The following night, Don and I were in the emergency room examining a woman transferred to Columbia from a nursing home when I saw Sam out of the corner of my eye. I removed the stethoscope from the woman’s chest and headed toward my patient. As I strode across the room, I felt my phone buzz. It was a text from Heather: BOTTLE OF WINE WAITING FOR YOU AT HOME.
The words made me smile. I had spent the year learning to take care of patients, and she’d largely spent the year taking care of me. Heather had acknowledged that seeing me unwell for so long had taken a toll on her; it had been difficult living with a humorless zombie, someone wholly focused on trying to avoid a mental or physical breakdown. CAN’T WAIT, I wrote back.
Heather possessed an innate sense of when I needed reassurance and when I just needed to get drunk. Or laugh. And now that I was off the HIV meds, I could finally do both. Regaining a feeling of normalcy in my private life, I discovered, helped me to cope with the emotional roller coaster of being a doctor. I could recharge at home, just as Ashley had once instructed. It was fun getting to see the real me again, Heather said, and I felt the same way.
Now that the needle stick episode was behind us, we began to speak more openly about just how awful that period had been. Heather confessed that she had responded internally with dark humor, telling herself that if I did get AIDS, we’d make lemonAIDS. I’m not sure if that line would’ve made me laugh or cry when I was living with the uncertainty of my diagnosis. Probably both. But the fact that she could now tell me these things helped me appreciate just how far we’d come. I put the phone away and greeted my patient.
“Sam,” I said, “what are you doing here?” He was lying on a stretcher, flashing those champagne-colored teeth around the emergency room. It was strange to see him outside of my primary care clinic.
“Dr. McCarthy,” he said, extending a callused hand, “it seems I’ve gotten myself in a bit of a pickle.”
I grabbed a chair. “Talk to me.”
“Started having chest pains again so I called your office. But it was closed so I came here.” Over the past few months we’d grown closer—detecting Sam’s subtle heart murmur in a routine clinic visit had been a turning point in our initially awkward relationship—but I’d watched in vain as his health steadily deteriorated. The long list of problems that had flashed on my screen before his first visit had proven to be accurate, and I’d been seeing him on a monthly basis in my clinic, sometimes overbooking him, but it wasn’t enough. Because of my hectic hospital schedule, I was only in the primary clinic one afternoon per week, and it left me with the constant, gnawing sensation that I wasn’t sufficiently there for him. “They did some blood work,” he said, “EKG, the usual stuff. Gotta say I appreciate you coming in to see me at, what, two in the morning.”
Did he need to know I was working nights and our rendezvous was merely a coincidence? I squeezed his hand. “You’re gonna get through this.” It was something I said to nearly all of my hospitalized patients, and it was a remark that I regularly wrestled with. In some cases—in a great many cases, really—I didn’t mean it. I tried to remain vague, never saying exactly what the person was going to pull through, but I knew when the odds were tragically stacked against a patient. Still, I felt the need to be positive, to offer hope to someone who’d been given up on. So I told people they were going to pull through something that maybe they weren’t, and I wasn’t sure if that was wrong.
“I know,” Sam said. “I know.”
“Where are things now?”
“They say I’m having a heart attack. A light heart attack.”
A light heart attack. What a weird term. “You look damn good for having a heart attack. Even a light one.”
“They say I need a cardiac catheterization.”
I couldn’t hear that term without thinking of Gladstone or Denise Lundquist. So much had changed since those first days in the cardiac care unit—I occasionally cringed at my initial incompetence—but in other ways, very little was different. I still thought about Professor Gladstone and Ms. Lundquist like they were my patients. I vividly recalled the tactile sensation of examining their lymph nodes, of pressing my stethoscope against their skin, of retracting an eyelid to peer into a pupil. “Okay,” I said, glancing at Sam’s vital signs. “It’s a fairly minor procedure. You’ll get through it.”
“But the dye they have to use might screw up my kidneys.”
“Right.”
“The cardiologist says I might need preemptive dialysis. But the kidney doc tells me that won’t do any good and is refusing to do dialysis. So, here I am.”
“Here you are.”
Moranis had warned me that this day was coming; Sam’s heart and kidneys were on a collision course, and we agreed the kidneys would have to be sacrificed. Sam and I had discussed this extensively over the past few months, and although I wasn’t a kidney or heart specialist, he knew I was his advocate.
To fully explore the anatomy of Sam’s injured heart, the cardiologists would need to inject a special dye into him. But that dye was known to harm the kidneys, and the nephrologists warned that his already damaged organs couldn’t handle the insult. Injecting the dye could destroy his kidneys and force him to go on dialysis. He’d need to visit a dialysis center three times per week for a long time—possibly the rest of his life—and might lose the ability to urinate on his own.
If that happened, the cardiologists might get in trouble—the need for dialysis after cardiac catheterization was a reportable offense—so there was talk of starting dialysis prior to injecting the dye. But the data supporting such a maneuver was sparse, and the nephrologists weren’t interested in doing it. So we were at a crossroads, one that left me utterly perplexed. Moranis told me that if anyone suggested there was an easy answer for Sam, they didn’t appreciate the complexity of his situation.
“Stuck in the middle,” I said, fingering the loose flesh on my neck. “This is a tough one.” I imagined Sam’s heart and kidneys in a boxing ring, fighting it out as Axel’s words once again wafted into my head: Do not fuck with the pancreas. “You shoulda called me,” I added, “directly.”
Because my hours in the primary care clinic were so limited, Sam was in the habit of texting me when he got his blood pressure checked at the grocery store. Moranis had warned against doling out my cell phone number to patients, but it was the only way to keep tabs on everyone. I thought about Jim O’Connell and what he did for his patients, wading out into the night, searching for life, searching for illness. Giving out my phone number seemed like the least I could do. I had spent so much of the year trying to connect with patients, but when I gave Sam and others my personal number, they were able to feel a connection with me. “I’m serious,” I added.
“Any chance,” Sam said, “any chance you guys can put your heads together and sort this one out?”
“I’ll see what I can do.”
“Thank you,” he said, putting a hand on his chest. “I’ll just hang here, having a heart attack.”
I walked across the emergency room and returned to Don. “Got a hypothetical for you,” I said. “My clinic patient over there is having a heart attack. Needs a cath but no one wants to touch him. Cardiology’s afraid they’ll destroy his kidneys, and the nephrologists don’t want to dialyze him preemptively. What do we do?”
Don stared at my chest. “Again, not a hypothetical if it’s actually happening.”
“What do you think?”
“It’s a tough one.”
“Right? I can see both sides.”
We looked at Sam, who was now reading The New Yorker. It must have been an exceedingly light heart attack, I thought. “Remember,” Don said, “you’re not the first to encounter whatever situation is stumping you. Never forget that.”
“Good point.”
“Could mention it to Dave,” he said, pointing at our chief resident, who was moonlighting in the ER to make a few extra bucks. I hadn’t had a one-on-one meeting since that encounter in his office, the one where he expressed concern that five interns were leaving our program and I admitted I was struggling. It had been an uncomfortable inter-action—I had replayed the dialogue in my head dozens of times—and I was left with the impression that Dave was trying to make my life more difficult. That belief may have been misguided, but it was how I felt, and even the improvement of my station at the hospital in subsequent months hadn’t quite dislodged the feeling.
I also wasn’t excited to venture over to Dave’s section of the emergency room, Area B, which held a large pit of dangerously inebriated or psychotic men and women. These erratic patients were monitored by a half dozen improbably large security guards, and in my brief experience, it was nearly impossible to set foot in Area B without having some sort of bodily fluid flung at you.
“Dave,” I called out as I approached the pit. “Hey.”
“Big guy!” he said, sticking out a hand. “How are things?”
“Fine. Quick question.”
He curtsied. “How may I be of service?”
It wasn’t clear if chief residents were the select few who truly retained the pseudoenthusiasm of intern year or were simply the best at faking being fake. “I got a bit of a situation.” I quickly recounted Sam’s scenario and asked for Dave’s advice.
“Let’s set up a talk!” Dave said. “We’ll get a cardiologist and a nephrologist to come and duke it out.” He pretended my belly was a punching bag and threw a few light taps to my midsection. It was weird. “It’ll be great, Matt!” He typed a few words into his phone and smiled.
“But, Dave, what do we do now? Like, right now.”
“Let’s talk it out,” he said, putting an arm around me. “Introduce me to Sam.”
I still didn’t know what to make of Dave. I couldn’t say why, but he rubbed me the wrong way. Like he’d sell me out if we were both suspected of a crime or squash me if it meant professional advancement. But why? He hadn’t really done anything to me. Maybe he had just been worried I was going to leave medicine. What if I was a bad judge of character? What if Dave was one of the guys in my corner and I didn’t realize it?
I stared intently at him, hoping his facial expression would tip me off. Was this guy on my team? As I glared at his thin lips, I wondered how often I had rubbed people the wrong way—and not just doctors but patients. How often did they find my probing questions too much? How frequently did my attempts to connect with people backfire?
Dave and I walked toward the other end of the ER, and I pointed out Sam. He looked calm, almost like he was on vacation and the stretcher was a chaise lounge.
“Hard to believe,” Dave said, “that a new crop of interns will be taking your place soon. You ready to have your own intern to boss around?”
“Ha. What do you think?”
“I think you’ve come a long way from those mopey days…after the needle stick.”
“Mopey?”
“I kid, I kid. I think you’re doing great.” My index finger still had the occasional phantom pain where I’d jabbed myself, but I appreciated the compliment. Dave always caught me off guard. “I’ve seen your faculty evaluations, Matt. Really strong. I was actually wondering,” he said, “if you’d be a tour guide for the new interns. And for next year’s applicants. We think you’d be perfect.”
We? I fought off a grin. “I’d be delighted.”
At some point I had apparently quantum-leapt into the body of a reasonably competent, capable doctor. I could feel it was true, but couldn’t quite figure out when it had happened. When had I gone from we’re worried you’re decompensating to wanna be a tour guide? Where was that transformative scene, like Don’s master diagnosis? Maybe it was something more gradual, like demonstrating that I could consistently function on eight minutes of sleep or that I could navigate a needle under duress. Perhaps, like Don, I had cemented my reputation with just one patient—but who?
“Awesome,” Dave said, “just give people a sense of what it’s actually like to work here.”
I looked over at the pit of dangerous patients in Area B and smiled. “Sure.”
My mind began to wander, as it often did late at night. Could I accurately represent the diorama of hospital life at Columbia? Or the strange enchantments of practicing medicine? Could I explain how wonderfully insane it all is? I thought back to the first few weeks with Baio in the CCU; did the tribulations of intern year appear different now than they had in July? I didn’t think so, but I couldn’t be certain. “So,” I said, transitioning out of my neurotic inner monologue, “my patient Sam. Let me give you the full story.”