I was back in the unit the next day before sunrise. Benny waved from his bike each time I passed his window, hustling from one room to the next, familiarizing myself with the new patients. A woman was now residing in Gladstone’s recently vacated bed. He had been transferred to another floor shortly before his wife, Sasha, arrived searching for answers. I gave her my best summary of the situation but ultimately referred her to my supervisor for a complete explanation. On her way out of the unit, she flagged me down to express her gratitude.
“He’s going to get through this,” I said, hoping that my optimistic spin on the situation was appropriate and, more important, accurate. It was a good sign that he was no longer in the unit, but I really couldn’t speak to his long-term prognosis. Sasha, with hair so white it appeared to be dyed, was twisting her lip back and forth as we spoke.
“I pray you’re right,” she said.
I grabbed her right hand and gave it a soft squeeze. “We have to stay positive.”
“Did you get to talk with him at all?”
“I did not.”
“He’s one of those creatures of habit. Starts every day the same.” She repositioned her purse on her shoulder and smiled at the thought of her husband’s routine. “Makes coffee, hops in the shower. Goes to his office. I don’t understand why the other day was different.”
“We’re going to do everything in our power to answer that.” Her lip quivered as I spoke. “Tell me more about him,” I said.
A few minutes later, Baio, standing in front of a chest X-ray, summoned me. “We’re going to do at least five minutes of teaching every day. Today’s lesson is the chest X-ray.”
I grinned. “That’s very kind of you.”
“I’m not doing it out of kindness. I’m doing it so you’re not a terrible doctor.” He slapped me on the back and grinned. “Okay, how do you read a chest X-ray?”
“Systematically,” I said, thinking about his approach to any- and everything.
“Correct. Without a system, things get missed. So what’s your system?”
“I don’t really…I know I should, but I don’t have one. I just kinda look at it. Like here,” I said, pointing at a white blot in the left lung, “pneumonia.”
“No!” He shook his head. “You’ve got to be better than that. But at least you’re honest. Take another stab at it.”
If Baio was Charles in charge, I was Charles’s dopey pal on the show, Buddy Lembeck. Perhaps it wasn’t pneumonia, but it certainly looked like it. “Okay, the left lung appears to show pneumonia and the right lung…”
“Stop.”
“What?”
“If you see a beautiful woman on the street,” he said earnestly, “do you first look at her chest?”
I wondered if this was a trick question.
“The answer is no, Dr. McCarthy. Start in the periphery. Does she have an ankle tattoo? Or a wedding ring? Then work your way in.”
I nodded. “Okay.”
“If you went straight for the lungs, you’d miss this at the edge.”
He pointed at a hairline fracture of the left clavicle. He was right: I certainly would’ve missed it.
“Let’s get started,” Dr. Badass bellowed from the other end of the hallway. “Chop, chop. Cut the bullshit.”
Rounds began promptly at 7:30 A.M. and proceeded at a dizzying pace. Blips of conversation were exchanged between the more senior members of the group in a medical shorthand that I was not yet able to fully process. My role was to present the overnight events on a handful of patients and to give a short presentation based on a question I had asked on rounds a day earlier, when I wondered aloud how long we had been doing heart transplants at Columbia. As it turned out, if you posed a question on rounds for which there was not an immediate and obvious answer, you would be asked to give a short presentation on the subject the following day.
In between presentations, I occasionally whispered questions to Baio, searching for further explanation of an acronym or clinical trial, but each time he held an index finger to his lips and shook his head. My notebook continued to fill up throughout the morning. We finished rounds shortly before noon. As I jotted down cardioversion, I felt a hand on my shoulder. It was the Badass.
“You’re doing a nice job,” he said softly, his large brown eyes staring down at me. It was the first time we’d spoken outside of rounds, and thus far I’d found him as approachable as a supermodel. Innumerable wrinkles lined his forehead and cheeks, and his hair looked like wet hay. “But, Dr. McCarthy, you should really know how to read a damn chest X-ray.”
After lunch, a ninety-second affair in which we gobbled down gamey tuna fish sandwiches, Baio gave me the task of placing a large-bore IV, what’s known as a central line, into the femoral vein of a young woman. Baio would supervise the procedure and suggested I watch a simulation of it on The New England Journal of Medicine website.
Shortly after the video began, someone tapped me on the shoulder.
“Phone call for you, Doc,” said the ward clerk.
I paused the video simulation and took the phone, wondering who knew to reach me in the unit. “Dr. McCarthy?” said the man.
“Speaking.”
“This is Dr. Sothscott.” He had a soft baritone and spoke quickly. Residents and attending physicians often called the CCU in search of an explanation or clarification pertaining to a patient recently transferred out of our unit, but they never asked to speak to me.
“Hi,” I said tentatively.
“I’ll cut to the chase,” he said, “you took care of a Carl Gladstone.”
“Yes. Are you—”
“I am.”
“How is he? I noticed he left the unit.”
“Well, I’ll get to that,” he said before blowing a deep breath into the phone. “I’m sitting here reading your note on him and I want to commend you on your thorough physical examination.”
A pleasant surprise.
“You performed an exhaustive ocular exam and correctly spotted anisocoria.”
The different sizes of his pupils. “Thank you.”
“Let me continue. Your note goes on to attribute this pupillary asymmetry to the sedatives he received.”
“Yes.”
“Now, Dr. McCarthy,” he said, his voice rising slightly, “what medication did you attribute it to…specifically?”
I scanned my memory. Images of the handwritten notes in his chart fluttered across my brain. “Hmm. Well, he received several sedatives.”
“He did indeed.”
“I’ll have to admit I don’t remember all of the medications he received.”
“No problem,” he replied. “I have a list right in front of me. I’ll read them to you.”
A medical variation of the Socratic method, I suspected, as he went through the list. It was a little annoying. I already had one Baio.
“I…I think several of them can cause pupillary constriction,” I offered.
“Right again.” There was a pause, and I looked at Baio, who was revolving his fingers to indicate that I should wrap up the conversation. It was time for me to insert the large IV.
“But how many, Dr. McCarthy, cause unilateral pupillary constriction of the kind you observed?”
I thought for a moment, suddenly wondering if I was speaking with another resident or an attending. “Off the top of my head…” I said.
“Oh, Doctor, this need not be off the top of your head.” His speech was becoming urgent. “Please, use references. Use a textbook. Use the Internet. Phone a friend. But please tell me, in all of medical literature, has anyone ever identified an intravenous medication that shrinks one pupil but not the other?”
Another pause. Now I wasn’t sure.
“The answer is no!” he screamed.
My head shot back from the phone.
“Carl Gladstone was on a blood thinner for a clot in his leg. When he fell and hit his head in his classroom,” Sothscott continued, barely able to contain himself, “he started bleeding in his brain.”
I closed my eyes.
“And I know you know he fell because you documented the abrasion on his scalp.”
“Oh…no,” I said softly and turned away from Baio.
“Oh, yes. And when you saw him, Dr. McCarthy, the blood was flooding his brain and starting to impinge on his cranial nerves.”
I couldn’t breathe.
“Yet your note does not reflect that. Your note is completely misleading. And it does a shocking disservice to—”
“I…”
“How much time was wasted?” he demanded.
“I am so sorry.” I wanted to hide. I wanted to disappear. I wanted to run, but there was nowhere to go. I was terrified to think of what I had done to Carl Gladstone. It had been more than a day since the Badass had said to scan his head. Was he bleeding the whole time until he reached Sothscott? That kind of time could have killed him. My knees buckled and I crouched toward the tiled floor, gasping for air as my eyes welled up.