A Doctor’s First Night On Call

The following is excerpted from Internal Medicine, by Terrence Holt. Tune in to Science Friday on September 26, 2014 to hear Holt chat about his book.

My first call night as an intern, I ran into Dr. M, one of the senior attendings, whom I had known for several years. “How’s it going?” he asked me. I told him I was on call. “First call?” He smiled. “I remember my first call. About ten o’clock that night, my resident said to me, ‘I’m going to be just behind that door. Call me if you need me. But remember—it’s a sign of weakness.’”

I don’t recall my response: I don’t think I even had time to consider the story until evening, when the frantic milling about that makes up an intern’s day had started to wind down. That day, we filled up early—three opportunistic pneumonias from the HIV clinic; a prison inmate transferred from Raleigh with hemoptysis, presumably TB, and a fever-of-unknown-origin. Keith, the resident, whose job it was to direct me in my labors, felt this was a good day—his work was essentially done by five, as together we wrote admission orders starting the workup of the mysterious fever. He said to me, “I’m heading off to read. Call me if you need anything.”

“But it’s a sign of weakness, right?” I said, remembering Dr. M’s story.

Keith laughed. “Right.” And sauntered off down the hall.

Later, I was on the eighth floor, getting sign-out from one of the interns on the pulmonary service. It was almost seven—this was early in the residency year, and nobody was getting out before dinner. This intern was post-call, red-eyed, and barely making sense. Her sign-out list was eleven patients long.

I don’t remember any of it except the one: Mrs. B was listed as a DNR/DNI 47yo WF w/scleroderma RD. “RD” meant “respiratory distress.” The little arrow meant this was one possible effect of her scleroderma. I had never seen scleroderma before, and what it was, exactly, I could recall only hazily.

“She’s a whiner,” the intern explained. “Don’t get too excited about anything she says.” She paused. “I mean, if she looks bad, get a gas or something, but basically she’s a whiner.”

Whiner, I wrote down in the margin of the list.

I sat at the workstation for some time after that, running through lab results on the computer—the scheduled seven P.M. draw was still going on, so there was nothing new on the screen, but it calmed me to go through the exercise.

A nurse stuck her head through the door. “Doctor?”

I was still unused to people calling me that.

“Do you know the lady in twenty-six?”

I fished the sign-out sheets out of my pocket. “What’s her name?” There were too many sheets. The nurse gave me the name and my eye fell on it at the same time. Whiner.

“What’s her problem?”

“She says she’s feeling short of breath.”

“Vitals?” I heard myself ask, marveling at my tone of voice as I did.

The nurse pulled a card out of her pocket and read off a series of numbers. When she was done I realized I hadn’t heard any of them.

The nurse read them again. This time, I wrote them down.

Then I spent a minute studying them. She was afebrile, I noted. That was good. Her heart rate was 96, a high number I had no idea how to interpret. Her blood pressure was 152 over 84, another highish set of numbers that told me nothing. Her respiratory rate was 26—also high, and vaguely disquieting.

Her O2 sat—the oxygen content of her blood—was 92 percent: low, and in the context of that high respiratory rate not a good sign. The nurse was still looking at me. “I hear she’s a whiner,” I said hopefully. The nurse shrugged. “She asked me to call you.”

The patient was alone in a double room. The light in the room was golden, the late sun of the July evening slanting through the high window. The face that turned to me as I knelt at the bedside was curiously unwrinkled. Her skin had a stretched and polished look, her features strangely immobile, the entire effect disturbingly like a doll’s face. Her chest rose and fell, but her nostrils did not flare. Her mouth was a tight puncture in the center of her face. Only her eyes were mobile, following me as I moved.

“What seems to be the problem?” My voice had taken on a strange quality: tight, almost strangled.

“Are you my doctor?”

“I’m the doctor on call,” I explained.

“I can’t breathe.”

I looked at her for a minute.

“What do you mean?”

“I can’t . . . catch my breath.”

I thought, but nothing brilliant came to mind. “Are you feeling dizzy?” I asked.

“No. Just. Short of breath.”

I watched, counting. They were quick, shallow breaths, about twenty-eight of them to the minute.

I bent over her and placed my stethoscope on her back. I heard air moving, in and out, and a faint, light rustling, like clothes brushing together in a darkened closet. “I’ll be right back,” I said, and left the room to find her nurse. A few minutes later the nurse reported back to me. “Eighty-nine percent.”

“Is she on any oxygen?” I should know this, I thought. I’d just been looking at her.

The nurse shook her head.

“Put her on two liters and check again.”

Ten minutes later the nurse was back. I was in the doctors’ workroom, looking up “scleroderma” on the Web.

“Ninety-one percent.”

“That’s better,” I said hopefully.

The nurse shook her head. “Not on two liters. Not how hard she’s working.”

“You think she’s working hard?”

The nurse smiled thinly. “Do you want to check a gas, Doctor?”

I smiled back, genuinely relieved that someone was willing to tell me what to do. “That’s a great idea,” I said. “Can you do that?”

“No. But you can. I’ll get the stuff.”

An arterial blood gas is a basic bedside procedure—the kind of thing third-year medical students are encouraged to learn. It involves sticking a needle into an artery and drawing off three or four ccs of blood. The reason a doctor has to draw it is that arteries lie deeper than veins. Even the relatively superficial radial artery—at the wrist, the one you press when checking a pulse—lies a good half-inch deep in most people, and sticking a needle in it stings more than a bit. I was not at that time very skilled at procedures—the arterial blood gas was about the limit of my expertise—but to my relief I had no trouble getting it: bright red blood flashed into the syringe.

The patient bore this without a grimace, although by now I wondered if the skin on her face was capable of expression at all. Her eyes regarded the needle in her wrist.

“How are you feeling?”

“A little. Better.”

I pulled the needle out, held a pad of gauze to her wrist. She subsided into the bed. “But still. Short of breath.”

I watched her. Twenty-six, twenty-eight. Shallow, the muscles at her neck straining with each one.

“I’ll be back in a bit,” I said, rising with the syringe in my hand. “Call if you need anything.” But it’s a sign of weakness, I echoed to myself. I hurried on down the hall, the echo following.

While I waited for the lab to process the gas, I skimmed over fifteen pages about scleroderma, a mysterious, untreatable condition in which the skin and organs stiffen. The most feared complications are cardiac and pulmonary. Some victims develop fibrosis of the heart early in the course of the disease and quickly die, as the accumulation of gristle disrupts the heart’s conduction system. In the lungs, collagen invades the membranes where the blood exchanges oxygen and carbon dioxide with air: the lungs stiffen, thicken, and fail.

It is possible to get an idea of how this would feel. Putting your head in a paper bag is a dim shadow of it; thick quilts piled high come closer. The difference, of course, is that you can’t throw scleroderma off. The bag stays dark; the quilts simply thicken, over years.

The blood gas was not encouraging. The numbers on the screen told me several things. Her blood was acidic. CO2 trapped in her lungs was mixing with water in her blood to make carbonic acid. The acid was chewing up her stores of bicarbonate, which meant that her lungs were getting worse faster than her kidneys could compensate. The really bad news was the amount of oxygen dissolved in her blood, which at a partial pressure of fifty-four millimeters was unusually low, especially for someone getting supplementary O2. Taken together, these numbers spoke of lungs that were rapidly losing access to the outside air.

I remembered a patient I had taken care of during an ER rotation a year earlier, an old lady with pneumonia. I had gotten a gas on her, too, and it had come back essentially normal. The attending had asked me to interpret it. “It’s normal,” I said.

“And?” the attending replied, directing my attention to the patient gasping on the gurney. I looked at her for a moment.

She was breathing about forty times a minute. “You’re about to tube her,” I said. “Right,” the attending said, and did just that. A normal gas on somebody working hard is a bad sign.

A below-normal gas on somebody working hard to breathe on supplementary O2 is a very bad sign, especially if her chart carries the notation DNI. The letters stand for “Do not intubate.”

It’s the patient’s order to her doctors and it draws an inviolable line. No breathing tubes, no ventilators, no call to the ICU for help.

I hurried back down the hall to the room. The sun had set, leaving the sky a dim purple. The room was dimmer still, the patient’s face a sheen on the white pillow, her chest visibly stroking from the door. I stood in the doorway for a minute, watching her, trying not to match her breathing with my own.

Her face was turned to me. The eyes glittered.

“How are you feeling?”

“Not. So. Hot.”

“I know,” I said. “I’m going to get you some more oxygen.”

I reached for the regulator in the wall and cranked it up to six liters, the maximum you can deliver by nasal cannula.

The nurse appeared at the door. “Do you want me to call Respiratory?”

“Yeah,” I said. “That’s good. Call Respiratory.” Respiratory therapists know all sorts of tricks: complicated masks that somehow squeeze more oxygen into room-pressure air.

I went back to the workroom and paged Keith. It occurred to me that I was displaying weakness. I told myself I didn’t care.

He called back in a minute, cheery, calm. “What’s up?”

I told him.

“She’s DNR? You checked the chart?”

I set the phone down and found her chart. There in the “Consents” section was the legal form, witnessed and signed.

“Yeah. DNR/DNI.”

“Well, that’s it,” he said. “If it’s her time, it’s her time. Just crank up her Os and give her some morphine. That’s all you can do.”

There was silence for a minute.

“Do you need me to come up there?”

“No. I’m on it. It’s okay. I’ll call you if I need anything.”

“Okay. Have a good night.”

It was eight-thirty. I went back to the patient’s room. A respiratory therapist had arrived, bearing a tangled mass of tubes and bags.

“What do you want her on?” The tech eyed the woman in the bed speculatively. “Fifty percent?”

“Let’s try that.” I watched a minute as the tech unstrung his tubes, fitting valves together. The face on the pillow was blanker than ever now: she had closed her eyes. Without that glittering motion, her face looked as if it were simply waiting.

Half an hour later, the nurse found me again. “Do you want me to do anything for twenty-six?”

“Like what?”

“She won’t keep her mask on.”

“Why not?”

“She says she’s claustrophobic.”

I threw my pen down on the desk.

The eyes were open again, looking out through the plastic skin. She was holding the face mask in her left hand, about a foot away from her face, as if restraining something that had tried to attack her. Her chest was still rising and falling too fast.

I went to the bedside and crouched beside her. The eyes slanted down with me, the head immobile on the bed. “I won’t,” she said, and pushed the mask into my hands.

“Why not?”

She shook her head. “Can’t.”

“Is it uncomfortable?”

“Suffocating. Can’t.”

I bit back an argument. “How about I give you something to help you relax?”

“Why?”

“You need the mask. You’re not getting enough oxygen without it. If we can relax you a little, maybe you’ll feel better about wearing it.”

The eyes closed for a moment. “All right,” she said.

I told the nurse to give her a milligram of Ativan and two of morphine, and to try to get the mask back on her.

Just after nine the nurse reappeared in the doorway of the workroom and shook her head.

“She won’t keep the mask on.”

I pulled myself to my feet. The patient was propped up in bed now, leaning forward, her hands braced on her thighs to support her. The posture is called “tripoding”; it’s something people do instinctively when they’re having trouble getting air. Her shoulders were lifting and falling rhythmically with each breath. She was using what are called the accessory muscles, anything to help expand the ribcage with inhalation. It can buy you a little extra air exchange, but the price, in terms of exertion, is more than most of us can pay for very long. The mask lay in her right hand, hissing.

She didn’t seem to notice me as I moved across the room; her gaze was straight ahead, intent on something. Each breath, I thought. Or perhaps something visible only to her through the far wall of the room.

“Mrs. B?”

Her gaze flickered my way, a brief acknowledgment, then back to her inner vigil, intent. My first impulse was to ask her how she was doing. I stifled it. I reached out instead and took the mask from her. Her hand was stiff; the fingers yielded slowly. Her eyes turned toward me.

“Does this bother you so much?” I held the mask out.

She nodded and drew away. As if it could bite her, I thought.

“More than the way you’re feeling now?”

Her gaze clouded a moment. Unfair, I thought. Arguing with a dying woman.

She nodded again.

I sat at her bedside, holding the hissing plastic coil, looking into the mask. Reluctantly, unwilling to place my mouth where hers had been, I fitted the mask to my face, pressed the vinyl against my cheeks. I took a breath.

There was only a smell of plastic, then a high, eerily open sensation of emptiness. I took a breath, feeling my lungs expand; a vivid impression of spaces opening everywhere. I found her looking back at me, the eyes from the depths of her immobile face dark and liquid and alive.

I took the mask off. “It makes you feel confined?”

She nodded, shrugged.

“Have you tried taking deep breaths?” I was still buzzing with the force of the oxygen; my lethargy and sleepiness were all gone. I felt ready to take this woman on and bring her with me to morning.

She looked at me only a moment before turning to the far wall again, shaking her head. It occurred to me that she probably couldn’t take deep breaths.

I was still holding the mask.

“Did the sedatives help any?”

No.

“Would you like to try some more?”

Shrug.

I went to find the nurse. We doubled the dose of the Ativan. I watched, this time, as the drugs ran in, saw the relaxation I hadn’t believed the stiff skin could show, the subtle slumping of the shoulders. I waited, and when sleep seemed about to take her I slipped the mask over her face. A hand stirred, rose a few inches, wavered, then fell to her lap; she settled back against the bed. I stood there beside her, holding the mask in place, watching. After a minute or two, we checked the pulse-ox: 94 percent. Her respiratory rate was settling into the mid-twenties. Hours of accumulated tension dissipated from my own chest. The nurse and I walked quietly out the door. “Keep an eye on her,” I said.

I don’t remember what time the next call came. Probably around two. I was back in the workroom, running blearily over the results of the one o’clock draw, fielding pages from the floor. There had been a shift change at midnight, followed by a flurry of pages from the new shift coming on with questions.

There was a patient down on 3 West who was refusing his prep for a scheduled colonoscopy. I heard a knock and an unfamiliar face appeared in the doorway. “Are you the doctor on call?” Shift change. I grunted something affirmative. “Do you know the patient in twenty-six?”

An uncomfortable sensation stirred in my chest.

“I got report on her,” the new nurse said. “Do you still want frequent vital signs?”

“How’s she doing?”

“I don’t know. Do you want me to check?”

“Please,” I said, and settled my head on my folded arms.

A hand shaking my shoulder. “Doctor?”

I stirred unpleasantly. My face was stiff. My sleeve was wet.

“I’m sorry to bother you, but that lady in twenty-six, she’s not looking so good.”

I sat upright.

“Her O2 sat?” the nurse went on. “It’s only eighty-two. And her rate is over thirty.”

“Is she wearing her mask?”

“No.”

“Christ.” I was out of the room, stalking down the hall.

She lay in the bed, looking expectantly toward the door, the mask gripped in her hand. Her other hand went up as I approached, waving me away.

“Mrs. B,” I called to her, pitching my voice as if into the distance. The head bobbled for a moment, turned my way. The eyebrows were lifted slightly, but the skin above them was unfurrowed. The mouth was a hole air moved through.

“Mrs. B,” I said again, willing her to look at me.

She did.

“You have to keep your mask on.” It did not sound so idiotic when I said it as it does now.

She shook her head.

“If you don’t do it,” I said, reaching out to take the mask from her hand, “you’re going to die.” She made an ineffectual motion as I placed the mask over her face, looping the cord behind her head. Her hair was greasy with sweat. She reached up and placed a hand on the mask. My hand and her hand held it there. Did her breathing start to slow? I held the mask through one long minute, another. The nurse was a silhouette at the doorway. Another minute more, and I was sure the rate had fallen, the laboring of her shoulders lessened. To the nurse: “Let’s check a sat.”

Ninety-two percent. To Mrs. B: “There. That feels better, doesn’t it?” She nodded, faintly, and seemed to settle into the bed. I let my hand fall away from the mask, crooning, “There, there.” After five minutes pressing the mask to her face, my outstretched arm felt like wood. I reached behind her head to snug the cord.

She pulled the mask away. “I can’t breathe. I don’t want it,” she gasped. “It’s too tight.”

And pulled harder until she snapped the cord in two.

I grabbed the mask and held it on her face. She reached up and clutched my wrist, and for a moment I thought we were about to struggle over it, but then she stopped and her hand fell away. Her eyes were fixed on mine.

The nurse was still at the doorway.

“Ativan,” I said. “Two milligrams IV. And two of morphine.” Mrs. B still stared at me, her face remote and motiveless behind the mask. My arm was aching. Was I pressing the mask too hard? I eased up, fumbled with the broken cord, but the ends were too short to make a new one. Mrs. B didn’t take her eyes off mine as the nurse reached for the port in the IV tubing. Just as the nurse’s fingers caught it she snatched her arm away.

“No.” The voice was a whisper.

The nurse turned to me, her expression stricken. “I can’t, Doctor.”

“What do you mean?”

“I can’t force a patient. It would mean my license.”

“She’s going to die if she doesn’t keep that mask on.”

“Then get Psychiatry to declare her. But until then it’s her decision. We can’t make it for her.”

Psych wasn’t going to declare her. I knew that. It was her decision. I knew that. But I couldn’t let it end this way. Surely I could make her see.

“Mrs. B,” I said finally, “is there any way we can make this easier for you?”

“How about a bucket?” said the nurse.

My expression must have requested explanation.

“A face tent, they call them. It’s open at the top. It works for claustrophobia. Do you want me to call Respiratory?”

“Please.”

The respiratory tech arrived after an interminable period during which Mrs. B refused again and again to wear the mask. Eventually we found a compromise. She would hold it a few inches below her chin. It bumped the pulse-ox to 88 percent. But her respiratory rate continued to climb. I couldn’t tell if it was hypoxia or anxiety. A blood gas would have told me, but I was reluctant to try. I didn’t know what I would do with the information. When the tech arrived and fitted her with the bucket, I stood at the door watching. It seemed to be doing something.

The next page from twenty-six came around four. I had gone into the call room fifteen minutes before, but the moment I lay down it was clear there was no chance of sleep. I lay rigid in the lower bunk, unwilling even to turn out the light, bracing against the sensation of my pager at my hip. My thoughts were an incoherent jumble: scraps of medical education—the innervation of the hand, the watershed areas of the mesenteric circulation, drugs to avoid in supraventricular tachycardia—none of which was relevant to any of the calls I had gotten that night. I was thinking of anything but the patient in twenty-six, two floors overhead. The next page was, of course, about her.

The nurse picked up on the first ring. “Doctor? I think you’d better get up here.”

I was out of the door without a word.

The scene in twenty-six was superficially unaltered. But from the bed I was hearing small whimpering noises, rhythmic, paced almost to the beating of my heart.

She was sitting bent over, the exaggerated movements of her chest and shoulders making her head rise and fall, rise and fall.

I counted, but lost track in the twenties, somewhere around half a minute. At least forty.

“Mrs. B?” I laid a hand on her shoulder. She didn’t turn.

Just the rapid rise and fall of the head. Her shoulder was clammy, her gown damp. Was she febrile? Was there something I’d missed? Should I have gotten cultures? Hung antibiotics? Was she having a PE? The body on the bed wasn’t telling.

Only the same carrier wave of distress, up and down, up and down. I looked to the door, where the nurse was standing.

“Get Respiratory up here.” She started to go. “And get me two of morphine.”

The patient didn’t resist this time. I don’t know if she was even aware, but as the plunger went down on the syringe I could see a change in her; she settled and her breathing slowed. The pulse-ox, which had been in the mid-seventies, climbed up a notch or two, settled in the low eighties. I had no idea if that was something she could live with. I stood at the bedside and watched. Her respiratory rate was in the low thirties. An eye opened, swiveled around the room until it met mine. The mouth moved, no sound came out.

“Mrs. B,” I said, and my tone was frankly pleading now, “you’ve got to let me help you.”

The eye held my gaze for a long moment, the dim gleam of the nightlight streaking across the cornea. A hand made a brief sweeping gesture, fell. Away.

Somewhere in the course of the night I had developed a fixed idea: if I could get her to morning, it would be okay. I had no idea where that notion came from. Years later, after what seems like countless midnight vigils, the trust and hope of it chill me. But then I clung like a child to the thought of morning. In the morning, her primary team would be on hand; someone would know what to do. By the light of the morning, ill spirits flee. In the morning, it would be off my hands.

The respiratory tech was at the door.

“It isn’t working,” I said.

The tech didn’t actually shrug. “You don’t think you can tube her?”

“I can’t,” I gritted out. “DNI.”

“BiPAP?”

“I can’t get her to wear an ordinary face mask.”

“Why don’t you just snow her?”

It was a thought. She hadn’t refused the morphine. I could try adding on sedation until she would let me put a mask on her—perhaps even a tight-fitting BiPAP mask, the next-best thing to intubation. It could be done.

“Yeah,” I said. “Nurse? Bring me four of Ativan. And another four of morphine.”

I knew the risk: knock her out too far and her respiratory drive would suffer; she’d lose her airway; she’d suffocate.

But she was going to die this way, too. I watched, holding my breath as the drugs went in, trying to remember the doses of naloxone and flumazenil that would reverse these, if I had to.

Her breathing settled still more. Her eyelids fluttered and fell. “Get a mask on her,” I said.

In a minute the tech had her fitted with an elaborate device that gripped her face like a diver’s mask. There was no protest.

The pulse-ox rose steadily to ninety, ninety-one, settled at ninety-two. I let out a sigh.

This time I did sleep. I must have, because my pager woke me from a dream of too many inscrutable objects, none of them fitting together, a puzzle I had to solve.

“Doctor? Twenty-six. She’s fighting the mask.”

She was sitting up, crouched as if clutching some secret to her chest. The mask was pushed up onto her forehead. Her shoulders rose and fell, rose and fell. She didn’t look up as I entered; her gaze lay burning on the opposite wall. The pulse-ox was eighty-two. I laid a hand on her shoulder, could feel her bones working as it rose and fell.

“Mrs. B.”

She shook her head.

“We’ve got to do something.”

She shook it again.

“What can I do for you?”

Her hand waved me away.

I stood beside her, watching her breathe, for a very long time. She lay on the bed within reach of my outstretched hand, within the sound of my voice, but behind the wall of her fatigue and her breathlessness, sunk deep in her adamant gaze, she was unreachable. Unreachable by me. I wondered if she even knew I was still there, and felt suddenly a revulsion—not at her, but at my own presence in her room.

Her pulse-ox was eighty-two.

“Call me,” I said to the nurse, “if she changes.”

Around 6 A.M. I was sitting in the call room, trying to shake myself awake. My pager went off. It was the eighth floor.

The room was different now. Light was striking in through the window, a dozen rising suns reflected off the opposite tower. The room was bright and still.

Fast asleep, even comatose, a living body moves. The chest expands, the nostrils flare, the eyelids twitch; pulses stir the skin, and over all of these there hovers an inarticulate hum of life. But a dead body is only that: dead, a body, given over to gravity and decay. The muscle tone that lends expression to the face is gone; the face is slack; the skin gone gray-green with the absence of blood (underneath, if you turn it over, you will find pooled at the backside a livid bruise).

I went through the motions of declaring death. Her eyes took my flashlight passively, the beam falling into the cloudy darkness of her pupils without a sign. I laid a stethoscope on her chest: only sporadic pings and creaks, sounds of a building settling in the night. Her flesh was cold, malleable, inert.

There were papers to fill out: organ donation, autopsy permission, the death certificate. I puzzled over “Cause of death,” wondering just what process I had failed to reverse.

Respiratory failure, I finally wrote, secondary to pulmonary fibrosis, secondary to systemic sclerosis. The last line asked if any underlying medical conditions (diabetes, hypertension, for example) had contributed to the patient’s demise. I looked at that a long time, and finally left it blank.

By the time I was done, the hospital had come to life around me. The intern who had signed out Mrs. B to me scratched the name off her patient list.

Keith, the resident, appeared on the floor just before rounds got under way. “How was your night?”

I told him. He listened to the story, pulled his lower lip, shook his head.

“You should have called me.”

I flinched. “What would you have done?”

“Nothing,” he said. “Just like you. There was nothing to do. But at least we could have done it together.”