Internal Medicine: A Doctor's Stories (14 page)

This made me uneasy, I say, as I found the family and ushered them into the conference room across the hall—dozens of them squeezing in until the room was walled with standing, silent figures. Around the table by some tacit agreement most of the elders had arranged themselves in some order of precedence. Mr. Wallace sat at the far end, wobbling, unseeing, fragile. I didn’t have the time to figure out for myself just where this plot seemed to be headed. With her massive bleed yoked to her unimpaired respiratory drive, Muriel Wallace was entering a gray area.

But I was running on autopilot, feeling pressure to move on to some next step in the process. My pager had buzzed twice while the family was filing in. One of the new admissions was crashing. I had a sense of events piling up just outside the room.

A large, stout woman to Mr. Wallace’s right—unmistakably Muriel’s daughter—spoke.

“We’ve been discussing,” she began. “Like you said.”

I nodded encouragingly. She went on. “We’d like to begin by saying how much we appreciate . . .” She paused here, and the silence filled itself with muttered assents. “Appreciate,” she said again, “all the care you’ve shown our mother.”

“And aunt.”

“And sister.”

“Amen.”

“We truly do,” the woman went on. I could hear a “but” looming, and settled myself, trying to remember that I wasn’t here to argue. I wasn’t pushing an agenda. I was here to help. My pager was going off again.

“But.” And her gaze swept around the room. No one stirred. “We have some questions.”

I murmured some polite invitation.

“What,” the woman began, “are our options here?”

I thought for a minute. “I suppose there are three.” But that wasn’t right. I was skipping something. “But before we discuss them, I thought you’d want to know how she’s doing.”

Yes, they sighed.

“She’s unchanged.”

The sigh flowed out of the room.

“She’s not better and she’s not worse.” This seemed to me to sum up the salient features of the case. I plowed on with details.

“She’s still unconscious. I have no idea when or if she’ll wake up.” I paused, letting the room absorb the sound of my voice. “Meanwhile, she’s still on the breathing machine.” I stopped, wondering where to go next. “But she’s not using it.” This elicited some stirring, eyebrows rising, nods exchanging, heads shaking. “She’s breathing in and out without any help from the machine.”

“What does that mean?”

It was messy was what it meant. But I wasn’t sure how to say that. “It means, basically, that her stroke hasn’t gotten any worse. The reflexes in the base of her brain, the parts that control breathing, they haven’t been hit. We could take her off the machine right now and she’d probably do fine.” No, that wasn’t right. “Fine” wasn’t right at all. But the words were out.

“Then let’s do it,” a voice said. The daughter stabbed him with a look, and turned to me.

“Is that one of our options?”

“Yes. It is. But there’s a problem. With what’s happened to her, it’s very likely that she can’t control the muscles in her throat anymore. All the reflexes that we use to keep from choking, to keep things from going down the wrong way—those don’t work anymore. We’ll need to do some more tests, but it’s very likely that if we take the tube out, eventually she’ll choke, inhale something she shouldn’t, and get pneumonia.”

More solemn nods from around the table; glances shifting side to side. I went on. “If that’s the case, then our options would be: to keep her the way she is now, to pull the tube out, and”—for a moment I considered referring to God again, but thought better of it—“let nature take its course. Or, if tests show us she needs it, we could have the surgeons put a permanent breathing tube in here.” I gestured to my own throat just above the sternal notch. “It’s called a tracheostomy, and it would allow her to breathe on her own. It would also offer some protection against choking.”

I stopped, not so much letting things sink in as wondering myself where we were going. I was thinking of how long it would take all this to unfold: days and days. And to what end?

“This breathing tube,” the daughter asked, “is that a big operation? Will she stand up to it?”

“She shouldn’t have any trouble.”

Another woman, another daughter from the looks of her, chipped in from down the table. “And can she go home after that?”

That was another question. I paused a minute, this time judging the effect—going for an effect, I realized. What was I trying to do here? “I don’t know,” I said. “There’s no way of knowing for sure. But I doubt it. From what we’ve seen so far, the damage is so severe, it’s unlikely she’ll ever rise from that bed again. Usually, with this kind of injury, you’re looking at a life in a nursing home—”

Mutterings of protest. Under the glare of the daughter, they died away.

“A nursing home would really be the only place that could care for her. Dealing with somebody so severely paralyzed is hard work. There’s constant care involved.”

“We can do that,” somebody said.

Don’t argue, I told myself. “It’s very hard,” was all I said. “But that’s not the issue we need to resolve. Not right now. The question you all need to decide is, would she want that? If all we can buy her is a little time—with frequent infections, bed sores, being unable to do anything for herself—do you think that’s what she would want?”

As I said this, I could feel myself becoming increasingly uncomfortable. Not with the question itself: it’s a common enough question, and one that needs to be asked—sometimes. As I listened to the sound of my voice dying away in the room, even the echoes struck me as wrong. Wrong and wrong and wrong: mistakes seemed to be showering out of me like sparks from a Catherine wheel. Listen to me, I thought: It sounds like I’m pleading with them to let her die. Like I
want
this woman to die.

Well, of course, on some level I wanted something close. There was nothing complicated or remarkable about that. Any resident who is remotely honest will tell you we become, if not comfortable, at least familiar with the sensation of wanting patients to die. We feel that way because they’re going to die anyway, usually, and we know that, out of the available options, dying quickly is the best that could happen to them. But it’s also better for us. There’s the rub. It saves them agony, but it seems to save us something as well: the exhaustion of watching, of causing nothing but pain as we struggle to forestall the inevitable.

Of course, it doesn’t really save us even that. Whatever hospitals once were, they are now largely places where people come to die. If they’re not at death’s door we rush them back home; only the dying linger, but in this parallel universe every dying patient is quickly replaced by another. The house staff come to see the ICU as the place where we manage that exchange, again and again and again. The feeling is understandable. It’s also, thank God, temporary, fading like bad dreams with the light of day as we get more sleep, more time with our patients, as we move up the hierarchy so that we’re not the ones actively, physically, holding off death just a few seconds more.

So there I was, using all the rhetorical tricks I had at my command, I feared, to seem to push this family into pulling the plug on my patient. Was I really doing that? It would be better for the patient, after all.

And it was my job, I told myself, to help them face up to a reality most of us would rather deny. Too few of us arrive at the hospital with a duly signed and witnessed DNR order in our hands. Too few of us have the conversation with our families. And nobody out there seems to understand that the survival we have to offer is sometimes worse than—I had been going to say “death,” but I don’t know enough about death to use it in a comparison. Worse than what? Worse than I want to give? Perhaps it’s that. I would save everyone if I could, but it’s a sorry gift I have to offer, sometimes. Life in a puddle of urine, bones laid bare as the immobile flesh turns black and rots away, long hours passing while a call for something simple—a drink of water, a runny nose wiped clean—goes unanswered. I didn’t want that life for Muriel Wallace, for any of my patients, for anybody.

But with every unassisted breath Muriel Wallace took, I was beginning to understand that what I wanted did not matter. My rhetoric did not matter, except insofar as it might impose my half-baked wishes on events. Muriel Wallace’s life was following its own plot. It had always been that way, I knew, but just then the reality of it left me feeling bleak, uncertain of where to go next. And the entire family was still looking at me.

There were more questions, which I did my best to answer, talking on autopilot about infections, fiber endoscopies, and skilled nursing. While the family threshed through the matter, discussing things I had no business hearing, I excused myself. They would let me know. I went across the hall and back into the Unit, moving through the noise of the nursing station to the dark and relatively quiet room where Muriel Wallace lay. She was still: a big, still woman with white plastic tubes taped to her face. Gently, I jostled the end of the endotracheal tube. No response. Out of habit more than any actual curiosity, I put my stethoscope to her chest: air moving in and out, backed by the rhythmic thud of the living. Her left arm was limp, utterly flaccid, falling when I let it go in a straight drop to the bed. A big, still woman lying motionless in bed.

A
NY PATIENT IN A
HOSPITAL
, when we take their clothes away and lay them in a bed, starts to lose identity; after a few days, they all start to merge into a single passive body, distinguishable (if even then) only by the illnesses that brought them there. In the ICU, with consciousness gone as well, there is rarely a trace of personality left behind. Spirit itself comes from a machine. The body remains behind, but all too often it’s a husk, doing the work of living for nobody’s benefit. It’s impossible to know what’s going on in there. It’s impossible to read how the body came to be there, what life it left behind. Just the rise and fall of the chest, the slow accumulation of data as labs and vital signs and consults and imaging fill up the chart, telling nothing about the person they surround.

But the question of Muriel Wallace and her care had become a question not of medicine but of an unknowable will. What would Muriel want? It was clear enough that she had had a stroke that should have killed her, and was certainly, I thought, going to leave her hemiplegic forever. She had to look forward to a future of infections of the lung, of the bladder, and then the slow ripening of sores. There was no easy solution for the problem of being Muriel. None that I could give.

And none that she could give, either. We go along in our lives, making plans, expecting things will continue the way they have, confident that we know what we want, what we might and might not have. But lives don’t go like that: no matter what we will for ourselves or others, time hides abrupt and wrenching dislocations, moments that change everything. Muriel had been through one of those moments. And after that, what anybody knew, what anybody wanted, was irrelevant. More and more the facts seemed to tell us that she was going to live. She was going to have to live with what happened to her. I picked her limp arm back up, folded it across her, covered it with the thin hospital sheet. She gave no sign. The ventilator heaved a sigh as I left the room.

I
WISH
I
COULD
provide something neater to end this piece. It didn’t end neatly—hasn’t, for all I know, ended at all. Muriel survived our care. She did develop pneumonia, but anyone will in her situation: we were waiting for it, and she responded within a day or two to antibiotics. Later, she woke up, just as her family had hoped. She even greeted me one morning with a half-wide half grimace, a strong grip with her good right hand. She nodded vigorously to almost any suggestion, nodded and squeezed about getting the trach and the G-tube, and as soon as her fever was down, on two successive days she got them both installed, and we were able to wean her off the vent without a problem, and the nurses started to teach her family how to pour into her G-tube the cans of gray-green liquid that from now on would be her food. Then, her need for intensive monitoring past, we transferred her to one of the general medicine services, who would manage her care until she had a bed somewhere beyond our walls.

A
S LUCK WOULD HAVE
IT,
I followed her a day or so later, rotating off the ICU to general medicine. My first day on the service, the family greeted me like lost kin. They were no longer a collective tableau of grief, resolving instead into individuals, who spoke, gestured, laughed. That day they were laughing—gently, happily—at me. Pulling me into the room during rounds, they interrupted the intern’s presentation with a delighted—and slightly ironic—demonstration of Muriel’s ability to move the toes of her left foot, the ghost of a grip she had developed in her left hand. Muriel beamed at me as she showed us what she could do. The intern beamed and completed her presentation. The plan for Muriel, for the remainder of her stay, was physical therapy, speech therapy, occupational therapy, and social work consultation for placement. The family had agreed to place her in a nursing home for rehab, confident that it would be a short sojourn before returning to the life she had known. I beamed back at them, nodding blindly, not looking at the figure still splayed so limply on the bed.

O
N THE DAY OF
her transfer to the nursing facility, Muriel was found unresponsive, and hypotensive to the eighties over forties. It seemed for a moment that her story had taken another turn, or turned back, anyway, into the usual course of things in the hospital. She spent that night in the ICU again, getting a liter of fluid. That fluid may or may not have been responsible for the recovery of her pressures. At any rate, something turned this climax into peripeteia: the story continued, again taking its own path to its own end. For now, at least, she rebounded. What set her back in the first place? Nobody knew. Things like this were to be expected. By the next day she was back on the general medicine service, and the day after that, her family took her away. I didn’t see her go.