Intern (29 page)

I nodded. In my case, the constant comparison had been with my brother.

“One time in internship I put a central line into an old woman who was on a ventilator. She needed it for something; I forget what. She had TB or something. It was me and a second-year. We tried a subclavian approach but we couldn't get it. I tried the internal jugular ten times,
and then the resident tried, and he couldn't get it, so we just kept trying. He finally got it, and we put the line in. I don't know if at some point he got air back in the syringe, but you can guess what happened. We checked a chest X-ray and we had dropped her lung. It was a big pneumothorax, so the woman ended up needing a chest tube. When the attending came back, he was pissed. He said, ‘I leave and now look! What the fuck! She's really fucking sick now. I can't believe that you did this. What were you thinking?' It stayed with me for a long time—not so much what we had done, as my poor resident. As a second-year, if I had been dressed down like that, I would have been devastated.

“Another time, second year, I took care of this woman whose potassium was low. We were repleting her potassium every day, several times a day even. When I left one evening, I signed out to check her potassium level. For whatever reason—maybe I didn't impress it hard enough, I don't know—it didn't get done, and in the middle of the night, she had a cardiac arrest because of high potassium. Her potassium was off the scale, and then it came to light that she had been getting saline with eighty milliequivalents of potassium chloride at one hundred and twenty-five cc's an hour. I didn't know it. I should have known it, but IV fluids weren't written on the nursing medication sheets, and I had been too lazy to check the computer. I marched straight to Dr. Wood's office and told him what happened. I said, ‘Dr. Wood, I just killed a patient. I killed her, or at least I didn't prevent her from being killed.' ”

“How did he respond?” I asked.

“Of course, he broke it down. He told me it was because of the bad kidney function. He said her kidneys couldn't excrete potassium properly. He said, ‘If I give you potassium-enriched fluids, will your body be able to handle it? Of course it will,' and so on and so forth. He broke it down medically, but really what I wanted to talk about wasn't medical. I had nightmares about that death. As an intern I never felt like that, but as a second-year, you just felt more responsibility.

“So I started this conference for residents to talk about their mistakes,
away from Dr. Wood, away from the attendings. Even the chief residents weren't allowed to sit in. I wanted it to be just house-staff run. Everyone makes mistakes; even if we don't think we've made them, we've made them. People would come to the conference and talk about their mistakes in a nonconfrontational way. I saw residents cry at that conference. I talked about the lady with the low potassium. It felt good to get it off my chest. I felt like, if I don't make this public—not out in public, of course, but just to my colleagues—if I don't talk about it, then it would become one of those things that never really happened. It would cease to exist.”

AFTER SPENDING JULY
in the outpatient clinic, I rotated to 4-North, the cardiac telemetry ward. Ward 4-North at New York Hospital was famous for its high-volume, assembly-line medicine. Each morning, patients would be shipped off for echocardiograms, nuclear stress tests, and cardiac catheterizations by an efficient, well-trained, and highly vocal cadre of nurses whose job it was to ensure everything ran smoothly. As a house officer, if you forgot to do something—fax a requisition, for instance, or write a “nothing-by-mouth-after-midnight” order—your oversight could disrupt the whole enterprise and bring the wrath of the charge nurse down on your head.

The patients on 4-North were mostly archetypes: middle-aged businessman who developed crushing chest pain sitting at his mid-town desk; elderly woman who forgot to take her medications and went into congestive heart failure; diabetic with diffuse vascular disease who needed bypass surgery. One morning, I had to present three cases of unstable angina from the night before but couldn't remember which was which. The only differences were the patients' ages and the small details, the social history, which we so often ignored. The same clinical narrative could apply just as well to my eighty-five-year-old widowed patient with Alzheimer's as to the fifty-five-year-old dentist with a family. Stuck, my mind a blank, I fumbled until Mira, the intern assigned to work with me, whispered something into my ear. “The
father of two disabled children?” I said out loud. “Oh yes, now I remember.”

Mira was a fast-talking, wisecracking Jewish girl from Long Island with a pretty freckled face who barreled through the unit as if she was on twenty cups of coffee. She showed up at 6:00 a.m. to preround, finished her notes before I even arrived on the ward, inserted central lines, drew blood, and generally did whatever was necessary to get the job done. She had a wonderful mix of directness, chutzpah, and easygoing charm. With Mira around, I never worried about the “July phenomenon,” where patients supposedly did worse at the beginning of each academic year because inexperienced interns were caring for them. She seemed to have mastered her patients much better than I ever had.

Rounds started at eight o'clock, when we sat down with David Klein, the attending physician, to discuss admissions from the night before. Klein was a short, graying man with a supercilious air and a perpetually exasperated expression that conveyed haughtiness. He spoke with a sneer, and he seemed to relish cutting into patients and house staff alike. One morning Mira presented a case. “The patient came to the emergency room in the middle of the night—” she began.

Klein groaned loudly. He often said that coming to the hospital in the middle of the night was a sign of irresponsibility.

“—after doing cocaine—” Mira continued. Klein groaned again.

“He was in his usual state of health until three a.m.—”

“Yeah, yeah, I get the point,” Klein snapped. “Is he a scumbag?”

Mira stopped, looking flustered. Klein threw up his hands, as if he had asked the most natural question in the world. “Is he a scumbag or a solid citizen?” he demanded. Mira seemed to draw a blank. I had never seen her hesitate before.

“I'm not sure,” she finally replied.

“Well, he snorts cocaine! Where does he live?”

“Manhattan.”

“Where in Manhattan?”

“I'm not sure.”

“Well, you can bet he's not from the Upper East Side.” Some residents laughed at this remark.

“You mean people on the Upper East Side don't use cocaine?” I interjected. I despised Dr. Klein, and he didn't like me much either. He had once warned our team to watch what they said lest I quote them in a newspaper column.

“No, not most of them,” Klein replied dismissively. There was an awkward pause as he uncrossed and recrossed his legs. Then he let Mira finish.

Rounds with Klein were exercises in division—making distinctions, pointing out the differences between people, the haves and the have-nots, and in fact he was quite open about it, as if his openness somehow absolved him of his prejudices. If patients on 4-North were archetypes, then Klein, too, was an archetype: overbearing, arrogant cardiologist.

Most days on the telemetry ward, we had to obtain informed consent from patients going for cardiac procedures. We were supposed to tell them the risks and benefits and answer their questions, but the process didn't always go smoothly. Sometimes we were forced to apply “gentle coercion” for the good of the patient.

José Villegas was a middle-aged man with kidney failure who had suffered a small heart-attack. One morning, he was scheduled to go for a coronary angiogram, but apparently no one had discussed it with him. When he was told that the dye used in the angiogram could damage his already weakened kidneys, he balked. He said he didn't want the procedure; he was unwilling to accept even the slightest risk of dialysis. That much was clear, even in his broken English, but Klein and the fellow had already decided that the benefits of the procedure outweighed the risks. “You could have a severe blockage in your heart,” the fellow warned.

Villegas said he would take his chances.

“You could have another heart attack,” the fellow intoned gravely. Villegas's resolve appeared to crack. “You could drop dead!” Klein
shouted. Few patients can resist that kind of pressure, and Villegas wasn't one of them. “I guess I have no choice,” he said resignedly, signing the consent form. We filed out of the room. In the hallway, barely out of earshot, Klein chuckled. “We can make them do whatever we want,” he said. “As long as they agree with us, they're not crazy.”

Though I detested such strong-arm tactics, I was aware that my own conduct as a physician was hardly blameless. I thought back to Jonah and his testicular mass. When he had asked me if it was cancer, I had lied and said that I did not know. I too was learning that deliberate half-truths are a part of the doctor's armamentarium.

Chest pain was the most common reason for admission to 4-North. Some of it was benign, like the hysterical Mexican women who screamed
“Ay, ay, ay.”
(Residents termed this “status hispanicus.”) But most of it was serious, and sometimes quite mysterious, too. One night I admitted a burly Russian man with a thick accent who was lying in bed, clutching his chest, looking very uncomfortable. He told me he had been experiencing chest pain at home that frequently got worse when he exerted himself and sometimes was relieved by nitroglycerin tablets under the tongue. Although his EKG and blood tests were normal, with no signs of heart damage, his story was too good, too characteristic of angina, to dismiss. I told him he was going to need a coronary angiogram. “Have you had one before?” I asked.

Yes, he replied. In California, Nevada, Arizona, Kansas, even New York. Every one was normal. My puzzlement must have been obvious. So was his annoyance. “They tell me it is Syndrome X,” he growled.

The next day, I obtained a tape of one of his angiograms from a nearby hospital. It confirmed what my patient told me. His coronary arteries were pristine, not a trace of obstruction anywhere. So what was wrong with him?

Most people with angina have atherosclerotic plaque in the large coronary arteries that supply blood to the heart. But up to 20 percent of angina sufferers have normal coronary angiograms, a condition cardiologists have dubbed
Syndrome X
. These patients often have chest pain
that mimics coronary angina and even abnormal stress tests. There appears to be a problem with their hearts, but no one knows exactly what it is.

One theory is that Syndrome X is a disease of coronary arteries too small to be seen by angiography. In one study, researchers using magnetic resonance imaging found that adenosine, a drug that dilates coronary arteries, does not increase blood flow to the inside surface of Syndrome X hearts, an area mostly fed by small arteries. They concluded that these arteries did not dilate appropriately and that the angina in Syndrome X was therefore from inadequate blood flow, not in the major branches of the coronary tree but in the twigs.

This theory appears to unify the mechanism of Syndrome X with obstructive coronary artery disease, the leading killer in the Western world, but there are holes. For example, if the chest pain in Syndrome X is due to diminished blood flow, then ultrasound studies of the heart during painful episodes should show some abnormalities, which they do not. EKG studies should reflect this inadequate blood flow electrically, but they do not. Another theory is that Syndrome X is a result of abnormal pain sensitivity, the so-called
sensitive-heart syndrome.
The chest pain in some patients can be evoked by electrical stimulation of the lower right heart chamber, which should have little effect on blood flow.

So which theory is correct? Maybe both. Syndrome X is probably not a single disorder but a constellation of disorders with many different causes. There is even evidence that psychological factors come into play. It is well known that patients with atypical chest pain often have an abnormal preoccupation with their health and anxiety or depression. One study found that two-thirds of patients with chest pain and normal coronary angiograms also have psychiatric problems.

It would not be the first time that a common cardiac symptom was thought to be predominantly psychological. In the 1990s, Dr. Arthur Barsky at Harvard Medical School studied patients with frequent palpitations. In one study he hooked up 145 patients to a continuous, twenty-four-hour EKG monitor and instructed them to record the exact
time of their palpitations in a diary. He found that only 39 percent of their palpitations were accompanied by an objective arrhythmia. The patients whose symptoms had the weakest correlation to EKG abnormalities also had the most hypochondria and other psychiatric problems.

Although Syndrome X can be debilitating—not to mention a drain on hospital resources—patients who have it tend to experience normal life spans. I tried to tell my Russian patient that despite his symptoms, he did not have a life-threatening disease, but this did not mollify him. Like the difficult patient in the clinic the previous month, he accused me and other doctors of insensitivity. He demanded another angiogram to make sure his disease had not progressed. After several days of intensive but ineffective medical therapy, the team finally acquiesced. He was taken to the cardiac catheterization lab once again, where more pictures were taken of his coronary arteries. Shortly after the procedure, he went home. He was still feeling chest pain but had a clean bill of health, a reminder that even in a field as highly developed as cardiology, some symptoms retain their essential mystery.

WHEN I WAS ON CALL
on 4-North, Sonia, who had recently moved in with me, often came to the hospital to bring me dinner. I'd meet her downstairs, in front of the library, where she'd hand off the curried chicken or lamb kebabs, or sometimes daikon paranthas with spicy cauliflower, courtesy of her mother. Occasionally she'd bring a plate for Mira, too, and sometimes even for the medical students on my team, and then we'd all sit in the conference room and scarf it down. She was now on a fourth-year GI elective, and it was good to see her in the hospital during the day. I always waited for her page; it was the one number I always called back immediately, no matter what I was doing. We sometimes discussed her difficult cases, and my advice was usually accompanied by a few words on appropriate etiquette for a fourth-year medical student. Afterward, I'd bask in the same sort of glow I'm sure Rajiv enjoyed when he advised me.