I spent the next few hours peering over Baio’s shoulder as he put out one fire after another. It was like being in the front row of a small concert, mesmerized by an undiscovered band on the cusp of stardom, thinking, Why didn’t I ever learn to play the guitar? On each of my trips to the cafeteria to retrieve snacks, I filled my notebook with terms and phrases to look up. It was three in the morning before I knew it, and twenty-one hours of my shift had elapsed in the blink of an eye.
Or had it? I had seen and done more in this one night than I had in entire months of medical school. A beating heart had stopped and I’d restarted it with the thumps of my palms. I’d broken ribs, mashed on groins, adjusted ventilators, and administered medications that were so new they didn’t appear in textbooks. Sure it was fun to delicately suture a facial laceration, but there was something unique, something otherworldly about critical care medicine. The patients were so sick, so close to death; there were no imaginary numbers in the cardiac care unit. The operating room seemed almost mundane by comparison. Axel would surely laugh at the suggestion, but he was missing out. Surgery had come to seem narrow to me; this was complex decision making that involved processing dozens of inputs at once.
Back at the nurses’ station, Baio emphatically struck a letter on the keyboard and spun in my direction. “All right, I’m wired and I’m happy. Time for some teaching. Let’s go over some EKGs. I will assume you are absolutely horrible at reading these,” he said, fighting back a smile.
I grabbed my pen and wheeled my chair closer to him. “That is an excellent assumption.”
“Let’s start with your new patient, Gladstone,” he said, holding up the EKG that hours earlier had set so many wheels in motion. “Everything we do in medicine has to be systematic.”
Systematic, I said to myself, ready to make it a mantra.
“Otherwise, things get missed and bad shit happens.”
“Understood.”
“When I look at an EKG, I say the same thing to myself every time: rate, rhythm, axis, interval. I start with the rate. Do you know why I start there?”
I shook my head.
“If the rate is wildly abnormal—say a hundred and ninety beats per minute…or twenty-five beats per minute—you need to drop the EKG and go evaluate the patient. Got it?”
I scribbled, wildly abnormal rate, drop ekg. “Yes, yes. Got it. Consider it a brain tattoo.”
“You remind me”—he chuckled—“you remind me a little bit of that dude from Memento.”
I considered the movie’s handsome star for a moment and said, “Thanks.”
“Not a compliment. Next, I examine rhythm. If the rhythm is anything other than normal sinus rhythm, we could have an issue.”
Over the next two and a half hours, Baio showed me how to read an EKG, interpret an arterial blood gas report, and process the deluge of data that was generated on each patient every few hours. I wished I’d been doing this from day one of medical school. Countless anatomy or pharmacology lectures had armed me with volumes of critical information and yet no way to translate it into the actual practice of being a doctor. Dealing with life-or-death situations required knowing not just body chemistry and physical science but how to assess a patient’s condition correctly and make quick decisions. And without a framework for organizing all the knowledge in my head for quick application, I was certain to flounder. What Baio was doing in the CCU, I realized, was providing a way of merging the knowledge in my head with the reality of my patients’ symptoms.
Around 5:30 A.M., physicians, including my three cointerns, began to file into the CCU. I had been assigned at random to spend the entirety of my three-year residency training with the same three women: Ariel, Lalitha, and Meghan. We would take turns working thirty-hour shifts every fourth day for the majority of the year. But our time together was somewhat limited in the CCU because we’d each been paired up with second-year physicians—in my case Baio—to learn the ropes. Every four weeks for the entire year, the four of us would move to a new rotation—infectious diseases, general medicine, geriatrics, medical intensive care, oncology, et cetera. In our second year, we would repeat the cycle while supervising an intern each, essentially becoming Baio, an idea that was mercifully remote. I couldn’t quite tell you what third-year residents did, other than apply for jobs or subspecialty fellowships.
“Breakfast!” Ariel said, handing me a brown paper bag and a coffee. She had frizzy red hair and green designer scrubs with a blue racing stripe.
Baio grabbed the bag and examined its contents. Dissatisfied with the options, he looked up. “How is your pod?” he asked, which was what the hospital called each team of interns.
“They seem nice. Great, actually.”
“Better hope you get along. You don’t see much of them now, but you will. You’ve got eighty hours a week, every week, for the next three years.”
“Hard to believe.”
“Personality conflicts,” he said with a mischievous grin, “can make for a bumpy ride.”
The interpersonal dynamics of working closely with three other interns for three years in a high-stakes environment were not yet clear to me. But it appeared that these trial-by-fire friendships would emerge in small bursts, and would be based wholly on trust. If my colleagues couldn’t rely on me, if they couldn’t be sure that I would take care of their patients as well as they could, our group would be dysfunctional. No amount of kindness or humor or empathy could overcome that. Without a shared sense of trust, we would have nothing.
I spent the next hour reviewing my patients and preparing for rounds. At 7:00 A.M. a new set of nurses arrived.
“Give them some space,” Baio said. “Let’s talk.”
I walked with him to a corner of the unit.
“Our attending is going to be here soon,” he said, referring to the board-certified cardiologist supervising us all. “He’s a total badass. Cardiologist to the stars. He’s brilliant but tough. Doesn’t like his time to be wasted. So make your presentations short. Get to the point. Tell him what he needs to know about the patient and move on. Got it?”
Thirty minutes later, rounds started. Eleven of us gathered in a white-coat-clad horseshoe around Dr. Badass: four interns, four residents, a medical student, a pharmacist, and a cardiology fellow named Diego, who was originally from Argentina. Diego had completed his residency training at Columbia and was now in the prestigious three-year cardiology fellowship, learning to become the Badass much like I was learning to become Baio. He had a perpetual squint and reminded me of Axel when I first met him—tired, curt, and wholly unimpressed with me.
Our group stood in silence, waiting for the Badass to speak. I had been up for twenty-six hours, and delirium was setting in. At twelve hours, I had been tired. At sixteen, a second wind had kicked in. But by twenty-four hours, basic faculties started failing, and now I felt about three hours away from needing to be admitted myself. The endurance marathon of the thirty-hour shift confused me. How could I be responsible for my patients if I was in worse shape than they were?
Slowly, heads turned in my direction and the Badass said, “Well?”
Baio nudged me and whispered, “You’re on, dude.”
It has been said that if you look around a poker table and can’t immediately spot the sucker, it’s you. I feared I might now be in the midst of something similar. I squeezed my notes and brought them up to my face. The word Gladstone popped out along with anisocoria, and in a margin, I had apparently scrawled solo synchronized swimming—an Olympic sport?, something I didn’t remember writing.
“Carl Gladstone is a fifty-eight-year-old man with no significant past medical history who developed chest pain at work yesterday,” I began, reading from my notes. “Collapsed and was brought to our ER.”
I had everyone’s attention, with the exception of Baio, who was whispering in a nurse’s ear. When I was finished, we entered the room and collectively examined my patient. I spoke for a few minutes more as Diego stared at the tile floor, gently shaking his head, before the Badass interrupted.
“Fine. Next patient. The thing about the pupil is strange. Scan his head.”
Bleary-eyed and stammering away, I proceeded to present the events of each patient as we moved around the unit. Most of it I got right, some of it I got wrong. Fortunately, my well-rested team was there to step in if I misinterpreted an EKG finding or misstated a lab value. As we approached Benny’s room, the Badass softly said, “Next,” and we continued past. Mercifully, I was dismissed after rounds and asked Baio if he wanted to head to the subway with me.
“Nah,” he said, “I’m gonna stick around for a bit.” He picked up a stack of EKGs and yawned. “By the way, nice work last night.”
With the gait of someone about to fail a sobriety test, I walked to the elevator and out of the hospital into the warm summer sun. It was just after noon and I had been awake for more than thirty hours—a new personal best. Crossing the street, I saw a large red banner draped down the side of a hospital overpass.
Amazing Things Are Happening Here!
The words made me smile. How could I possibly describe the things I’d just seen and done? Amazing seemed as good an adjective as any. A few minutes later I plopped into an empty seat on a southbound subway car and drifted off to sleep.