“Por tres meses,….” For three months, she had endured griping pain in her stomach. Her stool turned midnight black and she felt weary at times. However, she was the fiercely proud seventy five-year-old mother of 5 strapping sons. Each son had married a contentious and ambitious wife. The whole family lived and bickered together in an ramshackle old mansion off Mount Royal Ave. So, the elderly matriarch chose silence regarding her ills, and continued to run her complicated, quarrelling clan. My patient explained this to me in a few heavily-accented phrases as I checked her into her ICU cubicle #8.
She succeeded in hiding her sickness, keeping the peace and holding her own pain at bay until today, Thanksgiving Day. Late this afternoon, despite her resolve, her disease overcame her. As she labored in the kitchen and instructed her “nueras” (daughters-in-law) as to the proper preparation of side dishes, the widow Gerolo vomited up a pint of blood into the kitchen sink before the horrified eyes of her family.
Now that an emergency evening endoscopy (camera down the throat) had revealed an angry, lurking stomach cancer as large as a man’s fist, she was being admitted to the ICU overnight where while her surgeon and internist tried to figure out the best plan of action. I was the nominal intern “in-charge”.
In reality, the “in-charge” part was ridiculous and untrue. I was a wet-ear, and I depended upon the experienced unit nurses to guide me in correctly caring for “routine” patient cases. For the complicated or unusual patients, I sought direction and help from the Intensive Care Unit Fellow, who was officially manning the Cardiac Intensive Care Unit (CCU) down the hall. The Fellow also supervised the ICU intern. Our Fellow, Homer Hardison, was “moonlighting”, earning extra money to pay back his student loans by working extra shifts at our quiet community hospital. Many young docs taking advanced training did this. Trading their precious sleep for cash in the less frantic environment of our small teaching hospital, Fellows made a real contribution to care. At the same time, they tried to catch some sleep in a kindlier atmosphere than the one that existed at their “real jobs” in Shock Trauma.
In Baltimore’s Trauma Center, where Homer spent most of his time, sleep was virtually non-existent. Even the patients there were bereft of this essential commodity. They were either awake or in coma. True rest, for doctors and patients alike at Shock Trauma was as rare as a legitimate sighting of Sasquatch.
Now I eyed my large, aged, endangered patient, who had arrived from the endoscopy suite with only a ridiculously small IV (22-gauge) in the bend of her left elbow. It would do for an IV fluid saline drip, but if she needed blood the diameter was too small for the thick liquid. I tried vainly to insert a larger IV, an 18-gauge, first in her left and right wrist veins, then in the bend of her right elbow without success. My patient’s blood vessels were fragile and clamped down, and I was nervous. Mrs. Gerolo glared at my timid smile. Finally, she drove me from her bed with curses:
“¡Maldita sea, déjame en paz!” (Damn you, leave me in peace!)
I went to the CCU, shame-faced, and woke Homer.
“Sorry to bug you, Homer, but I’ve got an Upper GI bleed without good IV access. I blew three line attempts. If we can’t get an 18-gauge line in her arms, I’ll need your help placing a central line. I’ve never done one alone.”
A central line is a very large IV that goes in under the collarbone to directly access a large blood vessel in the chest.
He sighed and arose and assessed Ms. Gerolo with me.
“Lyons, look, she’s stable, her hemoglobin is 10.4, and she’s not bleeding now. She’ll be fine for a while. Just let me get a few hours’ sleep, and then I’ll help you put in the central line.”
Alas, for poor Homer and Mrs. Gerolo as well, his next few hours were filled by two Thanksgiving Day heroes, who had shoveled snow to the detriment of their coronary arteries, and an adolescent idiot on a snowboard, who had impacted the corner of a house with his chest. This earned him a fractured breastbone, a bruised heart, an overnight stay in the CCU and the undying admiration of his beer buddies.
I grabbed Homer as he sagged back down the hall to his call room.
“Homer, sorry, but Mrs. Gerolo?”
He looked at me with thinly-disguised irritation, and true exhaustion.
“Later, Lyons.”
I was too green, too intimidated to insist. Besides, Homer was my superior in years and experience. Surely, he knew what was right and what was not?
I had misgivings. In the privacy of the supply closet, I took out a central line kit, and “wasted” it by opening it up in unsterile fashion, and handling all of its parts. This particular kit would never be used on a patient. This kit was for target practice. I put the pieces of the kit together, rehearsing again and again. I memorized all of the steps of the procedure. I practiced until I was smooth. I could do this myself.
Then I considered again that this was a blind “stick” (puncture made without being able to see the target vein) into a live patient’s chest. Twice, under careful supervision, I had found the correct angle to get into the large but invisible chest vein. Now I was alone.
Do it wrong, and a lung might be punctured. Or I could pierce both walls of the vein, and my patient would bleed out into her chest. Less bad, but still awful, I might totally fail to find the vessel, causing my patient significant pain with no benefit.
I remembered Mrs. Gerolo’s gimlet eyes skewering mine as I failed three times to start a working arm IV. She knew I was inexperienced. I knew I was inexperienced. Was I a coward, or merely practical? I realized that I could not face Mrs. Gerolo with a central line kit and pretend that I knew what I was doing. I would have to wait for Homer.
I swallowed my unease and got on with my work.
At 3:27 a.m., I was puzzling over a leukemia patient’s bizarre lab results at the central nursing station, when I heard the sonorous voice of an aspiring angel.
From cubicle #8 came the rising wail:
“¡Mama, te veo! ¡Mama te amo! ¡Mama ya voy!” (“Mama, I see you! Mama, I love you! Mama, I’m coming!”)
Hairs rose on my nape and arms as I darted a look at #8’s monitor screen from my seat in the nurse’s station. Mrs. Gerolo’s pulse was rising, her blood pressure was dropping. Truly, I didn’t need to look at the electronic monitor to know what was happening now.
When an ICU patient sings to dead relatives, everyone involved understands that we are all in deep shit. My patient was bleeding out from her gut cancer, wicked fast.
I stat-paged Homer, who came running, bleary-eyed, with the central line kit. But Mrs. Gerolo was combative, and big, and rolling wildly in her bed. What a tough old bird! We couldn’t restrain her adequately. Homer couldn’t get a good shot at her subclavian vein. Meds for sedation at this point would likely kill her, even if we had the time to administer them. Homer missed, (no wonder!) and Mrs. Gerolo’s heart stopped during our second attempt. Needless to say, further attempts at resuscitation were futile.
“Call the surgeon and the attending, Lyons,”
Homer spat in exhausted disgust as he turned back towards his call room.
Trembling with reaction and apprehension, I called the surgeon.
“She’s what!!!???” He screamed, “Jesus Christ! Shit!”
The line went dead.
Totally unnerved, I called the attending, Mrs. Gerolo’s internist.
“Oh my God,no! ¡Nunca esta familia! ¡Son locos avinagrados! ¡Dios mio, es terrible! Ay caray….”
(“Not this family! They are crazy and cantankerous! My God, this is terrible! Oh damn…”)
I cringed. Then the attending gifted me with me a morsel of mercy.
“O.K., Lyons, I’ll call them myself”.
Miserable and guilty, I hid in the nursing station. Fifteen minutes later, a wailing knot of relatives entered in a distraught mass. They invaded Ms. Gerolo’s cubicle. With extreme reluctance, after the discordant sounds of grief had wound down to a less frantic level, I entered the tiny room.
“Hello, I am Dr. Lyons. I am so terribly sorry about Mrs. Gerolo’s death. If you have any questions, or if I can help in any way, please, just ask.”
I stood silent, facing the stares of a dozen agitated strangers.
“Yeah, I gotta question,” came the aggressive response of an angry-looking brunette.
Oh my God, I thought, here it comes. I could hear the question in my head even before the “nuera” spoke it. I imagined an interrogation that never actually took place:
“Why did my mother-in-law die? What did you do to our mother? What did you do wrong?”
My own pounding head accused me. Why shouldn’t Mrs. Gerolo’s survivors do the same?
I thought with burning guilt about the central line. If I had insisted upon help to place it while Mrs. Gerolo was stable, we could have sedated her for the procedure, got it done; then we could’ve pushed blood if and when she bled massively from her tumor. She might have lived. At least she might have lived for a little while longer. Stomach cancers of the size and advanced state of Ms. Gerolo’s were ultimately a death sentence.
I knew what my patient had desperately needed in the short term, and I hadn’t insisted on it. I had worried more about Homer’s sleep, his good opinion of me and my fear of being thought an anxious jerk, than I had about my patient in peril. I had failed to take a chance: to attempt the procedure myself. I realized now, belatedly, that had I done so, and gotten into trouble, Homer would have been forced to come rescue us no matter how tired and angry he might have been. I had clearly defaulted to the “easier” path. My fault.
“Please then, just ask, I’ll tell you whatever I know.”
I braced myself to confess my shortcomings to this distraught gathering of relatives. What an idiot I was!
“You just better tell us everything you know! When my mother-in-law was admitted, she was wearing her necklace! It’s a very valuable necklace! It’s gone! What did you do with it?”
I was stunned, blindsided. I thought slowly, carefully, as one recovering from concussion. This situation was surreal. The rules as I understood them clearly didn’t apply. Had I seen a necklace?
I looked at the crowd, bewildered. Multiple pairs of angry eyes dissected me.
I remembered vividly how Mrs. Gerolo had struggled to dislodge the sterile drape from her chest as we attempted the central line. Had there been a necklace? I couldn’t remember seeing one.
A second, more detached part of my mind thought:
“To hell with her damned necklace, this woman is dead and she shouldn’t be!
A third part of my baffled brain reared its ugly head.
“I love my husband’s mother! If she died, would her jewelry matter to me? No! What is wrong with you, woman, if your mother-in-law’s necklace is what you care about most?”
I shook myself mentally, stomping down hard on my tongue. I responded as best I could to the situation at hand. I kept my thoughts to myself.
“I…I don’t remember a necklace. Did you look in her belongings bag?”
I pointed to the plastic bag of clothes and other effects that were on the bottom shelf of Mrs. Gerolo’s ICU bed. This was ransacked in a moment, but the missing item of concern was not within.
“It’s gone,” accused the spokeswoman, “Who took it? Was it you? Our lawyer is going to see that you don’t get away with this! We’re going to make a big complaint about you to the head of this hospital. He is a personal friend of our family!”
With one final look of censure and ire, she turned back to the rest of the grieving relatives and burst into tears.
Clearly superfluous to the family’s needs, demonstrably useless, distrusted and unwanted, I made my stupefied way back to the nursing station.
Which was better? To be accused of inadequacy rightly, or to be accused of theft, wrongly? Which was worse? I didn’t know. I didn’t know whether to laugh or cry or punch something. I was floored and had no idea what to do next.
I looked at the clock: 4:38 a.m. I quickly surveyed the unit; no one else was in dire straits at this moment. Therefore, I did what all interns do when exhausted and overwhelmed. I dragged my sorry ass to the call room and fell fully-clothed into a bed for a bit of exhausted sleep.
Mrs. Gerolo, her necklace, and my guilt would have to wait until later.
Three hard weeks later, three frightening ICU weeks smarter, I once again stood by a patient’s ICU bed in the wee hours of the night. Once again, a patient of mine was bleeding out and “crashing”.
I was at the bedside of a 57-year old plumber who was hemorrhaging from a diverticular bleed (a vessel arising from an out-pocketing of the large bowel). His earnest, determined, red-headed nurse was standing at the opposite side of his bed from mine. We were each squeezing a maroon bag of blood as hard as we could into the 18-gauge IV lines I had painstakingly placed in the bend of each of this man’s arms hours before. The nurse and I eyed each other, praying for luck and time.
I had insisted upon placing both of these large-bore intravenous lines myself despite my patient’s joking protests when he arrived that evening from the emergency room with a single hand vein 22.
He said, “I only bled a little bit. I’ve had worse shaving cuts, doc!”
My patient hated needles despite his tattoos. On admission to the ICU he told me that he rode a Harley Fat-Boy every day to work on the Baltimore Beltway, and therefore was clearly unkillable. He told me he didn’t need one line, much less two. Certainly, he looked great when he arrived at the Unit. I laughed along with my patient, admiring both his bravura and his silver-streaked goatee.
Nonetheless, I insisted upon generous IV access. This time, I would not be fooled.
My patient’s bed was now tilted so that his head was lower than his feet (reverse Trendelenburg) to preserve perfusion to his heart, lungs, and brain. My less-than-patient plumber was pale and frightened, yet alert and angry. His pressure was holding at 80 over palp, and the surgeons were scrubbing. The nurses and I–the rapidly-learning greenhorn—bought this tough guy the time that the surgeons needed to try and save him.
No angels sang this night. My patient’s loud and angry curses sounded sweet to me, as they accurately displayed his vital reserves in the face of hemorrhage.
This fortunate man lived. I smiled grimly when I heard the happy news from the OR and tolerated with good humor the ICU nickname: “Two-Lines Lyons” that followed me from that day forward.
I thank you, Mrs. Gerolo. I have no way to apologize to you, no matter how much I want to. Nothing can erase my fatal mistakes with you, but your death has made me a better doctor. Lives have been saved because I remember, every single day, the personal flaws that let me fail you.
Paula Lyons, MD
Story Editor: Thomas Corby
December 19, 2009