The Crapshoot

What’s that, kid?

There wasn’t anything about him being a doctor in the last story? Sure there was. He mentioned the phrase “tonic part of a seizure” and “Basal Cell Carcinoma.” What more do you want?

His hospital life? Not a good idea. Not a place for the kiddies.

What? Stop mumbling. Spit it out, kid. You want a story about hospital life anyway? You want to know how doctors think? Oh, all right, let me think. I’ve got one to tell you. Make it funny? You got it. Where’s my scotch? Thanks. Let me take a sip. Ahhh. So do you know anything about Neurology?


Working for a month in Neurology is, number one, boring. It is month of roaming the hospital, trying to talk to patients who are largely confused, disoriented or comatose. It’s not all that different from a Fraternity party, really, but with less beer.

Number two; the most critical patients—the stroke patients—are the patients for whom you can do the least. Control the blood pressure. Keep them alive. Figure out if they have a treatable underlying condition that caused the stroke. Treat the cause. Keep them alive and send them to rehab.

Number three; if those critical stroke patients can get to the hospital, through the ER, evaluated by the ER docs, and see a neurologist within three hours of their symptoms beginning, then we have a chance at reversing the stroke and nullifying the previous two dictums: Neurology then becomes exciting and life saving.

But those patients are few and far between, most wait too long. And I mean way, way too long. There are two extremes in patients. There are those that show up in the ER repeatedly for trivial complaints (stuffy nose, hangnail, or “does my face look puffy?”) and those that aren’t brought in until they are half-dead. The gentleman I have been asked to see down in the ER falls into the latter extreme. He is not in the category of making it within three hours of symptom onset. He is not exciting. He is one of the critical patients for whom I can do the least.

And while I am thinking about it, kid, it is not the ER that he is going to: It is the ED. They get a little testy about that. It is not a room. It is a department. This is not some cheese filled show with billionaire dilatants getting smoldering looks from residents. If their looks are smoldering, it’s because they’ve been up for going on 24 hours and are technically in REM while trying to listen to you.

This is not some little one-story hospital in rural Alabama. The ED has treated, if the infonet home page is to be believed, 242 patients in the past 24 hours. I can hear the helicopter landing on the parking garage right now, bringing some new tragedy to our doors.

I hate helicopters. I loathe parking near the top of the garage for fear one of those swinging blades will—somehow—snap loose and rip through my car and tear me in half, leaving me laying in the trauma unit of—where, kid? That’s right, not the ER but—the ED.

This gentleman I come to see, he is in the resus unit. Resus is short for resuscitation, not a place you want to be. It means you either just got—or are likely to get—resuscitation. I am reading this man’s chart while standing at the foot of his bed. Let me describe what he looks like the way I would to another physician. He is a 55-year-old white male overweight, slightly disheveled appearance, minimally responsive, not protecting his airway secondary to absent gag reflex, GCS of 8 and then I would go on with information that would become progressively more technical and less interesting.

Let me describe what he looks like the way I would for his wife, helping explain to her what she is seeing. He is nearly comatose, but can still talk from time to time. He is snoring, but it is not a healthy snoring. The difference between snoring and the snoring he is doing is apparent to both the trained and the untrained ear. He has many tubes and lines going into and coming out of him. The blood pressure cuff is self-explanatory. The line in his neck is to give him fluids and medications and to draw blood for labs. The white piece of plastic on his finger is to monitor the oxygen content of his blood. The Foley catheter drains his urine through a tube in his penis.

This is the start. These are the lines he has for now. There will be more. Many more.

I ask her the story. What happened, in her words?

She tells me that after dinner last night she found him sitting in his chair complaining of not being able to move his left side. He told her to bring him some aspirin and let him sleep it off. In the morning, he was still in his chair and she was not able to wake him up.

She is telling me this story and I am trying not to cringe at her words. I am trying to think about how to tell her that her husband needs to be put on a breathing machine. That we are going to need to put a breathing tube down his throat and that we are going to need to sedate him even further than he is au natural at this point.

I am trying to think about how to tell this woman she needs to talk to her husband before we do this, to tell her that the reason she needs to talk to him is because there is a real possibility that he will not come off the breathing machine.

I am trying to think I need to tell her that she is getting ready to talk to her husband of 37 years for the last time, that I will not say, “Last time,” that I will not say “this is the last time. Ever.”

I am trying to think of all these things, but I can’t. All I can think of is this man, last night, going limp on half of his body, not able to move, not able to get up. And he wanted to try to sleep it off.


Last month, after Bush won re-election, the Daily Mirror, a yellow rag of a paper in London, ran the headline “How Can 59,054,087 people be so dumb?” I am thinking right now, as I face this tearful woman, that it is no mystery. Politics are complicated and removed. I know that people believe that presidents do not impact their lives and ask only for a likable president. Voting one way or the other is not so dumb.

Having half your body go dead and trying to sleep it off is dumb.

Bringing your husband an aspirin and going to bed is dumb.

Is that unsympathetic of me to say? Unempathetic, maybe. But not unsympathetic because I do pity this woman and her husband, who—frankly—is not going to leave the hospital alive.

But they did a dumb thing, and not dumb like driving after a couple of beers kind of dumb. That kind of dumb is like voting. You think you understand the risks involved and you take them. That’s part of being human, misunderstanding the risks.

This kind of dumb is driving after a couple of beers, hitting an old man and dumping his body in your neighbor’s lawn kind of dumb. It’s a rolling the dice, getting snake eyes and trying to quietly pick up your bet and lurk away from the table without security stopping you kind of dumb.

And now I am playing the role of the neighbor, waking up to get my newspaper and seeing a heap of a figure lying on my lawn. I am the security guard that has to put my hand on her shoulder and say, “excuse me ma’am, I can’t let you walk away from the situation.”

Are they just dumb? Is it simple denial? Maybe I don’t know. I do know it’s nothing new, and I certainly have no time for people who say it is confined to “Americans.”

But after I tell her everything that needs to be told, and I prepare the equipment to intubate this man, this infuriatingly dumb man, I hear them as she leans close to her husband’s ear and they say words that I have no right to repeat.

And I am focusing on the weight of the Miller laryngoscope in my left hand and I am focusing on seeing his vocal cords so I can pass a seven and a half endotrachial tube through them and down his throat and I am trying not to think of the 37 years that this couple had together.

I am trying not to think of the words that this husband told his wife of 37 years while I call out for meds and vent settings and x-rays.

I am trying not to think that they are the last words that this man will tell his wife. Ever.