poor prognostic sign.”

Outside the room, Mrs. Jusczak stopped me. “He is my best friend, you know,” she said. “Don't get me wrong; he isn't perfect. But he is smart. And he is a good father. He did a good job with our son.” I asked her where her son was. “At home,” she replied, her voice breaking. “He thinks his father has pneumonia.” Down the hall, a peal of laughter rang out from the nursing station. Takeout food had just been delivered.

“I know you're busy but he's all I have. He's only one person to you but he's everything to me. He is my whole life.” She rested her arms against the countertop. A nurse came scurrying up. “Watch out for my clipboard, hon,” she said. “I don't want you to knock it over.”

I informed Mrs. Jusczak that I needed to get back to rounds.

Later, a surgeon came by. He was an older man with gray hair, blue scrubs, and a potbelly. “I've been trying to call your office all morning,” Mrs. Jusczak told him. He looked at her impatiently. “They tell me he's brain-dead,” she quickly added. He looked puzzled, and then his expression softened. Apparently he was unaware of what had happened over the weekend. “Call my office if you want to talk,” he said. And then he was gone, too.

I wanted to stay, commiserate, maybe even grieve—after all, he was my first death, too, or at least the first one in which I had played any significant role as a doctor—but I was on call again that night. Soon new patients would be rolling in, the runway would be lined up
with stretchers, and I was going to get swamped with the usual tasks. In the afternoon, I heard her crying loudly in his room. “Wake up, wake up, I don't want to live without you.” Her cries could be heard in the unit for hours, yet the place just rolled on. The telemetry monitors kept ringing. They had never been able to distinguish between mundane stirrings and real danger, and now, it seemed to me, they could not distinguish between life and death.

Mr. Jusczak was pronounced brain-dead by the neurology team the following morning. That afternoon, his wife ordered him removed from the ventilator. She wept uncontrollably as attendants put his body on a gurney and took him to the morgue. On the death certificate, the cause of death was accurately noted as status epilepticus. No mention was made of the high sodium. When I called Rajiv later that day, he stopped me in the middle of my rant to ask me what the hell I was talking about. He had already forgotten.

What about the wife and babies if you have them? Leave them! Heavy are the responsibilities to yourself, to the profession and to the public. Your wife will be glad to bear her share of the sacrifices you make.

—SIR WILLIAM OSLER

 

O
ne night in August, about two months into internship, Sonia and I were strolling past a red firehouse on Seventy-fifth Street when the subject of marriage first came up. The Upper East Side was languid and barren, as denizens had feverishly gotten themselves out of the city to savor the last spell of the summer. After nearly two months basically living in my apartment, Sonia herself was getting ready to return to Washington to start her third year of medical school. I had been thinking that it was just as well. I liked her very much, but frankly, I didn't think the relationship was going to survive if she stayed in New York.

I had had so little to offer in our summer together. Though we managed to go out on dates a couple of times a week, it was almost always on my post-call days, when I was edgy and sleep-deprived. Between fourteen-hour shifts in the hospital and every third night on call, it was all I could do to plop myself on my couch, order dinner delivery, read a few pages of medicine, and watch a few minutes of
Seinfeld
before going to bed. Just last week, Sonia had spent three hundred dollars to get us tickets to a
Mostly Mozart
concert at Lincoln Center, but I
had slept through the entire performance. At my apartment, the mail was piling up; the newspaper went unread; clothes needed to be laundered. Most evenings I found myself wanting to be alone to catch up on life. To me, all this spelled a relationship in trouble, but Sonia, ever an optimist, seemed to take the bumps in stride.

She came from a family of physicians, so she seemed to understand much better than I the pressures on a dual-doctor relationship. As the firstborn daughter of two doctors, she had been cloaked in the medical profession her whole life. Her mother had trained as a radiologist but was now a practicing internist. Her father was the director of intensive care units at three hospitals. Her grandfather, like mine, had been a doctor in India. Two out of her three maternal uncles were doctors, and so were their wives. Her aunt was a primary care physician in Ohio, and the aunt's husband a gastroenterologist. Her sister was already in medical school, and most of her high-school-age cousins were preparing to pursue premedical studies. My father yearned to be a doctor; my brother, of course, was training to be an interventional cardiologist. I found it ironic that though I had never wanted to become a doctor, physicians now intimately surrounded me in virtually every sphere of my life.