Authors: Robert Marion
One afternoon she had an acute respiratory attack; it was probably just mechanical, just her
[endotracheal]
tube slipping down her right mainstem
[bronchus, the breathing tube going to the right lung],
and she began deteriorating. She became cyanotic
[blue],
and her heart rate dropped. We readjusted her tube and she recovered a little but she still looked shitty. I felt really uncomfortable doing nothing, and yet, to bag her back was kind of a resuscitation. It was very unclear. And there was a senior, Eric Keyes, sitting there, and he said, “Forget it, just leave it, don't do anything.” It was so easy for him to say that, it was nothing for him, he was just looking at her and thinking, This kid's just a GORK, forget her. But I felt bad doing nothing. She was my patient. I'd made a pact, in a sense, to support her. So when she continued to deteriorate, I in fact did bag her a little. And then, after a while, she was fine again. I'm still haunted by that issue. It's one of those very gray areas of medicine.
I talked to Karen so many times about this baby. One night after a really long discussion, she said, “Listen, you have no medical basis for what you're doing with this kid. Why don't you just put down the side rails on the bed and let the baby fall to the ground and die? Is that any different from letting her electrolytes get out of whack because you're not doing blood tests on her? Why not just put down the rails?” In fact, putting down the rails wouldn't make a difference; the baby never moved anyway. But she was right; there was no medical basis for so many of the decisions that were made. Everything seemed so arbitrary and based on emotions rather than facts. I think we were very much guided by the fact that the mother just didn't want that baby anymore, she didn't want a baby who was so severely damaged. We consulted the mother at many points along the road, we involved this poor woman who had no support system and who had other kids at home to worry about, and these decisions were difficult for her to make. One day I asked her to come in because we needed to talk about something; she showed up late at night, hours after the time I had asked her to come. She came with this young guy, about seventeen, who looked scared and a little intoxicated, and it turned out to be the baby's father. I had never seen him before; he had been nowhere near the hospital for at least two and a half weeks. We sat in the family room for a long time and talked; we talked about DNR and the new thing we were going to withdraw and she said, “Go ahead.” It was as if she were saying, “Please don't let this baby live!”
It didn't really hit me how dismal Kara's prognosis was until I saw her CT scan. Her brain looked like a minefield; there was more space and fluid than there was brain tissue. This little baby had so little substrate to build her life on. But by then it was too late, all the miracles had been done on her; she just wouldn't die. I eventually got her off the ventilator and off the dialysis. I got her electrolytes corrected, I got her to feed, we stopped the antibiotics, and she became just a baby in a basinette. And one day we needed a bed in the unit and she was the most stable patient, so she was shuffled off to the Infants' ward.
The third patient was Emilio Diaz, a really adorable three-year-old with AIDS who had done so well for so much of his life. Emilio spent his first year in the hospital because there was no place for him to go. He was finally adopted by one of the nurses who had taken care of him when he was a baby. This woman really loved him. She married Emilio's father, an IV drug user who had AIDS so that she could legally adopt him and take care of him. She had done a lot to try to give Emilio as full a life as possible. He'd gone to Puerto Rico to visit relatives, he'd gone for trips all over the place, he'd done a lot more than your average Bronx three-year-old. And then he became sick and was admitted to the ICU and rapidly deteriorated. He had terrible pneumonia; he became ventilator-dependent and reached ventilator settings that nobody had ever seen before in the ICU. And he just kept getting worse until finally I had to have that horrible discussion with the parents about DNR on him, too. In Emilio's case, though, it was his parents who first asked about DNR. I suppose it's not surprising, since his mother is a nurse and very medically sophisticated. But one day she came to me and said, “He's suffered enough; we want to make him DNR.”
Emilio died one evening just after I left for home. He was there the longest of all three of these patients; he was my patient for a good three and a half weeks. It was so sad taking care of him. There finally came a point, around the time that he officially was made DNR, when I felt very, very depressed. Every time I had to go over to his bedside, every time I had to write a note in his chart or I had to look at his bedside clipboard or call for his lab results, I became severely depressed. It was really sad. Really sad.
Well, anyway, I learned a lot of medicine from those three patients and from the other patients I took care of in the ICU. I learned how to put in A lines
[arterial lines; like IVs, except going into arteries instead of veins],
I got good at intubating, and I learned about Dopamine and Dobutamine drips
[a class of drugs known as pressors, which raise blood pressure; they're used in critically ill patients who cannot maintain their own blood pressure]
. And I did a lot of thinking about ethics and the fact that, basically, we can keep just about anybody alive for an indefinite period of time but that keeping people alive may not be such a good thing. That's a hell of a lot to pick up in one month! And I think one of the reasons I was able to do all that was because of the people I worked with.
Diane was a great resident. She's very, very bright; extremely capable; and very talented. She has a very wry sense of humor. We were on call together five of my nine nights, and we had a lot of fun. I thought she was kind of attractive, too, but of course that was something I couldn't really tell her. Her body is very similar to Karen's, and I found that very erotic. I told her that the morning after the last night of the month we were on call together. I was kind of delirious and I don't know how it came up but I said something like, “You know, you're very erotic,” and she said, “What's wrong with you? You must be completely out of it!” And I said, “Yeah, I guess I am,” but in fact I had been thinking about it for a while. But I couldn't say it until then because we'd been on call and slept in that little on-call room so many nights together. Not that it would have mattered, for God's sake. Anyway, it would have been an inappropriate thing to have done.
Alex is a great attending, and he really was very supportive. He'd come up, give me these big bear hugs during the day, and ask me how I was doing. He said he was worried about my psyche all the time because I was taking care of all these very sick patients. He was a good teacher, too. And he has a really big heart, he really cared about so many of the patients. He was somehow able to be a very devoted and involved ICU director, there all the time, always available and really involved, and yet he could keep some distance and let the residents try to run the place.
On the last day of the month, Alex took us all to lunch, which no attending has done for me before. He was a role model for me. I felt maybe I could actually do this kind of thing for a living. Even though it was depressing and even though taking care of critically ill children is so far removed from what I originally thought I'd wind up doing, I felt having someone who really cared made a big difference. When you think about it, all you really need in the ICU is a good technician who knows how to run all the machines and monitors. You don't
need
an Alex George to run a unit. But I think his heart makes a big difference; Alex is what makes that place seem human and not just a mechanical torture chamber. I'm sure his being there has helped a lot of families. I know it really helped the house staff; his fatherliness, his caring attitude, it really made a difference.
And finally, there were the nurses. I really got to like those nurses. They're superb; they're fun to work with, they've got a great sense of humor. I learned to depend on them totally and to trust them. They do a lot of things that need to be done without you ever knowing about them. They ask you to write the orders for them after they've finished. They know so much, they're each like a doctor. Many times we'll be sitting there, scratching our heads, trying to figure things out, and they're flipping the dials, running the lines, drawing up meds, making decisions they are confident with. And they just say, “This is what you want, isn't it?” as they push it in the line. So they are real lifesavers, and I'm going to miss them.
Sunday, February 2, 1986
All year, anytime anybody's asked me to do something, I've done it without an argument. It seems it works only one way, though, because whenever I've asked someone to do me a favor, nobody's willing to help out. It's disgusting.
This is what happened: I started my two weeks in OPD last Monday. I had only two weeks to go before my vacation, so I figured it would be a cinch. But when I got home from work last Monday afternoon, Marie told me she thought Sarah was coming down with something. She hadn't eaten well during the day, which isn't like her, she'd been kind of sleepy, and she had a runny nose. Sure enough, I put her to bed at about nine and she woke up at a little after eleven, screaming at the top of her lungs. Larry and I ran into her room and found that she was burning up. I took her temperature: It was a 103.4°. It took about twenty minutes to get her to stop crying, and when she finally calmed down, I checked her over. I couldn't find anything specifically wrong, her ears looked fine and everything, but she still had rhinitis
[runny nose]
and she was coughing a lot, and I noticed the whites of her eyes were red. I figured it was just the virus that was going around. I gave her some Tylenol and rocked her back to sleep, and she finally dropped off at about midnight.
She woke up again at 2:00
A.M
. She was screaming, and her temperature was back up. I gave her more Tylenol and tried to calm her down, but this time she just wouldn't stop crying. I was sure she had meningitis and I told Larry to get dressed because we had to take her to the emergency room, but just as he finished getting his clothes on, she quieted down and fell back to sleep. I guess the Tylenol had kicked in. Anyway, she slept the rest of the night, but I didn't; I stayed awake in her room, watching her constantly. I was sure something terrible was going to happen.
On Tuesday morning, she woke up in a much better mood and her fever was gone. I figured whatever was wrong had reached its peak and now she was getting better. When Marie came, I told her about what had happened and made sure she knew how much Tylenol to give if the fever came back. I had clinic that morning and was going to be in the ER that afternoon and night, so I left Marie a schedule of where I'd be if she needed to contact me, and I left for work.
I should have called in sick, but I went to clinic anyway. Marie called at about ten-thirty to tell me that Sarah's fever was back and that she had this rash all over her. I told her I'd be home in a few minutes and I rushed through the rest of my clinic patients. I was done by about eleven and I ran home to find Sarah's fever back up to 103. She was miserable; she was coughing and sneezing and covered with snot, and she had a whopping conjunctivitis. And she had a raised red rash on her face and chest. I wasn't sure what it was, so I called Alan Cozza. He told me to bring her right over.
Well, to make a long story a little shorter, Alan took one look at her and said, “My God, she's got the measles!” I had never seen anyone with measles before; kids just don't get it, because we immunize them. Alan brought some of the other interns who were on the floor in to see Sarah just so they'd know what measles looked like. I have no idea where she got it; she's a baby, she doesn't go outside, she doesn't hang around with other kids except sometimes when Marie takes her down to the lobby, but that's rare. But anyway, she had it. Alan told me to take her home and give her Tylenol and fluids and just make her as comfortable as possible and that it would pass in a few days.
By that point it was nearly one o'clock. I was supposed to be in the ER starting at one, and since I was on call that night, I'd be staying in the ER until maybe three or four in the morning. So I decided to stop in and talk to the chief residents; I figured, hearing that Sarah was so sick, they'd naturally say, “Well, why don't you just stay home with your daughter tonight?” Yeah, right!
What they said was that two people who were supposed to be on call that night had already called in sick and they had to pull one person from the emergency room to cover and although they sympathized with me, they just couldn't let me off. If I didn't show up, there'd only be two house officers to staff the entire emergency room, and they just couldn't allow that to happen. They told me I should try to switch with someone who was scheduled to be on the next day, if I could find someone who would be willing to switch, but there was just no way they could give me the night off.
How nice of them! After all the abuse I've taken through these seven months! After everything I've done for them! Whenever they've asked me to do anything, I've always done it without a whimper! I filled in for other people, I covered wards I'd never been on before because somebody was out, and I never complained. I've repeatedly put my job ahead of my family, and this is the thanks I get! The one time my daughter is sick, the one night I need to take off, of course no one would do a thing for me. I asked everybody if they'd switch, if they'd cover for me this one night, and they all had some excuse. I should have just gone home. I should have taken Marie and Sarah home and stayed there and when they called me to find out where I was and why I wasn't in the emergency room, I would have said . . . I don't know exactly what I could have said. But, of course, I didn't do that. What I did was, I brought Sarah and Marie home and went back to the hospital.
The rest of that day was ridiculous. We were short-staffed in the emergency room; the place was like a zoo. Everybody in the Bronx was sick with the flu and had fever and vomiting and coughing. There was a six- to seven-hour wait to be seen through most of the afternoon and night. I rushed around that emergency room until four in the morning, and during all that time I didn't see a single patient who was as sick as Sarah. I really resented being there, and I must have told that to the nurses and the rest of the staff at least a thousand times.
Marie kept calling me all through the afternoon. She didn't exactly feel comfortable taking care of a baby with a fever that ranged between 103 and 104, and I can't say I blame her. I'm sure she was afraid Sarah was going to have a seizure or something. That idea crossed my mind a few times. So she called every half hour or so, saying, “Her fever's still up. What should I do?” or “Her eyes are getting very glassy. Are you sure you can't come home now?” Even she had a hard time understanding why I couldn't just come home to take care of my baby. And there wasn't anything I could say to her to make her understand because I wasn't sure I understood it myself.
I finally got out of the emergency room at about four. Larry was wide awake; he hadn't gotten any sleep, having been up with Sarah all night. Her fever was still up, and she was very irritable. She'd sleep for maybe a half hour and then wake up howling. It's so strange seeing her like this; she usually has such a good personality. And she was absolutely covered with the measles.
I was all set to call in sick on Wednesday, but Larry had already made arrangements to take the day off, and he told me I should go in. I went, and in the morning Alan called to ask me how Sarah was doing. I gave him a piece of my mind! I told him about how the chiefs had made me work the night before, and he seemed amazed by it. He said he'd go have a talk with them, but a lot of good that's done me! I'm really so angry. I'll tell you, this episode has really taught me a lesson. Let them ask me to do anything, let anybody ask me to cover or to switch; my answer is going to be
“NO!”
I don't care what it is or who it is, I'm not doing anything for anybody ever again! I've had it with these people! I've got to look out for my own interests, because no one else is!
Sarah's better now. The rash is starting to fade. Her temperature came down to normal on Friday, and she's not irritable anymore. By tomorrow she should be back to her old self. But I'm not going to forget this. You can bet they're going to regret making me work Tuesday night!
Saturday, February 8, 1986
I've just finished packing. My vacation starts after I finish my call in the ER tomorrow night, and we have a ten-twenty flight to Fort Lauderdale on Monday morning. I really need this vacation. I'm physically and emotionally exhausted. We're spending two weeks in a condominium near Fort Lauderdale; two weeks of lying in the sun and sleeping late. I can't wait!
Things have pretty much returned to normal. Sarah is back to her old self. The measles have disappeared, and the only things left from the whole episode are my anger and resentment.