A day later, while sitting in on an informal talk by Dr. Chanel on the emergence of multidrug-resistant tuberculosis, I received a page from my faculty adviser, Dr. Petrak. A former chief resident, Petrak was now the junior faculty member responsible for providing me with clinical wisdom and career guidance. He was, in theory, the guy who would help me decide if I wanted to become a rheumatologist or a cardiologist. I excused myself from rounds and walked down the hall to his office.
I knew that every few months, I was supposed to review my faculty evaluations with Petrak and figured he was paging me to do so. I expected the initial evaluations to be weak—the Badass had scolded me for not knowing how to properly read a chest X-ray—but I knew I had made substantial progress. Both Ashley and Dr. Chanel had complimented me on my bedside manner with angry patients, and on the general medicine service I’d convincingly demonstrated that I could perform a poop check.
As I entered the office, I took in the diplomas and certificates of achievement that hung just millimeters apart from one another on a crowded beige wall. Dr. Petrak—a forty-something Lithuanian with bushy black eyebrows—stood up and smiled. Small framed pictures of his family were scattered across his desk.
“Dr. McCarthy,” he said, extending a hand. “Please…take a seat.”
“Thank you.”
The last time I had been in this office, a year earlier, Petrak was interviewing me for a spot in the residency program. Since then we had exchanged small waves and quick handshakes as we briskly passed each other in the hospital’s lobby, but that had been the extent of our contact. “How are you?” he asked.
“Good,” I said, removing my stethoscope from my neck and placing it in my coat pocket. “Very good.”
“Good,” he said as he sipped from a coffee mug. “Great.”
We stared at each other for a moment before he cracked his knuckles. “The purpose of this meeting,” he said, “is just to check in.”
I took two quick breaths and found myself once again drawn to the eyebrows. Under the fluorescent lights, I noticed that they contained hints of gray, just like my own hair. I’d finished medical school with a thick brown mane, but I’d been discovering more thin gray hairs by the day. At first I wanted to blame the HIV medications, but I knew it wasn’t that. It must be the overwhelming workload; I had aged several years in several months.
“So…” Petrak said as he pointed an index finger at me, “how are you?”
These conversations all seemed to be the same way. “Like I said, I’m good.” I held up a computer printout of my patient’s vital signs. “You know, staying busy.”
“Good, good.” The eyebrows bounced on his forehead; you could probably braid those fucking things. “So here’s the deal,” he said. “I talked to Dave and a few other people.”
“Okay.”
“And I hear you’ve been through a lot.”
I leaned back in my chair. “Huh.”
“What can I say?” he said, shrugging his shoulders. “People talk.”
“I’m aware.”
“People are worried about you. Interns are dropping out and we need to identify those who might—”
“I’m okay.”
“People are worried you are…how do I say…decompensating.”
“Decompensating?”
“Yes.”
It was a word I had never used before coming to Columbia, but now I heard it tossed around all the time. To decompensate meant to unravel. We used the term to describe clinical phenomena—Benny’s failing heart was in the process of decompensating—and to describe emotional turmoil. A frazzled intern who appeared to be on the verge of snapping, or who was seen yelling at a nurse or a patient, was said to be decompensating. It was a word that at some point could be applied to every intern. I might have used it to describe myself earlier in the year, but not now. Petrak took another sip, and I folded my arms. “I don’t know what to say.”
“You don’t have to say anything, Matt. But for your own sake, I want you to know that you’re now operating under a microscope. People are watching you. We don’t want to lose any more interns.”
“Okay.”
“And they may begin to question your clinical decision making.”
My thoughts flashed to Dr. Phillips. Had he said something to Petrak? Was that what this was about? I carefully considered my words. “Are people questioning my decisions?” I asked.
“No.”
“Well, that’s good.” I took another deep breath. Were these kinds of threats or warnings common?
“Not yet.”
“Oh.”
Operating under a microscope? Was increased observation supposed to prevent me from decompensating or precipitate my decompensation? I ran my hands through my hair, and the specter of Carl Gladstone in a rehabilitation facility flashed across my mind. In its place appeared a vision of Magic Johnson giving me a high five in a public service announcement for HIV. Soon Banderas was going to draw my blood and call me with the results. I tried to imagine him saying, I have some bad news.
“Look, Matt,” Petrak said after a long pause, “I’m only telling you this for your own benefit.”
The meeting concluded a moment later. I stepped out of his office and apparently into the crosshairs of the microscope. “You have got to be fucking kidding me,” I said softly as I approached a vending machine next to the hospital’s elevator. I smacked the machine’s Plexiglas with the palm of my hand. “Fuck!” An Orthodox Jewish couple walked by, and I sheepishly took off my white coat and pager. I couldn’t remember the last time I’d hit anything in anger. “Fuck!” I said and again slammed the machine.
I had never felt lower. The entire chain of command appeared worried that I might either leave or accidentally kill a patient if I stayed. No one seemed angry; in fact the overriding attitude from both Dave and Petrak was concern. But it didn’t make me feel any better. I was living day to day in constant pain, creeping closer to a verdict on my future health, and every time I thought about it, I thought about what an awful stupid fucking mistake I’d made to be in this position. Over the months I had become better at so many aspects of being a doctor, but it wasn’t enough. Not enough for me, not enough for Dre, not for Phillips and his patient, and apparently not for the people who were supposed to be looking out for me.
If I had blown off any steam at intern retreat, it had just come back with reinforcements. As I wound up for a third shot at the vending machine, the overhead intercom went off.
ARREST STAT, SEVEN HUDSON NORTH! ARREST STAT, SEVEN HUDSON NORTH!
I grabbed my coat and was off, sprinting down two flights of stairs.
ABC, ABC…
I bounded past Moranis—he was giving a tour of the hospital to a group of medical school applicants—and was the third person to arrive at the bedside of a twenty-one-year-old African-American woman who had been found unresponsive by her nurse. I thought of Baio’s hypotheticals in the cardiac care unit as the arrest resident arrived a moment later. She quickly gave orders—chest compressions, defibrillator, epinephrine—before turning to me and saying, “Central access.”
Shit. My job was to insert a large-bore IV into the young woman’s groin, a procedure I’d done just once before. Learning medicine was about being thrown into the fire, learning on the fly, but since I’d left the CCU, I’d been dealing with different types of fires. My patients on the infectious diseases service were not critically ill, in the strictest sense of the term, and as a result, they hadn’t needed the critical care that I’d learned in the CCU. So I felt uncomfortable inserting this enormous IV, but I knew I had to do it. I imagined the lens of a giant microscope hovering above me.
I reached for the central line kit and took a deep breath. I did not want to do this procedure. I didn’t want to fuck up and I didn’t want administrators to talk about me. But there was no time for my existential crisis. The room became more and more crowded as I swabbed the young woman’s groin with iodine. I could feel blood coursing through her femoral artery with each chest compression. An anesthesiologist quickly snaked a breathing tube into her trachea.
“No pulse for four minutes,” the arrest resident said to the group. “Let’s go.”
I uncapped the large needle and moved it toward the woman’s right hip. Her lifeless body bounded like a rag doll’s as the team performed CPR. I told myself to breathe. I briefly closed my eyes and thought of the anatomy. Ashley taught me to remember the anatomical location of the vessels in the groin with the mnemonic NAVEL. Starting from the hip and moving inward, the order is:
N—femoral nerve
A—femoral artery
V—femoral vein
E—empty space
L—lymphatics
The IV has to be inserted in the femoral vein; striking the artery or nerve would be devastating. The only vessel you can feel is the artery. Once it’s identified, the needle is inserted medially, striking the vein. If deep purple blood fills the syringe, you’ve hit your target; bright red blood means you’ve landed squarely in the artery. I imagined Dave, Dr. Phillips, and Petrak in the corner of the room, whispering about what I might do wrong.
I took a deep breath and shoved the needle, which was attached to a large syringe, into the woman’s leg. Pulling back on the syringe, I slowly advanced the needle, waiting to see it fill with blood. There was nothing.
I pulled back and inserted the needle again as the young body bounced. It was critical to get the IV into the vein as quickly as possible so that the powerful, potentially lifesaving medications could be rapidly administered. My heart was racing, my breathing ragged. Sweat pooled under my arms. Several physicians looked on as I fished around inside her pelvis, wondering if I was in the E of NAVEL. The hole in her punctured skin became a bit larger every time I readjusted the needle.
“Eight minutes without a pulse,” the arrest resident announced. “And does anyone know if she’s pregnant? Matt, how are we doing on access?”
Pregnant? Sweat began to drip down my arms. The insides of my gloves were soaked. “I’m trying,” I said. “Trying again.” The idea that there might be a fetus just inches from the tip of my needle was almost too much to fathom. I looked at the patient’s belly as my heart continued to heave.
“Just put it in the vein,” someone shouted. It reminded me of those moments on the pitcher’s mound when I found accuracy eluding me and fans would yell out, “Just throw strikes!” I steadied the needle and again felt for the femoral artery. I plunged the needle even deeper. Suddenly, the syringe filled with fluid and I exhaled. But the fluid was not purple. It wasn’t red either. It was yellow.
“That’s piss, dude,” someone said. “Try again.”
Had I inserted the needle so far that I’d punctured her bladder? It seemed unlikely, but I didn’t know. “I can’t get it,” I said and quickly withdrew the needle. It was impossible to tell if I’d stabbed the uterus.
“No, no,” a different voice said from behind me. “Stay.”
I didn’t have to turn around to know it was Baio. “Do this,” he said, placing my hands in the appropriate locations like he was teaching me to play billiards. “Here…here and go.” He took a step back from me and said, “Do it.”
The woman’s body was still bouncing from the CPR. I took a deep breath and plunged the large needle into her groin. Again nothing. I stared at the empty syringe as the team continued chest compressions. What was I doing wrong? I placed my hand on the groin and felt for the artery. I thought I felt something and quickly plunged the needle in yet again.
A moment later dark blood filled the syringe and the IV was in.
“He got it,” Baio said to the arrest resident. Atropine, epinephrine, and dopamine quickly streamed through the IV.
He got it. I mouthed the words to myself. My heart felt like it was going to jump out of my chest. He got it. As the medications coursed into her body, the image of Charles McCabe and that banana peel twinkled brightly in my mind. I imagined him watching this chaotic scene unfold, encouraging us to save this young woman. I imagined Dave turning to Petrak: He got it.
“Come on,” I said to the lifeless body. More than anything, I wanted her to live. I didn’t know her, but I wanted her to be a success story, one I would remember. A moment I could build upon.
We had just passed the ten-minute mark when a nurse yelled, “We have a pulse!”
Chest compressions were held and a pulse was confirmed. “ICU. Now!” someone shouted and a path was cleared. We had just brought the woman back from the dead and I’d played an integral role. Without that large IV, the essential medications wouldn’t have been given at a sufficient rate. Six of us frantically wheeled the young woman to a service elevator.
“Keep your finger on the pulse,” the arrest resident said to me, placing my free hand onto her femoral artery. “If you lose that pulse, we have to restart CPR.”
In the elevator, I closed my eyes to focus on the sensation of the weak, thready pulse. A minute later we burst into the ICU, where a small group of physicians stood waiting for us. While we were finding an empty room for the young woman, a thought crossed my mind: Should I tell the ICU physicians that I might have punctured her bladder? It could potentially heal on its own. I’d seen residents do far worse things to a groin. Time seemed to slow down as I considered the retreat, the microscope, and those damn Lithuanian eyebrows. Was the second-guessing inevitable? I stared at the woman’s belly as we transferred her from the stretcher to an ICU bed.
“We have a pulse and we have a blood pressure,” the arrest resident said as a respiratory therapist squeezed a bag of oxygen down her breathing tube. “She was asystolic for ten minutes, but we brought her back.”
“Excellent,” the ICU attending physician said as he put on a pair of gloves and approached the patient. “Great work. Anything else we should know?”
I shook my head.
I made my way toward the elevator, contemplating my next move. What was I doing before the arrest? I retied the drawstring on my scrubs and scratched my head. Oh, right, I had been battering a vending machine. I looked down at my scut list and the two doodles I’d drawn on it earlier in the day. One was of a pyramid and the other was of Scrooge McDuck. The scribbles recalled Peter and his legal pad, and
Denise + Peter
I came to a halt in the center of a long hallway and stared at a newly painted taupe wall. On it I imagined the heart Peter had drawn—a punctured heart, really—and Diego’s words wafted into my head. Who are you looking out for? Yourself? Your reputation? Or the patient?
I boomeranged back into the ICU, dashing past a group of nurses to find the attending physician, who was explaining ventilator settings to a medical student. “Gotta tell you something,” I said quickly. “Your new patient…during the arrest, it took me several tries to get the line in. I might have…punctured her bladder. It’s possible.”
I didn’t care if word got around, I didn’t care if I had to sit in front of advisers and explain how it could’ve happened. It was an accident. The attending removed his hand from the ventilator and nodded. “Okay.” He frowned briefly and looked at his medical student.
“I’m sorry I didn’t mention it before. I don’t know why I didn’t say something. I’m sorry.”
The doctor put his hand on my shoulder. “Thank you for telling me.”
“I’m sorry, it was an accident.”
He shook his head. “It’s okay. We’ll take care of it.” He gave me a gentle tap on the back. “Good work.”
I left the ICU and headed toward the lobby to buy a bottle of water. I passed a large mirror and noticed I was a bit hunched over, perhaps still trying to catch my breath and wrap my head around the moment. He got it. I felt my phone buzz and read the new text message from Mark: NICE WORK DUDE!
I checked the time and realized it was almost time for my next round of HIV medications. Standing in front of the elevators, I encountered Moranis and his tour group.
“Save her?” he asked.
I nodded. “We did.”
“Super!” He started to clap, and the applicants joined in.
It was an odd moment, receiving a round of gentle applause from a group of strangers. “I put in the line,” I said.
Moranis smiled. “That’s great!” He leaned his head toward mine and to the side and softly said, “Hey, I know you’re busy, but when you get the chance, give Sam a call. He’s got a few questions about his medications. Just give him a little TLC.”
“Oh, sure. He wants to talk…to me?”
Moranis smiled. “He wants to talk to someone. And I think it should be you.” As the elevator arrived, Moranis turned to the tour group and said, “Dr. McCarthy is one of our internal medicine interns, and he’s doing a bang-up job. Keep up the good work, Doctor.”