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Triplets

My doomed internship was at a very famous place. I must have had shortcomings.  Could this world famous place be wrong and I am right? Unlikely. I mean this place was really famous, a historic, venerable institution.

At my exit interview the chairman of the department of medicine said he was very disappointed in me. They expected much more.

“So did I,” I said.

“But then you came from a new untested medical school. We were curious. We’ll be more careful about taking doctors from that school in the future.”

Thanks.

I graduated number one in my class or so it said on my dean’s letter but I’ve always wondered how they knew I was number one seeing how everything was pass- fail.  Anyway I got a lot of notoriety because as a third year medical student I diagnosed a bowel obstruction in a very old lady, using sophomoric clinical skills and Sir Zachary Cope’s Early Diagnosis of the Acute Abdomen. My copy is over forty years old.  I love that book. It’s a go to book and can get you out of a jam.

I recalled examining the old lady. I heard the high- pitched tinkling bowel sounds of her tight as a drum, distended, obstructed abdomen. Her abdominal x-ray revealed the air fluid levels of obstruction. They looked like clouds in an Ansell Adam’s black and white landscape photograph. I told a fellow third year medical student that I believed the woman had a bowel obstruction, and that she had a lump in her groin. So it looked like an incarcerated inguinal hernia causing a bowel obstruction.

My classmates told me I should call her doctor.

“Her doctor’s treating her for the stomach flu,” I said. “I shouldn’t disturb him. He’s with patients.”

I must be wrong. I wasn’t a doctor yet. I didn’t want to embarrass him and I couldn’t believe he would miss the diagnosis and that a neophyte, an uninitiated, had bettered him.

To show respect I waited until the next day.

The doctor, a white haired, friendly, seasoned family practitioner took us on rounds. We approached the bedside of the patient and I said, “Doctor I think the lady has a bowel obstruction and she has a mass in her left groin.”

The old physician looked at me, smiled, felt the ladies left groin. She winced. The smile left his face. I, a lowly medical student, had saved his ass.

He looked at me. He knew it. I knew it.

He frowned, shook his head.

He folded his stethoscope into his white coat.

“I’ve been at this too long. I’m slipping,” he said. “Someday you’ll be in my place.”

He seemed to age in just a few minutes.

Those words didn’t register then, but now as I approach that old doctor’s age , they serve as a warning.

At that time I was simply in the stratosphere over what I had done.

The family practioner called a surgeon, who examined the patient, announced it was a bowel obstruction due to an incarcerated femoral hernia and took her to the operating room.

I saved the woman’s life.

I was an instant hero. The old doctor retired six weeks later.

The faculty of the medical school was very happy with me.

Internecine competition and animosity existed and polarized the non-academic private practitioners and the university physicians. The medical students were caught in the crossfire. I scored one for the university doctors and received excellent well-connected recommendation.

I would graduate from medical school and start my residency in eighteen months. Despite they hype I couldn’t take care of patients. Not yet anyway. Of that I was certain.

It was important for me to find a training program that provided adequate supervision. I didn’t want to hurt anyone.

I toured several medicine programs but was concerned that the teaching and supervision was the primary responsibility of senior residents. Residents who didn’t have many more years in than I had.

I interviewed at a very famous hospital and was informed that seasoned physicians provided the primary teaching and supervision. The ultimate responsibility rested with internationally renowned experts.  My exposure would be gradual. I would learn from individuals who had been doctors for decades, not just a couple of years.

I was reassured and chose to go to that famous program.

The joke was on me. The experienced clinicians were in the hospital for only a few hours a day. I learned they considered their teaching rotation as a quasi vacation.  The rest of the day we were unsupervised first year interns.

Nights were a lonely, frightening, disaster.

During that year of a trial by fire internship I took care of very difficult patients without support. I used the Merck Manuel and the Washington Manuel and Zachary Cope to try and navigate my way through. It was frightening.

Affluent insured people came from all over the world to have their case taken care of by me, a doctor now for a few days. Unsupervised I took care of patients that even today would give me pause: a pregnant woman who threw a blood clot into the lung, an acute leukemic, actually several acute leukemics, a few in blast crisis, a patient with colon cancer that caused renal failure due to metastatic obstruction, septic shock and hemorrhage, a condition that should have gone to surgery but remained on the medicine service. GI bleeders, pulmonary hemorrhage, etc.etc.etc.

There was also very little sleep.

One weekend I went into the hospital on Friday and did not return home till

Monday with maybe three hours of sleep per night tops.

I don’t think I hurt anybody except maybe one patient.

That patient was dying of advanced cancer. She lost her intravenous line and there was no port through which we could administer fluids.

I called the surgeons. A second year surgical resident came to the bedside and I told him that the lady was dying, in a coma, was not to be resuscitated but I thought we should insert an intravenous line to provide fluids and comfort medications.

The resident said he would place a large central line. I told him we should do a cut-down on her arm as she had a prolonged bleeding time. A cut down would allow us local control of any bleeding that might develop. He frowned and complained that a cut down was a time consuming procedure.

He attempted to place the line in the large vein behind the woman’s collarbone.

He hit the artery rather than the vein. We watched the patient bleed and choke to death. Slowly. She was a comatose, terminally ill cancer patient oblivious to what happened, but still.

It sickened me.

I had enough.

I went to the head of the medical department and told him there was something wrong at the hospital and I believed the lack of supervision was institutionalized malpractice.

The head of the department was now an administrator who didn’t appreciate or care what was really going on, but like all administrators I have come to know became very offended, hostile, and vindictive once the institution was questioned. Mistakes don’t bother them, discovery does. An administrator must first protect his or her job.  It was a lesson I would learn over and over.

They must shoot the messenger.

I was shot. I was history. I was out.

I needed a place to finish my medical training so I called several programs that a year ago I turned down. A few remembered me. A very prestigious university program accepted me in their program.

So I left the famous place. Was it me? Was it them?  Somebody didn’t know what they were doing. But they had the reputation. Perhaps I wasn’t cut out to be a physician. Doubts seeped in.

I was required to repeat my first year. Actually I wouldn’t repeat the first year as a medical resident. I would have to come to the program as a resident in medicine and anesthesia. I would have to spend six months putting people to sleep.

Today anesthesia training programs are very competitive. But forty years ago medical students wanted a patient centered career in medicine, surgery, pediatrics, or obstetrics.

The modern medical student endeavors to score high enough on the national boards to comp out of being a doctor. If you score high enough you can be a dermatologist, radiologist, ophthalmologist, something with very little emotionally entangling patient exposure.

It’s the long white coat flight away from the bedside. Only the students who don’t score high enough on the national boards, or the foreign grads, go into patient care.  Patient care is difficult and doesn’t pay as well.

So I entered the university program as a resident in medicine and anesthesia.

The anesthesia training was a pleasant surprise. I learned to do stuff. It gave me the confidence I needed. I felt I could raise the dead. Anesthetized patient are often close to death so it’s good practice. If you suffer a cardiac arrest you should hope an anesthesiologist is there.

I learned to put in central venous lines, arterial lines, Swan- Ganz catheters and intubate patients and put them on a ventilator. I did it as an intern; supervised by second and third year residents. I developed a deep respect for the unsung anesthesiologist, and second and third years residents, and their ability to teach.

I learned and nobody got hurt.

I was committed to be a doctor that took care of patents. Not just ancillary. Medicine fascinated me and it still does.

The anesthesia department needed somebody to work in the surgical ICU. Real anesthesiologists want to be in the operating room, not in the ICU.

Also anesthetized patients produced flashbacks of that lady in a coma who bled to death before my eyes. I wanted to avoid any reminders.

I volunteered to work in the ICU and help the comatose wake up.

I was on call every other night. Shocking by today’s schedules where every fourth night is considered onerous. Hours are regulated.

To be immersed and focused in a clinical setting with appropriate supervision is a good way to learn. Disease is not regulated.

The surgical ICU was located on the first floor of the hospital, adjacent to the operating rooms.

The doors to the ICU opened and closed giving a vacuum sound.

I was sealed into a world of alarms, flashing monitors, ventilators, and the critically ill.

The ICU was a large open space about the size of two basketball courts. An isle bisected the space. One side of the isle was reserved for the post open-heart surgery cases and the other side was for general surgery cases and obstetrical cases. I was responsible for the management of the post open-heart cases.

I was not to cross the isle.

Taking care of the open-heart cases was routine and the nurses guided me through. The major difficulty was the temperament of the cardiac surgery residents. They weren’t very affable nor were their attending bosses. But opening a man’s chest and fixing the heart is a high stress, highly scrutinized occupation. It leads to a short fuse and decompensation. I understood.

I gave it my all and got along with them.

We avoided the general surgery cases and the OB cases. We hovered over the hearts.

It changed one night when the nurses told me I had to examine a young woman who had just delivered triplets.

It was a time before fertility medications turned women into octo-moms.  Triplets were rare.

“I’m supposed to take care of the hearts,” I said.

 

“The nurses can take of the hearts. We got a sick girl who just delivered triplets. She’s in a coma.”

“Call her attending.”

“I did.”

“Who is it?”

“Smith.”

“Damn,” I said.

“What did he say?”

“He said, ‘I’ve removed the placenta, that’s all that’s needed.’”

“Okay,” I said. “I’ll take a look at her.”

I crossed the isle to the other side of the ICU.

Several nurses huddled around the girl. Her abdomen remained distended. Her body drained of color.

She was young and in a coma.

Another flashback, another reminder, another woman in a coma.

This one wasn’t terminally ill; this one could be saved if I had acquired the skills.

“How old is she?” I asked.

“21.”

“What are her vitals?”

“Her pulse is 50, her respiratory rate is 10 and her blood pressure is 240 over 135.”

The nurse pointed to the Foley catheter draining her bladder.

“She has no urine output. She’s in kidney failure.”

I looked at the patient and noticed her breathing had slowed.

“We have to intubate her. Put her on the ventilator.”

I went to the head of the bed, pried her mouth open and used a straight blade laryngoscope to visualize her larynx.  Her vocal cords were white and glistening. I slipped the breathing tube into her trachea and attached her to the ventilator. Her lungs filled with oxygen, her chest moved up and down. Her color improved.

“Set her up for twelve breaths per minute.”

With her safely on the ventilator I could focus attention on the high blood pressure.

A nurse said, “You got to get her blood pressure down. She could have a stroke.”

She had malignant hypertension, which led to the kidney failure and the coma. Pregnant women with hypertension have a high incidence of stroke. Her extremely high blood pressure and low pulse rate were indications that the pressure in her brain was dangerously elevated.

It was my time. I believed I was ready. I no longer needed supervision. Smith wouldn’t come in anyway. I was alone, but now I had skills.  I should be able to do this. If not, I would quit. A woman and three little babies depended on me.

To control her blood pressure I decided to put her on nitroprusside. At that time it was the most powerful anti-hypertensive drug available. It still is, but you’ve got to be careful when you use it.

“Get the art- line kit. I’ll call Smith and see if we can use nitroprusside so soon after a delivery.”

“Can you use it in kidney failure?” a nurse asked.

“Not for very long.”

“It turns to cyanide,” the nurse said.

“Yes, but it’s the only move I have. She can’t have a stroke or end up in a coma for the rest of her life.”

I called Smith. His voice was interrupted sleep heavy, and slow.

“Yes.”

“Dr. Smith, that young girl, the one who delivered the triplets, her blood pressure is extremely high and her kidneys have failed and.”

“She’s toxemic, I’ve evacuated the uterus. She’ll be fine.”

“Well, I would like to put her on nitroprusside, get her blood pressure down. I just want to make sure it would be safe to give nitroprusside.”

“As long as she doesn’t nurse.”

“Well I don’t think she’ll be nursing for a while.”

Smith hung up.

I returned to the girl’s bedside. I put a catheter in the artery at her wrist and attached it to a pressure monitor. We could now have second to second feedback of the blood pressure. Once the line was sewed in I started the nitroprusside.

I slowly brought her blood pressure down. You can’t bring the pressure down too fast, that too can cause a stroke.

There was still no urine output.

A nurse approached.

“The family and husband want to see her.”

“It’s okay,” I said.

The girl’s mother and father and husband walked in.

All three cried. The husband fell on the bed holding his wife and sobbed.

I watched the monitor, and the husband, making sure his forceful sobs didn’t knock anything loose. He was a big kid with a farmer’s tan.

The blood pressure was coming down, slowly and controlled.

Nitroprusside’s a good drug. Watch out for cyanide toxicity.

The family left. The husband’s tee shirt was wet, stained with tears.

A nurse said, “He looks younger than his wife. How would you like to be a widower raising triplets.”

“All three are girls.”

“Girls,” I said. “They’ve a better chance of making it than boys.”

“Not if they’re raised by a grief stricken father. He’ll screw them up.”

“How are they doing?”

“I’m told they’re in the neonatal ICU but they’re doing okay. One had to go on the ventilator.”

“How much do they weigh?”

“They’re between three and four pounds. They have a good chance.”

I wanted this girl to survive. I had four lives at stake, five including her husband. God knows what would happen to him if she didn’t make it.

Mom and dad didn’t look so good either.

I moved a cane rocker to her bedside. I sat, and rocked, and observed.

I dozed off and would wake up periodically to check the monitors and see if the kidneys were working. The blood pressure was controlled nicely with the nitropursside but there was no output from the kidneys.

Back to sleep.

A nurse gently squeezed my shoulder. I woke up.

She pointed to the catheter draining the woman’s bladder.

“You did it. Her kidneys are working.”

I was groggy, headachy, nauseated.

“She’s still in a coma,” I said. “But with her kidney’s working she should be able to clear the cyanide.”

I left the general surgical area to survey the condition of the post open-heart patients.

The nurses gave me the thumbs up. All was well with the hearts.

I went back to the girl.

A gurgling sound came from her throat. Her eyes opened. She reached for the tube in her throat.

The nurse grabbed her arm.

The girl used her other arm and removed the tube from her throat.

Patients coming out of a coma are very clever.

More gurgling and stridorous snoring sounds. My mind flashed back to the woman who died at the famous hospital. Her trachea collapsed from a massive blood clot.

The nurse suctioned her mouth, removing blood and all sorts of other junk secretions.

I got a new tube to put down her throat.

“Wait,” the nurse said.

We watched. She took a few breaths.

She went back into a coma but now she was breathing on her own. She could swallow and protect her airway.

The family came in.

They watched her breathe.

The husband broke down and once again hugged his wife.

I wasn’t as concerned because the big guy couldn’t knock her off the ventilator.

“She’s doing better I announced to the family. She’s breathing on her own.”

Mom and dad smiled.

“But she won’t wake up,” her husband said.

I shined a light in her eyes.

Her pupils constricted to the light, which was a good sign. I looked deep into her eyes with an opthalmoscope. Her optic nerve was blurred indicating that despite control of her blood pressure, the brain pressure remained dangerously high.

“She has increased intracranial pressure. It will be a few days before she wakes up.”

“Will she wake up?”

“Of course,” the nurse said.

The family left.

I asked the nurse.

“Why did you tell the family she would wake up?”

“Because that’s the only thing that will keep her husband together. That boy’ll blame himself if anything happens to his wife. Look at him. He’s the type. He’s simple but nice. He won’t tolerate a bad outcome. His life, his future, his beliefs rest on what happens.”

“What if she doesn’t wake up?”

“She will.”

“How do you know?”

“I’ve been praying.”

I forgot I was in the Blue Ridge Mountain Bible Belt.

“I’m leaving, I’ll be back in the morning.”

I went home. My wife met me at the door. She was very pregnant. I didn’t tell her about the girl.

I returned in the morning. I hustled to the ICU.

The woman was sitting up. She was awake. Surrounded by her husband and parents.

She looked around the room. He eyes focused on me. But nothing registered in them. They returned to bewilderment.

“She doesn’t talk. I think she’s blind,” her husband said.

“It will take time,” I said. “She’s made a lot of progress in twenty-four hours.”

She remained in the ICU for a week. She no longer met ICU criteria but the nurses wouldn’t let her go.

Her neurologic status was still tenuous. She continued to gaze around the room.

Every morning I would arrive and my first stop was the girl’s bedside.

Minimal, if any progress.

Most of it wishful thinking by me.

On the tenth post partum day it happened.

The girl sat up. Her confused eyes scanned the room stopped and focused.

“Who are you?” she asked.

Her voice was slow and thick.

I started to reply but the nurse said, “The doctor who saved your life.”

As if on cue the girl’s family walked in. Each held an infant.

The babies wore pink hats and pink booties.

They looked a little small and orange- yellow but they had healthy, loud cries.

 

*     *     *

 

I spent three years at the university hospital located in this bucolic southern city. I became a doctor, confident and trained other young physicians.

My wife delivered. All went well. We had two children and would stroll our babies through the city and wave to the young couple pushing their babies in a three-passenger baby carriage.

It made me feel real good.

The babies must be in their mid thirties now. I hope they did well. I hope their mother didn’t suffer any long- term complications.

I hope they’ve had a nice life.

I have.

 

published in : paperplates Vol 8 #3

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