M&M

By Danielle Ofri

[“M&M” first appeared in The Missouri Review, then in Singular Intimacies: Becoming a Doctor at Bellevue]

The body wasn’t even cold when they informed me that I would be presenting the case at M & M.  For the next forty-eight hours I clawed at the minutia of the chart, trying to absorb every laboratory value and X-ray report.   I was already hallucinating blood gas numbers and ventilator settings.  My intestines were roiling from caffeine.

I had never killed anyone before, so I didn’t know what to expect.  I mean I had been to M & M before, but never as victim.  One year, in a brief fit of morbid quaintness, the chiefs actually passed around M & M candies at Morbidity and Mortality rounds.

Lord. 

I hesitated at the door, determined to control my hyperventilation.  The heat was building up under my stiff white coat and I could feel my skin growing sticky.  I made a damp grab at the doorknob.

The conference room was already packed, but it wasn’t the usual crowd of scruffy medical students and overtired residents.  It was all attendings – all real doctors.  I scanned the assemblage of gastroenterologists, cardiologists, radiologists, surgeons and critical care attendings.  I saw junior attendings, senior attendings, division heads, nursing supervisors and hospital administrators.  There was even someone from legal affairs.  There were so many levels of hierarchy in the room that I couldn’t keep track of who feared whom the most. 

The case summary was gripped in my right hand, a cup of coffee in my left.  Only a few drops spilled onto the typed sheets as I squirmed into my seat under the weight of their stares. 

 I wasn’t the only person who had made the error, but as medical consult – the senior medical resident – I’d been in charge.  Well, since this was UH, University Hospital, the attending was really in charge, so I guess he’d be at the top of the lawsuit.  And there were all those consultants on the case too.  But it’s always the resident who gets flayed for the screw-ups.  Residents are cheap labor for the private attendings.  We carry out their orders, do all their scut, but have little say in the important medical decisions like we do at Bellevue.  Of course when something goes wrong, who gets tossed into the fire at  M & M?  After all, this is an academic institution and we’re all here to learn!

Killing a patient.  Just a couple of months before the end of residency.  What a way to launch a career in medicine.  I had hoped for some salvation this morning, maybe a collision with the First Avenue bus on my way to the hospital, but no such reprieve was forthcoming.

 The head of the department uttered some platitudes about how this session was intended to be a learning experience.  I felt faint.  He nodded at me to begin.

 Sour tastes came up in my throat, but no voice.  I stared straight at the page, coaxing my vocal cords.  The buzzing of the fluorescent lights swarmed in my head.  I quickly sipped my coffee, realizing too late that I’d forgotten to put sugar in.  The bitterness smarted on my tongue and finally my dry words emerged.

“Mr. H is a 31 year-old white male who attempted suicide three years prior to admission by ingesting a bottle of lye.  His esophagus was destroyed, but a piece of colon was surgically inserted between his mouth and stomach.  Periodically he experienced esophageal strictures, but they were easily opened with balloon dilatation and he had no difficulty eating or drinking.  He had no other medical history and his only medication was an anti-depressant.

“Last Wednesday he was admitted to University Hospital with symptoms of nausea, vomiting and dizziness.  His admission labs were within normal limits.  On Thursday, endoscopy showed esophageal strictures.  On Friday he underwent successful balloon dilatation of the strictures.  By Saturday the patient was already able to swallow soft foods.

I was medical consult at UH that weekend.  As the senior medical resident I was responsible for all the interns and residents on call.  I had to handle all admissions and transfers, and of course any codes.  I was irritable just having to be there – I preferred to work in Bellevue.  Maybe Bellevue didn’t have as many amenities, but at least we residents got to make all the decisions about patient care.  At UH we had to ask the attendings permission for every little thing.  It was bad enough when I was an intern taking care of Dr. Schwartz and didn’t know that much medicine, but as medical consult, when I finally knew what I was doing, it was annoying and insulting.

“Later that morning the covering GI attending (Mr. H’s regular doctor was off for the weekend) was called at home because the patient was hypotensive.  Systolic blood pressure was in the 80s, whereas the patient’s baseline pressure had been 100-110.  The attending gave a phone order from home to administer intravenous fluids.

 Weekends at UH were the worst.  Thirty hours of roaming this infernal place.  Everybody was old and sick and in a bad mood.  The nurses were crabby on weekends.  The attendings hated to be disturbed at home.  I had an old bunk bed to sleep on, with sagging springs and sheets that usually smelled like the previous resident.  Luckily, I suppose, I rarely had time to use it.

“Later that afternoon the intern was called to see the patient because the blood pressure was still low despite IV fluids.  At that time the patient complained only of mild nausea and some dizziness when standing.  The intern documented a blood pressure of 81/59 and a slightly elevated pulse of 110.  There was no fever and the patient was breathing comfortably.  On physical exam the patient was noted to have minimal abdominal tenderness.  Labs were drawn, including a blood gas.  Portable X-rays were ordered.”

The intern caught up with me at the elevator at 6 p.m. on Saturday. “I don’t know about this guy,” he said to me.  “His pressure’s still low, but he looks great and says he feels fine.  I don’t know what to make of it.”  I gulped down my coffee and we went together to see the patient. 

The smell of sickness wasn’t so strong in Mr. Herlan’s room – he hadn’t been there long enough.  The New York Times was spread out on the bed and I could see that he’d already finished the crossword puzzle.   Saturday’s puzzle!  I was impressed.   A half-empty bottle of ginger ale was on the nightstand.  My left  hand probed Mr. Herlan’s belly as we spoke.  He was a slender white man with dark hair, dark eyes and finely chiseled features. “Really, doc,” he said, “I feel okay.  I’m a little dizzy, a little nauseous, but it’s no different than I’ve felt all week.”

“The X-rays were within normal limits.  The white count, electrolytes and hematocrit were unchanged from baseline.  But the lactate was elevated at 6.8.”

Damn, 6.8!  Elevated lactate meant that something was brewing somewhere.  Somewhere in his body there were tissues that weren’t getting enough oxygen.  Mr. Herlan certainly didn’t look as sick as his lactate suggested, but I had learned the hard way never to trifle with elevated lactates.  Something bad was going on.

What could be causing the elevated lacate in Mr. Herlan?  Maybe the balloon procedure from yesterday had ruptured his esophagus.  Or maybe it had caused a few ‘micro-perforations,’ enough to allow intestinal bacteria to seep into his bloodstream and spread an infection.  Or maybe something totally unrelated to the balloon procedure was going on.  Any one of a hundred bad things could raise the lactate.  But once the lactate was elevated things could turn sour quickly.  Based on his blood tests, X-rays and physical exam, I  couldn’t really say what exactly was percolating under his skin, but I sure as hell wasn’t going to stand around doing nothing with a lactate of 6.8. 

I called the covering GI attending at home to ask if I could move Mr. Herlan to the intensive care unit.  No attending at UH ever wants to get sued – he said okay.

“The patient was started on triple antibiotics to cover for possible infection.  He was transferred to the ICU at 7 p.m. with a blood pressure of 77/54.  The patient was anxious, but he was mentally alert and had good urine output.  He had no other specific complaints except mild nausea.  His temperature remained normal.”

Mr. Herlan pestered me as we wheeled his stretcher down the hall.  “Why do I have to go to the ICU?  It’s only a little upset stomach.  I’ve had this a million times before.  Ginger ale and Mylanta usually do the trick.  Maybe we should just wait a little longer and see if it gets better.”  He twisted his head on the pillow so that he could see me better.  “I’m not really that sick, am I?”

Why do patients always ask these questions?  How can you answer honestly without scaring them?  Nobody goes to the ICU because they’re healthy!  But at least he’s talking and urinating.  If his blood pressure – low as it is – is sufficient to send oxygen to his brain and kidneys, then things can’t be too bad.  

I leaned over to Mr. Herlan as we waited for the service elevator.  “I’m concerned about your low blood pressure.  The fact that you feel okay is an excellent sign, but the ICU is the safest place to be.  Just in case…”  My words and thoughts trailed off.

Mr. Herlan reached for my hand.  “I’m kind of nervous, doctor.  I don’t really like hospitals and IVs and blood tests.  Even Band-Aids give me the willies.  Do you think you could call my friend John at home?  Don’t make it sound bad, but I’d like him to come to the hospital.  Would you mind?”  I nodded as we entered the ICU.

Six nurses descended like locusts upon Mr. Herlan.  They whisked him from me and swallowed him into their domain, hooking him up with tubes, wires and monitors.  I leafed through the chart until I’d located John’s number.

After the nurses finished mechanizing Mr. Herlan, it was the doctors’ turn.  Time to place the Swan-Ganz catheter into Mr. Herlan’s body to monitor his internal pressures.  Swan’s were much larger than standard central lines.  Three feet of bright yellow rubber tubing that would loop from his jugular vein to his heart through to his lungs.  From there it would transmit detailed information about the blood pressure inside his heart and lungs. 

I loved to show off to the interns how efficiently I could insert a Swan with barely any blood spilled from the needle stick.  Then I’d impress them with the one-handed sutures I’d carefully honed over the years.  Between the numerous Swans and central lines I’d done at Bellevue and my evening practice with mint dental floss, I could spin those one-handed sutures with my fingers so dexterously that they appeared to arise like magic. 

But this time, the Swan wouldn’t go.  I got my needle easily into the jugular vein, but I could not coax the catheter to float down to the heart.  I wiggled the Swan, trying to take advantage of the natural curvature of the tubing, but it wouldn’t go.  I pulled back, then reinserted, but nothing happened.  Just go in, damn it!  I pushed and twisted and goaded and prayed.  Come on, get in there!  The bright yellow Swan curled up on the bedsheet mockingly.  Two other people tried.  The Swan would not yield. 

I don’t have time for this aggravation.  I need to figure out what’s going on with Mr. Herlan.  I can’t waste my energy with this stupid Swan.  I’ll just have to live without those internal pressure readings.

“Because of initial technical difficulties placing a Swan-Ganz catheter, a regular central line was placed, along with a femoral arterial line.”

Mr. Herlan’s blood pressure hovered in the 70s.  I couldn’t let him sit with that low a pressure – any one of his organs could give out at any minute without sufficient blood and oxygen.  Time to start pressors!  I chewed on the edge of my tongue, hating to take such a drastic step without a Swan in place.  Pressors without a Swan was like driving a car without a steering wheel, but there was no way around it.  I had to get his blood pressure up.

“The patient was placed on a ‘neo’ drip at 8 p.m.  The surgical resident recommended a gastrografin-swallow X-ray to evaluate for possible esophageal rupture.”

I did another physical exam on Mr. Herlan, checking his heart and lungs.  He did not have an ‘acute abdomen’ suggesting an esophageal rupture, nor did he have a fever or white count to suggest an infection.  What the hell was going on?  Why was his pressure dropping? 

‘’I’m okay, really I am,” Mr. Herlan said, his voice quivering faintly.  “I just… just don’t like X-rays, that’s all.  All that radiation and everything.  Can’t I just try some Mylanta?  That’s what John always gives me when I get like this, Mylanta and ginger ale.  He says his grandmother swears by it.”  Mr. Herlan tried to laugh, but the sound came out in thin, stilted gasps.  “I’m going to be okay, right?”

The gastrografin-swallow X-ray would show escaping dye if there was a rupture, but in order to do it I’d have to send him down to radiology on the second floor.  Sending a patient out of the ICU with a tenuous blood pressure and a lactate of 6.8 was definitely courting disaster, but I needed to figure out what was going on.  Otherwise, how would I be able to help him?

“The patient’s blood pressure did not increase with maximum doses of Neo, therefore Levophed was added, again with minimal response.”

 “Another medicine, doc?  Do  I really need another medicine?”  Mr. Herlan asked as the nurses began the complicated process of preparing him for the trip down to X-ray.  They arranged the many intravenous lines, the arterial line, the cardiac monitor, the blood pressure monitor and the pulse oximeter on a portable cart.  “What’s going on, doc?  This is making me really nervous.  I…I don’t like all these medicines.”  His voice was beginning to sound parched.

I wished I knew what to tell him.  â€œWell,” I said, trying to sound casual, “your blood pressure is still a bit low.  At this point it’s not clear if it’s an infection that is making you sick, or a maybe a tiny hole from the balloon.  If this special X-ray shows a hole then the surgeons would come to fix it.”  No big deal, just a lactate of 6.8 that I can’t explain.  Just a crashing patient that I have no clue about. 

“Surgeons?  An operation?  I don’t know about that, doc.”  Sweat was accumulating at his hairline.  “I’m really feeling scared, doc.  Really scared.  Do you think you could you give me something to calm down?  Just a little something, because I…I get nervous in situations like this.” 

I hesitated, not wanting to further complicate an already confusing situation.  “It wouldn’t be the best idea, because it could lower your blood pressure, and it’s already pretty low.  I’d like to avoid making things worse.”

“Please doc.  You gotta help me.”  Mr. Herlan grabbed my hand forcefully and pulled himself up.  There was a wild look in his eyes.  “Please, I’m not going to make it otherwise.  I’m really, really scared.  Hospitals always make me scared.”

Medically, I thought it was the wrong thing to do.  What if I made him worse?  I had to watch out for myself too.  Mr. Herlan looked at me beseechingly.  His words were coming in fits and starts.  “Please doc.  I get anxiety attacks.  Ask John, he  knows…especially when I’m in hospitals.  I get so scared.”  His hair was plastered to his forehead with sweat and his pupils were as wide as cat’s eyes.

But how could I leave him in this state?  The poor guy was terrified.  I asked the nurse for a tiny dose of a sedative, hoping for a placebo effect.  Before I injected it, I sent off an arterial blood gas to check his oxygen status. 

“At 9 p.m. the patient was being readied to go to radiology, but his blood pressure was still low and he was complaining of increased anxiety.  A blood gas was sent and 0.5 mg. of IV midazolam was administered.”

Predictably, the sedative did nothing.  Placebos rarely work when you really need them.  Mr. Herlan became more and more agitated.  He was twisting in bed trying to sit up.  “You gotta help me, doc.  Give me something more.”  He yanked at my white coat, his teeth chattering.  “I’m so scared.”  He was breathing heavily and panting out his words.  “I can’t take it anymore,” he sputtered.  “I’m really scared!”  This was about to be a disaster – I didn’t need the results of the blood gas to know.

“Intubate this man right now,” I snapped, “he’s about to go down!”  The nurses rushed over with equipment trays.  I was ready to do it myself, but Mr. Herlan was a lot more agitated than Leo Teitelbaum had been.  Mr. Herlan was awake and fighting, whereas Mr. Teitelbaum had coded and was unconscious – or dead, depending on how you looked at it.  Luckily the anesthesiologist showed up quickly.  He placed the laryngoscope in Mr. Herlan’s mouth and started to feed in the breathing tube, but Mr. Herlan’s jerked his head violently and threw his elbows into the air.  He coughed and gasped for breath, lashing out with his arms.  I tried to explain why we had to do this, but he clawed desperately at us.  I held him down and rubbed his chest with my palm while the anesthesiologist took a break from trying to force down the tube.  He clamped an oxygen mask over Mr. Herlan’s face and took a few breaths himself.  I was glad I wasn’t doing the intubation.

“Listen to me,”  I said, trying to make my voice sound calm and reassuring.  “I know this is horrible, but you need this tube to breathe.”  Alarms were squawking and the oxygen mask was fogging up around Mr. Herlan’s mouth and nose.  “It’s uncomfortable going in, but it’s going to make you breathe better.  You’ve got to trust me.”  Mr. Herlan continued to thrash.  Tears were running into his oxygen mask and they sloshed recklessly each time he swung his head.   Reluctantly, I turned to the anesthesiologist.  “Put him out.”

“The patient was intubated with some difficulty at 9:45 p.m. on Saturday night.  Heavy sedation was required.  Copious pink frothy sputum was noted in the endotracheal tube.”

 â€œShit,” I said, “he’s in pulmonary edema.  His lungs have flooded.  Twenty milligrams of IV furosemide, stat!” I shouted.  “Somebody get me an EKG machine!”

“The EKG showed sinus tachycardia with normal intervals, but there were no R waves.  The admission EKG had been normal.”

 â€œWhat the hell is going on now?”  Panic started to constrict my stomach.  “Is he having an MI?” I asked to no one in particular.  “He’s too young for a heart attack!  He’s only 31.  Get me another Swan-Ganz catheter kit.  I’ve got to get a Swan in.” 

Just stay calm.  Stay calm.  Gotta get that Swan in to figure out what’s going on inside.  Don’t puncture the lung when the needle goes in.  You still have a clean record in the pneumothorax department.  Residency is over in a couple of months – this isn’t the time to drop a lung.  Just stay calm.  Don’t drip sweat on the sterile field.  Ease that needle into the jugular.  Don’t let your hands shake.

Good blood return, now slide in the guide wire, nice and easy.  Don’t cause any arrythmias when you get near the heart.  Don’t puncture any vessels.  Now ease that catheter in.  Slow and steady.  Your patient is crashing, but you gotta stay calm and focus on the Swan going in.  If you screw up now you can really make things worse.  Right atrium, right ventricle, pulmonary artery.  Wedge the balloon, slow and steady, don’t cause a pulmonary hemorrhage…and we’re in.

Thank you, God.

“Initial Swan-Ganz readings were: pulmonary artery pressures of 48/39, wedge pressure of 42, cardiac output of 3.6.  Patient continued to produce pink, frothy sputum.”

 Jesus, he’s in cardiogenic shock, his whole circulatory system is collapsing.  I think I’m collapsing.  What the hell is going on?

Everything was happening so fast that I hadn’t even thought about calling the GI attending.  This is UH, I reminded myself – I have to call the attending.   And it’s not even Mr. Herlan’s regular doctor, it’s a covering attending. 

I stumbled over my breaths as I recounted the downward spiral of the evening over the phone.  I prayed that the attending would have some magical solution that I hadn’t thought of.  After all, he’s the attending.  But he didn’t.  I asked him for permission to obtain a cardiology consult and a critical care consult.  

The intern leaned over my shoulder, “Is the attending going to come in tonight?”

“Nope,” I said, “He didn’t even offer.  Thinks we’re doing a great job, though.”  Life in a private hospital.  Only a few more months of being at the bottom of the heap.

I called the critical care attending at home.  Maybe he would be so impressed by the gravity of the situation that he would drop his Saturday night plans and come right over to the hospital.  But he didn’t.  I know, it’s a hassle driving in from Westchester.  He suggested that we evaluate for auto-peep on the ventilator.  The cardiology attending didn’t offer to see the patient either; he sent over the cardiology fellow instead.

“The blood gas revealed severe acidosis, with a pH of 7.0.

“Bicarb,” I shouted, my voice starting to crack.  “I need bicarb.”  If his pH drops any further, he’s going to code any minute now.  “Two amps of bicarb, stat!” 

Mr. Herlan was bucking the vent and thrashing in bed.  He fought the air that was pulsing down his throat.  Sedatives weren’t helping.  Cardiogenic shock, severe acidosis and I can’t even get him to take in the oxygen that he needs.  “Let’s start a pancuronium drip,” I called out to the nurse.  It was a last ditch effort, but paralyzing all his muscles might be the only way to allow the ventilator to give him oxygen.  I wasn’t going to waste time calling the required pulmonary consult for this one.

The nurse pointed out his blood pressure.  It was in the 60s even with the Neo and the Levophed running in at maximum doses. 

Damn!  What else to do?  Think of something.  Anything.  Now.

“Dobutamine!  Let’s get a dobutamine drip going.”  I didn’t know what the hell a third pressor would do if the first two hadn’t worked, but I had to do something.  “Another round of furosemide, IV push!  Let’s go.” 

Stay calm.  Keep thinking.  Hypotension.  Cardiogenic shock.  Pulmonary edema.  Severe acidosis.  What’s the common factor?  Which is the cause and which is the effect?  What’s precipitating the whole chain of events?  Think, damn it.  Think.

The nurses buzzed furiously at Mr. Herlan’s bedside administering the medications.  All the patients in the ICU were watching the action at Mr. Herlan’s bed.  I stood in the middle pressing my hands against my temples trying to make the brain cells work harder.  Think.

In the meantime, Mr. Herlan’s friend John had arrived.  I didn’t want him to see all that was going on at the bedside so I took him to the ICU lounge.  How to say that the patient is crashing and the doctors don’t have a clue.  The words ensnarled my tongue, mocking my frustration and ignorance.  I wanted to scream, I wanted to vomit.  I wanted to curl up in a corner and make Mr. Herlan, the oppressive ICU, the damn Swan-Ganz catheter, and the paralyzing pancuronium drip all disappear.  But I sputtered out some vague words about ‘hovering blood pressure’ and ‘possible infection.’  John listened attentively and waited politely for me to finish.  Then he spoke.

 â€œRaphael and I have been together for more than five years.  I’ve seen him go through lots of hard times.  When he tried to kill himself three years ago, that was the worst.  But he’s gotten a lot better and we’ve had some very happy times.  One thing I know is that he doesn’t want to suffer.  Do what you can, doctor, but if it seems like you can’t save him, let him go.  Just don’t let him be in pain.  I promised him that I would always look out for him.  Please…”

I led John to the ICU for quick visit.  Mr. Herlan’s skin was ashen but his body was now calm.  John could not know that the stillness was a cruel pharmaceutical hoax from the pancuronium.  I stared at the preternaturally tranquil body.  What was raging inside?  What was the answer?  John held Mr. Herlan’s hand and spoke quietly to him for a few minutes.  The nurse tapped him gently and said it was time to go.

“The cardiology fellow arrived at 11:30 p.m. on Saturday night.  A bedside echocardiogram revealed diffuse left ventricular hypokinesis.  The cardiology attending was consulted by phone.  He felt that the cardiogenic shock was likely secondary to esophageal rupture, not to a primary process in the heart.  Therefore neither an aortic balloon pump nor emergent cardiac angiogram were indicated.

“At that point the patient’s blood pressure was 64/35 on max doses of Neo, Levo and dobutamine.  Pink, frothy sputum continued to accumulate in the endotracheal tube despite vigorous and repeated suctioning.  Over the next few hours the pressure slipped to 43/27.”

I called back the GI attending.  His voice was heavy from slumber.  He reminded me again that he was only covering.   “Listen,” I pleaded, “this patient is going down the tubes despite everything I am doing.  He’s in cardiogenic shock, but cardiology doesn’t want to get involved because they don’t think it’s a primary cardiac problem.  Surgery doesn’t want to get involved because he doesn’t have an acute abdomen.” 

I felt my voice beginning to break.  “They want a gastrografin-swallow X-ray, but he’s too unstable to send down to radiology.  I’m trying to convince the surgeons to take him to the OR anyway to look for a ruptured esophagus, but they won’t take him with a blood pressure of 43/27.  The critical care consult won’t come in to the hospital.” 

Please, please don’t let me start crying on the phone.  “I’m treating him with triple antibiotics even though he has no signs of infection.  He’s on three pressors but his blood pressure is still bottoming out.  I even had to paralyze his body just so I could get some oxygen in him.  I don’t know what else to do!” 

“At 2 a.m. the covering GI attending came in to the hospital.  All the X-rays in the patient’s folder were reviewed.”

We arranged the X-rays in chronological order.  The GI attending, the surgery resident, the intern and I examined each and every film.  We scrutinized them for ‘free air’ that would indicate esophageal rupture.  Each chest X-ray showed a line of clearing just behind the heart.  We all agreed that it wasn’t free air – it was just an unusual shadow resulting from the surgically-attached piece of colon where his esophagus had been repaired.  We poured over every lab result and every Swan-Ganz reading.  We listened to Mr. Herlan’s lungs and palpated his abdomen.

The attending sighed and looked at the three of us.  “I don’t have the answer, either.  You guys have done an excellent job, but I think it’s over now.  Just keep him comfortable.”  He turned to me, “Listen, since you know Mr. Herlan’s friend and I’ve never met him, would you mind explaining all this to him?”   I nodded my head numbly, too weary to argue about whose responsibility the ‘discussion’ should be.  The attending jotted a note in the chart and went home.  It was nearly 4 a.m.

 â€œAt that point the decision was made for supportive care only.”

I went into the lounge to find John.  “I’ve called Raphael’s parents,” he said as I walked in.  “They’re catching the next plane in from St. Louis.”

I recounted the events of the night.  He nodded gravely with each pronouncement that I made.  I finally led up to the inevitable.  “At this point,” I hesitated, hating my job, hating the attending, “I think there is not much more we can do.”   I gestured stupidly in the air, batting at my meager words.  “We’ll just have to watch and wait.  But we’ll make sure that he is comfortable.”

John didn’t blink.  “I understand, doctor, and I appreciate your efforts.  I just don’t want him to be in any pain.  Would it…would it be okay if I spent a few hours with him?  Just until morning?”

I accompanied John to the ICU, but when I saw Mr. Herlan, I had John wait at the door.  I asked the nurse to help me. 

The nurse and I moved the EKG machine away from Mr. Herlan’s bed.  We unhooked a few IVs that were not necessary.  We tucked extraneous wires and tubes behind the bed.  We covered the yellow Swan-Ganz catheter sticking out of his neck with a folded white pillowcase.  We removed the old bandages and cleaned his skin where there were traces of surgical tape.  We switched the blood pressure and oxygen monitors from his arms down to his legs so that the blanket would hide them.  We adjusted the breathing tube in his mouth so the saliva wouldn’t accumulate in the corners.  We swept away the extra syringes and gauze pads from his windowsill.  We changed his hospital gown and combed his hair.  Then I called John in. 

From the door I watched John clasp Mr. Herlan’s hand in his own and kneel at the bedside.  He rested his head on their interlocked fingers.

 â€œThe patient’s friend remained at the bedside for the duration of the night.”

Dawn broke only a few hours later.  The sedatives and paralytics were slowly wearing off.  John came out to tell us that he thought Mr. Herlan was responding to him.  We all crowded at the bedside in disbelief, but indeed Mr. Herlan responded to the simple commands of “Squeeze my hand” and “Open your eyes”.  A chill ran through my shoulders and my palms flew to my mouth.  Faint rays of sunlight filtered over the gray of the East River and trickled into the ICU.   There was magic to a new day, I knew it all along.   I held my face tight, afraid that a smile might jinx our good luck.  Mr. Herlan’s blood pressure was still 54/34 on maximum doses of three pressors, and his lactate was still high, but he was responding.  His brain was still getting oxygen.  Silently I cheered for the sun.  I rooted for it to climb high and dazzle its brilliance into our little corner of the ICU.  I dispatched the intern to call the attending.  “I don’t care what time it is.  Wake him up.”

“The covering GI attending was contacted and informed of the patient’s condition.  He felt we should continue with supportive care only.”

 â€œWhat?  He doesn’t want us to do anything else?”

The intern nodded silently at me.

“Jesus Christ!  I hate this place.”  I started pacing violently in the cramped workspace of the ICU.  “I mean, the patient is still in terrible shape, but at least he’s somewhat responsive now.  That’s more than we had five hours ago.”  I banged into the chart rack each time I whirled around.   There was clattering as vials of saline flipped over onto the floor.  “I don’t know what else to do, but we have to do something!  Get critical care on the phone.”

“The critical care attending was also contacted.  He suggested an epinephrine drip, but said he would not be in the hospital that day.”

Now it was Sunday.  My thirty hours were over.  I was reluctant to go home and let anyone else take care of Mr. Herlan, but I had no choice.  I slept fitfully during the day, calling the ICU every few hours.  There was no change in Mr. Herlan’s condition.

First thing Monday morning I sprinted over to the hospital, even before I had my coffee.   Mr. Herlan was already dead.  I grabbed the chart and the intern and demanded to know what had happened.

The intern was despondent.  I could see the exhaustion in his body as he labored to speak.  “Sunday morning Mr. Herlan was really responsive to me.  He nodded his head and squeezed my hand to answer my questions.  I kept trying to convince the attending to get another cardiology consult but he wouldn’t do it.  He just wanted to stick with supportive care.”

The intern rubbed his eyes and then reached for a 10 cc syringe.  “Another cardiologist was in the ICU visiting a different patient,” he continued, pulling and pushing on the plunger of the syringe, “and I asked him to take a look at Mr. Herlan.   He didn’t want to get involved unless he was officially consulted.  But I pleaded with him, I begged him and he finally said yes.”

“The patient was seen by a different cardiology attending on Sunday whose impression was ‘cardiogenic shock with acute myocardial infarction superimposed on underlying cardiomyopathy.’” 

“So he agreed with us,” I said, “that Mr. Herlan was having a heart attack.”

“Yeah,” sighed the intern, “but he couldn’t say if it was the primary event, or just secondary to either esophageal rupture or overwhelming infection.  Besides, Mr. Herlan was too unstable at that point for any cardiac intervention, so there was nothing the cardiologist could do.  Mr. Herlan’s blood pressure was so low, but somehow his brain was still working.  He was communicating with me, I swear he was.  He heard my words.”  The intern looked at me with heavy eyes. 

“Sunday morning the patient’s family and significant other made him DNR.  Over the next twelve hours the patient’s blood pressure remained at 40/20 and he gradually became less responsive.”

I dropped the chart and stormed into the chief resident’s office.  “You’ll never believe this case from the weekend,” I burst out.  “ I don’t know what the hell went wrong!”

My chief resident looked up at me blandly from the journal she was reading. “Oh, Mr. Herlan?  He had free air in his heart.  That’s why he went into cardiogenic shock and died.”

“Free air?”  My muscles froze.  “What free air?  When did he have free air in his heart?”

She looked at me, half-bored, half-incredulous, “On Friday afternoon, right after the balloon procedure.  It’s in the X-ray report.  Didn’t you read it?”

 I reached for the edge of the desk for support.  I could feel my blood pressure plummeting as the chief resident calmly scrolled through the X-ray reports on her computer screen.  “It’s right here – ‘Free air superimposed in the right heart and base of the aorta, most likely within the pericardium or anterior mediastinum.’”

I sank back into the chair, my head reeling.  Could I have missed that?  Did I not notice free air?  I had examined every single X-ray myself. 

But I hadn’t, I realized with rising nausea, read the written X-ray reports. 

Usually the radiologists call immediately if they see an ‘emergency’ problem.   As the clinician, however, it was still my responsibility to read the X-ray reports in addition to examining the actual X-rays.  It wasn’t the radiologist’s fault, it was mine.  I killed Mr. Herlan.

“Family and significant other remained at the bedside.  Patient became asystolic and was pronounced dead at 12:35 p.m.”

I stumbled over the final words, trying vainly to keep my voice from cracking.  I took a sip of my lukewarm coffee.  I closed my presentation by quoting the X-ray report:

“Free air superimposed in the right heart and base of the aorta, most likely within the pericardium or mediastinum.”  

I lowered my eyes, adding that I had only read these reports on Monday morning, after the patient had died. 

My words fell off into an aching silence. 

Was I supposed to say something else?

The head of the department turned to the radiologist and asked her to formally review the X-rays.  She, herself, was only a moonlighter, who had been covering for someone else that weekend. 

The radiologist pointed to the X-ray that had been taken just after the balloon procedure on Friday.  With a sober, Eastern European accent, she explained the findings.  “Here we can see some air next to the heart.  I reported it as being within the pericardium or the mediastinum.”  Her voice began to quiver.  “I should have called the doctors immediately.  I should have, I know.”  She was nearly whispering.  “But I did not.  I made a mistake.” 

I tried to swallow, but my tongue was caked to the roof of my mouth.  The heavy air of the room seemed to shrink around me, pressing on my eardrums with that horrible feeling like plane propelling downwards.

The radiologist paused, attempting to smooth her white coat with trembling fingers.  Her hands skittered off the stiff material and hung, twitching, in the air.  “But now I realize that I had made two mistakes.  This is not free air in the heart at all,” she stammered.  “It’s not free air at all.  It’s only a shadow from the piece of colon that was added during his surgery three years ago.  This X-ray is normal.” 

The room was silent.  The radiologist slumped down in her chair and her head collapsed into her hands.  I tried to breathe a sigh of relief, but my mouth was too dry.  My eardrums were still throbbing.

The head of the department opened up the case for discussion.  Most of the audience stared down at their fingers.  One or two spoke up with some irrelevant comments on minor details.  A few glared at me from across the room.  No spirited academic debate ensued.  No enlightened educational themes emerged.  The proceedings were conspicuously anemic.

I wanted to get up and scream.  I wanted to yell at these pompous attendings who had abandoned the patient and the residents.  I had called them at home.  I had pleaded with them for help.

This is supposed to be a teaching institution, I wanted to holler.  I am still a doctor-in-training.  Where were they that night? 

And what about collegial respect, I wanted to add.  The patient’s well being notwithstanding, why couldn’t they have risen to the occasion for my sake? I was crashing on that night also.  Couldn’t they have helped me?  We’re all on the same team, aren’t we?  We’re supposed to be colleagues, right?

But I said nothing.  I still had to deal with these attendings in the future.

 If this patient had been at Bellevue instead of UH, I wanted to shout in their faces, it all would have been different.  The residents, not the attendings, would have been in charge.  We wouldn’t have had to beg for a cardiology consult.  This patient would at least have been taken to the OR to look for an esophageal rupture before his blood pressure had bottomed out. 

But no, in this place we were not allowed to make any decisions without the attendings’ permission, the same attendings who wouldn’t get out of bed to see the damn patient.  They didn’t have to sit with the patient’s friend at four in the morning and confess that our fancy medicines and high-tech ICU were powerless.  They didn’t have to watch the patient’s lover kneeling at the bedside for hours.  They didn’t have to look at the patient squeezing John’s hand, and then spit out someone else’s opinion that the situation was hopeless, even though there might still have been a chance.  They didn’t have to witness a patient their own age slowly expire before their eyes while they stood by like a useless shaman.

I remained silent.  The truth was, I realized miserably, no matter what we might have done, Mr. Herlan would probably have died anyway. 

The preliminary autopsy report was read out loud.  There was no perforation of the esophagus.  No bacteria were identified in his blood.  No traces of illicit drugs were found.

The department head felt that cause of death was most likely from widespread infection, despite the fact that the bacterial cultures were negative.  Micro-perforations from the balloon had probably released intestinal bacteria into the bloodstream.  The resultant infection overwhelmed the heart and circulatory system.  

“In reality,” the department head concluded, “Mr. Herlan died of his own hand.  It took three years for his suicide attempt to be completed, but it finally killed him.”

 I sat in my chair as the conference room emptied, my limbs unable to respond to my commands for movement.  The critical care attending came over to point out that I had never specifically asked him to come in to the hospital that night.  I could only look at him blankly. 

The room was shrinking around me fast.  My eardrums felt like they were about to implode from the pressure.  My stomach was in knots and the taste of vomit was in my mouth.  I suddenly had an overwhelming urge to disembowel someone with my own bare hands. 

But I just didn’t know who.