Terminally Ill Page 22

  He nodded, running a hand through his rumpled hair. His lab coat hung awkwardly because of all the handbooks and the reflex hammer he’d stuffed in the pockets.

  “Mrs. Tong, this is Dr. Hassan,” I said in a loud, clear voice. I knew we were disturbing her roommates, but there was no help for it. “He’s the senior resident on internal medicine, and he’s going to examine you.”

  Omar spent a few minutes feeling her leg and asking her to move it, much the same as me. Mrs. Tong rolled her eyes and clutched her leg.

  “Hmm.” He glanced at me. “Where is the Doppler?”

  I called the nursing station using Mrs. Tong’s land line. No answer. After six rings, I said, “I guess they’re getting the Doppler. But you see how cold it is?” I pointed to her left leg. He touched it, then touched the right again and grimaced.

  “Surgery’s not answering,” I said.

  “Okay.” He touched his hand to his head. “Let’s try to find that Doppler.”

  “Do you want me to page 5 South?”

  He shook his head. “They should have one on OB. I’ll get it myself. You stay with the patient.”

  “Okay.” He strode out of the room, not sprinting. Not like we were on a TV show. Of course, if this were a TV show, we’d be running the patient to the OR so that I could single-handedly perform endoscopic revascularization of Mrs. Tong’s leg, and then Omar and I would bang each other.

  The smiley nurse reappeared at my side. “I can’t find a Doppler. There’s supposed to be one in emerg and in OB, but neither of them will send it up.”

  “My senior’s getting the OB one. I guess we’ll just wait.”

  “Okay.” She patted Mrs. Tong’s good leg. The lady groaned. The nurse said, “Can I give her something for pain?”

  “Oh, yes, of course! I’m sorry.” We’d been so busy trying to save Mrs. Tong’s leg, I’d forgotten all about her primary complaint of pain. Nurses are great for reminding you about the stuff that’s important to the patient. “Does she have any allergies?”

  She didn’t, so I ordered morphine, which has become my favourite drug of choice. Dr. Huot had approved. She said that morphine had been used for hundreds of years, was relatively safe and reliable, and was the benchmark for all the other pain-killing drugs. I added Gravol, since the wonder drug often makes people feel sick.

  While the nurse went to find the keys for the narcotics cupboard, I called locating again for surgeon on call while Mrs. Tong moaned.

  One of the other room’s patients complained feebly, “The light!”

  “I’m sorry, sir.” I called to the man. I always found it weird how they mixed male and female patients in a room, but I guess that’s the nature of the bed shortage beast. “I’ll turn it off as soon as we finish examining her. We’re just waiting for an instrument.” I considered racing down to the emerg to borrow their ultrasound machine, but I’ve never been trained to use the Doppler blood flow probe, and when I stuck my head in the hallway, Omar was bearing toward me with a portable Doppler in his hand.

  “Good job,” I said.

  “They said I could have it for five minutes.”

  You couldn’t even get from the obstetrics floor to the eighth floor in five minutes, but at least they’d relinquished it temporarily. Omar was explaining to Mrs. Tong, but she frowned like she couldn’t understand his accent, so I said, “Ma’am, we need to do a test on your leg. We need to hear your pulse.”

  Omar squirted gel out of a squeeze bottle with a farting noise. It landed on the top of Mrs. Tong’s foot, and she groaned again. “I am sorry it is cold,” said Omar, but he was already pressing down on the top of her foot with the Doppler probe while turning on the machine with his other hand. “Do you hear anything?”

  I shook my head while he turned up the sound and glided the probe in a small circle, searching for a pulse.

  Both of us listened intently to the static. Usually, on OB, you hear healthy fetal hearts whooshing away. Whoosh! Whoosh! Whoosh! at about 120 to 160 beats a minute. Once in a while, you hear the woman’s heartbeat instead, which is more like 80 beats a minute and has a less brisk crescendo. But for Mrs. Tong, we just heard crackles, as if we hadn’t quite found the right radio station.

  Omar silently lifted the gel bottle and squirted it once more. Ffft! This time, he aimed for the inside of her ankle, for the posterior tibial artery. Mrs. Tong honked her disapproval.

  “She must feel something,” I whispered, although I didn’t know if it was so much the ultrasound gel as the pain of the muscles and nerves dying in her leg. Maybe the nerves that conducted heat and cold might be preserved even as the ones conducting other sensations perished. Hot and cold sensation synapse in a different part of your spinal cord, and we see difference in sensation all the time: when we inject local anaesthetic in a laceration, we freeze the nerves that conduct pain, but not pressure, so patients often say “I can feel that” when the suture is tugging through. But that’s just something they have to deal with, since we can’t freeze every nerve.

  Speaking of which, we could probably do a nerve block on her to reduce her pain, but that’s a tricky thing. When I was doing plastic surgery, the surgeons would murmur, “You know what a nerve block is? General anaesthesia plus two hours.” Meaning that the anesthesia resident and staff would struggle their mightiest to block the right nerve for two hours before just knocking the patient out the old fashioned way.

  Meanwhile, Omar tried for the popliteal artery, behind the knee, but Mrs. Tong started to thrash. “Hold still,” said the nurse, who had magically reappeared. “I’m giving you some medication. You’ll feel much better.” She swabbed Mrs. Tong’s skin and pushed the morphine into her deltoid. “There.” As an aside to me, she said, “I gave her five milligrams.”

  “Does she have an IV?” I said, distracted. I hadn’t thought to check because they’re practically mandatory on arrival on the acute side of the emergency room, and the patients tend to wear them permanently on 5 South as well.

  “I’ll put one in when I can get in there. I brought my kit.” She gestured to a blue basket filled with needles, alcohol swabs, and other goodies.

  Omar sighed and said, “Could someone please hold her leg?”

  We tried holding her leg rotated to the side, and held in the air. She moaned. Now I could smell old urine from her diaper, and even holding an old lady’s leg got tiring after a while. But finally, Omar gave up on the popliteal pulse and moved up to the femoral.

  Most people know now that there’s a pulse in your inner thigh, thanks to the vampire craze, but Mrs. Tong must’ve missed that memo. When we started to undo her diaper so Omar could get in there, she started fighting us.

  “Do you really need to do the Doppler? I can feel the pulse with my fingers!” I called to him.

  “I want to record it,” he said, and the way his jaw was set, he wasn’t taking no for an answer. So I grabbed the bottle of gel and squirted in her inguinal crease, which is what we call that line between your thigh and abdomen, and held down her thigh.

  He was fast with the probe, I’ll give him that much. He got the femoral right away. Whooosh, whoosh, whoosh. Slow and steady.

  Omar wiped the probe and disinfected it with those Handi-Wipes. “I need to page the attending doctor.”

  I said, “I’ve been paging surgery—”

  “No. The internal medicine doctor.”

  I didn’t want to miss the drama, but someone had to get the Doppler back to obstetrics before they raised a fuss.

  I took the stairs instead of the elevator, since at least gravity was on my side this time. I strode past the corridor of case rooms, where I could hear healthy fetal hearts pumping away, much more vigorously than Mrs. Tong’s leg. I didn’t glance into the darkened chambers where women laboured with a partner by their side, although I felt a pair or two of eyes peering at me from the cavern-like rooms.

  I held the Doppler in the air, making eye contact with a plump brunette, probably a case room nurse,
at the central table behind the nursing desk. “Hi, I’m Dr. Sze from internal medicine. I’m returning the Doppler that Dr. Hassan borrowed.” I started to place it on the table, beside the charts. Behind her, the fetal monitor strips ran on six different monitors in real time.

  She scowled at me from behind her glasses. “Did you disinfect it?”

  I paused with the Doppler still in my hand, before it made contact with the wooden table.

  “We need that Doppler for the women in triage. But we can’t have it contaminated from the eighth floor. I told him to wrap it in Saran wrap and disinfect it.”

  Uh oh. I was pretty sure Omar didn’t bother with the Saran Wrap, but I didn’t want to lie. “Um…”

  “You have to disinfect it! Do you want all of our pregnant women running around with MRSA?”

  That, at least, I knew the answer to. “No.” I saw a box of wipes and said, “Could I use that?”

  She blew her breath out in an exasperated way, which I took as a yes, so I wiped the probe first. That was the part that had made contact with Mrs. Tong. She hadn’t been isolated with MRSA, but truthfully, I didn’t know how often they tested the patients. They swab them before they’re admitted to the floor, but once they’re on the floor, it could be a while before they re-test. I wouldn’t know.

  I hesitated when I got to the body of the Doppler. It uses sound waves to bounce off the arteries and detect a pulse. There are buttons for on and off and a dial for volume. I didn’t want to get alcohol in them and destroy the Doppler.

  “Oh, let me do it!” She snatched it away from me and tore several wipes from the box. “You’ve made enough trouble.”

  I considered telling her that a woman upstairs was in danger of losing her leg, but decided that it wasn’t worth arguing at what was now getting on 3 a.m. “Okay, thanks.” I strode away.

  When I got back upstairs, Omar was writing a note in the chart. The dark circles under his eyes had deepened, if that was possible. I wondered if I looked that horrible as I slid beside him. “Hey. Doppler is back and the nurse is disinfecting it.”

  “Good.” He kept on writing. His head drooped.

  I’d never seen him so exhausted. I said, “Do you want me to write a note after?”

  “Sure.”

  “What did the staff say?” In Montreal, they call the main doctors “staff,” instead of “consultants,” like at the University of Western Ontario. Really, it just means “real doctors who’ve finished residency and fellowship and don’t have to be woken up at all hours anymore, unless it’s an emergency or they’re stupid enough to work in the ER.”

  “Dr. Samson said we needed to check with the family to see if they want an operation.”

  I was momentarily confused. “But she needs an operation.”

  “Yes, but she’s no code. Her family might not want aggressive measures, and she might not survive the operation.”

  How strange. My tired brain tried to process that. The vascular surgeons had impressed upon me that when blood stops flowing to a patient’s leg, it’s an EMERGENCY. STAT. But because this woman had declined CPR, we were going to sit on her.

  Now, “no code” or “do not resuscitate” generally means no intubation, or tube down the throat to help the patient breathe. But surgery is temporary. It’s not like going up to the ICU on a ventilator and never knowing if you’re going to come off again. Once the operation’s over, you should start breathing again on your own.

  On the other hand, it was true that she couldn’t really give consent for an operation, since she didn’t really seem to speak and was probably demented. Plus, did they even have vascular surgery at St. Joe’s? I said, “Did surgery call back?”

  “Yes. I told them to wait until the morning.”

  “Huh.” Altogether unsatisfactory. My first urgent, or even emergent case of the night—probably of my whole rotation, since palliative care was not about fighting death, but about letting them go gracefully—and we were going to wait until the sun came up. On Nurse Jackie, I’d say “Fuck you!” and whisk her up to the OR myself before snorting some OxyContin. Unfortunately, I’d have no idea what I was doing, I had no OR privileges, and the nurses would never allow it. Once again, TV fail.

  “We have to get a hold of her son. He lives in Baltimore.” He glanced at me. “Do you want them to page you when he answers?”

  “Sure,” I cheered up. Who needs sleep when you can talk life and death, or at least a limb’s survival?

  Omar finished his note and shoved the chart toward me. I read his and added a quick one myself. Then we headed to the call rooms. If I was going to get any sleep at all tonight, it would have to be between Mrs. Tong’s son and the floor and emerg paging me.

  I did drift off to sleep, but woke up on my own at 6:42 a.m. I never sleep right when the plastic-covered pillow crunches every time I shift my head. I decided to check on my CHF patient before rounds anyway.

  When I pushed open the stair doors and headed turned left, aiming for 5 South, a man’s voice said, “Excuse me.”

  I stopped very still when I saw an unshaven, middle-aged, brown-haired Caucasian man moving toward me. Most patients aren’t up and about at this hour, and you don’t get visitors at this time of day. I was still around the corner, maybe fifty feet away, from the nurses’ station where the night nurses were getting reading for sign-over. “May I help you?” I asked in a high-pitched voice that meant, Can you get away from me?

  He nodded and half-laughed. His breath smelled like old coffee and bad breath. “I wish you could. Dr. Sze, is it?”

  “Yes. Right.” I cocked my head, not smiling back. If he turned out to be a kook, I could either scream bloody murder and sprint for the nursing station, or scream bloody murder and head down the stairs. The nursing station was the better bet, since I’d probably fall to my doom on the stairs.

  And then I recognized him. The rich pharmaceutical guy. I bit back a gasp. I was pretty sure that he used to smell like cologne and freshly-ironed shirts.

  His mother must be doing really badly.

  I leaned against the wall. That’s what they tell you to do when you’re breaking bad news. Sit down, or lean against the wall, to make sure it looks like you’re not about to take off. I made a mental apology to the CHF patient, whom I might never get to reassess, and said, “Hi.” I couldn’t remember his name, but I said, “How’s your mother?”

  He gave a ghastly smile. “They tell me she’s about as well as can be expected. But the chemo’s not working. She’s got mets growing in her liver and peritoneum now. We already knew it had spread to her lymph nodes, but she had a new scan today. Or yesterday, I guess it is now.”

  I nodded. It was a story I’d heard before, unfortunately.

  “She moans all the time. She doesn’t want to open her eyes.”

  This was actually my area of expertise now, sort of, so I perked up. “Oh, you need to talk to palliative care again, for better pain control! I can increase it now. I won’t be here for fine-tuning, because I’m post-call”—Thank God—”but Dr. Huot would be delighted to help with any pain medication, and”—stimulate her appetite, dry up secretions, and God knows, induce the bowel movements of champions—”make her comfortable.”

  He shook his head. “It hasn’t worked so far. She’s on palliative care already. They moved her today.”

  Oh. That kind of made sense. These stairs were at the junction between palliative care and the 5 South ward, but I’d assumed she was on the latter because she’d been getting active chemo, and because I was focused on the internal medicine patients right now. “Tell her exactly what you told me, or make a list of problems if you have to be at work. She can help you.”

  “I’m counting on it. Thanks, Dr. Sze. I’ll look forward to seeing Dr. Huot and her oncologist, Dr. Underwood,” he said.

  What an unfortunate name. But not the worst. One of the doctors at Western was named Dr. Kille. As in, kill. He said Kill-ey, but we all called him Dr. Kill. Anyway. I was so tir
ed, I was raving. “I’ll see you on Friday,” I said.

  He nodded and turned away from me like he was going to cry.

  I felt bad, but figured I’d done all I could, so I checked on my CHF patient. She was still satting okay, at 94 percent, and had peed out over a litre. Another life saved. Or at least maintained.

  When I wandered back to the nursing station to chart, a day nurse had turned the overhead fluorescent lights back on. It looked like we’d all survived the night. If I could remember the pharmaceutical guy’s mother’s name, I’d check her chart, too, but the nurses were in the medication room, counting narcotics and benzos and/or doing sign-over, and I still couldn’t place the name before my pager went off again for the eighth floor.

  By the time I checked on another 5 South patient and charted some more, a medical student had showed up at 7:49. I gave him the rundown through my patient list, with special emphasis on Mrs. Tong.

  His eyes widened. “You think they’d do a revascularization?”

  “I don’t know what kind of window they have for that. We may have missed it, but even so, I’d like to know what’s going on.” I told him my CHF patient seemed stable right now. “And there’s probably a palliative care consult percolating its way through the system as we speak.” He looked confused, so I said, “Never mind. It doesn’t affect you, unless the patient’s son asks for more morphine in the meantime.”

  And then, to my intense relief, one of the internal medicine staff doctors, Dr. Baker, floated toward the nursing station table in his white coat, so I did another patient update for him. He raised his bushy eyebrows about Mrs. Tong, but said that it made sense to ask her family what they wanted. The doctor covering the eighth floor would take care of it.

  We officially rounded on all the patients, which took three hours. That was pretty quick, for internal medicine. Then I attended lunch time rounds on implantable defibrillators, which I was too tired to remember most of, but one of the companies sponsored lunch, so I got a free sandwich out of it. One last trip to grab my backpack from the call room and return my key before I bustled out of the hospital and took a breath of fresh air. Free, free, free!