Reaching Down the Rabbit Hole (15 page)

5. EVERYBODY MUST GET STONED

A year later, while on a rotation down at San Francisco General Hospital, I got a call from Bob Johnson, one of my co-residents up at UCSF. He was worried sick. He said that his sister’s roommate had just called him, all frantic and disorganized, saying: “I can’t wake your sister up. What should I do?”

They were living in Haight-Ashbury, so the first thing that came to my mind was drugs. But since it was Bob’s sister, and because he came from an extremely respectable Wichita family—big Republican donors, five generations in the military, Bob even had a crewcut—and because Bob himself seemed to rule it out, I immediately thought,
It can’t be drugs. It must be something else.

Bob was in the middle of a shift and couldn’t get away. The ambulance had just arrived at his sister’s house, he told me, and they were bringing her down to the General, where I was working as the senior
medical resident in the emergency room. “I just wanted to let you know, just to make sure that she’s being taken care of.”

As residents, we spent a third of the year at the General. The place was spectacularly but lovably squalid, like something out of a B-movie. As one of my surgical co-resident friends said when they started to renovate it, “You can’t dress up shit. It’s the same crappy place.” The General was a converted tuberculosis sanitorium, an unholy mess, a snake pit. Parts of it had been at times taken over by a drug gang. Two female physicians had been raped in an elevator. Yet if you were in the soup and you needed something ripped open and taken care of, or if you were having a massive heart attack, it was by far the best place to go. We residents couldn’t get enough of it. We loved the half-mile long halls with their giant leaded windows, loved it for the free midnight meals of tripe and Mexican chocolate with a side of cheese strata (probably just leftovers from the cafeteria that were reheated in an X-ray machine), loved it for the autonomy. We thrived on the exhilaration and novelty of serving an underserved population: the Mexicans, Filipinos, Cambodians, and Vietnamese in the neighborhood, along with the out-of-control, underprivileged, underbelly of San Francisco in the ’70s. Of course, not all of our patients were victims of society.

“Okay, Bob,” I said. “I got it. Don’t worry. I’ll take care of it, and I’ll call you.” Because there were no cell phones back then, this kind of give-and-take involved a lot of running back and forth to the nurses’ station.

With a few charismatic exceptions, you couldn’t find an attending physician within five miles of San Francisco General, but some of the best staff in the world were there: name-brand people. Because the place was, in effect, independently run by the residents, the chief resident was king and the senior resident was the prince. The most senior medical and surgical residents running the emergency room were the Tsar and Tsarina (no spirit of democracy there). As the senior resident
in the ER, I was the Tsar of Potrero Hill, enjoying a brief but eventful reign.

I remember a night when a woman came in and I thought she was in Addisonian shock—that she had Addison’s disease, a disorder of the adrenal glands that can lead to coma. How I sussed that out I can’t recall. It was about 10:00 at night. Unsure what to do, I called the hospital switchboard to get the phone number of the head of endocrinology, who was the only full-time endocrinologist on the staff. The operator assured me: “Sure, it’s okay to call him at home. He’s your colleague.” When he answered and listened to my plea, he said, “Are you fucking kidding me?! Take care of it!” and he hung up. So I took care of it. That was how it worked.

Bob’s sister was a Midwestern belle, blonde, very attractive, a little on the plump side, but very lovely. She arrived with the usual screeching fanfare that was the leitmotif of the San Francisco ambulance corps. We had it on good faith that anyone who couldn’t make it in the sanitation service was hired as an ambulance driver. There were no EMTs back then. The ambulance drivers could perform CPR and they could put in an IV. That was about it. And they could drive like mad.

The ambulance pulled into a bay surmounted by a portico, columns, and a little cupola—one of the entrances to the old TB sanitorium. Two ambulances could fit there at one time, and one bay was already taken. I watched as the attendants wheeled the girl out. She was deeply unconscious. In a car following close behind was the roommate, who rushed up to me and said, “You know, she’s got diabetes.” That was interesting, and would even have been useful had it been true.

They brought her to the trauma room. She looked bad: pale, sweaty, and her fingertips and toes were blue. Clearly, she was in shock and was vaso-constricting. Everybody on the team was nervous. After all she was a doctor’s sister.

Nurses in trauma rooms are brilliant automatons. They’re adept at shearing off clothes in one fluid motion from bottom to top. They
stripped down Bob’s sister, put leads on her, and right off the bat we couldn’t get a blood pressure. She was about to die. They slapped on a cardiogram and it showed a very slow sinus rhythm. Tony Cimaranno was my surgical resident. He was a short, square Mafioso-looking guy from New Jersey, with the thickest, blackest, greasiest hair this side of the Rockies, and we were great together. As he used to say, he did the big cutting and I did the big thinking. “Al,” he’d bark at me in a deep gruff voice, “what do I do now? I can’t think for myself.”

It was all hands on deck. Her blood pressure was so low that Tony couldn’t find a distended vein to put in an IV. I started to do a cut down on her ankle, once a very popular and macho thing to do. There’s one big vein in the medial ankle, and if you can find it and slip your finger under it, it will fill with blood and you can stick whatever you want into it. Just as Tony said, “You’re never going to find it down there,” I found it, put my finger under it, incised it, and slipped a feeding tube into it—a quarter-inch pediatric feeding tube for infusing large volumes of fluid for shock and trauma. Once the line was in, the nurses started furiously squeezing the IV bags to flood the body with fluid and get her blood pressure up. We grabbed some neosynephrine and piggybacked it onto the saline to give it some heft. Neosynephrine is a drug that further constricts the peripheral blood vessels in order to ramp up the blood pressure. You sacrifice perfusion to the limbs in order to keep the brain, the heart, the viscera, and the lungs getting adequate blood. The fluid was now pouring in, the neo was pulled along with it, and when I say pouring, I mean pouring. You could look at the buret hanging from the IV pole—a long transparent fluid-filled cylinder with marks on the side—and it was like Niagara Falls. Her blood pressure came up but her limbs looked awful. She was intubated by this time, and somebody was breathing for her by squeezing a bag connected to the tube. I told one of the nurses that this was Bob’s sister, and she said, “What could it be? Diabetic coma? Shock?”

“She’s having her period,” another nurse said, “and there’s a tampon in there. It looks like toxic shock.”

At that time toxic shock syndrome was just being recognized. It was named in 1978, but we had been seeing cases for a few years before that, and at first had called it staph sepsis. Several of our clinicians were already onto the idea that it was due to an infection caused by tampons, and that’s what this looked like at first. She had a rash, which fit, and I said, “Holy moly! You’re probably right.” So we grabbed some antibiotics, gave them to her, and she stabilized, but too easily. “It’s not toxic shock,” I said after a few minutes. We had already had a few deaths from toxic shock, I had seen it, and this definitely wasn’t it.

We were now twenty minutes into it, and had been through one wrong diagnosis and one feint to the side (the roommate trying to juke us out with the diabetes). I said, “What else could it be? Let’s get blood cultures and bring her up to the ICU.” She was still on a ventilator. Her blood pressure was acceptable, but it was dependent on the continued infusion of massive amounts of fluids. Every time we tried to reduce any of it, the bottom fell out.

At San Francisco General in those days, the first, second, and third diagnoses in a case of coma was overdose. That was just common sense. The neighborhood was awash with drugs. Opiate overdoses were a dime a dozen. At that time Seconal was freely available on the corner opposite the hospital. You often could not figure out what kind of junk was out on the street on any given day, but if you supported the victim’s breathing, they would get through it. Often, it was a cocktail of drugs that produced mental depression, excitation, and psychosis all together, as if everybody was in a rush to finish an advanced psych course and meet their maker at the same time. But not Bob’s sister, no way. That just seemed too weird.

I called Bob and said, “I think you better get over here. I don’t know what the hell’s going on. Your sister’s here, she’s in really bad shape, I’m calling in Hibbard. I want him to come down and help us out.” Hibbard Williams was the legendary chief of medicine.

The powerhouse service at the hospital—the medical intensive care unit—was called CHEST because the pulmonary specialists ran it. It was a coveted rotation because as a resident-in-training you were right in the meatball stew. It was like a MASH unit. Ambulance drivers would routinely go the extra five miles if they had somebody in really bad shape, somebody who needed the Navy Seals of acute medicine. A few things were probably done wrong, but more lives were saved there than in any other place I’ve worked. Hibbard was supposedly on his way, the team was still trying to stabilize her, and now Bob was coming. That’s when our intern showed up: Linzner, a kid who was perpetually in my doghouse. Linzner came over, lifted up her eyelids, and said, “Another heroin overdose?”

I said, “What the hell are you talking about?”

He said, “Look at her pupils! Sheesh!”

Nobody had noticed. Her state of shock and the neosynephrine had given her enlarged pupils down in the ER, but now, almost two hours into it, I could see her tiny pinpoint pupils. We gave her some Narcan and she woke up almost immediately. She and her roommate had both been doing heroin.

Narcan, or naxolone, is an antidote for an opiate overdose. It competes with narcotics to bind to the brain’s opiate receptors, and kicks them off so that they lose their effect. We infused it, and she woke up in thirty seconds. Her blood pressure came back. Great news, but I was fuming.

Linzner! Why of all people did it have to be Linzner?

I was constantly riding him while the other senior residents were cutting him slack because he had been sick for most of the previous year. As far as I was concerned, he was one of the worst interns we’d ever had. He was a distracted, unkempt, thick-glasses, nebbishy kind of a guy, which would have been fine if he had just done the damned work.

Yet out of the mouths of babes . . .

If anyone who was not one of Bob’s friends—somebody from another
service, maybe, or even Linzner—had met her at the ambulance bay, he would immediately have said, “Overdose!” He would have given her Narcan within the first two minutes, and restored her blood pressure immediately. What I should have known, what I now know too well, is that on any given day anyone can poison herself, accidentally or not, and have a seizure or fall into a coma. Suspecting an overdose of some kind is not a transcendent judgment about them or their lifestyle or their character. It is one moment in somebody’s life. People poison themselves all of the time.

In spite of me, Bob’s sister came through it just fine, and was none the worse. But she had taken such a massive dose that Linzner had to stay up all night to give her more Narcan every ninety minutes. Served him right.

Fortunately, Hibbard, the Big Chief, never showed up.

6. A WISE OLD BIRD

As a fourth-year medical student, my mind was set on cardiology. I had gone to the National Institute of Health to do a cardiology rotation at a time when that specialty was making a change from the classical approach—listening to the heart—to a technologically driven skill set, with echocardiography and coronary angiography at its core. As soon as I realized this was the case, I started to think cardiology didn’t need me. I wasn’t convinced I would be more useful than any other schmo. Then something happened that left no doubt that this was indeed true.

Her name was Denise Arduzzi, a twenty-two-year-old Portuguese-American woman who had lupus. She was in the ICU recovering from an attack when she became comatose. I can still picture everybody arching over the bed like a siege of herons: the kidney doctors who were taking care of the renal failure and the dialysis, the cardiologists who were taking care of her pericarditis (frequent in lupus), and the
rheumatologists, who are supposed to be in charge of lupus in general, all of them struggling to keep her alive but unable to figure out what was going on. Then an old-time neurologist, a wise owl by the name of Robert Layzer, showed up as the consultant, and the herons made way for him. He touched, he tapped, he turned her head from side to side, and when he was through, he looked up and said, “Basilar artery thrombosis.” This was before MRIs, and just as CT scans were becoming available, and it absolutely blew me away. How the hell did he do that?

“Give her heparin now,” he said before he left. “Don’t wait for an angiogram. Do that when you can, but give her the heparin now.”

Because there was so much at stake, they gave her the heparin, an anticoagulant, and she got better. Eventually they did the angiogram, and—what do you know?—she had a thrombosis in the basilar artery: a stroke.

Who was that masked man? Before he had arrived, it was an instance of the blind men and the elephant, and not even an elephant, more like a pachyderm with humps, a mane, and horns. Then the owl drifted in, and using only his clinical skills, he cracked the case. It was a save, but it wasn’t the save that sold me. If she had died it would have been upsetting, but it wouldn’t have discouraged me because I was still thinking:
Where am I needed?
The herons were busy keeping her alive by giving her dialysis, but that was nothing, a trivial and almost axiomatic thing.