MR. Woods grinned when I walked into his room in the ICU. He raised his eyebrows and lifted his hand in a jaunty wave. His hair, usually carefully combed, was a mess over his bald spot. His nose had a subtle crook in it, just like my dad’s. His black hair, thinning on the top, looked like Dad’s, too.
“Good morning,” I said. “How was your night?” At five forty-five, it was still dark outside, and the window looked like an obsidian mirror. The fluorescent lights of the ICU made it difficult to keep track of time. Near the end of my internship, I’d gotten used to working in the early mornings and late nights.
He jammed two thumbs in the air, nodded, and raised his eyebrows again. Maybe he’d gotten used to life on the unit as well.
“Good.” I smiled back at him and nodded. I glanced at his monitor. The wave form of the silently bouncing green line was reassuringly normal; the numbers for his blood pressure, heart rate, and oxygenation were good, too. “Any problems?”
Mr. Woods shook his head, and turned the corners of his mouth down, as if to say “Piece of cake.” He couldn’t actually say, “Piece of cake,” because several weeks previously, a surgeon had taken him to the OR, made an incision into the front of his neck, and slipped a short plastic tube into his trachea. Mr. Woods needed the tracheotomy because he’d become dependent on the ventilator to breathe for him and we couldn’t wean him off of it.
“I’m glad your night was good,” I said, wondering how good his night could’ve been, propped up in a bed in an ICU, a blue crinkly tube connecting him to a ventilator that puffed humidified air into his lungs through the tube in his neck.
Mr. Woods had been on the ventilator for several weeks because he’d suffered a respiratory arrest from COPD. Chronic obstructive pulmonary disease is almost always the result of smoking. You can think of your lungs as microscopic clusters of spherical air pockets, resembling little bunches of hollow grapes. The stems represent the tubes through which air flows to the hollowed-out little grapes, where oxygen diffuses across a thin membrane, into the surrounding network of blood-filled capillaries.
Smoking, over years, had destroyed the walls between the tiny air pockets in Mr. Woods’s lungs. Instead of billions of microscopic alveoli, his lungs had become large bubblelike spaces with significantly less surface area. He had to work harder and harder, and expand his lungs further and further, just to get enough air in and out to oxygenate his blood. A few weeks before I met Mr. Woods, he’d developed a bad bronchitis which had overwhelmed his limited respiratory reserve. His gasping efforts failed to supply adequate oxygen. He’d made it to the ER in time for a doc like me to slip a tube through his mouth into his trachea and hook him up to a breathing machine. After several weeks, they’d taken the tube from his mouth and replaced it with a tracheotomy, a hole the surgeon cut in the front of his neck. Day after day I’d gone in to check on him, said, “Good morning,” and watched his eyebrows go up in greeting, just the way my dad’s did when he was amused. My father was a smoker, too.
If Mr. Woods had been intubated for respiratory failure secondary to something reversible, like congestive heart failure, he probably would’ve already been weaned off the ventilator. Congestive heart failure results in fluid building up in the lungs, prohibiting the exchange of oxygen. In those cases, you can intubate the patient, give them a diuretic to pee off the excess fluid, and then pull the tube out when the lungs clear. The machines have little dials on them, and you can incrementally dial back the amount of ventilatory support they offer. As the patient improves, you dial the ventilator back, until he can breathe on his own. But smoking had destroyed so much of Mr. Woods’s lung tissue that he’d gotten stuck on the machine.
Any doc or nurse who’s worked in a VA hospital can tell you about seeing a patient hunched over in a wheelchair, holding a cigarette up to the tracheotomy hole at the front of his neck, puffing away. You’d think that after smoking had damaged a patient’s body to the point he’d had to have a tracheotomy, he’d quit. Of course, if it were easy to quit smoking, most people, knowing the health risks, would’ve already quit. But I hated the thought of my dad sticking a cigarette to a hole in the front of his neck, or ending up on a ventilator, like Mr. Woods.
The machine puffed and Mr. Woods’s lungs expanded.
“Today we may try to wean you down a little further,” I said. “You feel up for it?”
He scowled with mock ferocity and raised both fists, then gave me a double thumbs-up. He was ready for the fight.
“Good.” I wanted to clap him on the shoulder but was afraid it would seem condescending.
“I’ll check back with you later.” I had three other patients to see before rounds.
He winked at me.
I winked back, and walked out of his room to the nurses’ station. Mr. Woods had been the first patient assigned to me that month. He was my favorite, even though I hadn’t been able to get him weaned off his ventilator. Until I did, he’d stay in the unit, and on our service. I felt pressured to keep moving my patients forward and off the service, because if I didn’t, I’d have too many patients, and the other team members would have to take all the new patients. A patient you couldn’t budge was called a slug.
I didn’t like thinking of Mr. Woods as a slug. Slugs were people who wanted to stay in the hospital, even though they were medically well enough to go home: lonely old people whose family wouldn’t take them back. Slugs were dependent, whiny, demanding people. Mr. Woods never made any demands. Of course, he couldn’t talk, and didn’t seem to like writing on the small dry-erase board the nurse had given him. But other intubated patients could be very demanding, snapping their fingers, scowling, and scribbling long diatribes about how miserable they were.
In the nurses’ station, I opened Mr. Woods’s chart and flipped through the nurses’ reports. Nothing new. Each patient room had a large window looking out to the nurses’ station. I looked through the slats of the Venetian blinds and watched Mr. Woods. Every time he took a breath, the machine puffed, and helped expand his lungs. He lay on the bed, his eyes closed, his face passive.
I checked on my other patients, and went downstairs to the cafeteria for breakfast before we rounded with the attending physician. The hospital gave us meal tickets for the nights we were on call. I used one to get some yogurt and an apple. I had money left over, so I got a Snickers bar and put it in the pocket of my white coat, for later. I ate quickly and went back up to the unit.
We began rounding on the patients when Dr. Solters, the ICU attending, arrived. We started with Mr. Woods.
“Any progress with the wean?” Dr. Solters asked. He was a short, wiry guy who fostered a reputation for being gruff and direct. On our first day of the ICU rotation, he’d stood in his shirtsleeves, with his hands on his hips. “Every resident kills three patients in the process of learning to be a doctor.” He shrugged. “Probably unavoidable, but don’t punch all three tickets on this rotation.” He grinned, glancing at each of us. “Okay?”
I tried to keep the surprise from showing on my face. Was he serious? I knew I hadn’t killed anyone, and I hadn’t heard of any avoidable deaths, except one surgery resident who’d accidentally pulled a clamp loose during surgery. The patient bled to death right there in front of them. There must’ve been other mistakes we’d made, but it’s not like we were on the Grim Reaper’s payroll.
“And I don’t want anyone to die in my ICU without knowing about it early on. If someone’s getting really sick, call me, and I’ll come in and help.” He paused. “If you fiddle around with them until they code, there won’t be much I can do. Any questions?”
I shook my head along with the rest of the residents. He sounded cavalier, but at least he wanted to be called and would come in to help. It seemed like most of the other attendings would rather sleep through the night at home, and hear about problems the next morning.
In the pecking order of a teaching hospital, surgeons are the aggressive big dogs; then comes internal medicine, then pediatrics, then psychiatry. Within surgery, of course, cardiac surgeons lord it over general surgeons. And in medicine, interventional cardiologists, the ones who can do cardiac catheterizations, are the big dogs; then come the ICU docs, and then the general internists. Until a cardiologist or surgeon walked up, Dr. Solters was a pretty cocky guy.
ER docs are kind of off to the side. We’re good at working in chaos and under tight time constraints. A good ER doc can keep a lot going at the same time. Most docs in other specialties understand this, or at least pretend to, and they give us a little credit for what we do. Can a cardiologist do a better job with a heart attack than an ER doc? I hope so; otherwise, they wasted three years after residency, getting their subspecialty training. But can they do the first ten minutes as well as an ER doc? Some of them can, some of them can’t. It’s hard to stay calm and bring order to the initial chaos. Paramedics are telling you what the patient looked like when they first arrived, nurses are busy popping off the paramedics’ monitor leads and snapping ours in place, the aluminum wrench clanks against the green oxygen bottle, people call out they need this or that. The other specialists may know more about any given disease than we do, but most of them couldn’t handle the chaos as well. So, although we’re not the big dogs, most ER docs have sufficient ego to walk out into the ER and pick up a chart and go see the patient, no matter what the problem is.
“The wean has been slow,” I said to Dr. Solters, glancing in through the slats of the Venetian blinds on Mr. Woods’s window.
Mr. Woods smiled and waved.
I smiled back, and nodded, but was too embarrassed to wave because the whole team was watching. “As soon as we get close to a wean, he tires out.”
“Smoker.” Dr. Solters shrugged. “Any questions, concerns?”
“Not really,” I said. “Guess I’ll just keep dialing him back in really small increments.”
Dr. Solters nodded, and led our small herd of white coats to the patient next door. As the other resident discussed his new patient, I wrote an order in Mr. Woods’s chart to dial back on his ventilator settings. I handed the chart to Hannah, his nurse. Some of the ICU nurses wore scrubs with patterns—little frogs with stethoscopes, Teddy bears in nurses’ uniforms. Hannah wore unisex green scrub tops tucked into the waist of unisex bottoms. A small golden cross glowed against the dark skin at the notch at the base of her throat. Her hair was a short, tight afro.
“Okay.” Hannah took the chart and placed it on the small desk outside Mr. Woods’s room. I couldn’t tell if she expected the wean to work. She’d been an ICU nurse for several years, and I trusted her judgment, but the team had moved on, and I didn’t have time to ask her.
Later that morning, Hannah asked me to come check Mr. Woods. “He’s not going to fly.” She looked from the ventilator to Mr. Woods’s face.
It must have been a nightmare for Mr. Woods, unable to get off the machine that kept him alive but also kept him tethered to the same bed, in the same room, week after week. When I was a kid, I had asthma, and I remember the frantic feeling that I was being held underwater, clawing my way up toward the air. I’d sit in bed, leaning forward, focusing every ounce of my energy on getting one more breath in, one more breath out, one more breath in, one more breath out. Mom would rub Vicks VapoRub on my chest and put a dab under my nose. The eucalyptus made the inside of my nose sting, but other than that, didn’t do much. But it was the only thing medicine had to offer in the 1960s, short of a trip to the ER for a shot of epinephrine. She used what she had.
Mr. Woods sat straight up in bed, hunching his shoulders with each breath, trying to pull more air in through the skinny tube in his neck. He pointed to his dry-erase board.
Hannah handed him the board and a marker.
In wavering letters, he wrote: “More air.” His hands trembled as he recapped the marker.
“I can tell you’re short of breath,” I said.
He bobbed his head in an impatient nod. No shit.
“If we can just tough it out a little longer,” I said, “we’ll probably be able to get you off this forever.”
He raised his eyebrows, as if suspending judgment. He carefully uncapped the marker. “OK,” he wrote in wavy letters. He closed his eyes.
Thirty minutes later, the alarms on the ventilator started dinging.
Hannah came and got me.
Mr. Woods sat in bed with his eyes closed. The muscles in his neck stood out with the effort of each breath.
Mr. Woods’s efforts made my shoulders and neck muscles feel tight, and made me want to take a full, deep breath.
“He’s tiring out,” I said to Hannah. I took a long, deep, silent breath.
She nodded.
The decision to keep trying or give up was partially dependent on personalities. Mr. Woods didn’t seem like a quitter. If he could make it, he would. But it was hard to tell. Hannah had seen more COPD patients weaned from ventilators than I had, which wasn’t hard, since this was my first. But she cared about Mr. Woods, and seemed competent. I was grateful for her help.
“Mr. Woods,” I said, “it looks like we may need to go back up on your vent settings.”
He nodded in defeated acquiescence. He didn’t look at me.
“Don’t worry,” I said. “We’ll try again.”
Mr. Woods closed his eyes.
We turned the vent settings back up, and Mr. Woods’s chest expanded fully. Poor guy. On one hand, we had a treatment that was brutally effective in helping him breathe, but on the other, we couldn’t get him off of it.
My dad smoked. He didn’t have any hobbies, other than books and his pipe collection. I wasn’t allowed to touch his meerschaum pipe, because it would break if I dropped it. Dad explained how the bowl would turn to a deep reddish-brown with use. I kept checking to see if it had changed, but week after week it was that same ivory color. Turns out he was talking about years of use.
I never liked cigarette smoke. It made me cough and wheeze, and it smelled bad. But who can resist the deep, complex aromas of a pipe? When I put my nose to the empty bowl of one of Dad’s pipes, it stank. But when he’d gently tamp the tobacco, and suck the fire from a match into the pipe, the whole room became rich with its aroma. In the years before my parents’ divorce, Dad would sit in his chair for hours, reading and smoking pipes or cigarettes.
Everyone knows smoking isn’t good for you, but in my second year of medical school, I found out that sure enough, smoking kills people. We had a lecture on smoking cessation, in which we were taught new techniques, and learned the results of recent research. I called Dad. “I had a lecture today about smoking.”
The line was silent. “Paul,” Dad finally said, “I’ve tried to quit. You don’t know how many times.”
“I know,” I said. “But every time you quit, you increase the odds that the next time will be successful.” I was proud I could tell my father about the latest research.
“I appreciate your concern,” Dad said, “but this isn’t something I want to talk about.”
Is there anything worse than a religious nut who won’t leave you alone, keeps yammering at you about whether you’re really, really saved? That’s how I must’ve seemed to Dad, with my repeated attempts to reopen the discussion about smoking.
He finally told me there was no point in bringing it up again. I knew I was in an absurd position. Go off to medical school, get a couple of lectures about smoking cessation, and try to change the world. Bottom line, he was the dad, I was the son.
On my last day on the intensive care unit, I said good-bye to each of my patients. I went to see Mr. Woods last. I didn’t look forward to seeing him, because I felt like I’d failed him.
“It was good to know you,” I said, shaking his hand.
His grip was stronger than I’d anticipated. He pointed to his chest, then to me, nodding.
“Sorry we couldn’t get you off that thing,” I said, pointing to the square machine beside his bed.
He glanced over at the ventilator as if it were a cranky family member. He looked me in the eyes and shrugged. I couldn’t assign an emotion to his expression. Defeat? Acceptance? I didn’t know.
“Better go,” I said, pointing to the door.
He raised his hand, palm up, and smiled. The ventilator chugged another breath into him.
I didn’t tell my dad I had a recurring nightmare that month, in which he was the intubated ICU patient hooked up to a ventilator. In my dream, I walked into my father’s room and stood at the foot of his bed. The windows were black with night. Monitors and technology loomed over him, their faint green glow giving the only light to the room. He couldn’t speak, and his eyes were all he could move. His eyes followed me. They looked scared, and were trying to tell me something. In my dream I turned toward the gauges and twisted the dials, relieved to be too busy to let my eyes rest on my silently frantic father.