Intern Page 24

  TODAY, AFTER MORE THAN TEN YEARS in medicine, I am no longer surprised by the small injustices I see in the hospital. Ours is a multi-tiered system, and the tiers can be defined any which way. I once cared for an Indian man with metastatic colon cancer who was in his early thirties, had been born in New Delhi, had gone to Berkeley as an undergraduate, where he studied physics, and later moved to New York for a job. For all the obvious reasons, I saw myself in him. Whenever I had a spare moment, I would steal away to his room, where we reminisced about college or about life in New York. I looked through his medical record with a keener eye than I did for my other patients. For him, I was willing to read up on experimental chemotherapy protocols or make an extra phone call to ensure that his tests were not delayed. Did it make a difference? Probably not—at least not in any tangible way—but the extra attention gave him solace, even if it didn’t change the outcome of his disease. If doctors discriminate against patients, then it follows that sometimes they have favorites, too.

  Frankly, what surprises me now are the rare doctors who treat the drug-abusing homeless person with the same care as the Madison Avenue socialite. They are the kind of doctors who seem untouched by bias, or at least recognize their biases and fight to disentangle them from medical decisions. Like their colleagues, they appear unaware of their behavior and how much it matters.

  CHAPTER SEVENTEEN

  informed consent

  Down, down, down into the darkness of the grave Gently they go . . .

  —EDNA ST. VINCENT MILLAY,

  “DIRGE WITHOUT MUSIC,” 1928

  In September, I returned to night float, this time as a second-year.

  At 9:00 p.m. each night, I’d wander over to the emergency room, where Dr. Chou or one of the other ER attendings would give me a thumbnail summary of a patient I was supposed to admit. The ER workups were typically quick and dirty. Blood tests were usually missing; X-rays or electrocardiograms had often not been done. One time, I watched a third-year resident argue bitterly with Dr. Seymour, the tall, overbearing night physician, because Seymour wanted to admit an anemic patient for gastrointestinal bleeding without even checking the stool for blood.

  In addition to admitting patients, I was also responsible for helping interns overnight. The first time I got called for backup was by an intern in his third month who needed help interpreting a tricky EKG. I liked reading EKGs. Unlike most problems in medicine, you could apply strict logic and reasoning to them. On the ward, with the intern raptly looking on, I took out my metal calipers and placed the sharp tips on two P waves. Then I advanced the calipers across the page, one arm over the other, showing how the tips landed squarely, sequentially, inevitably, on the downstream squiggles. It was a thing of beauty, really, and then I launched into an explanation of what it all meant. To the intern, the tiny markings had meant nothing, but now, thanks to my simple demonstration, they meant everything. If only the rest of medicine could be so straightforward.

  One night, around 10:00 p.m., I was called to the Memorial ER, across the street from New York Hospital, to admit Armen Izanian, a man in his late thirties with salivary gland cancer that had spread to his lungs and bones. As I looked over his chest X-ray, which showed “cannonball” lesions throughout the lung fields, the ER attending said: “Sad case. Young couple, no kids. All they have in the world is each other.”

  Izanian’s wife, Anna, was sitting with him. A small chocolate cake with caramel spears sat on a small table by his bed. It was his birthday.

  He was of Middle Eastern descent, bald and gaunt, with a slightly pitted face but otherwise handsome features. A long scar coursed down the side of his face, where, I assumed, he had had surgery. The bones in his face were unusually prominent because of his wasted musculature. His eyes were dark brown and large, conferring on him a look of amazement. An oxygen mask was strapped to his mouth. The flow through it produced a steady hum, like a leak from a tire.

  He answered my questions politely. He said he had been having fevers for the past couple of days. In the ER, he had been given intravenous diuretics and a medicated mist to open up his airways, and though he was feeling better, he still was unable to speak in full sentences without stopping for breath. In fact, he was taking in about thirty breaths a minute, even though the oxygen in his mask was nearly at maximum concentration. Given his debility, I wondered how much longer he was going to be able to continue at this rate. If he tired, the next step would be intubation: insertion of a breathing tube into his trachea for artificial ventilation. But a respirator wasn’t going to help a man with disseminated lung cancer, at least not for long. I decided to broach the subject of DNR (Do Not Resuscitate): whether to try to revive him if his heart stopped beating or if he stopped breathing.

  “If . . .” I hesitated, though I knew exactly what I wanted to say. “. . . in the event that you could not breathe on your own . . .” I paused again. “. . . would you want us to insert a breathing tube and put you on a respirator?”

  Izanian stared through me. For the past few minutes he had been friendly, even good-humored, but now he appeared annoyed. “You’re saying I’m in trouble?” he growled.

  “I’m not saying anything is going to happen imminently,” I said, quickly backtracking. “I just wanted to ask the question so that we do everything in accordance with your wishes.”

  “No one talked to us about it before,” his wife interjected. She was stylishly dressed, with short brown hair, thick-rimmed designer glasses, and a pious reserve I found appealing. In different circumstances, I might have described her as sensual. “But we want to try everything,” she said, looking at her husband. “Right, Armen? We don’t have a choice in the matter.”

  The choice, of course, was to limit aggressive measures if the end was near. I thought of what Dr. Omar Morales, the young Puerto Rican attending with pockmarked skin and a gangster’s demeanor, had once said to the wife of a cancer patient being admitted to the ICU. Initially she, too, had wanted everything done. “He will get intubated,” Dr. Morales told her with glum conviction. “Then we will not know his volume status, so we will have to insert a catheter into his lungs. He will get an infection. We will give him antibiotics. His blood pressure will drop. We will give him intravenous pressors. His kidneys will fail. He will need dialysis. And, despite everything we do, his cancer will not go away. Eventually you will make him DNR, but by then he will have suffered for no good purpose.”

  He spoke like a clairvoyant looking into a crystal ball. The course was tragically stereotyped; there were no surprises, no miracles; he had seen it over and over again. The wife agreed to DNR that day, and the patient died a few days later. But even though Izanian was in similar straits, I knew that I had neither the experience nor the fortitude to hold such a discussion.

  “Do you need an answer tonight?” he demanded.

  “No,” I replied, though in fact I probably did. “Why don’t you think it over and discuss it with your doctor?”

  Anna followed me to the workstation. “We are scared,” she said apologetically. “We know he is dying, but we want to hold on for as long as we can.”

  I told her that DNR did not mean we would stop treating her husband. It only meant we would limit life-prolonging interventions in case of a cardiopulmonary arrest. (Even though this was technically true, I wasn’t sure how well it was implemented in practice. Too often I had seen nurses and doctors use DNR as an excuse for laxity.)

  “He is all I have,” Anna said, her eyes moist but steadfast. “I want everything done to keep him alive.”

  The encounter reminded me of a patient I had seen at New York Hospital a couple of weeks prior. One morning, around 2:00 a.m., I was hanging around the ER when paramedics wheeled in a ninety-year-old woman named June Steinway on a stretcher. She was having severe chest pain, which an EKG immediately confirmed was a massive heart attack.

  The ER staff sprang into action. Doctors whisked her into a treatment room, placed a monitor on her, slapped an oxygen mask o
ver her face, and began an IV drip of nitroglycerin. Though in pain, she was alert, clearheaded, and quiet. The only indication of an emergency was in the buzz of the many doctors and nurses around her.

  Doctors began preparing her for cardiac catheterization. The chest pain had started only three hours ago, so there was still time to open the blocked artery that was cutting off blood flow to her heart. The cardiology fellow, an earnest man, stepped outside the room to talk with the woman’s middle-aged daughters.

  “Your mother is in critical condition,” he told them. “If nothing is done, she could die.” Angioplasty probably offered her the best shot of surviving this crisis, but it was risky, particularly in an emergency. Their mother could die on the table or suffer brain damage or end up on a ventilator. No one could predict with any certainty what would happen.

  “She can also be treated with a thrombolytic drug to dissolve blood clots,” the fellow said. It was administered through a simple injection and required no invasive procedures. But it was not as effective as angioplasty in this situation, and it carried a risk of causing bleeding, especially at her age, into her head.

  So what did they want to do?

  The daughters asked for a couple of minutes to talk it over. When the fellow came back, the elder one faced him squarely. “We can’t bear to watch our mother go through any invasive procedures,” she said. “She is ninety years old. If she was sixty, it would be a different story.”

  The fellow nodded. “So you want us to give her the thrombolytic then,” he said.

  “But you said there was a risk of stroke with the drug,” the elder daughter said.

  “Of course there are risks,” the fellow replied impatiently. “But you have to weigh the benefits. She could recover from this and go on to live a few more years.”

  “We want her to live as long as possible, but with quality,” the younger daughter said tearfully. “We don’t want to see her on a ventilator.”

  “I can’t offer any guarantees,” the fellow said. “My job is to tell you the options. The final decision is up to you.”

  The daughters looked perplexed. “We can’t make this decision,” the elder daughter said. “Perhaps you should ask our mother.”

  Now ordinarily, in an emergency, doctors are not supposed to waste precious time discussing risks and benefits. They—we—are taught to treat first and ask questions later, on the assumption that rational people would prefer treatment to prolong their lives. But this emergency was different. The patient was awake and seemingly competent. The fellow could decide how best to treat her heart attack, but only she could decide whether the effort would be worth it.

  In the treatment room, Steinway’s blood pressure had stabilized and she was a bit more comfortable after receiving a shot of morphine. She was an obese woman with thinning, salon-done brown hair, lying on a narrow gurney dressed in a faded teal hospital gown. A tangle of EKG wires snaked across her chest, terminating on green electrodes pasted to her hefty, exposed breasts. A nurse was struggling to place an oxygen tank under the stretcher in preparation for transport to the catheterization lab. The hubbub in the room had given way to a sort of heaviness as everyone waited for a directive to proceed or not. If the decision was for angioplasty, an attending cardiologist and the catheterization staff on call were going to have to be summoned. Everything was on hold until a decision was made.

  Steinway smiled as her daughters approached. They hugged and kissed her and stroked her hair. She clutched their hands and beamed at them. The fellow took his position at the foot of the stretcher. “You are having a heart attack,” he announced, bringing a hush to the room. “There are some things we can do to treat you but we need your consent.”

  He quickly went through the treatment options and risks. Cardiac catheterization, thrombolysis, groin puncture, local anesthesia, simple injection, contrast dye, blood thinning, vascular complications, allergic reactions, bleeding, infection, stroke, renal failure, heart attack, death. Steinway listened but did not say anything. He repeated the options. She nodded. So what did she want to do? She shook her head. “What is best?” she asked.

  The fellow’s speech picked up nervously. “It’s difficult to say what is best in this particular situation,” he said. “Studies comparing angioplasty and thrombolytics have shown advantage for angioplasty if it is performed by an experienced cardiologist within three hours of the onset of symptoms. Death rates are lower, and angioplasty results in an open coronary artery much more often than thrombolytics. And angioplasty also reduces bleeding complications, especially in the brain.”

  He paused for a second, waiting for her to process what he had just said. “But,” he went on quickly, “your blood pressure is low, which makes angioplasty riskier. And people in your age group might not get the same benefit, though we don’t know this for sure.”

  Steinway turned her attention back to her daughters. The younger one asked for a blanket for her mother, but the nurse replied that she wanted to keep Steinway’s chest exposed.

  “I know I’m presenting a lot of information,” the fellow said evenly. “But we have to proceed quickly if you’re going to get any benefit. The longer we wait, the more your heart is jeopardized.”

  Steinway stared at him blankly, as if expecting him to say something else. When he didn’t, she turned away again.

  The fellow moved in closer. A sense of urgency crept into his voice. “Is there any other family you want me to talk to?”

  “We are her only family,” the elder daughter replied.

  “Then tell me what you want to do,” he said sharply. The attending physician was surely going to chew him out for taking so long to obtain consent. “If she were my mother,” he added almost parenthetically, “I would tell her to have the angioplasty.”

  “But you said there is a risk of kidney failure,” the younger daughter said. “You said she could end up on dialysis.”

  “Of course there are risks!” the fellow cried. “There are risks with everything we do. But there is a risk of doing nothing, too.”

  The elder daughter cleared a strand of hair from her mother’s perspiring forehead. “What do you want, Momma? Do you want the surgery?”

  Though it wasn’t clear how much of the complicated situation Steinway understood, it was pretty clear that she didn’t like any of her options. She wanted assurances the fellow could not give. And he wanted a decision she could not make. Finally, she looked out at the room of white coats, slowly shook her head, and said she didn’t know. She was taken to the cardiac care unit for observation.

  To me, this outcome was hardly a surprise. Hospitalized patients have a hard time weighing their options under the best of circumstances. In an emergency like this one, where the stakes were high and the time frame to make a decision so compressed, how could we expect a ninety-year-old or her suffering daughters to make the proper choice, any more than I could have expected Armen Izanian and his wife to decide on the spot whether to authorize a DNR order?

  I remembered how the cardiology fellow used to obtain “informed consent” for procedures on 4-North. He told the patients the risks and benefits, but rarely did this prompt any sort of meaningful discussion. Patients invariably told him, “You’re the doctor. I’ll do whatever you say.” Most of them seemed to think informed consent was a sham, demanding they either ratify decisions that had already been made or make decisions they were not equipped to make. Even when patients were not agreeable, they could easily be persuaded to change their minds, like the Mexican man who was bullied into having a catheterization against his better judgment. The words Dr. Klein, the attending physician, had used after wresting consent from him were emblazoned in my memory. He said we could get whatever we wanted from patients. “As long as they agree with us, they’re not crazy.”

  The next night, around 3:00 a.m., I stopped by Armen Izanian’s room to see how he was doing. I expected to find him asleep, but when I peeked in, he was sitting bolt upright in bed, eyes closed, hands
folded, in an almost meditative pose. A pressurized mask was strapped tightly to his face, its plastic straps digging deeply into his neck. A machine whooshed like a steam engine with each breath. His wife, Anna, was standing at his bedside, stroking his perspiring forehead. Feldman, an intern, was also in the room. He was a young punk with pointy eyebrows who talked so fast he stammered. He had a reputation for being a cowboy, confident and cocksure.

  “Who called you?” he demanded when he saw me in the doorway.

  I told him I had admitted Izanian the previous night and wanted to see how he was doing.

  “Well, look at him!” Feldman exclaimed, walking out into the hallway. Izanian was breathing over forty times a minute. Though he was receiving pure oxygen, his pulse oximeter was reading only 90 percent, critically low.

  “He probably has pneumonia,” Feldman said. “The chest X-ray shows a new infiltrate.” This did not surprise me. Lung tumors can obstruct the breathing passages, causing fluid and secretions to build up, a disorder called postobstructive pneumonia.

  Wondering why he hadn’t called me for backup, I asked Feldman which treatments he had given Mr. Izanian so far.

  “Lasix, Solumedrol, Atrovent, albuterol,” Feldman replied rapid-fire, counting out the interventions on his skinny fingers. “But he’s getting tired. I think he’s going to crap out pretty soon.”

  “Have you called the ICU?”

  “He’s DNR!” Feldman cried indignantly. “Right now, I just want to keep him comfortable.”

  I assumed the DNR order had been issued earlier in the day. “Did you start antibiotics?”

  Feldman shook his head, as if the thought had occurred to him but he had decided it wasn’t worth it.

  “DNR doesn’t mean we’re not going to treat him,” I snapped. “Start him on broad-spectrum antibiotics. Let’s see if we can get him through this.”

  As Feldman headed over to the nursing station, I heard his beeper go off. Beep . . . beep . . . beep. The sound transported me back to a year ago, when I had been the night float at Memorial. For a moment I felt a pang of sympathy for him. Night float during internship had almost broken me; I was thankful those days had long passed. But from what I could remember of it, I was certain that the last thing Feldman wanted to do that night was spend precious time on a patient who was DNR.