Authors: Sandeep Jauhar
The MRI showed what by now everyone suspected: a severe herniation of the disk between my fifth and sixth cervical vertebrae. The gelatinous core had ruptured through the fibrous capsule, pinching a nerve root. When the radiologist showed me a sideways view of my spine, it looked like the herniated disk was partially compressing the anterior column of my spinal cord.
I went to a neurologist at my own hospital, who told me there was a slight chance the disk would heal on its own but that it was likely going
to require surgery. At the very least, he advised taking a break from internship.
That afternoon on the ward, I was unable to turn my head because of my neck brace. I had to rotate my entire body to look in any particular direction or to perform physical maneuvers. My patients joked that I should see a doctor. My colleagues were mostly reserved, politely inquiring about the injury but not paying it much attention. I remembered how they'd been when a classmate claimed to have a hairline foot fracture back in August: resentful, unsympathetic, whispering that she was faking it. Of course, I was aware that one of them was going to have to cover for me if I left.
A couple of days later, I got a phone call from Dr. Wood. He had just spoken to the neurologist. “So you need some time off?” he said pleasantly.
“That's what I was told,” I replied, then quickly added, “But I'm not planning on taking any.”
He asked me why. I wasn't sure what to tell him. I had been contemplating quitting internship before my injury, but now the situation had become more complicated. Leaving now, I feared, would have adverse lasting consequences on my psyche. I didn't want to be forced out. I wanted to leave on my own terms.
“I'd stay home if I thought it would help,” I said. “But I might need surgery no matter what.”
“Take the time,” Dr. Wood urged. “We all admire the way you've handled this, not drawing too much attention to yourself. No one thinks you haven't been sincere.”
I didn't say anything, but his kind words lifted my spirits. Though we had little in common, I liked Dr. Wood. I admired his commitment and integrity. And I was glad that he liked something in me, too.
I told him I'd think it over. At the very least, I wanted to complete my upcoming rotation at Memorial Sloan-Kettering. The Memorial rotation was the toughest of the year, and I had been looking forward to it as one might a sickening thrill ride. Cancer was the icon of deathly
disease, and as a den of illness, Memorial had a sort of mystique. The patients there were as sick as any we were going to encounter all year. If you overlooked something at Memorialâa rash, a feverâyour patient could crump quickly, and no patients were more crump-prone than Memorial patients. I was hoping that taking care of such patients would deliver confidence, courage, a sense of purpose. I felt like a marathoner trying to finish a race even though his legs are collapsing.
The challenge of Memorial was multiplied by the fact that I was going to be doing “night float” there. Night float was a relatively new concept in residency training. Older physicians, like Dr. Wood, had trained under a very different system, when call was every second or third night and residents routinely stayed up for thirty-six hours at a stretch. But things started to change late one spring evening in 1984, when a young woman named Libby Zion entered the emergency room at New York Hospital. She was agitated and running a high fever. Eight hours later, she was dead.
Though the exact cause of her death remains a mystery, her case aroused intense debate over what until then had been little discussed: the way residents are trained in New York State. The residents who cared for Zion the night she died had given her a powerful narcotic, and then had been slow to respond when she developed an adverse reaction. If they had been more rested, medical educators wondered, would they have been able to save her life?
In 1987, a special commission led by Dr. Bertrand M. Bell, a professor of medicine at Albert Einstein College of Medicine in the Bronx, proposed a number of changes in residency training in New York State: closer supervision of residents in emergency rooms, more help with routine tasks like drawing blood, and strict work limits. Residents were prohibited from working more than twenty-four hours at a stretch or more than eighty hours per week. Eventually these changes spread to residency programs throughout the country. Teaching hospitals that had relied on interns and residents as medical staff were forced to grapple with the problem of cross-coverage: providing care to patients when their primary resident was not on duty. As a result,
many hospitals created night floatsâresidents who worked the night shift for specified periods of time, usually a few weeks.
Many in the profession, including most residents, applauded the Bell regulations. Studies have shown that, under the old system, residents after a call night score lower on tests of simple reasoning, response time, concentration, and recall. Many, both inside and outside medicine, argued that residents could not provide proper care for patients if they were chronically fatigued. In an editorial in
The New England Journal of Medicine,
one educator wrote: “Few would choose to ride in a car driven by a resident coming off a 36-hour shift. It should come as no surprise that the public would question the ability of sleep-deprived residents to make life-and-death decisions.”
However, some educators argued that there was no clear-cut scientific evidence showing that tired residents harm patients, either by increasing mortality rates or complications. One doctor wrote in
The New England Journal of Medicine
: “My own experience in staffing our intensive care unit both in the traditional manner and with a ânight float' suggests that errors due to faulty transfer of information are at least as frequent as those due to fatigue from being on call overnight.” Educators also argued that the work limits that led to the creation of the night-float system were detrimental to a resident's training because they interrupted learning and created a kind of shift-work mentality. Of course, the shift aspect of night float was precisely the attraction for many interns. After doing night float, Vijay had told me, echoing the sentiments of many of my classmates: “I walk into the hospital empty-handed, and I leave empty-handed, and I like that.”
“Are you sure you can handle it?” Shannon asked me worriedly as I drained my last sip of coffee.
“I think so,” I replied.
Outside, it had started to rain, a late October drizzle that glistened on the tar-black wrought-iron railings guarding the aging brownstones in the neighborhood. Mist pecked at my skin and moistened my hair. The spray cooled my upper body, which felt hot and sweaty because of the neck brace. Under a tree, a water droplet splattered on the bridge of
my nose, the intense sensation momentarily dulling the pain in my neck. The pain had been terrible all afternoon. Before leaving the apartment I had popped two pills of Lodine, a painkiller.
My shift was supposed to begin at 5:00 p.m., when residents and nurse practitioners departed for the day, and end at 7:00 a.m., when they returned. Meanwhile, I was going to be responsible for about eighty patients.
At the security desk at the front entrance of the hospital, an officer gave me a quizzical look. I rode up the escalator, passed through a waiting area where families were sprawled on green and orange couches, and turned down a corridor going to the cafeteria. Not wanting to draw attention to myself, I removed the neck brace and stuffed it into my backpack.
It was a typical hospital cafeteria, with grimy brown carpeting, potted plants, and cheap Kandinsky posters. A corkboard on the wall was plastered with announcements from various support groups, invitations to join in research studies, and urgent appeals for bone-marrow donation. Large paneled posters told the storied history of the hospital and predicted the next generation of advances from the Human Genome Project. Two New York Hospital interns were waiting for me at a table reserved for house-staff conferences. One of them, Caitlin, was a very attractive brunette from Georgia. She handed me a list of her patients with their major medical problems, allergies, and a short summary of their hospital course. “Don't worry about seeing this guy,” she said, pointing to a name with a star next to it. “He's signing out against medical advice. I told him not to leave. I told him the risks, blah, blah, blah, but he wouldn't listen, so sayonara,” she concluded with a flick of her hand.
“There is one patient I have to tell you about. This guy Schroeder has been hallucinating all afternoon. We don't know why; maybe he has brain mets. We gave him some vitamin H”âHaldolâ“and he's quiet now, so he shouldn't give you any trouble, but if he does, just snow him with more Haldol and Ativan.” I nodded intently; Caitlin had great breasts.
“I'm sorry to dump this on you,” she said, gently caressing my arm.
“No problem,” I replied, affecting nonchalance. “The longer you stay, the longer you stay.”
Six cancer teamsâGastrointestinal (GI), Allogeneic Bone Marrow Transplant, Genitourinary, Head and Neck, Breast, and Melanomaâsigned out to me. (The other night-float intern got sign-outs from Leukemia, Lymphoma, Lung, Autologous Bone Marrow Transplant, Hematology, and Multiple Myeloma.) By 6:00 p.m., everyone had left.
The first hour of night float is supposed to be relatively tranquil, the calm before the storm, but not this night. A few minutes after the last intern signed out, I got paged.
Beep . . . beep . . . beep.
“Are you covering Schroeder on GI?” a voice inquired.
“Hold on, let me check my list.” I sifted through the papers as the voice kept talking. “Okay, here he is,” I said. “Schroeder, patient of Dr. Raymond.” Of course: he was the patient Caitlin had just signed out to me, and whom I'd so smittenly pledged to look after. “Sixty-four. Colon cancer status-post 5-FU and leucovorin. All right, go ahead.”
“I just told you. He's delirious and his oxygen saturation is dropping.”
There was a long pause.
“Are you coming?”
“Yes, I'll be right there,” I said.
The GI ward was shaped like a racetrack, with two dimly lit corridors encircled by wooden banisters and painted a dull yellow. The nurses' station was almost deserted, save for a clerk and two nurses having coffee. In his room, Schroeder was sprawled in bed, his arms and legs tied to the rails. He apparently did not speak Englishâapart from obscenitiesâbecause a German translator was there, a lanky, greasy-faced fellow who was grinning nervously. “He says that things are coming down at him,” the young man said, clenching his teeth to keep from laughing. “He feels that things are crawling on his skin.”
When I attempted to apply my stethoscope to his chest, Schroeder lunged at me with a force that shook the entire bed. His hands turned
white as the cloth cuffs cut off his circulation. “What do you want me to do?” the nurse who had paged me demanded. “I can't keep him tied up all night.”
Beep . . . beep . . . beep.
I glanced at the beeper on my waist. “What's his baseline?” I asked, checking the display. About the only thing I had been signed out was that he wasn't going to give me any trouble.
“I'm just a float,” the nurse replied, referring to the fact that she worked per diem shifts. “I'm meeting him for the first time, too.”
At the nursing station, I answered the page. A patient's heparin drip needed to be renewed. I told the caller that I'd come by as soon as possible to write the order. Sitting down, I perused Schroeder's chart. Caitlin had written an “event note” that afternoon, but it didn't say much more than what she had already told me. When I called Schroeder's family, hoping they could clarify his baseline mental status, his daughter told me in fluent English that he had a history of alcoholism but had never behaved anything like what I was describing. “He had an MRI of his brain this afternoon,” she said. Caitlin had neglected to mention that. “Can you tell me what it showed?”
Beep . . . beep . . . beep.
Another page.
“I'm going to have to get back to you,” I said.
“When will that be?” she demanded.
Beep . . . beep . . . beep.
Fourth page in ten minutes.
“Listen, I'm sorry but I'm covering eighty patients right now,” I blurted out. “I will have to call you back.”
“It's just that I live in Westchester and it takes me a half hour toâ” she started saying before I hung up.
When I got off the phone, an attending physician in the nursing station took me aside. It was Jim Krank, a clinical trialist who specialized in acute leukemia and the withering stare. He was a chubby man with a brown, bushy toothbrush mustache. I had taken care of one of his patients recently, an elderly man with drug-resistant leukemia and fungal pneumonia. When the end was near, his son had tried to put restrictions on blood draws. “I know my father, and he didn't want to live this way,” he had said. “The one thing he always prayed for was
that he would go in his sleep.” But we quickly discovered that it was almost impossible
not
to draw blood from a cancer patient. Some reason or another always came up. Eventually his family instructed us to provide “comfort care,” which meant no needle sticks and a steady infusion of morphine. For a while, his condition seemed to improve, making Dr. Krank grumble thickly, “It always happens this way. Patients do better when we leave them alone.” It was the most devastating critique I had heard of the profession, and though I knew it was made flippantly, it still made me think:
What is the point of all this?
All the protocols, the chemotherapy, the transplantsâwhat was the point of it if, in the end, the sickest patients, the ones we were beholden to help, or at least not to harm, were better off without us? My first instinct when the old man started getting better was to turn off the morphine drip, but Krank dialed it up even further. I was afraid he might stop breathing, but of course that was the whole point. It was called the law of double effect. It was okay for us to hasten his death in the service of treating pain and discomfort.