This entry is written out of chronological order.
[ … 7:37 AM … ]
My intern sees me on the floor and says, “Hey you shaved. How much sleep did you get?”
“Couldn’t sleep. I was helping Fuzzyhead (another resident) in the MICU after that last CODE until 5 in the morning. At least I had time to shave and shower.”
[ … 5:50 AM … ]
If you can’t get at least 3 hours of sleep it’s not worth the trouble. So I drudged on towards my call room, planning on washing the uncomfortable tightness in my chest away. At the door it hit me. An alien feeling in my chest slithering into my throat, strangling me. It penetrated my sinuses and began to bleed from my eyes. I could feel my face wrinkling into the “tragedy mask” of an old theatre. I couldn’t stop it. I started to cry uncontrollably.
[ … 1:48 AM … ]
… Unghh.
Awake all of a sudden in the dim call room bed and I had no idea why. I didn’t hear my beeper and I had just gone to bed an hour ago. Instinctively I checked my pager. Two pages? One was a CPR page from 1:30 a.m. The other was one minute ago from my student at the room where the previous CPR was called. Fuck, this can’t be happening. I’m 18 minutes late to a CPR? I ran out of the room. The halls were quiet with only the clack-clacking of the gear in my pockets synchronized with the pounding of my soles as I ran. The room number was vaguely familiar and it wasn’t until I was halfway there and fully awake that I realized whom it was.
God.
No.
[ … earlier that afternoon … ]
I’d been talking to Terminal Girl for the past half-hour. I’ve known her since my first month as an intern 2 ½ years ago. She is both the unluckiest and the luckiest of all living souls. She has alcoholic cirrhosis, AIDS, Hepatitis B and C, epilepsy, and multiple other related problems. Most of her problems stem from her vices – alcoholism, promiscuity, and drug abuse. The “lucky” part is that she has survived as long as she has. Every person who goes over her history is amazed at the things she has survived.
MY INTERN: “Sorry I’m late. I just finished with the other new patient. She’s a demented old lady from a nursing home with COPD (chronic lung disease), heart failure, diabetes, post-stroke, coronary disease, hypertension, and dementia here for weakness and dehydration. No family, no medical records.”
ME: “So … the usual. I talked to the other patient, Terminal Girl, already. They drained 8 liters from her abdomen last night. She’s hypotensive (low blood pressure) right now. She’s probably redistributing the fluid back into her abdomen. Her belly’s tender, she’s febrile, looks like peritonitis. Cultures pending. She’s on I.V. antibiotics. Her breathing’s not so good either. I’ve already ordered a STAT chest X-ray, a pulse ox, and arterial blood gas. Oh, and she had a seizure last night, threw up in the E.R., her veins are shot, and she’s demanding Demerol. Fill out the transfer form – we’re moving her to another floor. How the hell did she end up on an Ob/Gyn floor anyways? This floor can’t handle someone like her.”
MY INTERN: “What do you think is going on with her?”
ME: “I don’t know. There’s something else. I don’t think it’s HIV-related, since her counts are normal. We’re missing something this time. We have to image her belly. I’m worried.”
She was my first permanent patient. My first clinic patient. The only patient I feel comfortable enough with to call by her first name. The only one who’s phone number I have memorized, not intentionally either. The one who gave me a tie last Christmas.
Amy always teases me, referring to her as, “your girl.”
[ … 1:49 AM … ]
I’m a breathless voyeur behind a wall of other residents. My Terminal Girl is lying in her bed, passive, unresponsive, exposed. Her hospital gown thrown open below the waist. She is a natural blonde. One resident is penetrating her groin with a needle, trying to get cherry red blood. Her breasts heave slowly and rhythmically with the movement of the respiratory therapist’s squeezing hands on the oxygen bag. Another resident is groping her inner thigh for a pulse. Her mouth lies open wide in a gasp with half-shut eyes. A long shiny tube rests against her tongue, thrust down her throat, and ending deep inside her chest.
The scene disgusts me. But I wish I had gotten there sooner and done it all myself. I can’t believe this is happening … to my patient … My Girl. My poor Terminal Girl.
Someone tells me that she’s already been shocked five times and without a pulse for 20 minutes. Fuzzyhead (the MICU resident) looks for a pulse. I try to project my thoughts into the back of his head. My mind screams, “Stop it! Stop the CODE! Let her die! She’s been down too long … she will never recover. She will never speak. She will never remember. She won’t even be able to think. Please, God, just let her fucking die. Stop this! Stop us! … please….”
He finds a pulse. The worst has only begun.
[ … two and a half years ago, the beginning … ]
She was admitted straight into the ICU because she was vomiting blood incessantly. They tried to send a fiberoptic scope down her esophagus to cauterize the bleeding vessels. All they saw was red. They couldn’t even locate the bleeding vessel. The next step was straight out of the ACME Book of Medicine. They screwed a catcher’s mask onto her face and dropped a long inflatable tube with a balloon at the end of it down her throat. They inflated the balloon in her esophagus and the bleeding stopped … for now. Like Little Boy Blue with his finger in the dam.
Just another one of her lives lost, but she would have plenty more where that came from.
Dr. Slick (a younger blonde ICU attending): “Dr. Scott, welcome to your new patient. Lucky you.”
A week later, she was out of the ICU and I was asking her how she was feeling, as I did every morning. She asked me,
“How old are you?”
“I’m just one year younger than you.”
“Hmm. I want to go home now. This place sucks. Pardon my French, Dr. Scott.”
“We don’t think you’re ready yet. You’ll have to sign this AMA (Against Medical Advice) form if you really insist on leaving.”
“Where do I sign?”
“Just promise me you’ll follow-up in my clinic this week or someone else’s if you want.”
“Promise. Where’s my clothes bag?”
She rarely showed up for her Infectious Disease doctors, or her Gastrointestinal doctors but she always showed up in my residents’ clinic.
[ … hours before the CPR at 1:30 a.m…. ]
MY INTERN: “That HIV patient refused to go down for the C.T. She says she’ll get it tomorrow.”
ME: “Sigh. Whatever. We can’t make her get it.”
[ … 5:51 AM … ]
I was frantically punching the combination buttons on the door to the call room as I felt the tears welling up. I had to get in before anyone could see me. Not that anyone would be up at this hour. I shut the door behind me, and turned the wall light off. I was ashamed of the fact that I was crying and I wanted to hide it in the dark.
I curled up in a chair and hid my face behind my knees. What the hell was happening to me? I couldn’t have been crying about Terminal Girl. We all knew something like this would happen eventually. But not tonight. She was my patient. I missed the CPR. Not that I would have done anything differently. Why of all nights this month did I decide to go to sleep before my usual 3 a.m. on THIS night?
[ … 12:25 AM … ]
OTHER RESIDENT: “Dude, why are you still awake? Everything is quiet tonight.”
ME: “I’m always afraid there will be a CPR when I’m on call and I’ll miss it. I never go to sleep before 3 a.m. That way I only have to worry about a CPR being called in the last 4 hours of my call shift.”
OTHER RESIDENT: “Well, I’m going to sleep now and I highly recommend you do the same.”
ME: “Yeah, you’re right. I’m so tired and it’s only midnight. Long month.”
[ … 6:01 AM … ]
I had moved from the chair to my bed. I hid under the covers in fetal position. I was dying and I was being reborn. I kept shaking in fits and spurts. I had to pull the blanket over my face due to the involuntary whimpering. I was afraid the resident in the adjacent room would hear me so I bit the edge of the covers. Bitter saline drops swam on my tongue. I could feel it dripping in my nose and down the back of my pharynx. Each drop in my stomach made me sicker. My lips retracted, exposing clenched teeth like a Chinese dragon mask scaring away evil spirits. I was losing it. At times I would stop for a few seconds and I would tell myself I was only crying because I’d only gotten 40 minutes of sleep in the past 24 hours and my defenses were down. That had to be it. Then it would start again. I tried to hold it in by straining my abdominal muscles and shutting my eyes tight but that had the effect of squeezing a peeled orange in an attempt to keep the juice inside.
[ … sometime during my first year in college, around 3 in the morning … ]
It was the first time I had ever told anyone how I felt after my father died. How I missed him. How I had never cried at his funeral. She had been listening quietly for the past three hours. The next three hours she held me. Misty ebony eyes and warm chocolate skin. Her rainbow velvet shirt absorbed my tears. It was two years later before I realized how a relationship had to be built on more than one healing moment.
I shed tears again when she told me this in her own way. It was the second time I cried in my young adult life. And she had been there for both.
[ … one week ago, in the cafeteria … ]
DR. DEBBIE (my attending): “I used to cry every night before call when I was an intern.” … She says this with her usual sunshiny smile.
ME: “Oh no. Are you serious? You always seemed so happy when you were my senior.”
DR. DEBBIE: “Well, I didn’t cry every night but … almost. I almost quit medicine my first year. I hated it.”
ME: “What made you stay with it?”
DR. DEBBIE: “My dad said he just wanted me to be happy – he told me to quit and do something else if it made me happy. My husband said the same. Once I realized I had a choice, I felt better and decided to stay with it.”
MY INTERN: “And now you’re Chief Resident and an Attending. Wow.”
DR. DEBBIE (to the other members of my team): “I was always afraid that Scott thought I was too cynical when he was my intern in the ICU. He never complained. But then I read his website … and whoa! … He is not what he appears to be! HAHA!” … big smiling blue eyes.
(She was one of the few who read my site. I didn’t mind.)
ME: ” … so … what do they put in the turkey burgers around here?”
[ … 6:16 AM … ]
I thought that if I took a shower I would feel better from the warm water. But the thoughts and the tears just flowed more freely over my body and through my head, like like an iceberg melting. I hit the wall of the shower with my hand, it echoed, and I stopped, remembering where I was, afraid I would be found in my moment of weakness.
oh god oh god oh god oh god oh god oh god oh god oh god oh god oh god oh god …
make it stop please god make it stop I don’t believe in god make what stop please god
stop it
Part of me was wondering why I was crying in the first place. I was afraid I was losing my mind … like Alan Alda in the last shows of M*A*S*H … I hated that show, everything was drab grey and green and brown … there was no red … all the death and none of the blood. And Alda was always the kindest doctor, the caring soul, the perfect bedside manner … how could anyone be like that, especially me.
She had been lying there frozen. I was watching her. I was frozen. I was wishing she would die. I was wishing she would just wake up and talk.
I let the shower beat against my closed eyelids and my twisted mouth. The water washed away the salty taste of tears in my mouth momentarily. A tidal wave of psychic despair struck me down again.
you’re not smart enough you don’t study enough you don’t care enough you don’t feel enough she’s dying her brain is toast you haven’t found a job yet or even finished your CV you slept through the page you’re going to fail the test they all think you are stupid you are not a man you are weak you cry like a baby amy will be ashamed of you are not a doctor you don’t fit the mold you don’t deserve to wear the coat they are waiting to get rid of you work all night on them and they always die always you can write about it all you want but you can’t
stop it.
I hung my head while the steaming rain from the shower pounded against the back of my neck and shoulders. I opened my eyes in-between sobbing and I saw that the water in the shower wasn’t going down the drain fast enough. It would soon overflow and spill onto the bathroom floor. There was too much to swallow or intellectualize. I had been holding back too much for too long. My life had become a metaphor for a shower with a defective drain.
I got a grip and turned it off. The showerhead continued to drip but at least the water level went down. I finished scrubbing myself in slow motion with the soapy rag in increasing circles the way I sterilize my patients’ skin with iodine before doing a needle procedure on them.
My feet were warm sitting in the old shower water. I remembered how cold Terminal Girl’s feet were when I talked to her yesterday.
She had wanted her Demerol. Morphine didn’t touch her. I told her,
“You can’t have the Demerol until we get your blood pressure back up. It will only drop it more. Then you’ll pass out and you might never wake up.”
“I don’t care about my blood pressure. Give me the Demerol!” she had said.
Those were the last words she would say to me. I never gave her the Demerol.
I finished showering — the stream had run dry. It was still early so I took the time to shave post-call. I never use shaving cream, just warm water and a razor. I brushed my teeth and even flossed. Polishing myself until I felt completely removed from the whimpering child I had just been for the past half-hour. Moussed my hair until it looked like razor black ice, impersonal and unfeeling.
[ … in college again, a video arcade with an acquaintance … ]
ME (dropping a quarter into a video game): “I always use Sonya. She’s harder to learn but she’s more well-rounded.”
ACQUAINTANCE: “Funny… you always struck me as the Subzero type.”
[ … last night … ]
Terminal Girl’s Mom: “Hello Dr. Scott. I talked to the neurologist already. I know how things are.”
ME: “Hi Mrs. T. Did you hear about the C.T.?” (CAT scans are called C.T.’s these days.)
Terminal Girl’s Mom: “Yes, she perforated her esophagus … into her lung. Is that why she was sick this time?”
ME: “Yeah. We’re not sure if it was slowly leaking or if it happened right before she CPR’d. I hear surgery talked to you.”
She should have agreed to get that C.T. last night, I think to myself. No wonder she was in pain.
Terminal Girl’s Mom: “Yes. She wouldn’t survive the surgery. She’s been through so much so why put her through more? It’s almost as if she knew. We had the best Christmas ever. She made a list of everything she wanted and my brother and I pooled together and got her everything on her list. She even went shopping last week and bought everyone else presents. Do you know how tiring that is for her to do? She knew it was coming to this. She even ate really well on Christmas and she didn’t drink either. We knew it would come down to this. I just didn’t expect it now…. “
Part of me is thinking she may have eaten too much. Because of her cirrhosis and her HIV, her stomach motility was decreased. She had medications that might have helped if she had taken them, but you never know. This may have caused the rupture in her esophagus. It’s strange because she usually hardly eats at all.
Terminal Girl’s Mom: “She’ll never be the same person again, will she?”
She shrugs her tired shoulders, sad face, polite smile. She’s wearing a puffy purple coat but she looks smaller than I’ve ever seen. For once, she looks like she is not a strung-out mother in denial … just a heartbroken one in an oversized coat.
ME: (… Down 20 minutes, I think to myself… .) “No, I don’t think she would recover much more than what you see now. The neurologist agrees.”
Terminal Girl’s Mom: “So I guess this is it. She’s come back so many times, that I thought she would come back from this. She just got mixed with the wrong crowd. She’s had more lives than a cat. Once she was on a boat in the Gulf of Mexico and it capsized during a storm and the Coast Guard rescued her. I never even knew about it. She’s seen so many places, done so many things … things I’ve never done. She’s lived so many lives…. She’s my only child. After her … that will be it.”
I remember hearing somewhere how there is no greater pain than a parent outliving her children, but I can’t bring myself to say it.
ME: “She was a great person.”
Terminal Girl’s Mom: (Looks at me in surprise, then smiles.) “Thank you. Will you be here Friday?”
ME: “Yeah, I’ll be here Friday.”
I know that’s the day they will decide to pull everything. It’s called a Terminal Wean and this time it’s for Terminal Girl.
We stand silently watching Terminal Girl breathing quietly on the ventilator for several minutes, monitors beeping continuously. At one point, her mother turns to look at me, probably wondering why I’m still standing there. She doesn’t say anything and just looks back at her only daughter.
I tell her she was my first patient. That she put up with a lot, but she always had a sense of humor. I almost feel silly for talking about her in the past tense. I consider telling her that I cried when I found out what had happened, but I don’t. I’m afraid her mother would say I should have been saving her instead of crying about it. But I couldn’t save her. No one could.
ME: “Please take care of yourself. I’ll see you on Friday.”
If I were a normal person I probably would have hugged her then. But instead I just walked out of the room looking at the floor.
[ … 7:36 AM … ]
I’m walking down the hallway, fully re-composed. Reborn. Clean and purged. I turn the corner and I get the sadness for a brief instant … it’s the sleep deprivation again, honest. I squint my eyes, and jut forth my jaw like an old 1940s comic strip hero. I stand up straight and keep my shoulders squared. My coat and gear are heavy, but I am heavier. I pretend my skin is steel again.
My intern sees me on the floor, “Hey you shaved. How much sleep did you get?”
“Couldn’t sleep. I was helping Fuzzyhead in the MICU after that last CODE until 5 in the morning. At least I had time to shave and shower.”
I walk away because I can’t sustain the smile for more than a half-second. I check her labs in the computer. I stare at it intently but I see none of it. I strengthen my reserves. Wall up the emotions. But it’s just a rice paper curtain painted to look like a wall. I’m not a builder. I’m not a superhero. I’m not a savior.
I am an illusionist.
A lot of good that does anyone.