Trouble Sleeping

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The HIV Gosling has continued to deteriorate. He’s now on a venturi mask at maximum oxygen concentration. The sound of the oxygen rushing into his mask makes it difficult to hear his weakened, whisper of a voice and he’s too short of breath to repeat himself.

I’ve discussed life support with him and the Geese several times. Part of the problem with pneumocystis is how friable it makes the lungs. A ventilator will likely rip his lungs open, collapsing them. I explain that if we put him on the ventilator, it’s extremely unlikely that he’ll ever be taken off of it.

I also explain that it’s probably the only chance he has at living much past tomorrow. I tell them he’s dying and recommend we try to make him comfortable during the process.

Neither the Geese nor the Gosling are willing to make a decision. They want to make the decision tomorrow.

‘What if he needs it tonight?’ I ask.

‘We’ve got family coming in tomorrow, keep him off of it tonight,’ the Goose, Sheri, says.

My forehead aches when she says this.

I close my eyes and run the Next of Kin algorithm again to ensure that she’ll be the decision maker when he cannot make his own. But I’ve run it twice already and know she’s the next of kin. Though the Gosling originally mentioned his ex-boyfriend, that guy never showed up and the Gosling began deferring to Sheri.

‘Well, putting him on life support isn’t something I’m going to do willy-nilly,’ I say. ‘I’m not going to do it unless I think he’s going to die without it.’

‘Don’t let it come to that,’ she says.

I look at the Gosling, looking even gaunter than when he first arrived. His hair’s greasy from his constant bouts with sweating and then chilling down. He’ll go apneic briefly, then breathe rapidly for a bit, the rate slowing, slowing, then apneic for a moment, then repeat the cycle.

‘I don’t know that I can prevent it,’ I say.

Something changes in her at that moment. For the first time since I’ve known her, her face weakens. For the first time since I have known her, she reaches out and touches me, taking my hand with both of hers. She says one word.

‘Please.’

I’m filled with revulsion. She hates me. Her effort to appeal to me to save her brother repulses me. My only power is to ease or prolong her brother’s agony.

‘I’ll do what I can,’ I say and extricate my hand from hers and myself from the room.

---

I’m overnight in the hospital that night and quite busy with new patients. I try to nap at 10pm, but get only fifteen minutes before a diabetic crackwhore comes into the ED in ketoacidosis. She does this once or twice per month. The ED doc makes the running joke about trying to figure out how to combine insulin with cocaine to keep her healthy.

I’m writing her admission orders around 11pm, when I get a call from the Gosling’s nurse. His breathing seems to be worsening. I order an ABG and some stat Nebulizer treatments.

On my way back to the MICU, I swing by his room. He’s confused, can’t even get a single word out, but maintains eye contact with me. Clinically, he’s worsening, but his ABG’s no worse than earlier in the day. I adjust him to enhance the anatomy of efficient breathing. I feel nauseous and uneasy. I should either be intubating him or giving him opiates.


In the MICU a patient with a subdural bleed has started seizing and is in status epilepticus. The MICU nurse and I work together to break the seizure. When he comes out of it, the nurse and I get him to the CT scanner to see if the bleed has significantly worsened.

It’s nearly 2am when I get a chance to break for a midnight snack—onion rings. I get another call from the Gosling’s nurse. She tells me he’s become agitated and confused and has been pulling the oxygen mask off his face. She’s spending all of her time in his room reapplying the mask.

I go up and examine him, putting the mask back on him. His O2 sat is in the high 80’s with the oxygen mask. Without it, it quickly drops to a level incompatible with life. His arms are weakly flailing, trying to remove the mask. His eyes are panicked and locked on me.

‘You need this,’ I tell him, in a soft, reassuring voice. ‘Don’t take it off. It’s keeping you alive.’

His hands continue to reach up toward the mask. I hold his hands by the bed to prevent this.

Should I make the confession now? Can you already see what’s going on, despite my lack of details? Is it obvious to everyone but me?

‘Get the restraints.’ I say to the nurse. She gets the restraints and ties his arms to the side of the bed. His oxygen sat’s stay in the upper 80’s now with the mask safely in place. He’s so exhausted himself in the struggle that he’s asleep now.


The CT of the subdural patient is relatively unchanged. I call the neurosurgeon and we review the scan together. My intern pages me with questions about a hypertensive patient and I tell him what meds to order. The Orthopods call me and ask me to do a pre-op evaluation on a hip fracture that they want to take to the OR in the morning.

At 4am I look in on the Gosling. He’s rapid panting like a big dog in the summer’s heat. His eyes are wide open, but not focused on anything. His hands are straining against the restraints, trying to reach his mask. This continues throughout the night.


At 7am, my intern, the bumbling one, shows up.

‘It looks like he’s trying to take the oxygen off,’ he says.

I explain that when patients are delirious they try to remove all the medically invasive tubes from themselves. I explain that it’s a predictable pattern.

‘But he’s not going for the IV’s or the Foley,’ he says, his voice politely lilting to suggest a question. But it isn’t a question. It’s obvious. The Gosling’s staring directly at me.

Nausea rolls over me and my stomach and bowels tighten into stone.

I call the Geese into the hospital. When they arrive, we talk at the bedside.

‘He wants the oxygen off. I need to make him comfortable. Now.’ I tell them. Sheri looks at the Gosling. She’s not crying, but clearly only because of extreme effort. She nods and goes to her brother.

I go to the nursing station and begin writing orders for a fentanyl drip. While I’m talking to the nurse, one of the Geese comes up to me.

‘He’s changed his mind,’ she says, ‘we told him his aunt and uncle are driving down this weekend, so he wants to stay on the oxygen for two more days.’

I close my eyes and rub my forehead.

Another of the Geese comes out of the room and looks at me expectantly.

I walk into the room.

‘Just the oxygen,’ Sheri says, crying and holding his hand, ‘not the ventilator or intubation.’

‘You think’ I ask, genuinely, ‘that he can make decisions right now and he wants to stay on oxygen for two more days?’

‘Yes,’ Sheri says.

The Gosling is panting into the mask, his head’s turned to the right and he’s looking down. He’s developed a patchy beard since he’s been in the hospital. His hands are still tied at his sides.

‘Well, then,’ I say, ‘I can untie his hands and he won’t remove the mask.’

Sheri looks at me and then at the restraints. Neither one of us say anything, waiting to see who will call the other’s bluff.

I walk over to his side, release the Velcro and unfasten the clip of the restraint off his right hand. He raises it and pulls the oxygen mask off his face and over his head with clear purpose.

‘No, Bobby,’ one of the geese says, crying, ‘don’t.’

He drops the oxygen mask off the bed and his hand falls to his side. I release his other hand. I walk behind the bed and turn off the oxygen valve. Without the oxygen rushing through the tubing, the room becomes quiet and funereal.

I come out from behind the bed and look at the Gosling, surrounded by the Geese. He’s staring at me.

He lifts his hand and slowly—ever so tenderly—raises his middle finger directly at me. He holds it—firmly in the air—for nearly five seconds, his eyes locked on mine as I stare at the finger. Sheri sees what he’s doing and closes her hands over his.

I take a deep breath and turn to leave the room. One of the Geese is in the doorway. As I walk past her, she mutters one word, ‘murderer.’