Somebody had mentioned the name of the patient's disease, and we were off and running on an intricate discussion of pH, sodium ions, and glucose pumps, with articles from Houston, California, and Sweden. Names flew back and forth in a kind of academic Ping-Pong game. Who would get in the last name, the latest change? We were nearly breathless with anticipation when someone noticed that we were standing by the wrong bed. The patient in front of us did not have the disease under debate. That had ended the game without a winner, and we had quietly moved on to the next bed. What the hell difference it made I couldn't fathom, since we hadn't had time even to look at the patient. Maybe everybody felt shy about discussing one disease in the presence of another.
"Try to get some sleep, Mrs. Takura. Everything will be all right." I glanced over my shoulder to see if the coast was clear. The nurses hadn't paid much attention to me, mostly because they were busy with a man in the opposite corner. He was wired up to an EKG monitor that showed a very irregular heartbeat.
The woman was still sobbing quietly by the bed of her heavily bandaged teen-age boy. He had a head injury, the result of an auto accident; the poor fellow never regained consciousness. I headed for the door, pulled it open, and went out. Day changed to night. The bright lights, the sound of the machines, the bustle of the nurses were suddenly cut off as the door shut behind me.
I was back in the hushed dark air of the hospital corridor. To my left, a nurse sat at her station, her face silhouetted by the light directly in front of her. Everything else melted off into darkness. I turned into a completely black corridor. All I had to do was turn to the right, go down the stairs, and cross the courtyard to my quarters. There was still time to get some sleep.
Suddenly a light flashed behind me, and a voice shouted, "An arrest, Doctor. There's an arrest. Come quickly!" As I turned around, the light evaporated, leaving scintillating blotches in the center of my visual field. Berlin blockade, Cuban missile crisis, Tonkin Gulf: crisis, all right, but not so close together or close to home. To me, this was a red alert, the type of catastrophe I dreaded most. My first thought was that I would be not only the first doctor to arrive, but also, since it was the middle of the night, perhaps the only one. Given a choice, I would have fled in the opposite direction, not worrying whether I was a coward or a realist. But there I was, running toward the patient, almost a cliche of the young intern dashing down a dark corridor with his stethoscope thrashing wildly in his tightly gripped fingers.
You've seen it all on television and movie screens, and it's thrilling — isn't it? — rather like the bugle call and the cavalry charge in the nick of time. But what is he thinking, this intern? It depends on where he's running. If it's pitch-black, he's trying to get there in one piece. Beyond that, it depends on how long he has been an intern. If not long, just a couple of weeks, then he's running scared — terrified, to be more exact. He doesn't want to be the first person to arrive.
Now he's there, a little out of breath but physically intact. His mind is another thing; what little information he owned appropriate to the situation has suddenly been drained out of his cerebrum by the shock of responsibility. Don't bother to learn drug names or dosages, the pharmacology professors insisted, just learn concepts. How do you tell a nurse to draw up 10 cc. of concept for a dying patient?
As I pushed open the ICU door, the weird world enveloped me again, and of course I found myself the only doctor there, quite alone with two nurses beside the bed of the man with the irregular EKG. While my mouth formed an inaudible obscenity, my fingers involuntarily clutched the side railing of the bed as if using it for support. I was no longer the television intern, but a real one, complete with inexperience and terror. Who would support me if this man died? The nurses? The medical-school professors? The attendings? The hospital? Most important, I had not yet learned to forgive my own mistakes.
Looking back at the door, I hoped against the odds that a resident would suddenly appear; it came home to me why many brilliant and dedicated students go all the way through medical school and then, facing internship, change course and switch to research or some paramedical field. Anything must be better than internship. Something's wrong here. Why can't the intern know something useful when he runs into the ICU during the first couple of weeks? And why don't the attendings back him up? Even the helpful ones are mostly no better than quietly aggressive. They seem to be saying, "We waded through all this shit. Now, goddamn it, you do it, too."
Well, I was doing it, here and now in the ICU, with no chance of any help, but this time I got lucky. The EKG monitor displayed on the oscilloscope showed a wildly erratic electrical impulse, like the scribbles of an irritated child. As its beeping sound rose higher and higher, to an extremely rapid staccato, I realized that the patient had slipped into ventricular fibrillation; his heart muscle was just a quivering, uncoordinated mass. Now I knew what to do; I would "shock" him.
Actually, the decision was not so much mine as the nurses'. Always a step ahead, they had the defibrillator charged up and one of them was holding the greased paddles out to me.
"What's it charged to?" I asked, not really caring, but needing the control the question gave me.
"Full charge," answered the nurse with the paddles.
I put one of them on his chest, right over the sternum, and the other along the left side of the thorax. Oddly, he hadn't stopped breathing completely. Nor was he unconscious. The only sign of distress besides his gasping respiration was a sort of dazed look, as if the breath had been knocked out of him.
I pressed the button on top of the paddle handle. His whole body stiffened violently, and his hands shot into the air and down. The EKG blip was driven off the oscilloscope screen by the sudden tremendous electrical discharge, but it came right back, looking normal. I was reassured when the beep reappeared, too, suggesting a normal pulse rate, and the man took a deep breath. Everything seemed fine for about ten seconds. Then he stopped breathing, and right away the pulses went to zero, while the EKG continued along with the blip at a normal rate. That was crazy. EKG blips and no pulses was a combination not in the textbooks. My mind played a huge indoor tennis match, with concepts flying back and forth— electrical activity, electrical activity, but no beat, no pulse. "Get a laryngoscope and an endotracheal tube." One of the nurses already had them in her hands. He had to have oxygen. Oxygen and carbon dioxide had to move, and for that we had to insert an endotracheal tube and breathe for him.
The tube is put down by means of a long, thin flashlight affair called a laryngoscope. This instrument has a blade on the end of it, six inches or so long, that is used to raise the base of the tongue and bring into view the entrance to the trachea, where the tube must go. As the blade slides into the throat, you try to locate the lid that covers the trachea during swallowing — the epiglottis. All this time you are standing behind the patient, pulling his head far back, fighting through extraneous material like blood, mucus, or vomitus. Once you see the epiglottis, you slide the instrument past it, down a little farther, and pull up. With luck, you'll then be looking past the trachea at the vocal cords, which are creamy white, in contrast to the red mucosa of the pharynx.
That’s the ideal situation. In practice, you must often push this way and that on the throat with your free hand, looking for the trachea, and sometimes you never do find it. And even when you do, your troubles are still not over, because sliding the tube down can be devilishly hard. The precious hole between the vocal cords will be obscured at the last second by the rubber tube. Nothing to do but push it in blind. Too often your dead reckoning leads the tube into the esophagus, so that when you try to ventilate the patient — force air into him — his stomach blows up instead of his lungs. And all the while there is usually someone else pounding on the man's chest, and the laryngoscope is clanking against his teeth or jumping out of his mouth, and the whole area may be filling rapidly with fluid of one sort or another. Putting down an endotracheal tube was, to me, a subject fit for nightmares.