I want to be a good doctor. But I don’t want to bend, fold, spindle or mutilate anybody in the learning process.
I tell myself the transition will be gradual. A world-famous place like this can’t allow the mistakes of an inexperienced intern. I’ll probably have too much supervision and my training will suffer. With my credentials I could have gone to any program in the country, but I chose this hospital because of its clinical, rather than research reputation. I want to be a clinician, not a rat-lab doctor hustling money from drug companies or defrauding the NIH.
It will be a good idea if I familiarize myself with the hospital before I start my internship. If I’m comfortable with the hospital, it should relax me.
I ride my bike to the hospital, lock it to the bike rack, and stand in front of the building. I gaze upward. The place is massive. The center story must go fifteen floors, and the wings of the hospital must go ten stories. The hospital has twelve hundred beds. Our medical school’s hospital has three hundred and fifty. As I approach the center entrance, I feel like the north and south wings close in on me.
Inside the place is old, stately, formal, and intimidating. Noise echoes down the corridors. I feel like I’m in a cathedral. A church and a hospital are similar. They harbor trust, hope, and faith.
On the walls hang portraits of ancient professors dressed in long, white coats or military uniforms. Their names are famous and recognizable for the medical syndromes or surgical procedures named in their honor. I’m impressed. Maybe my picture will hang there someday.
They look stern, confident, and have lots of gray facial hair. They have seen it all and they know it all. The oils are dark, cracked, and need cleaning. The historic professors stare at me in judgment, with little expectation. In unison I imagine them saying, “Your portrait will never hang here.”
There are nine paintings on the west wall and twelve on the east. Three ancient elevators service the floors. I time them. If it takes less than twelve seconds for the elevator to arrive, I will take the elevator. If it takes longer, I will use the stairs. No wasted time; efficiency will make up for my lack of skill. I will be of help to my supervising resident even though I have little experience.
Each floor is separated by two flights of stairs, and each flight has twenty-one steps. There are three nurses’ stations on every floor, six bathrooms, and between every sixth room is a wall clock. The hospital is organized in comfortable multiples of three. This is good. Three is my lucky number. I try to avoid thirteen. Friendly numbers and counting relax me. I’m a bit obsessive, but then obsessives make the best doctors.
I’m issued a long, white coat that is too baggy. I feel like I’m wearing a starched tablecloth. Stuffed into the pockets are medical instruments and notes on what to do in case of any medical emergency. I transposed a large medical textbook into three-by-five cards using a hand-cramping, fine-point Bic pen. It’s beautiful work. We are told to arrive tomorrow at eight in the morning.
I didn’t sleep the night before. I arrive early. It is ten minutes before eight; I am punctual, as always. I notice a young man sitting at the nurse’s station. Ignored. I’m ignored also so I introduce myself.
“Hello,” I say. “I’m David Larco. I’m the intern.”
He stands. We shake hands. His hand is almost as cold as mine. He is tall, thin, has shoulder-length brown hair and a well-trimmed beard. He looks like an Anglo-Saxonized portrait of Jesus on black felt.
“Good to meet you. I’m John Ross, the other intern on the service.”
“Are you nervous?” I ask, hoping he would say yes, for my anxiety needs company.
A little didn’t do much for me. I’m jump-out-the-window nervous.
“We’re the only ones here. The other residents and interns should be here by now,” I say.
“What if it’s only us?”
“They wouldn’t do that.”
I try to reassure myself and start to count the number of tiles on the floor till I hit a multiple of three, then add, “They wouldn’t have us round on all these patients without second- and third-year residents. We’re really med students, we don’t know anything.”
“Of course not. Not at The Hospital. They couldn’t risk their reputation on us screwing up.” John adds, “Did you see who is our attending professor?”
“It’s Benjamin Owens. He’s a big muckety-muck around here.”
“I’m a what?”
We turn around.
“I’m Dr. Owens.” He ignores the muckety-muck comment.
I’m David Larco, intern.”
“I’m John Ross, fellow intern.”
“You boys look good. I wish I was your age and starting all over again.”
I wish I could walk out of the hospital.
Dr. Owens looks like he stepped out of one of the oil portraits. He wears a black suit, white shirt, and silver tie. He looks formal and overdressed for secretion-rich hospital work. His gray moustache and goatee are trimmed to a millimeter. Wire-rimmed glasses with thick lenses magnify his eyes, so when he looks at you, you feel like a specimen on a microscope slide. He removes and cleans his glasses, holds them up to the light, making sure he gets all the smudges. He puts his glasses on and starts picking at his pants and suit coat, removing lint and other particles. His hands are small, with glossed nails.
He looks at us a little too long, not saying a thing, then finally, “Boys, I know it’s your first day. You must be nervous. You’ll do fine. Relax. Tell me about yourselves; I want to get to know you better.”
“David Larco, from the Ohio State University.”
“Great football school. Woody Hayes, three yards and a cloud of dust.”
I’m in my place. Woody just got fired for clobbering a Clemson player.
“John Ross, Harvard.”
“Oh, Harvard, very impressive. World’s best medical school. You didn’t get into the MGH, but you can probably help Dr. Larco anyway.”
“Just kidding. In fact I think the best interns we have are kids from schools that have a VA. They get lots of practical experience, thanks to those veterans. Those medical students get to do lots of procedures; some have done surgery.”
I’ve never stepped into a VA.
Owens continues, “Now, here is a list of your patients. Get to know them. I’ll meet you here tomorrow at eight, and we’ll go over them.”
There are twenty-two names on my list. John’s list is longer. We only carry four or five patients in medical school.
“Excuse me, Dr. Owens, where are the supervising residents?” I ask. “The second- and third-years, those with experience?”
“They’re on other rotations,” he says. “We’re all equal at The Hospital, even on day one.”
“So we have no backup? There’s nobody to go to for help?”
“You won’t need it. You’ve been selected because of your great credentials. Our reputation allows us to take the top American graduates, no foreigners.”
“Those are medical student credentials,” I say. “They don’t mean anything.”
“Dr. Larco, the internship is about finding your threshold. We throw you in the deep end to see if you can swim. We’re doing you a favor.”
“Threshold?” I ask.
“Yes, threshold. If you have a high threshold for stress, you go into cardiac surgery. If you have a low one—dermatology, medical administration, or research. You will find your niche somewhere between those extremes. You know I can’t, for the life of me, figure out why dermatologists make more money than heart surgeons. It doesn’t seem right.”
“What happens to the patients while we’re finding our threshold?” John asks.
“It doesn’t seem fair or safe,” I say.
“You boys will be fine. See you in the morning.”
I lose the coin flip and am on call the first night. Shit. Forty lives depend on me. I start to count my breaths in an attempt to slow my breathing down. Yoga stuff. I’ll try anything to avoid hyperventilation. I hyperventilated once, before an organic chemistry test, and went to the student health center, where the old doctor laughed at me and had me breathe into a paper bag. Then he said, “It happened to me, son. That’s why I work in a student health clinic. No stress.” I didn’t appreciate his words until now. I thought a doctor is a doctor.
The paper bag works better and faster than Valium. I keep one handy. What if it happens here and I’m incapacitated? I imagine a nurse telling the patient, “See that young man over there, the one breathing into a paper bag? That is your doctor. Feeling confident?”
Owen’s gone. John’s gone. I’m alone.
I count breaths—one Mississippi, two Mississippi, three Mississippi… The pager screams. I jump. I call back.
“Dr. Larco, medical intern,” I say.
“This is Dr. Masters, senior on the orthopedic service. We got an old boy here, did his hip. Now he’s crashing. He’s trying to die on the orthopedic service and we can’t allow that. Ruins our stats.”
“I’m just an intern. This is my first night. I don’t know how to order anything. You guys keep him on your service, and I’ll write some orders. I have no supervising resident.”
I am desperate.
“I know,” he says. “I don’t know why they run the place like this, but they do. It sucks for you guys. You have no help. This is a famous place. If the truth gets out, they’re screwed. It’s a con game. What is and what should be are very different at The Hospital. Last year they had a suicide on the medicine service. The guy was married and had two kids. Freaked out. We’ve too much backup on surgery. We can’t cut alone. Your patient’s coming up on the elevator. May the force be with you.”
A guy committed suicide last year? I feel real good now. Can it get that bad? Must have been bipolar, I hope, and not a high-functioning obsessive-compulsive. I look around for something to count, but the elevator door opens and discharges an old man delirious and moaning. I put my hand on his head. He’s hot.
“The man has a fever,” I say.
“Brilliant,” the orderly says.
The nurse laughs.
“We’ll get the old gomer in bed, then you can examine him.”
I wait outside the room. They’re waiting for me to call the shots. I think back to med school lectures. It must be an infection and shock. But what if it is a blood clot in the lung? That happens after hip surgery. I review my medical notes.
I try to get a history, but all the old guy can do is mumble. I put him on vancomycin and gentamicin, the antibiotics we use when we don’t know what we’re treating. But he could have a blood clot, so I put him on heparin to thin his blood.
I did it all in thirty minutes, during which time I answer calls from nurses asking for aspirins, laxatives, and sleeping pills for their patients.
“I’m dealing with life and death, don’t bother me with that crap.”
“Larco, you can’t talk to nurses like that. I’ll write you up.”
I slam the phone down. I sit alone, having just taken care of my first patient. I did okay. What if something more challenging comes in? I’m the person responsible. They’re firing real bullets at me, and I can’t call for back-up.
I start to get nervous again. I count ceiling tiles, the number of charts in the chart rack, my breathing, then stick some gum in my mouth and count chews. I’m trapped. It is ten o’clock. Ten hours to go. Ten is not a multiple of three and that bothers me. Not even the numbers are helping. The beeper whines, sending a tonic-clonic bolt of adrenaline through my body.
“Dr. Larco here.”
“This is Dr. Jaworski from Lance Community Hospital; got an eighteen-year-old girl. She’s just delivered a baby. She’s toxic, blood pressure’s over two-fifty systolic. We got to get her to you guys. I can’t stabilize her. I can’t get her pressure down. She’s gonna have a stroke.”
“Can’t you keep her till the morning, when our staff comes in?”
“No, we’re not equipped to deal with this sort of thing.”
“How long have you been in practice?” I ask.
“Fifteen years,” he says.
“Well, I’ve been a doctor for a day, and I’m really not comfortable with this.”
I also want to tell him I might hyperventilate myself into a seizure. Then who’ll take care of the girl?
“You have infrastructure; it’s a bad case. I’ll probably get my ass sued for being at the wrong place at the wrong time. I switched calls. You’ll get help. Besides, you have insurance; I’m in OB, I’m bare. If you don’t get her blood pressure down, she’ll bleed into her brain.”
“No, I won’t get any help. This place isn’t what you think. You don’t understand what’s really going on here.”
He hangs up while I say, “We don’t have infrastructure, we don’t have shit, it’s just me.”
The beeper goes off. More laxatives, aspirins, and sleeping pills. A nurse calls me for an IV start.
“I’ve only put in two IVs in my life.”
“Well, she doesn’t have any veins left. Call the surgical resident.”
I go to the patient’s bedside. The patient has a blood disorder, she’s hemorrhaged into her brain. She’s in a coma. No hope. I call the surgical resident. He arrives. He’s not happy.
“What’s this all about? I’m trying to sleep. I have to operate tomorrow. Damn interns.”
“You mean hold retractors,” the nurse says. “They don’t let you guys do squat.”
“The patient’s line came out. She needs a new one, and she has no veins,” I say.
“I’ll throw in a central line.”
“Her blood won’t clot,” I say. “A central line’s too dangerous. She could bleed to death. We should do a cut-down on a vein in her arm; we can control the bleeding. You put an IV line in her neck, and we’ll never control the bleeding.”
“It’ll take too long, I need to get some sleep. I’m putting in a central line.”
“I think that’s a mistake.”
“You’re just a July first intern. Let me handle this.”
He opens the central line kit and goes to work. I want no part of the central line. I leave for the cafeteria, but it’s closed. It is now two in the morning. No food. It’s okay because I am too nauseated to eat. No sleep; I’m wired anyway. I didn’t count my breaths for a while; too busy. I don’t have time to think about having a panic attack. As long as I am in motion, the panic wouldn’t come. When I stop and think about what I did or what I might have to do. I get nervous. I am doing okay. No major disasters. But I have this girl coming in with high blood pressure. I’ve never managed high blood pressure in a pregnant girl. I don’t have a supervising resident, so I go to the library. It’s locked. I start to breathe fast. The beeper sounds and snatches me back from hyperspace.
“Code blue on the general medical service, room 779.”
I have to run to a code, even though we have not been instructed on how to manage a patient in cardiac arrest.
I’m a fast ex-track man. I arrive first. Damn, that’s a mistake. Should have run slowly or backward.
A nurse shoves me into room 779. The patient is not breathing. Eyes open, mouth open. He’s turning blue.
“Call anesthesia,” I shout.
They follow my orders. That surprises me. I have this blue guy in front of me. Now what do I do? I’ve only resuscitated rubber mannequins. It’s how we learned mouth-to-mouth resuscitation.
I start doing mouth-to-mouth. I didn’t think if he had a communicable disease. The patient comes first. He starts to pink up. I am surprised how well you can inflate another person’s lungs with mouth-to-mouth. You get a pretty good seal. I am breathing life into the guy. Resurrection. The CPR team and anesthesia show up. The surgeon looks at me. It’s the same one who put the central line in the other dying patient.
“Cut that out,” he says to me. “That’s the nurse’s job.”
Then vomit splashes my face.
“He got ya. See, I told you that’s the nurse’s job. Get out of here. Take a shower. Don’t ever do mouth-to-mouth again. It’s not worth it. It’s disgusting. What if he has TB? They always vomit. They didn’t tell you that in med school? God, everybody wants to die tonight.”
I keep my head down, turn off my pager, and head for the shower, counting my steps. I don’t care who would call for what. I must get clean. I shower, towel off, and put on surgical scrubs.
I check the beeper—nine unanswered calls. One stat, logged in ten minutes ago. I’m in trouble.
I call the floor. The nurse is screaming, “Larco, where the hell have you been? That lady he put the line in is bleeding. There’s a lump the size of a golf ball in her neck. You told him not to do it. It’s not your fault.”
I race to the patient. My oversized coat catches on something, ripping the pocket, and my three-by-five cards fall out. I can’t stop to pick them up.
I stop at the patient’s door. The patient has a mass of blood around the inserted central line. I enter the room and place my hand over the line, applying pressure, but the bleeding continues.
“What’s her blood pressure?”
“Ninety over sixty. I’ll open up the saline and page the surgical resident.”
I count the monitored mechanical pings of the patient’s heartbeats. After 187 beats the surgical resident appears.
“Look.” The nurse points to the patient’s neck. The mass of blood expands to the size of a softball. Her head is turned up and to the left. Then a loud, grating, snoring sound.
“Shit, the blood is collapsing her airway. She can’t get any air,” the surgical resident says.
He looks worried. He no longer appears cocky and confident.
The wet, snoring sound grows louder.
“We need to put her on the ventilator; get a tube down her.”
“She is not to be resuscitated. She’s terminal.”
“I can’t listen to that noise,” says the nurse. She leaves the room.
“I won’t listen to that,” the surgeon says. There is a tremor in his voice.
He takes a tube and places it into the woman’s windpipe. The snoring stops. He should not do that. He should not have put that line in her either. The patient is not to be resuscitated. No tubes. No respirator. But I’m glad he did. I can’t stand that noise either.
“Damn, we need to open her chest and tie off what’s bleeding.”
“Get the transfusion ready.”
Then the shrill whistle signaling that the person is dead. You have five minutes to do something.
“Call a CPR,” the surgeon says.
“No, you don’t,” the nurse says. “She’s a no CPR. You’ve done too much already.”
Her blood pressure is zero, her eyes fixed and dilated.
The three of us stand there like gawkers at a car wreck.
I break the silence. “I guess I should pull the tube out of her mouth.”
You can’t,” the charge nurse says. “She still has a heart rhythm.”
She points to the metallic green heartbeats that snake across the monitor. She turns on the volume—blip, blip, blip.
“But that’s just an agonal, useless rhythm. She is dead,” I say.
“As long as she has a heartbeat, you can’t pull the tube out unless your attending professor is here. If she goes flat line, you can pull it.”
“Let me get this straight. I’ve worked all night, flown by the seat of my pants. I’ve had no help with the living patients. Now I’ve got a dead patient on a ventilator and can’t take her off without my attending here? That makes no sense,” I say.
“That’s the way it is at The Hospital.”
The patient is dead, but the machine continues to move her chest up and down. She still has a heartbeat that’s imitating life. Ventilating a dead person is eerie. The breaths are slow, steady, and peaceful. I admire the peaceful rhythm. My breathing subconsciously becomes in sync with the dead patient. I start to count the patient’s breaths rather than mine. The dead patient is helping me; a final good deed. She slows me down. I’m calm. The dead really do teach us.
We have her set for twelve breaths per minute, that’s 720 breaths per hour; my attending will be here in two hours. I will count 1,440 breaths, then my attending should arrive, and we can take her off the ventilator. Count and I will be all right, provided that the young girl with the high blood pressure doesn’t arrive.