Surgeons have the stamina of fighting marines. Despite their lack of sleep, they have always impressed me with an unequaled endurance and constant enthusiasm. As promised, Dr. Ungaman met me in the intensive care unit at five in the morning. In the meantime he had gone home, slept with his wife for a couple of hours, and taken care of his personal hygiene. He looked quite refreshed. As usual he was clean shaven and had his ironed suit on. "Good morning, Mick. You look tired. Here's your coffee."
"I survived the night, Cutter. The unit players were all sick. The ruptured abdominal aorta kept me busy. He was playing blood pressure tricks on me all night. I kept chasing it up and down. He's a little bit more stable this morning. They all survived the night," I said while turning my head towards Room 2220, Mr. Jacobs' room. Now that Cutter was here, I was hoping that he would finally die.
"Where do you want to start rounds this morning?"
"I've already seen all the ward patients. We can discuss the intensive care unit patients and then venture to the wards. How does that sound?" I asked.
"Sounds good. So what happened with our farmer overnight?"
"His head scan didn't show any bleeding. He had changes mostly in his right temporal lobe, consistent with a middle cerebral artery distribution infarction," I answered.
"So, Mick. Did you blast him with thrombolytics? Did you dissolve the clot and open that vessel?"
He was eager to know. I was eager to let him guess.
"Can you guess, Cutter?" I teased him.
"Oh, come on. It's too early in the morning. Did you do it?"
"You know the answer," I replied.
"You aggressive son of bitch. Wow! What a cowboy! You're sure you don't want to become a surgeon?"
"No," I answered.
"You don't think that surgery is good enough for you, Mister X-ray," he added sarcastically.
"No. I didn't dissolve his clot."
"What? There was no bleeding. Why didn't you?" he sounded a little disappointed.
"Put yourself in my shoes. If a neurologist and a vascular surgeon couldn't decide for the patient, how do you expect a burned out intern to decide for him? Cutter, thrombolytics are not without side effects. Did I ever tell you the story of the Armenian man I met when I was a student?"
"Unfortunate man. He waited all his life to immigrate to the United States to join his two sons who had escaped years ago and became prominent computer engineers in California. Finally with the fall of the Eastern block, he was allowed to leave Armenia. He was eighty-two years old. He came to California. He saw his sons after thirty years of separation. His right hip had been bothering him for the longest time. The first week of his visit, he underwent hip replacement. The first day after his surgery, he suffered a clot in the main blood vessel of his heart. He had a huge heart attack. A bunch of smart specialists gathered around his bed to decide whether they should dissolve the clot or not. The orthopedic surgeon took the heat since it was his patient. He decided to thin his blood. The man bled into his hip in the middle of the night. His blood pressure dropped. His heart couldn't take it. I was there to help bang on his chest for a good hour. He was far away from Armenia. He kissed his eighty-two years good-bye. His body was in the morgue that same night."
Dr. Ungaman shook his head. He fully understood.
"Mr. Sullstein is still with us this morning. Half of his brain may be gone, but he's here. Thalamus will see him this morning. We'll go from there. Hopefully, he'll regain some function," I said.
"I hear you, Rastus. That decision was beyond your level. But we had a crazy day yesterday. It was true chaos to say the least. Now, what's going on with Jacobs?"
We walked to Room 2220. I was afraid that Dr. Ungaman was going to be upset regarding the morphine. We stood in front of the room. Silvia was at the end of her night shift. He looked at the monitor and saw the blood pressure in the sixties. He looked at Mr. Jacobs. He seemed comfortable. His respiration was infrequent and deep. Cutter didn't know what to say. He looked at me, then looked at Silvia. She looked at the patient. Silence reigned for about two minutes.
"He seems stable," he finally said.
"Stable? The man is dying, Cutter. These are his last breaths. He loved his morphine drip."
"I didn't mean stable. I meant to say stable in peace. I meant peaceful. How about that blood pressure?" he nervously asked.
"Are we going to treat blood pressure? The man is dying. We did what we could for him in the operating room. There's nothing else we could do for him. His cancer has eaten him up."
"Weren't those ugly tumors? It was so much fun to see how frustrated, disgusted, and pissed off the boss was. HA! You missed the beginning of the case. I told you, he hates the belly cases. He only cares about the blood vessels," he smiled nervously. "Anyhow, I think that you did the right thing. I agree with you. Let's hope he'll die before Harshberg comes in this morning. Let's put the whole thing behind us. Today is another day, Mick. Come on, tell me about the ruptured aorta next."
Dr. Ungaman was comfortable with the plan. I had his support. He would back me up in front of the boss. I felt relieved. I felt happy for Mr. Jacobs. Finally he was going to go in peace. We moved to room 2218. Suddenly, Cutter's emergency pager went off.
"Shit, not this early. It is only 5:45 am, " he said as he went to the nearest phone to answer it.
The conversation was brief. He didn't talk much. I heard him say 'yes, sir' a few times. He hung up and walked towards me. He looked disappointed.
"It was the boss. He wants the care of Mr. Jacobs to be transferred to the critical care team. He has already called the consultant in the intensive care unit. His residents will take over."
"What?" I said in disbelief. "This man is dying, Cutter. He needs a rabbi, not a critical care team. He needs his family next to him. What are they going to do to him?"
"I don't know. But these are the bossı wishes," he answered softly.
"But how about this poor manıs wishes? That's bullshit. You know it ain't right. We're his doctors too. We can convince Harshberg to let this man die. Come on, Cutter," I started raising my voice.
"I hear you, Rastus. But that's what the boss wants," he firmly said.
"Who's the boss to decide? He dug in his belly last night and then took off. What is it, Cutter? Harshberg doesn't want him to die on our service. So he's turfing him to critical care to die. Is that what it is? You surgeons don't like to see them die on your service. Do you? You look bad when they do. Come on, Cutter. You're the chief resident. Look at him. He's sucking in the last few breaths from this world. He's dying in peace. Let's not torture him again," I begged him.
"I'm sorry. He's the boss. Let's talk about the next patient."
I felt hopeless, helpless, and betrayed. I was Mr. Jacobs' doctor. Yet I couldn't even offer him a peaceful death. I refused to follow Cutter on rounds. I stood in front of Mr. Jacobs' room. I wished him death. I wished I could drown him in a pool of morphine before the critical care team laid a hand on him. But it was too late. It was 6 a.m. already and the critical care team was in the intensive care unit. Their first order of business was the new customer that was referred to them. Their senior resident was the first to show up in the room. "I know that Doctor Harshberg has asked you to take over the care of this man. But I've been providing him with comfort care over night. He's ready to go," I gently said.
"Well, I was told he needed intensive care management. Besides, if he was truly ready to go, why did you operate on him last night?"
"It was a mistake. This man didn't need an operation in the first place. Please keep the morphine running," I begged.
"Until I hear otherwise from my consultant, he's going to get intensive care. He's on our service now. Look at this blood pressure. Silvia, let's get a neosynephrine drip. His pressure is unacceptable. He needs a heart catheter to monitor his hemodynamics. I'm getting my intern right away to put one in," he said as he walked to the desk and picked up the telephone.
Surprised, confused, and overwhelmed, Silvia's body froze. She looked at me. She was waiting for an explanation. I couldn't offer her one. I felt helpless. I was Rastus. I was the intern. I was worth nothing. I was furious with Cutter. But it wasn't his fault. It wasn't his decision. It was the big dog, the big boss' decision. I walked away. I ran down the hallway. I didn't dare look back.
|Chapter Six||Chapter Eight|
Copyright © 1996 Maher Abbas, M.D. All rights reserved