Intern (19 page)

When the nurses woke you in the middle of the night, you had to be prepared to deal with the unexpected. You knew that energy, clarity, fluent speech were coming; you just didn't know when. One night I was half asleep when I got paged.
Must be blood culture time
, I thought, reaching for the phone. In the dark, the receiver vibrated like an image from a jittery screen projector. When I called the number on my beeper, an urgent voice told me to go to Mrs. MacDougal's room. When I got there, it was as if I had walked in on a play. Mrs. MacDougal was standing precariously in the middle of her private room in a puddle of urine. Bright ceiling lights were beating down on her like stage spotlights. She was an attractive woman, for ninety-one, with a sharp patrician nose and handsome cheekbones like Lauren Bacall's. Her gown
was open in the back, exposing her scoliotic torso, which was covered with age spots, like cow patties in a field. A nurse and two orderlies were circling her like muggers. They were trying to get her to go back to bed, but the old woman was insisting on going to the bathroom alone.

“We'll help you go in the bedpan,” someone said, grabbing her arm to keep her from falling.

“I want to go to the bathroom!” she shrieked, trying to wriggle free.

“We can't let you walk there.”

“I'm not going in the bed!”

“You're going to slip and fall.”

“Leave me be!”

I was trying to keep from falling over myself. I tried reasoning with Mrs. MacDougal, but she wouldn't listen to me either. After a couple of minutes of urging, I asked the nurse why we couldn't just let her go to the bathroom.

“She could break her hip,” the nurse said indignantly.

“She could, but I don't think she will,” I replied.

“I can go by myself!” Mrs. MacDougal cried.

“I know,” I said, “but let me walk you anyway.” I offered her the crook of my arm and, much to my amazement, this appeal to her ladylike instincts seemed to work. Off we went, with an aide on either side, to the toilet.

An aide went in with her while the rest of us waited outside. “She's sundowning,” the nurse said, clearly irritated, referring to a kind of nocturnal delirium often observed in nursing homes. “Before you leave, order restraints.”

“Do you think that's necessary?” I asked skeptically.

“What if she sundowns again?”

“Just call me,” I replied. People in the hospital were always obsessing about disasters that never occurred. I had seen it myself in the CCU, where nurses would use PRN (“as-needed”) sedative orders to keep patients groggy and cooperative through the night.

When Mrs. MacDougal came out, I walked her back to bed. “You're a nice young man,” she said.

“Thank you,” I replied.

“I like you.”

“Well, I like you, too.” That was the nicest thing I had heard all week. I was going to show these nurses that a little kindness could go a long way.

The next page came about forty-five minutes later. When I arrived back in the room, the scene was much the same as before, except now Mrs. MacDougal was standing in a slurry of feces. She was yelling some of the vilest obscenities—“Cocksuckers! Motherfuckers!”—that I had ever heard from a nonagenarian's lips. The stench was overpowering. I cupped my hand over my face, but the putrid odor still registered in my olfactory lobes.

“Mrs. MacDougal!” I cried through my fingers. “What are you doing?”

“Who the hell are you?” she screamed hoarsely.

“Dr. Jauhar!” I said, incredulous. “Don't you remember me? You promised you were going to stay in bed.”

“I need to go to the bathroom.”

I ordered her back to bed immediately.

“You're not my doctor!” she shouted. “Call Silverman. Tell him to get me out of here.”

I told her that Dr. Silverman wasn't available.

“Get out of my way,” she cried, swinging wildly at me. She slipped and fell into my arms, rubbing brown excrement onto my scrubs. Steadying myself, I felt my right sandal slide a bit. The nurses were looking at me with I-told-you-so satisfaction.

For a moment I fantasized about putting Mrs. MacDougal into a choke hold and dragging her by the neck to bed, elbowing the nurse and orderlies out of the way, hissing, screaming at them to end this godforsaken shitfest. But, of course, that couldn't happen; I had to deal with the situation calmly. “Give her five of Haldol and two of Ativan,” I shouted out as I tried to keep her from tipping over.

“Yes, Doctor,” the nurse responded sarcastically before going out to get the medicine. The two aides and I managed to force her back to bed. When the nurse returned, she administered two intramuscular injections. Almost immediately, Mrs. MacDougal stopped struggling. Within minutes she was snoring heavily. I felt momentary relief, until the reading from the pulse oximeter started to drop: 99 . . . 98 . . . 97 . . . Pretty soon an oxygen mask was plastered to her face and I was turning a knob counterclockwise on the wall. Ninety-four . . . 93 . . . 92 . . . The brief calm quickly turned into another round of panic. Why had I been so impulsive? Was there an antidote for Haldol? Should I call an ICU consult? Where were the nurses now? For the next couple of hours I remained at her bedside, watching her snort like a pig. I stabbed her wrist with a needle to get an arterial blood gas, which revealed borderline oxygen and carbon dioxide levels. I prayed the drugs would wear off. Why had I allowed myself to be goaded so rashly? In an effort to protect her (or perhaps myself), I was afraid that I had killed her. It was an apt metaphor for my internship thus far.

By the next morning, Mrs. MacDougal had returned to her sweet, great-grandmotherly self. At lunchtime a few days later, nurses, social workers, and people with nondescript titles like “coordinating manager” met to discuss patient “disposition”—who was going to be able to go home, who was going to require long-term care, and so on. Rohit told me to attend on his behalf. At the meeting, everyone seemed to be having a rollicking good time talking about the patients, exchanging gossip about family dynamics, and so on. The subject of Mrs. MacDougal came up. “Dr. Jauhar had a wrestling match with her a few nights ago,” a social worker said, and everyone laughed except me. Someone asked where Mrs. MacDougal was going to go once she left the hospital. Her daughter wanted to put her in a nursing home, but she wanted to go back to living independently. “No way that's going to happen,” someone said with a certitude I found troubling. Someone asked me for my opinion. I had had so little interaction with her, just one unfortunate incident, that I wasn't sure how to respond. I was wary of saying anything that could send her to a nursing home for the rest of her
life. She had been delirious, no doubt, and a danger to herself, but she had also been in an unfamiliar environment with people she thought were trying to hurt her. Surely that had to enter the calculus for predicting future behavior. It was anyone's guess what she would be like in a more familiar environment. Wouldn't putting her into an institution just increase the likelihood of further sundowning? I thought of the Chekhov story “Ward No. 6,” and the incarceration of Yefimitch. I did not want to be responsible for institutionalizing another person. I had seen it before on the psychiatry wards. If someone said they were well enough to go home, we would say they lacked insight into their disease and keep them even longer.
Where was Dr. Silverman?
I wondered. We were discussing the future of a stranger over sandwiches and soft drinks. And that was beginning to seem normal.

Yes, there are two paths you can go by, but in the long run, There's still time to change the road you're on.

—LED ZEPPELIN
, “STAIRWAY TO HEAVEN”

 

I
'd been working for thirteen hours straight, without even a toilet break. One week ago, as an October chill started to take hold, a gnawing tightness had developed at the base of my neck, extending into my right shoulder and radiating down to my elbow. Now, my eyeballs were stinging, too, as if they had been doused with salt water. Pressure extended from the back of the orbits into my brain and down into my throat, rendering it parched and my voice feeble. I could almost feel my cortex rubbing on the inside of my scalp, producing a kind of tactile white noise, like strips of Velcro being pulled apart. Extreme fatigue heightens physical sensation. It makes time run slower, trapping you in the moment.

I was supposed to meet the resident Josh for dinner to talk about switching to psychiatry, but first I had to drain the fluid out of a young woman's cirrhotic abdomen. I had put off the procedure all day, and even though it was past seven and Rohit and Alphonse had already left, I wanted to get it over with today. I was on call again tomorrow, and Saturday calls were the worst. No cap on admissions, scores of patients to cross-cover. I wouldn't have time for any extra procedures.

I walked over to the stockroom to get vacuum bottles for the
drainage. In the large white bins I found the usual assortment of test tubes, catheters, syringes, bandages, gloves, plastic tubing, tape, gauze, dressing-change kits, drainage bags, syringes, scalpels, thoracentesis kits, bone-marrow biopsy kits, triple-lumen catheter kits, lumbar-puncture kits, saline bags, bedpans, cups, straws, socks, mouthwash, needles, diapers, sponge pads, iodine soap, hydrogen peroxide, masks, and bunny boots—but no vacuum bottles. Without vacuum bottles to speed up the drainage, the procedure was going to take forever. I went downstairs to the gastroenterology floor to find some.

Most interns have a favorite procedure. Already, mine was the abdominal paracentesis. I admired its brute-force simplicity. You push a catheter directly through the abdominal wall and into the abdominal cavity to drain accumulated fluid. It's easy and safe. Plus, your patient almost always ends up feeling better.

Wafting through the corridor on 10-North was the sickly sweet smell of
Clostridium difficile
diarrhea. I marveled at how the nurses were able to go about their business, without masks, seemingly oblivious to the stench. The thirty-something woman, HIV-positive, was lying in a room at the end of the hallway. She had unruly black hair and bloodshot eyes, and apart from her protruding abdomen, which looked like it was carrying triplets, she was wispy thin. Her belly had been hurting for weeks, she said, and she had been getting satiated after only a few mouthfuls of food. She had to sashay from side to side when she walked. I set the vacuum bottles down on the floor at her bedside and told her that I had come to drain the fluid. “Okay,” she replied flatly. She had gone through this procedure many times before.

I went over to the sink and washed my hands. After toweling off, I tried putting on a pair of gloves, but my hands were still moist and my fingers kept getting stuck in the latex fronds. I tried pulling on the latex but it clung tightly to my skin. I walked back to her bedside, the tips of the gloves hanging uselessly off my fingertips.

Her belly was laced with stretch marks, like thick, wrinkly worms. I pressed just below her navel, a sharp, shallow jab that set the fluid in motion, like water in a pail. There must have been ten liters in there, a
consequence of cirrhosis, from hepatitis, AIDS, her insatiable thirst for rum—or all three. I tapped on her abdomen like a drum, using the transmitted sound to map out the location of the fluid. Dull was fluid, hollow was air—and as best as I could tell, the fluid was everywhere.

I scrubbed her belly with iodine soap—she shivered; it was cold—and then injected lidocaine into the skin and soft tissue of the left lower quadrant. The injection formed a mound the size of a fingerprint, which I pressed down to distribute the anesthetic, liberating a tiny spot of blood, which trickled away. I pushed a big 22-gauge needle through the site of the injection, forming a fleshy tract for a plastic catheter, which entered the abdominal cavity quite easily. Almost immediately, warm yellow liquid came bubbling back, soaking my gloved fingers. I attached one end of a piece of tubing to the catheter, plunged the end with the needle into a vacuum bottle, and then sat down to watch the fluid drain. It came out in a steady drizzle, like a leak in a water balloon. “Take it all out,” the woman insisted. “I'm only supposed to take out a few liters,” I replied. Someone had once told me that it was unsafe to drain more than that at one sitting. I had forgotten why, but I was glad to have a reason to stop so that I could keep my dinner date with Josh.

The bottle filled up quickly. Midway, I got paged. It was Josh. He wanted to know if we were still on. I told him I was running late but that I would meet him at the restaurant as soon as I was finished.

The fluid was really gushing; perhaps the catheter had settled into a high-pressure pocket. I reached for another bottle, but then I realized that I had stupidly left it on the other side of the bed, out of reach. I placed the nearly full bottle on a chair and hopped around the bed to get the unused bottles. I heard a snap, and when I looked back, the tube was whipsawing back and forth on the chair, like a garden hose, spraying lemonade-colored fluid on the floor. For a moment I was paralyzed. What happened? Did she move? Did I not secure the needle? I watched horrified as tiny puddles of HIV-infected fluid settled onto the uneven tile floor. My gloves were still hanging off my fingertips, so I tore them off and stepped around the spill to put on another pair. Then
I grabbed the gushing needle and plunged it into a new vacuum bottle. Even with the fluid safely discharging into the glassy cavern, I continued to grip the needle tightly, my heart pounding in my ears. The young woman stared out at the room, oblivious to the disaster that had just unfolded.
Fool!
I shouted at myself. I had been rushing to get out on time, and now I had created an even bigger problem for myself, a veritable biological hazard. I was going to have to call Housekeeping, write an event note, maybe fill out some sort of incident report. The evening nurses were irritable enough without giving them another reason to be annoyed.