Playing Doctor

Initial Visit?

Friday, May 27

That’s Just Life

My day begins talking to Dr. Pasteur on the wards, when a nurse comes out of a room calling a code. We are the only doctors on the floor, so we go into the room.

‘You get the airway, I’ll run the code,’ he says, as I make my way to the head of the bed, grabbing the blue patient by his armpits and lifting him as the nurse slides the CPR board beneath him.

The crash cart is being brought in the room and the respiratory therapist is connecting the ambu-bag to the oxygen. I pull the man’s dentures out of his mouth. We begin ambu-bagging the patient to ventilate his lungs. There is no pulse, so a nurse begins compressions.

I’m looking down the man’s throat to place the endotrachial tube. His throat is full of spit and I can’t see anything. I call for suction, but they don’t have it yet. So I manipulate the blade and get the glottis to fall, his saliva bubbles and pops and I see the cords. I place the endotrachial tube and inflate the cuff. We connect the ambu-bag and begin ventilations, the nurse listens to his left chest, then his right, then his stomach.

‘Breath sounds bilaterally, not in the abdomen.’

But the CO2 monitor attached to the bag has remained purple. When it’s exposed to CO2 from an exhaling lung—as opposed to an air filled stomach—it turns yellow.

I’m in his trachea, I know I am. But the damn thing stays purple. I deflate the cuff, withdraw the tube. The suction is now ready and I clear the saliva. I am now looking down his windpipe. I’m surprised to see his vocal cords fully retracted. I can see all the way down to his corina. That’s not typical, and it strikes me that it’s a bad sign for the patient, but it does makes placing the tube easier.

We repeat the listen here, here and there. We repeat the CO2 monitor. It stays purple again.

‘I need another CO2 monitor,’ I call. ‘Now.’

The only venus access we have is a small line in his right hand, and I called for a triple lumen catheter when we walked into the room. While I was securing his airway, Dr Pasteur was getting central access via his right femoral vein.

I am watching the pulse ox. In a well oxygenated patient it reads in the nineties. It was reading in the seventies when we got into the room, it’s now in the fifties.

The new CO2 monitor stays purple.

The code team shows up at this point, a little confused to see the patient already intubated and with central access. Dr Pasteur has called for a round of epinephrine, and it’s being administered. I ask for a senior attending to check my tube placement. He confirms that it’s in the correct position.

There are a lot of people milling in the room and Dr. Pasteur tells everyone not involved in the code to get out. Most people stop talking and look at everyone else to leave.

‘If you are not on the code team: Get Out,’ He shouts, and everyone starts to make for the door. I see a medical student leaving.

‘Except the med student.’ I bark. ‘Stay in that corner, watch and don’t say anything.’

Eventually, I bring the med student out to do the chest compressions.

‘I can feel his ribs snapping,’ she says.

‘That just lets you know you’re doing it right,’ I say. ‘If the ribs aren’t breaking, you aren’t pushing hard enough.’

We continue coding the patient for a full twenty-five minutes. We figure out the likely cause of the CO2 monitor not changing, the same thing that caused the patient to code. We attempt to fix it emergently, but it does not work. Dr Pasteur pronounces the patient dead.

I begin to thank everyone for their efforts when the med student approaches me.

‘Thanks for letting me participate,’ she says.

I meet my intern to do a paracentesis—removing free fluid from the abdominal cavity. When someone has a cirrhotic liver, fluid can build up in the abdomen. Eventually, this fluid will press up on his lungs and make it difficult to breathe. It will become so taunt that he will feel a constant stretch pain that can be quite agonizing.

We drain off one liter from this man and his abdominal pain goes away and he begins breathing comfortably again. The relief on his face is obvious. I write my procedure note, and on my way off the floor look in on him. He is eating his lunch.

‘How’s the pudding?’ I ask.


‘Your lunch.’ I point at his tray. ‘How’s the pudding?’

‘Oh! The banana pudding!’ he says, smiling. ‘It’s good!’

‘I love the banana pudding here,’ I say and begin to walk out.

‘Thanks, doc,’ he says.

I have eaten more banana pudding in the two years of my residency than I have in all the years that preceded it. It seems to be the municipal dish of most southern towns.

In the afternoon, I tell a woman that her breast cancer is a particularly aggressive form and has spread throughout her body. I tell her that she likely only has three months to live. I tell her that her main complaint would require major surgery to address, followed by radiation to fix. And that surgery would likely require her to be in the hospital for another month, a week or two of it on a vent in an ICU. And that’s if things went really well. And that would only be preamble to the joys of radiation.

‘Asking you to decide if we should attempt the surgery is not fair,’ I tell her, calmly. ‘It’s asking you to make decisions as if you were a doctor. So let me tell you what I would tell you if you were my sister… I’d tell you not to do it.’

‘If she only had three months,’ I continue, ‘I’d want to spend them chatting, and remembering, and laughing as much as we could. I wouldn’t want her to spend a month laid up in a hospital, with half of that time in an ICU on a vent.’

I begin to leave the room to give her some time to think. She had asked me to tell her alone. She asks me to now tell her family.

So I walk into the quiet room and tell her sister, her husband, her twelve year-old son, and her fourteen year-old daughter that their sister, wife, mother is likely to only be around for a few more months.

‘Hope for a miracle.’ I say. ‘We’re giving her the best that medicine has to offer. But the cancer is aggressive and it’s spread throughout her body.’

One of the nurses on the floor has gotten a promotion, and all the nurses are going out to celebrate. They invite me to join them and I accept. As I am leaving the hospital, I walk by the patient’s room and glace in to see her talking and laughing with her family.

On my way to the celebration, I’m listening to an old Rod Stewart song. The thought suddenly strikes me that life can be kind of like an old Rod Stewart song. It’s kind of annoying and you feel like if you changed the station there would likely be something better out there. But if you let go of that cynicism, it can be quite beautiful.

I roll down my windows and begin to sing along.

When I get to the Red Lobster, I drink my beer, walking around the table of nurses, chatting and laughing with them. One of them has brought her baby, and someone at the other end of the table is holding him when he begins to cry. Since I’m standing, I offer to walk the baby to his mom. I pick him up and his wail quiets. I walk toward mom, bouncing him a bit and he begins to hum a little song.

‘You’re doing a fine job,’ his mom says, putting a towel over the shoulder of my guayabera. ‘You should have been a pediatrician.’

My day ends holding a five month-old baby. I wrap my hand around the back of his head, rolling my thumb up to feel the soft spot. He cradles his head into my neck and I kiss his tiny ear and whisper to him, ‘You have so very much to look forward to.’

Nashville Epilogue:



Blogger Spider writes:

I love a post that can make me cry - nice job! Come to Orlando - I need a good doctor!


Blogger Erik writes:

We have a winner. Someone has figured it out. So no jelly doughnuts for you!

But you can still have bragging rights if you can send me the answer before the Tuesday morning post.


Blogger Damon writes:

Great story. I just caught up on your last couple weeks. Consistently well thought-out and touching blog you have here.


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