ONE Awakening A young doctor means a new graveyard. --German proverb I had been pedaling furiously for nearly a decade--on a stationary bicycle. Medical school, internship, residency, and fellowship: my education seemed as if it would never end. So it was with no small measure of relief that in the late spring of 2004 I accepted a position as an attending cardiologist at Long Island Jewish Medical Center in New Hyde Park, New York. This was the last step in a long and grueling journey. After medical school I'd completed three years of hospital instruction in general internal medicine to earn the privilege to practice independently. After finishing this internship and residency, I'd elected to do a fellowship: three more years of study in cardiac diseases to further specialize. Now, with the fellowship concluded, I'd become an attending physician, the senior level of the hospital hierarchy, with ultimate responsibility for patients and junior doctors. Nineteen years after starting college and a few months shy of my thirty-sixth birthday, I finally had my first real job. The complexities of academic medical training had long since worn thin. I was ready to simplify, consolidate, and perhaps even reap some rewards for all those sleepless nights. Cardiology was a natural career choice. I had trained as a physicist before going to medical school, and the heart, with its complex rhythms and oscillations, appealed to my predilection for patterns and logic. Heart disease was also no stranger in my family. Both my grandfathers had died of myocardial infarctions--one in his forties, ten years before I was born--so I had grown up with an awe of the heart as the executioner of men in the prime of their lives. Plus, the heart, with its symbolic meanings, had always occupied a special place in my (and the broader cultural) imagination. Take heart! Have a heart! He wears his heart on his sleeve. Of course, I was nervous. Every new doctor should be. Cardiologists specialize in emergencies. The culture is fast-paced, pressured. I was going to have to learn to become quick and decisive in precarious situations. By nature I was slow and deliberate, and I had never felt comfortable acting on instinct--not exactly adaptive in a cardiac care unit where people can drop dead on you at any moment. In neuroscience there is the concept of the reflex arc, in which a threatening stimulus can effect a response without passing through the conscious brain--for example, when you see the taillight flash red on the car speeding in front of you and your foot automatically moves to the brake pedal. I was afraid that as a cardiologist I would now have to follow a similar reflex arc. "Well begun is half done," my father reminded me with his usual Aesopian wisdom. Dad possessed the annoying certitude that there were no more life lessons to be learned in this world, that whatever was worth knowing our forebears had already taught us. Traditional and moralistic, he liberally quoted proverbs and scriptures even if he didn't always live by them. But when you think in axioms and parables, when the collective wisdom of the world can be distilled into the concentrated tonic of a few sayings, then you feel as though you have all the answers. He had always wanted me to become a doctor--one trained at Stanford University, no less. That, he believed, would be the pinnacle of professional attainment. My family immigrated to the United States in 1977, when I was eight, to advance my father's career as a plant geneticist, but in America my father never achieved the kind of success he felt he deserved--denied, he believed, by a racist university tenure system, which forced him to take postdoctoral positions with no long-term stability and left him embittered and in a constant state of conflict with professional colleagues. In medicine, my father explained, I would not be plagued with such insecurity. One reason for my father's struggles was that he always seemed to do things the wrong way. When I told him the mnemonic I had learned in school to remember the colors of the spectrum, he said: "Roy G. Biv? Oh, you mean Vibgyor!" He'd mow the lawn at night, waking the neighbors. He'd bring up controversial subjects like Sikh separatism or Kashmiri violence at low-key social gatherings. He'd trim our nails with a Gillette razor blade, twisting our fingers painfully so they wouldn't get lacerated. As long as the nails got cut, it didn't matter to my father how much we protested. That sort of encapsulated his personality: disciplined, unsentimental, focused solely on the task at hand. My mother affectionately called him poottha, "awkward." She accepted his idiosyncrasies with a kind of bemused resignation, as if they had been written in the stars. The eldest daughter of a wealthy New Delhi physician, she abided her station as the working wife of a discontented plant geneticist as though it had been ordained, just part of the deal of an arranged marriage, and she resolved to make the most of it. She didn't believe in talk or analysis or drama, only in putting your best foot forward and grinding ahead, accepting your circumstances with dignity and grace. Yet for all her equanimity, she still regarded medicine as the hammer that would break her children out of the middle-class mold my father had set. She often told us she wanted her children to become doctors so people would stand when we walked into a room. My apprehensions about my new job were only slightly mitigated by the fact that my older brother, Rajiv, an interventional cardiologist who performed invasive procedures, was already working at the same hospital. Rajiv was my parents' firstborn, their pride. They had always favored him, and Rajiv demanded it, too. He knew the privileges of being the elder son in a traditional Indian family and guarded them closely, like a trust fund. Like most brothers close in age, we were fiercely competitive growing up, evenly matched at most things (Ping-Pong, chess, tennis), our rivalrous parity enforced by the unspoken fear that if one of us pulled away, we'd lose the other's companionship. One sphere in which we were undoubtedly unequal was social relationships, however. Rajiv had the kind of gregarious and easygoing personality that I had always desired but somehow never could develop. The only time we had worked together professionally was during my internship at New York Hospital in Manhattan, where as a star senior cardiology fellow he unwittingly reminded me of my incompetence again and again. Toward the end of my own cardiology fellowship at NYU, he had invited me to apply to LIJ and had used his considerable influence to get me a job. Now he was in a position to guide me through another, perhaps more challenging apprenticeship. At Long Island Jewish I would work as a cardiologist with a specialization in congestive heart failure. This was no small task: heart failure is the common final pathway for a host of cardiac diseases, including heart attacks, acute valve disorders, viral infections of the cardiac muscle, etc. There are many challenges in caring for these patients. They have multiple comorbid illnesses, such as diabetes and emphysema. Their symptoms--for instance, shortness of breath--are often nonspecific. They frequently have poor health literacy or cognitive impairment or are socially isolated because of their chronic disease. Despite these difficulties, I chose to specialize in heart failure because I wanted to develop close relationships with critically ill patients and provide long-term care, unlike my brother, who almost exclusively performs procedures and knows his patients mostly for the duration of an operation. I also wanted to be in a specialty where I would not have to perform surgical interventions. I'd never been especially good with my hands. Growing up, Rajiv had been the tinkerer and I had been the thinker. Of course, I knew this decision was going to involve a certain degree of monetary sacrifice. Heart failure is a money loser for most hospitals, which make most of their revenue from lucrative procedures like stents (wire mesh cylinders used to open blockages in the coronary arteries that feed the heart) and pacemakers, or hip replacements. In the American system doctors are paid much less for exercising their judgment than their fingers. * * * Dawn in July, a few weeks after starting my new job. Sirens puncture the early-morning stillness. I open my eyes. Twilight leaks through the window blinds, dissolving the gloom into tiny grains of black. I remain motionless, savoring the void. My wife, Sonia, is still sleeping--sleeping for two. I peer at the hazy sonogram framed on the windowsill. It is faded from the sunlight that beats on it daily, betraying nothing of the complications of the past few months. I get up quietly and tiptoe to the bathroom. In the mirror I notice I've developed a touch of gray. A bracing splash, some bloody nicks, a suitable tie, and I am outside. It is a bright day, nearly cloudless, the skyline marred only by the steam drizzling out of a tower in the distance. I pull out of my building and drive north, past empty playgrounds and cracked brownstones and apartment complexes stacked like Lego blocks. Street sweepers are out in force, ravenously whirling over the grime and debris. I turn onto the FDR Drive. A few joggers are out on that lonely stretch of waterfront. A couple of miles on, I enter the blue-green expanse of the Triborough Bridge. Pigeons flutter off the ramparts. Across the shimmering East River, skyscrapers in Midtown are arrayed like an irregular bed of nails. I press on the gas pedal. The brilliant day is pulling me forward. I was asked during job interviews how I planned to create a heart failure program. I replied that if you provided good care and vigilant monitoring and were responsive to patients' needs, community physicians would refer their patients. I had no idea if this was actually true; but it sounded good, and I got the job. I promised to decrease lengths of stay, improve hospital performance measures, improve the discharge process, decrease readmissions, install a computerized database, enroll patients in clinical trials, write emergency room protocols, and start an intravenous infusion clinic. Eventually I wanted to hire a nurse practitioner, a dietitian, a social worker, and a physical therapist. But I had accomplished none of these things as I drove to work that July morning. It was a few minutes past seven-thirty when I arrived at the hospital, and I was late for morning report. I pulled into the attending physicians' lot and parked between two cars whose license plates read "BEAN DOC" and "GAS MD." At the sliding glass doors leading into the lobby, two patients in teal hospital gowns were leaning on their IV poles, sucking hungrily on cigarettes. I skipped down a concrete stairwell to the basement. The corridors were deserted, save for a tardy first-year fellow racing ahead of me. When I walked into the conference room, a fellow was presenting a case from overnight. About a dozen fellows and a half-dozen faculty members were there. The fellows rotated each month through the various cardiac subspecialties: electrophysiology (which focuses on arrhythmias, or heart rhythm disturbances), echocardiography (cardiac ultrasound), nuclear stress testing (which uses radioactive tracers to noninvasively detect coronary disease in hearts under stress from exercise or certain drugs), cardiac catheterization (Rajiv's specialty), heart failure, the general consultative service, and the cardiac care unit (where the most critically ill patients of any subspecialty usually ended up). As faculty members we were responsible for teaching the fellows: scrubbing in with them on procedures, going on rounds with them, and instructing them over discussions at morning report or noon seminar. In the conference room, Rajiv and two of his interventional colleagues were sitting together, arms folded, legs crossed, in purple scrubs, like some sort of academic tribunal. My brother looked at me sharply, glanced at a phantom wristwatch, and winked. I quietly took a seat in the back. The fellow was trying to explain his management of a critically ill patient the previous night. "The patient's pulmonary artery saturation was in the mid-forties, so I ended up putting him on some dobutamine and gave him a little fluid back," the fellow said. "He started putting out some urine, and his blood pressure went up. Over the next twelve hours, his oxygenation improved dramatically." Dr. Morrison, one of the interventional cardiologists, demanded to know why the fellow had given the patient intravenous fluid. "At that point his central venous pressure was two," the fellow said defensively, describing a state of dehydration. "His pulmonary artery diastolic pressure was six, and his wedge pressure was like eight." "And you're sure the transducer was zeroed and level?" Morrison pressed him. "We see this a lot with the residents. They look up at the monitor and quote a pressure, but it's just garbage." The fellow hesitated. "When we first put in the catheter, the wedge pressure was in the thirties--" "Well, see, that's what I'm saying," Morrison interjected, as if the fellow had just made his point. "This guy wasn't dehydrated! He was in florid heart failure. This is a textbook case of acute heart failure, from the frothy sputum to the missed myocardial infarction." "Anyway, good case," the chief fellow said, trying to move things along. "What this patient really needs is a doctor," Dr. Morrison added caustically. "As opposed to a plumber like us?" Rajiv shot back, coming to the fellow's defense. "Exactly," Morrison replied, laughing. (Interventional cardiologists who relieve coronary obstructions with stents are often disparagingly referred to as plumbers.) Looking around the room, I reminded myself how lucky I was to be working at a teaching hospital where residents and fellows would be making rounds on my patients and assisting me on cases. LIJ is one of the largest teaching facilities on Long Island, sitting on fifty acres on the Queens-Long Island border, housing nearly eight hundred beds, and employing seven hundred physicians on its full-time faculty. The evidence shows that patients treated for several common medical disorders, including heart failure, heart attack, and stroke, fare better at major teaching hospitals and have better overall survival. One reason may simply be redundancy: residents and fellows may be annoying when you're reciting the details of your fainting episode for the third time in the middle of the night--"So tell me, did you pass out before or after you hit the floor?"--but so many pairs of eyes on each patient mean things don't get overlooked. Eighty percent of medical diagnoses can probably be made on the basis of a patient's history, and the more people asking, the more likely doctors are to get it right. Another factor is the sheer number of patients treated at the average teaching hospital. Patient mortality tends to drop as doctors get more experience. Would you rather have angioplasty performed by a cardiologist who does two hundred a year--or twenty? Though I'd been hired to start a heart failure program, I'd been informed that for the first year or so I'd also be assuming frequent responsibility for the cardiac care unit (CCU), where I'd be treating not only patients with heart failure but also those with other, more general cardiac problems (myocardial infarctions, arrhythmias, etc.) to help me build up my practice. So after morning report, I headed up to the CCU, where I was substituting for Dr. Vaccaro, the director, who was on vacation that week. Fifty years ago there were only about a hundred "special care" coronary units in the United States. Since then there has been a veritable hailstorm of cardiac advances, including implantable pacemakers, prosthetic heart valves, coronary bypass surgery, and heart transplantation. Today most hospitals with more than a hundred beds have a cardiac care unit. Chiming alarms reminiscent of a video arcade greeted me when I arrived. The CCU was a refurbished unit with gleaming tile and a distinctly modern feel. The faintly pleasant odors of disinfectant and talcum powder wafted through the corridors. Nurses were weaving in and out of rooms, attending to their patients. Families were loitering in the hallways or sitting at bedsides, keeping vigil. At the front desk an old woman gruffly answered the phone. "CCU, Eva, may I help?" As I joined the team for rounds that morning, the bleary-eyed postcall fellow was signing out to Ethan, the CCU day fellow. Ethan was a short Jewish guy with glasses that were too big for his face, spiky gelled hair, and a geeky hyperexcitability. Like most fellows, he was eager to make a good impression. He was constantly toeing that fine line between being assertive and kissing ass. The postcall fellow was telling Ethan about a cardiac arrest from the previous night. "You're doing things, and you're doing them because you've got to do them, but you're thinking, Why the hell am I doing this?" he said, shaking his head in resignation. "Sometimes it's out of your hands," Ethan said sympathetically. "I told the daughter I was going to go down swinging--" "It wouldn't have mattered," Ethan interrupted. "It was a finger in the dike. That patient was destined to die, and that's all there is to it." The postcall fellow nodded appreciatively. After he departed, Ethan turned to me and said matter-of-factly, "We got lucky, Dr. Jauhar. One transfer patient didn't show up, one patient the private attending decided he didn't want the consult, and one patient died." The team of doctors in the CCU consisted of Ethan, three residents, and three interns, including Paul, a nerdy East Asian who was supposed to quickly present overnight admissions and leave the hospital by 10:00 a.m. to meet the latest work-hour regulations. As an intern I would never have been allowed to leave the hospital before completing all my responsibilities for the day, but times had changed. All week I'd constantly been checking my team's work, pushing them to do what they were supposed to be doing, nothing extra. Just getting the trainees to do what was expected of them was hard enough. Everyone was casually dressed--oxford shirts but no ties--not what I remembered from my own residency. Huddled around the rolling chart rack in the hallway, we stopped outside the first room. "Jerry Simons is a forty-nine-year-old man with a history of drug abuse who was admitted to another hospital on Friday after doing cocaine," Paul narrated. He chuckled before continuing. "He was sitting in his kitchen having dinner when he broke into a sweat. His wife noticed his shirt was drenched, so she got him a towel, and then he changed his clothes, but they got drenched, too--" "You can just say he was diaphoretic," I interrupted. Paul nodded. "He started having chest pain. He described it as a burning, or rather squeezing, pressure, not really sharp, though it had a pins-and-needle--" "Just show me the electrocardiogram," I said, trying to hurry him along. Paul pulled it out of his coat pocket. An electrocardiogram, or EKG, measures the electrical signals coming from the heart. On this one were ST segment elevations, a serious abnormality, indicating an acute attack, or infarction, of the inferior wall of the heart. "Do you see a Wellens sign?" Ethan asked me, referring to an esoteric EKG finding. I shook my head. The residents stared blankly. Paul continued, taking no notice of Ethan's ass-kissing: "So in the ER he reported shortness of breath and light-headedness. He had ST elevations but didn't spill any cardiac enzymes," the latter indicating irreversible damage to the heart muscle. "All right, let's go see him," I announced. Before we walked into the room, Paul quickly added: "By the way, he doesn't want to talk about his drug use. He already told me he wasn't going to stop." Mr. Simons appeared to be sleeping when we got to the bedside. He was a thin black man with curly gray hair and a grizzled face. The sheets were off, and his gown was pulled up. There was a bloody patch on his right groin where a cardiac catheter had been inserted. He opened his eyes slowly when I started to speak. I introduced the team and asked him how he was feeling. "I just swallowed some pills," he said flatly. "Oh, did you swallow them the wrong way?" I asked. He gazed indifferently at the roomful of doctors. "Before you came in, the nurse gave me my pills, so when you said how you doing, I said I swallowed my pills." He threw a blanket over his exposed leg. "That's all." I applied my stethoscope to his chest. His heart was racing, perhaps a sign of drug withdrawal. I explained to him that we would normally start him on a beta-blocker to slow down the rate, but the medication had a potentially harmful interaction with cocaine. Was he planning on using again? "All you cats love throwing that word 'cocaine' around," he said, his voice rising. "I don't want to hear that word again." "Look, I don't know whether you regularly use drugs or not," I said, my jaw tightening. "I just want to know about the future, so I can decide how best to treat you." Moral reform was not my objective. Getting him on the right medications was. "You don't know nothing about me," he said angrily. "I know that cocaine is addictive." "I'm not addicted!" "Then why don't you quit?" "I did! Yesterday." I told him he was going to have to follow up as an outpatient and undergo at least two negative drug screens before I would prescribe him a beta-blocker. "You have to do something," I lectured him. "You're on the path to self-destruction." He stared at me tensely for a few moments. "I know I've got to quit," he said quietly. "I tell myself I'm going to stop, and then the pipe just appears in my hand. It's gone in thirty seconds, and I don't even know what I've done." The cast of patients in the CCU that morning was similar to Mr. Simons: sick, indigent, on a slow journey to dignity. Arthur Batista in room 6 weighed over 350 pounds. His body resembled a collection of interconnecting spheres: soccer balls for thighs, a bag of tennis balls around his waist, and a beach ball for a rump. He had an unsightly growth of facial hair, a thick, almost absent neck, and the rancid odor of someone who has too much body surface to wash. His heart was functioning at less than half capacity. He was standing with one foot on a banana peel, as a nurse put it. When we walked into his room, he was lying on his side, trying to generate enough momentum to stand up. There was a large stain on his bed, which explained the musty smell. "Man, this is just crazy!" he cried, pulling on a fluid-filled plastic line. "I'm all tangled up. I have to get up and take a piss!" Four of us helped him to his feet, rotating an IV pole twice around his body to untangle the line. While we remained assembled around him, he peed into a plastic urinal. Just that bit of exertion made him winded, and he plunked down into a sofa chair. "How is your breathing today, Arthur?" I asked pleasantly. "My breathing's fine," he said, even though he was panting. He pointed up at the monitor. "I don't think I even need the oxygen anymore, but they're going by the numbers up there." He picked up his face mask. "This thing is broken. I need you to call the respiratory therapist and get me a new one." I told him we would. A nurse's aide barreled in to check his blood sugar. In one seemingly continuous motion, she prepared the lancet, swabbed his fingertip with an alcohol pad, pricked the finger, coaxed a droplet of blood onto a card, and inserted the card into a glucometer. Then she turned and walked out. "What's the number?" he roared as she slipped away. "They always walk out before they give you the number!" The howl brought his nurse in. "What's the matter, Arthur? You okay?" "I'm fine!" "He was all tangled up," I explained. "I had to stand up to pee, okay! To do that, I have to take off the oxygen." "Not a problem," the nurse said calmly. "Just ring the buzzer." "That's what I did! Nobody comes." Scowling, he turned to me. "The first day they're fine, but after that they ignore you." He surveyed the group of doctors standing around him. "You guys just keep throwing pills at me. One doctor says one thing; another doctor comes in and says, 'No, you got a problem with your kidney.' Now, which one is it, guys? You should get your stories straight." I told him that our role as the cardiac team was to focus on his heart condition. Different doctors were managing his kidney problems. To judge from his groan of frustration, such division of labor did not sit well with him. (There was an inverse relationship, I'd discovered, between patient satisfaction and the number of doctors coming and going through their hospital rooms.) He placed his hand on his scrotum, edematous from the fluid overload of heart failure. "My nuts are starting to go down," he announced. "So when can I go home, Doc?" I told him that he would likely have to go to a rehabilitation facility first. "Rehab? What the hell for?" "To get you stronger." "But I'm fine! This doctor"--he pointed at Paul, the intern--"whatever his name is, Chao--" "Cheung," Paul corrected him. "Whatever. He was telling me something else." "Well, I'm running the show here," I said. "Then let me go home." I hesitated. "I'm just covering for the week. I'll have to speak with Dr. Vaccaro." Exasperated, he shook his head. "Well, if I had known that, I would've just invited you to sit down and play cards!" The most tragic case in the unit was Delmore Richardson, a forty-eight-year-old man who had collapsed three weeks prior after coming home from a dinner party. His wife had recounted the event for me. "He walked into the bedroom, but then he kind of stumbled and held on to the doorjamb," she said. "I watched him fall backward. He bashed his head on the floor. First, I thought he was having a seizure. He kind of went awwgh ." She made a deep, guttural sound. "I yelled for my brother. He came downstairs and started doing chest compressions. I tried to breathe for him. His mouth was open, but every now and then he'd go awwgh ." She stopped, overwhelmed by the memory. "We called 911. They shocked him twice. It was pandemonium. There were so many people working on him, I got pushed into the kitchen." When I asked where her children were, her lips quivered. "Unfortunately, their bedrooms are right off the living room, so they walked in on it. They saw the whole thing." Mr. Richardson had clearly suffered significant brain damage because he had been out so long. That morning, on rounds, his arms and feet were splayed rigidly outward in a position called decorticate posturing, a sign of severe neurological injury. Air bags, inflating and deflating to prevent blood clots, were wrapped around his immobile legs. A bottle of medicated fluid, hanging on a metal pole, dripped into his vein. A plastic tube in his rectum was draining pond green diarrhea, which was decanting into a bag, solids on bottom, clear liquid on top. His head rested on a towel, which caught secretions from the breathing tube taped to his chin. The ventilator recorded the respiratory rate: machine: 11; patient: 11. He wasn't breathing on his own at all. A nurse slipped a thin plastic catheter down the breathing tube. With her thumb covering a hole in the vacuum line, she suctioned out thick yellow secretions, which pooled into a bucket. With her help, I hauled him onto his side and listened to his back, which was slippery with ointment. On his tailbone was gauze dressing, which I pulled aside to inspect the bedsore underneath, a pink crater about the size of a small saucer but less than half the depth. Inside it were tiny black flecks, perhaps dead tissue. I picked up his swollen arm. An allergy band was eating into the wrist, leaving a deep furrow. I let the arm go and it dropped with a thud. I used a pen to stroke up on the soles of his feet, unwittingly peeling up dead skin. Both big toes went up, a primitive reflex seen in newborns, a sign in adults of neurological devastation. Emma, his wife, had been keeping vigil for three weeks, spending most days (and some nights) on a small flower-patterned couch by the window. She was a pretty, muscular woman who, despite the tragedy unfolding before her, still managed to maintain a brave front embellished with lip gloss and eye shadow. "He is going to pull out of this," she had told me adamantly. "I have hope he is going to walk out of here." But by then there was virtually no hope for any sort of meaningful recovery. His blood pressure was starting to fluctuate. He had unexplained fevers. He was entering the downward spiral of the terminally ill, where competing problems grow in significance, where a solution to one problem causes another. "Did he ever express any wishes about intensive care?" I'd asked her. "About being on a respirator or life support?" "No, we never had that conversation," she answered, shaking her head sadly. "We joked once about a close friend who was sick, how we wanted to keep him alive, but that was just joking." Without a do-not-resuscitate (DNR) order, we were going to have to try to revive him if he had another cardiac arrest, a possibility we all dreaded. "I know you want him to get better," I told his wife that morning on rounds, trying to convince her again to sign the paper. "It is only human to want to see improvement, but the chances of him going back to the way he was are basically nil." It sounded harsh, even to me, and I was sorry I had to say it. I reminded her that he would soon require a tracheostomy, during which a breathing tube would have to be inserted externally into an incision in his throat just below his Adam's apple. We couldn't leave him with an oral breathing tube much longer without inviting serious complications. "Well, I am not agreeing to that right now," she said, waving off the suggestion. "And I am not going to make him DNR either. He just needs more time. All these medicines and antibiotics are making it harder for him to breathe--" "If we stop the antibiotics, he will die," I said sharply. "And he has been off sedatives for at least a week." "It's only been six days," she replied. "Last Sunday it looked like he was ready to go home with me." I had encountered such resistance many times in my career, when loved ones see only what they want to see. As in those cases, it was obvious to me that our efforts here were futile and that they were only going to make him end his life more miserably. "So you would want us to do CPR if his heart stopped?" I said, no longer trying to hide my disapproval. "Yes, of course," she replied, as though it were the most obvious thing in the world. "Give him the best possible chance to wake up, even if it's just to say goodbye." A nurse was seated in front of a computer monitor outside the room. "She would never do this if she had to pay for it," she snapped when I came outside. And though I cringed at her flippancy, she was probably right. Some of the wastefulness in hospitals, I'd learned, especially in intensive care units, is driven by families unable to let go. I sat down to pen a note while the team moved on. The nurse turned to me. "She doesn't understand his brain is mush and where he is going from here. We keep telling her, but she just looks at you with this blank stare." She turned back to the monitor and clicked the mouse. "God, I hate buying used cars!" she cried. Rounds lasted about three hours. By the time we were finished, there was a plan in place for all the patients. After leaving the unit to go to my office, I stopped by the cath lab to add a patient's name to the board. The cath suite, like most procedure rooms at the hospital, was shiny and new. Fluorescent lights created a zigzagging stream on the polished tile. Rajiv was sitting at a console in one of the control rooms, finishing up a report. Tapping on the keyboard, he spoke fawningly on the phone with a referring physician. "No, sir ... yes, sir ... okay, ji ... yes, boss ... no, Plavix is for six months only, boss ... okay, boss ... okay, boss ... thank you, boss ... thanks, boss." No doctor I'd ever met took the business of medicine more seriously than Rajiv. He was the ultimate rainmaker, taking referrals 24-7 from his vast network of physician friends. He viewed medicine on Long Island as a ruthless competition in which only the most adaptable and socially savvy would survive. He boasted that his success derived from the three A's: availability, accessibility, and affability (virtues, he claimed, that he'd learned from private practitioners and applied to his salaried hospital practice). He always carried his beeper, even when he wasn't on call. People could (and would) reach him at all hours. He even attended the notoriously dull Indian doctor parties. "I'm a prostitute," he once crowed. "I'm not ashamed; hell, I bring Vandana. I make her socialize with all the Indian ladies." His wife had smiled, a knowing, resigned smile. "I ask him, 'Just this weekend, can we have family time? Do we have to go to another party?' But he says it's good for business." After Rajiv hung up the phone, I gave him a quick update on his patients in the CCU. Ms. Wink had acute kidney injury, so we had decided to do a pharmacological stress test instead of a catheterization with potentially kidney-toxic dye. Mr. Lawner was whacked-out and noncompliant, plus, his family was loopy, so I had decided he should get no further testing. Ms. Sankar was a new patient with unstable angina. She needed to be catheterized that afternoon ... Before I could finish, Rajiv put his arm around me in an unexpected show of affection and gave the back of my neck a hard squeeze. "It's great seeing you every day," he said, beaming as I winced in pain. "I still can't believe you're here." * * * That afternoon, on 7-North, the cardiac ward, I quickly saw three CCU outliers, patients who had been stabilized and no longer required intensive monitoring. When I sat down to write my notes, it was almost 3:30 p.m. How limited our interactions with patients, I thought. We see them for a few minutes, then pen a quick summary and leave directions for the nurses to follow. To whom are we speaking in these inky chart drizzles? Doctors, patients, a phantom lawyer ("I spoke with the patient at length, but he is still refusing...")? Or perhaps we are just talking to ourselves, regurgitating the patient's history to create a tidy narrative. The audience shifts, patient to patient, note to note, even sentence to sentence. At four o'clock, while I was finishing up my last note, Ethan, the CCU fellow, paged me. "Mr. Richardson just dropped his pressure," he said nervously about the brain-damaged patient in the CCU. "I tried going up on the Levophed and the Neo-Sinephrine, but it didn't work. When I turned on vasopressin, his pressure dropped even more." I thought for a moment. This was the kind of situation I'd feared most as an attending, when I had to respond almost reflexively. (And how hard should I try to save a severely brain-damaged patient anyway?) All the medications Ethan had mentioned had half-lives, so it was hard to know how to interpret the results. "I would back off on the vaso," I said carefully. "Just start some dobutamine at 2.5 micrograms per kilogram per minute. I'll be there in a couple of minutes. Did you call the wife?" "I got through to her a few minutes ago," he replied. "I told her to come right away." When I arrived back in the CCU, the code had already begun. A group of doctors and nurses were at the bedside. The rhythm on the monitor was ventricular fibrillation, random electrical oscillations. An intern was doing chest compressions. Saline was running wide open through an IV. Defibrillator pads adhered to Richardson's hairy chest. His body jerked up and down with every administered shock. Because his heart had effectively stopped, his lungs had filled up with pink, frothy liquid, mostly blood plasma, like beaten-up Jell-O, which came up through his breathing tube. The compressions sent the nurses scrambling for face masks and yellow gowns to protect themselves from the red spray. "This is a conspiracy to prevent me from getting my afternoon coffee," quipped a doctor who had shown up to help. I chuckled at the wry shoptalk. After a couple of adrenaline injections, Mr. Richardson regained a pulse; but it immediately started to die down, and within a few minutes it disappeared. It seemed his body had finally given up. The sequence continued: shocks, chest compressions, and drugs. He got four doses of adrenaline at 1 milligram each, then 5 milligrams, then 10, but the pulse did not return. He received several ampoules of sodium bicarbonate. By then he was blue in the face, a sickening color, like an old hematoma. We continued CPR while I called for an echo machine, which takes ultrasound pictures of the heart. "Let's take a quick peek before we call it," I said. When the machine was wheeled in, I pulled the window shades closed and applied the ultrasound probe to his chest. The heart was in standstill, hazy clots filling the ventricles. I pressed a button to take a picture. The room was quiet as I pronounced him dead. Gowns and masks were stuffed into a trash bin, and people started filing out of the room. Then a strange thing happened. My gloved fingertips, soaked with blood on his pulseless groin, started to vibrate. Wait, I ordered the group. In the Bible, Lazarus is raised from the dead by Jesus. In medicine, Lazarus is the patient who, believed dead, spontaneously starts to circulate blood. About forty cases of the Lazarus phenomenon, a number that experts believe is too small to be valid, have been reported in the medical literature. (I have seen at least three cases in my own career.) Though most patients died soon after the event, in eight cases they left the hospital, neurological functions intact. The cases share a kind of morbidity: A man, eighty, is pronounced dead after thirty minutes of CPR. His doctor showers and returns five minutes later to find his patient has a pulse. A man, eighty-four, goes into cardiac arrest while biking. After fifteen minutes of CPR he is pronounced dead and taken to a mortuary, where attendants see him breathing. A woman, sixty-eight, suffers a heart attack and goes into prolonged cardiac arrest. Removed from her ventilator, she is taken to a separate room, where about twenty minutes later a nurse notes she is breathing and moving under the sheet. She is discharged from the hospital and dies three months later in her sleep. Why are certain deaths "reversible"? The phenomenon remains a mystery. Some have speculated that cessation of CPR decreases pressure in the chest cavity, allowing blood to return to the heart. In 1993 a doctor described the Lazarus phenomenon in a seventy-five-year-old man with a lung hemorrhage. "How [increased blood return] would stimulate the completely quiescent myocardium ... is not readily apparent," he wrote. "There had been no electrical cardiac activity ... for several minutes at the time the efforts were terminated. This situation spontaneously reversed." There is even a kind of Lazarus phenomenon that has been described in brain-dead patients who make spontaneous movements after they are disconnected from ventilators. Patients have been observed to develop goose bumps on their arms and trunk, raise and flex their arms rapidly, and display complex finger movements. A doctor described one patient raising his arms off the bed and extending his elbows, as if performing a benediction, and another crossing his hands in front of his neck, as if grasping for his breathing tube. These movements sometimes occur despite no measurable blood flow to the brain. Some doctors speculate they are generated in the spinal cord. However, as with most Lazarus patients, Mr. Richardson's awakening was short-lived. After about five minutes his pulse disappeared, and despite a few more doses of adrenaline, it never returned. He was pronounced dead a second time after about ten minutes. I found his wife sitting in the waiting room. She looked up when I walked in. "Is it over?" she asked. "Yes," I replied. "Did he die?" I put my arm around her. She began to cry. "I'm sorry," I said. As I drove home that night around eight, Long Island Sound was pitch-black, apart from the glimmering reflection of light poles. Fat rain droplets, like little eggs, started to splatter on my windshield, smearing with each sway of the wipers. In the distance the fractured skyline of the city stood out like shards of glass. Though I was physically exhausted, my mind was filled with the heady, mysterious events of the day. What had restarted Mr. Richardson's heart? Was it the delayed action of adrenaline? Was it the bicarbonate? Was it something else? In Harlem the roads shimmered shiny black. Red taillights winked at me through the watery haze. Police sirens were sounding out loudly. On 116th Street, dented low riders slinked by, windows open, music blaring. My headlights caught a lonely figure under the elevated train tracks. I called Sonia to tell her that I was almost home. "How did Lamaze go?" I asked. Regrettably, I had missed it again this week. There was silence. "Honey?" I heard sobs. "We need to talk," she finally said, composing herself. "Dr. Edwards just called. She thinks the baby is in danger. She says I need a C-section before she goes on vacation next week." Copyright © 2014 by Sandeep Jauhar Excerpted from Doctored: The Disillusionment of an American Physician by Sandeep Jauhar All rights reserved by the original copyright owners. Excerpts are provided for display purposes only and may not be reproduced, reprinted or distributed without the written permission of the publisher.
