Sometimes my voice is the last sound a man hears before he dies. When this happens, the realization, during the inevitable replaying of such dire cases, makes my stewing inadequacy suddenly more acid. That small talk and trite one-liners—the pattering reassurances of my profession—were his last human contact seems achingly unfair. Whoever he was, he deserved more.
Last Saturday, my 24 hours as the first-call anesthesiologist began with coronary artery bypass grafting for John Walter Patterson, a victim of a fresh MI. “First call” means I stay in the hospital from 7:00 a.m. Saturday until 7:00 a.m. Sunday, first up for anesthesiology responsibilities.
Mr. Patterson waited alone in the pre-op room. I read his chart and introduced myself: “I am the anesthesiologist who will be taking care of you.” I always say it that way because I want the patient to understand—as much as he can in the few minutes we have with him conscious—that I am there to take care of him, not just, as some people think, to give a potion and leave. I say, “While the surgeon is working with the heart (hernia, uterus, spine, ankle, etc.) I am responsible for the rest of you.”
Mr. Patterson had been healthy. When I asked him if he smoked, he sputtered, “Well, I did. Before this. I guess I quit.”
“When did you quit?”
I added my encouragement to his new resolution.
I explained my various jobs, then added that it should all be routine for this kind of thing, though we were working with an injured heart and there was always, of course, the risk of rare things.
He said he understood.
John Walter Patterson was 55.
Here it needs to be made crystal clear that, while no team is error-free, our anesthesia, surgery, and intensive care teams are very good at what they do. We demand excellence of ourselves. We regularly review problems and update protocols. We have anecdotes, plaudits, and years of statistics adequate to support self-confidence. We are nationally known for our care of the crashing and burning—figuratively and literally.
Mr. Patterson’s case was altogether ordinary. He went to sleep with the usual reassuring drone I use in hopes of imparting calm: “Close your eyes and picture where you like to go on vacation. It’s just oxygen in the mask—fresh from the mountains. You have nothing to worry about. We’ll see you in the ICU.” The nurse was holding his hand.
From there everything hummed along. We got Mr. Patterson onto the heart-lung bypass machine—the pump—and cooled him down without incident. His heart needed five grafts—an altogether ordinary procedure these days. There were no technical glitches, no unusual swings in blood pressure, no signs of trouble.
As we rewarmed him toward the end, his heart fibrillated—a common event. A quick shot of electricity brought it around to a normal rhythm. It was entirely undramatic—no one shouted ‘clear.’
His heart “squeeze” looked weak so I started a routine cardiac stimulant. The surgeon then weaned him off the bypass machine—the touchiest part of the affair. His blood pressure held up. The heart looked vigorous. The surgeon tended to bleeding points and I slowly gave the drug that restores normal blood clotting. The home stretch.
Everything looked fine for another ten minutes. Then Mr. Patterson’s blood pressure fell off a cliff. A perfect 110/70 went sharply to 75/45. I gave a dose of a pressor—a blood pressure booster. 65/40. I gave a bigger dose. 55/35. I gave epinephrine.
“I don’t know what’s happening,” I said to the surgeon. “I’m pushing meds and getting nothing. I’m giving epi.” This last sentence was not for drama, only to convey that I was at the end of the rope on my side of the surgical drapes.
The surgeon began squeezing the heart a perfect 80 times per minute and asked the team to get everything ready to go back on pump. Though there was no response to the epinephrine, my numbers and waveforms suggested the surgeon’s massage just might be adequate to keep Mr. Patterson’s brain alive.
During a brief suspension of the surgeon’s squeeze, we watched the heart beat with sonogram pictures from a probe sitting in the esophagus—right behind the heart. Three of the four walls of the left ventricle—the chamber that does all the serious work—were not squeezing with any force. Not completely flaccid, but weak. Too weak to support life.
We went back on pump, letting the heart muscle rest and hopefully regain some strength. The surgeon broke scrub and called Mr. Patterson’s cardiologist, then the next of kin—a brother in one of the suburbs. He told him he might want to gather any family.
I set up continuous drips of more heart stimulants. Re-scrubbed, the surgeon placed an intra-aortic balloon-assist device. Essentially an internal pump, the balloon can keep someone propped up for a day or two, sometimes long enough for the heart to recover.
The sonogram pictures were encouraging: all four walls of the ventricle were now contracting well. Relatively speaking, things looked good. The surgeon weaned Mr. Patterson off the pump. The vital signs, though far from perfect, were acceptable. “Survivable,” we say.
Again, for ten minutes, nothing changed. The surgeon tended bleeders.
Then, the cliff. 110 became 55. The sonogram again showed only a quarter of the ventricle squeezing.
The surgeon said, “He’s going to die.”
I said, “Yes.”
Friends, over drinks, will ask if we’ve been doing anything interesting at the hospital. When I tell them, some say, “I don’t know how you do it.”
I’ve never had anything meaningful to say in response. I picture them wondering how we stay up all night, how we work in body parts and bodily fluids, how we drive in each morning knowing the potential consequences of a serious lapse. They want to know how we redecorate the family room and make dental appointments while there are children and grandparents dying at work. From some, there is a hint of minor adulation for front-line health care workers. I shrug. I say, “Oh, you get used to it,” as if that somehow explained something. The real answer—at least what I know of it—doesn’t fit at dinner parties.
When I first saw patients die, I was totally unprepared. Like most med students at the time, I’d been a white-bread college boy who’d known for a long time—in the abstract—that he wanted to be a doctor. For most of us, the most arduous part of preparing for medical school had been organic chemistry in departments with institutionalized contempt for grade-grubbing pre-meds. We thought that was tough. The telegram of acceptance to the next level was an end in itself.
A few in my class had observed medicine, as hospital volunteers or research grunts. Such outings were said to impress med school admission committees as signs of sincerity, but they had struck me as having no more intrinsic value than watching Marcus Welby. I had rounded with my uncle, a general surgeon, and observed surgery. I think I’d seen enough to have sensed the nut of the thing: until you hold in your hands minute-to-minute responsibility for someone’s life, it’s all abstraction.
Medical school, for the first two years, was more abstraction: forty hours a week in lectures and labs, and most of the other waking hours buried in a book. Besides being emotionally desiccating, serious disease remained as theoretical as the enantiomeric structures of substituted benzene molecules, albeit more interesting.
Day one of Third Year, though, brought immersion.
Three classmates and I reported to our assigned ward at the University Hospital. Immediately before us was one four-bed room housing three women dying of advanced breast cancer and a schizophrenic woman suffocating from end-stage emphysema. Next door was a sweet little old lady whose debilitating scleroderma was splintering her skin and supporting structures. Next door to her was a 27-year-old drug addict, whose heart valves were being ravaged by bacteria from her needles. Across the hall lay a moaning woman whose kidneys and nerves had been destroyed by diabetes. She never rose from her bed during her nine months in the hospital.
Doctoring began thus: Several times a day I was called to help the woman with scleroderma. I was to push her rectum back inside her bottom. She would smile an embarrassed apology. I was more embarrassed that I had nothing to offer that would make it stay where it belonged.
The 27-year-old user adeptly bullied me, wanting to bargain something for every blood draw or medicine dose. With coaching from the senior resident I learned how to enforce limits and keep order in the treatment of her disease. I was a negligible annoyance in her life; she was an important passage in mine.
The emphysematous schizophrenic coded and died one night during week one. The moaning diabetic died during week three. Tallying both as unfortunate blessings was a fundamental lesson: we are limited. “Bad things happen to people with bad diseases,” we say.
My immersion is now going on 26 years. My job is, by turns, fascinating, boring, depressing, uplifting. The only constant in the subject matter is an ocean of breadth and depth. Disease, even at three decades, can show a new trick at any time. As an anesthesiologist, I once in a great while pull someone back from the edge. More commonly, I simply ease anxiety. Other times I feel like little more than a voyeur with mouth agape, barely able with my meager contribution to the show to pay for my seat, the best in the house.
John Walter Patterson suffered a massive heart attack during his operation. This is an unusual, but hardly unknown, phenomenon. Unfortunately it is a non-specific diagnosis; it merely describes the end point. There are a half-dozen major precipitating causes and twice as many less likely ones.
With the balloon pump and our continuous scrambling after minutiae, we were able to close Mr. Patterson’s chest and transfer him to the ICU, technically alive. His blood pressure stayed around 50/40. At one point he jerked his arms and head—possibly a reflex, possibly the first glimmer of consciousness. I spoke to him. He moved again. Even knowing it would take at least 10 points off his blood pressure I pushed more anesthetic.
Mr. Patterson’s case filled the first seven hours of my 24 as first call. My hospital is half the trauma system and a major referral center for the sickest patients for all of Oregon and parts of Washington, Idaho, and California. We are “shock troops” in a literal, if alternative, meaning of the term. Sometimes we idle away a day waiting for accidents or shootings that never happen, sometimes we fail in 24 hours to achieve a recumbent position or close our eyes longer than a blink.
With Mr. Patterson delivered to the ICU, I ate a late lunch. I walked to Medical Records and signed my incomplete charts. I checked the sports scores.
About 6:00 I was back in the ICU. Mr. Patterson’s brother was sitting and stroking his hand. The blood pressure was 45/38. I caught the nurse’s eye and raised my eyebrows, motioning to the monitor.
She half-closed her eyes and shook her head.
At 7:30 the trauma team was activated to the ER. A 45-ish man had been found unconscious halfway into a busy street, perhaps struck by a car, but no one had witnessed anything. He had told the paramedics his first name—Darryl—then refused to say anything more, probably regretting even that.
The medics delivered him in spine stabilization—a routine precaution. His wrists, though, were secured by half-inch plastic cable ties, a highly reliable sign that Darryl was unconvinced we were on his side.
My assigned spot is at the head end of the patient’s stretcher. I am responsible for examining what lies above the clavicles. Darryl and I regarded each other’s inverted faces. He was quite clearly awake and alert. He was just as clearly drunk. The only sign of injury in my arena was a small laceration at the top of his scalp.
One of the nurses took his arm and looked for a vein. Darryl had thus far resisted all attempts to get an IV and he thought to resist this one too. He rose in slow motion to forty degrees and shouted, “Fuck y’all. Bitch. Bitches! Assholes!!”
Being the person at the point of maximal leverage, I grabbed a fistful of his hair and returned him to his supine position.
“Fuckin’ bitch,” he said at me, his tone implying that he had truly dissed me.
I said, “Darryl, do you remember what happened to you?”
The nurse said, “Little sting here, Darryl,” and stuck his forearm with a needle the diameter of a #2 pencil lead.
He shouted, “Fuck y’all,” and lifted both legs off the board, flailing them sideways to try to connect with any flesh or bone he could find.
I said, “Oh, you shouldn’t have done that.” It had become precipitously clear that, for Darryl, compassion would require general anesthesia. He could be deeply injured and we could only examine him adequately with him unconscious; any other way would not be safe for the staff or for Darryl. I stepped a few feet away to retrieve drugs and a breathing tube.
Thanks to new and absurd regulations, such items are stored in locked cabinets. We have to fight with a computer, every time, to get what we need in order to restore order in these situations. Punching the keyboard, I cursed effete regulators.
Meanwhile Darryl continued his invective. The trauma surgeon, the ‘captain of our ship,’ counted the Fuck-you’s. He turned to me. “That’s three. He gets the tube.”
I replied, “Oh no. He bought the tube when he kicked at the nurses. You only get one of those.”
We do this so often that the nurses and therapists have everything teed up for me by the time I have the tube and meds ready. The nurse held up the injection port of the IV for me, an eighth-inch bulls-eye wavering slightly in space. Her other hand rested on Darryl’s throat, ready to press closed his esophagus the moment he was unconscious. This keeps whatever might be in his stomach where it belongs, not in his lungs or in my face.
As I pushed one, then another drug into the port I said, “Darryl, you’ll be going to sleep now.”
I lifted Darryl’s tongue with a steel blade, found his vocal cords, slid in the breathing tube, and then we hooked him to a ventilator. What had been dangerous and emotionally charged was instantly rendered methodical, competent, professional, quiet. The man could now be cared for.
The trauma surgeon that night happened to be the head of the trauma service. One of his favorite teachings to the residents was time-efficiency. He said to me, “You let him get over his limit on fuck-you’s.”
“It took too long to get the drugs,” I said. “I kind of liked his style, though. That Southern flavor. ‘Fuck y’all.’ Get all of us at once. More efficient.”
The surgeon said, “I’ll bet you ten bucks there’s not a thing wrong with this guy.”
“Does a cut on the scalp count?”
“Only if it needs a layered closure.”
“Then no bet.”
Within a half hour, by way of extensive lab work, X-rays, and CAT scans, we knew that Darryl had a blood alcohol four times the state definition of intoxication and a small cut on the top of his head—no stitches required. We mumbled rhetorical apologies about the $10,000 we had just spent on Darryl’s inebriation and scalp laceration, but we knew from experience with bodies found in busy streets that such money can only be tagged a waste looking backwards.
About 10:30 p.m. I got a “stat” page to the ER. This was most unusual. People in ORs and ERs generally use “stat” as a polite euphemism for an expletive. Paging the on-call anesthesiologist “stat” probably meant that somebody’s airway wasn’t open and the ER doctors—quite competent at airway interventions—had exhausted the usual tricks, most of mine included.
Sitting fully upright on an ER stretcher was a thin, 60-ish, black man with his tongue swollen to the size of an orange, protruding well out of his mouth. Surrounding him were a half-dozen ER nurses and techs. The ER doctor was emptying a syringe into the man’s IV. The faces turned to me.
I said, “Angio-neurotic edema.” I had seen, before this, two such cases.
“Uh-huh. He was gargling and this happened.”
“Last one I saw came from a peanut allergy,” I said. In that man, no one could pass a breathing tube via his mouth, so he received an emergency hole in the front of his throat to save his life. This man, Edgar, on close examination, was not struggling to breathe. At least not yet. We had a minute to think.
The ER doctor had pushed the medicines quickly, in order to hasten recovery from the allergic reaction, but things could still get worse. The calculus was simple: getting worse equaled no airway equaled dying. We decided to call the available surgical troops while transporting Edgar to the OR for a tracheostomy.
Once in the OR, Edgar was, luckily, still not in dire trouble. I had time to try a more elaborate procedure to pass a breathing tube via the nose. I knew it was unlikely to work, but there was little to lose and if successful it would save the man a surgical airway.
The procedure is done with the man sitting up, awake. To put him to sleep first is to risk airway collapse. I sprayed inside his nose and mouth with topical anesthetic then slid a flexible fiber-optic scope up one nostril and around behind his tongue, hunting for his trachea. I came close, but succeeded only in aggravating Edgar and creating a spectacle for a large audience of doctors, nurses, and techs, punctuated with cryptic denigration of my breeding in the voice of the trauma surgeon.
My futile efforts did bring some benefit though: in the time it took me to fail, we noticed his tongue had noticeably shrunken. The ER doctor’s medicines had, in Edgar at least, outpaced disaster.
We decided that it would be safe to put Edgar and his tongue under close observation in the ICU, tracheostomy instruments ready at the bedside.
Leaving the ICU, I stopped in Mr. Patterson’s room again. Nothing had changed. EKG was still pacemaker-driven at 100. Blood pressure was still 50’s, balloon-pump-driven. With most patients I could have tried a brief pause in the balloon pump or pacemaker to get a hint of any recovery of the heart. But I knew without touching a button that any interruption in either machine could have been the end for Mr. Patterson.
Mr. Patterson’s brother was still rubbing his hand.
What is remarkable about these cases is that they are unremarkable. They will not make the papers. They will not be written about in medical journals. Within weeks the only teaching point from the lot will be this: Someone will see a case of angio-neurotic edema and say, “Patients with their tongues swollen out of their mouths don’t always need a tracheostomy. I saw a case once…”
I know beyond doubt that our successes are not the product of any individual’s talent or hard work, but the current state of medicine, built on 2000 years of science, the ceaseless labor of our predecessors, and a medico-industrial complex that consumes/generates nearly an eighth of the American economy. The taking or assigning of individual credit for saving a life would be the height of arrogance, foolishness, or both. One could as well credit a rivet in an airplane for having delivered people safely across the ocean.
When the surgeon made rounds and found John Walter Patterson hanging by a thread, he did the compassionate thing: he turned off the machines. Cardiac activity ceased within minutes.
To take credit for saving a life would imply, in the converse, that the death of John Walter Patterson should consign us straight to hell, as killers.
Sunday morning, 1:00 a.m. In the nurses’ lounge I made hot cocoa in a Styrofoam cup. I ventured to the call room to try my luck at remaining in bed (versus the ER, the OR, or the ICU), and then actually sleeping, should I manage to remain in bed. Neither seemed likely. It was, after all, a hospital call-room. I’d been eating greasy food. I had in the not-too-distant past been scrambled from that bed like a pilot to a dogfight and my subconscious knew it would happen again. Or perhaps I was just slipping into the insomniac patterns of the aging human. Whatever the reason, at 7:00 a.m. Sunday, when I was no longer first call but had slid down the list to fourth call—last resort—I only counted myself lucky to have remained in bed since midnight, no matter how unrestful were the minutes with my eyes closed.
I signed out to a partner. She hinted that maybe I’d want to stay over to take care of a sick infant—my subspecialty—but we decided that second call could pick it up.
I dragged myself home. My dog was his usual overjoyed self. My wife pointed me at the coffee.
I attacked my desk. The pile of unpaid bills, unread articles, unwritten letters, and unwanted telephone service offers was a foot tall. The bills, having immediacy, won. By late morning I was frustrated, irritable, thrashing, and uncertain why. Had I been neglectful not staying for that infant? Maybe it was the poor sleep. It was the bills, I always hate paying the bills. Maybe I was a little rough on Darryl, an ordinary drunk. I was mildly chagrined I did not get the breathing tube into Edgar. I hate flailing in front of an extra-large audience. Still, I gave both men what they most needed from me.
I poured more coffee. The caffeine was probably a bad idea, but screw it, I like coffee.
My wife and I tripped over each other in our closet-sized den. I scowled. I cursed the dog, over whom I had stepped and nearly tripped four times. My wife, a developmental pediatrician who was probably feeling like she was at work, wondered why I was so cranky.
“My expense reports,” I said. “And global warming.”
She knew to say nothing to that; my mood had become non-linear.
By afternoon I was ready to punch walls or crawl out of my skin. I went for a run. When my knees are behaving I can clip along for 40 minutes, long enough to empty my head.
Halfway around my usual loop, my guard apparently down, the unbidden, unwanted truth popped up in my path like a slasher in a horror movie: twenty-four hours ago, I’d failed to keep a man alive through his heart surgery.
There it was.
In full stride, I recited the mantra: bad disease, bad outcome.
Still, I felt like crying.
Had we missed something? Could I have done anything differently? Was I not competent?
I visited my mental trophy gallery: An elderly man who ruptured his heart against his steering wheel and 36 hours later was reading a newspaper. A woman who filled her lungs with amniotic fluid while delivering her baby—usually fatal but she walked away unscathed. The local police paint their preference for our hospital on their flak jackets. Thousands of less memorable cases patched and propped up and eventually given nutritional advice and follow-up appointments.
Was I a total narcissist, looking inward to my own personal issues when a 55-year-old man had just lost his life?
But what else is there? However trivial, cogitations—private or shared—are the only things we have left.
Hell with it: I hurt. Of course I was discombobulated. A pillar of doubt, a bumbling fool, a running wreck. Emotionally inverted. Or is it inside-out? How do I do it? Stand in there, day after day, playing doctor? Voyeurism. Hubris.
Spare yourself, my dinner-party friends, even the minor adulations: a healthy man put his life in my hands and died.
I was not attached to Mr. Patterson, but appropriately detached. How bad did I need to feel? Our drugs and techniques are imperfect. No one made mistakes.
Still my eyes were welling up.
Repeat: No one made mistakes.
In another quarter mile I found this simple thing: death hurts the living, even professionals. And we were not—I was not—incompetent. Even when we have every reason to think we’ll win the day, some will slip away.
The admission to myself that I was hurting over John Walter Patterson, a man whom I had known awake for less than thirty minutes, gave me hope. Maybe I did or did not do something more or less than I could have or should have done. I will continue to try to know better the art and science of medicine; it’s a life’s work. Given that, should I not have been upset by a man’s death? Would I want to be that hardened? Would I be better or worse for my patients if I had seen it all and did not care anymore?
Monday and Tuesday were routine, frankly boring—a welcome change. As I wheeled one patient into the OR to get his knee scoped he asked, “How many of these do you do in a day?” He was an educated man who had done the math: dozens of other patients had come and gone that morning, and there are a dozen hospitals in the area. He was pondering the immensity of illness as I had done 26 years ago.
I said, “Oh, some days we do one big case and it takes all day. Some days we do 15 or 18 little cases. It all depends.”
Once again I did not answer the question. I have no answer. After 26 years I still catch myself thinking disease ought to be an interesting abstraction.
We succeed not with brilliance, but with well-developed systems. We fail not with personal inadequacy but with imperfect prescience. To get back to work we wave conceits at the doubts. We make compromises and rationalizations and ultimately have to believe that, imperfect as we are, we are as good as can be had, sometimes good enough. It is some comfort that my humanity, though often crusty, is still rousable.
If ever it is not, I want to be long out of the way.
Wednesday I am again first call.