Alpha Docs (8 page)

Rounding with him is like watching a virtuoso. Dr. Martin instructs more by example than by lessons, and his method is so low-key that it takes a while to realize that he is pulling the invisible puppet strings, gently guiding residents or Fellows to the right assumptions and decisions. But his strongest suit is his bedside manner. Communicating with patients and families is sometimes taken for granted in the high-tech world of today's medicine, but it's even more critical when the science involved can be so intimidating. Every doctor has to talk to families in sensitive situations. Most do it passably. Some overdo it and come across as too sensitive, over the top, like a bad movie actor. Some flip a switch—time to be sincere—and recite the script. But patients and families usually can tell the difference. Dr. Martin simply knows how to talk to people. He relates to the patients and their families, connecting with each one in a way that makes them all feel comfortable, no matter how dire the situation.

Case in point: I am at home late on Tuesday night when I get a call from the on-call resident about a patient coming into the CICU from the emergency room. Mr. Werdna, a retired plumber in his midsixties, was discovered by his wife, unresponsive, on the kitchen floor. When the ambulance arrived, the EMTs found the patient with no pulse, no gauge of how long he'd been down, without critical life signs, and with no apparent cause for the problem. The team intubated him “in the field”—that is, at home—and brought him to the nearest hospital: Bayview.

On the drive back to the hospital, I piece together what might have happened in order to get a sense of our options. Mr. Werdna may have had a primary cardiac arrest, which could have caused the loss of heart rate and drop in blood pressure. Or he might have had secondary arrest, due to a noncardiac event such as a seizure or stroke. In either case, during a critical time period, his heart was not delivering blood to vital organs, including his brain, and that may have done irreversible damage to one or more of those organs.

By the time I get to the hospital, his blood pressure and heart rate are improving. The twin goals are to keep him stable, with his systems running, and to put together a plan for his potential recovery. To try to fill in the blanks, I speak to his wife by phone. Mrs. Werdna is older than her husband by a good ten years, in her midseventies, evidently with poor vision and health issues of her own. In a shaky voice, she re-creates finding him, trying to rouse him, calling 911, the EMTs putting the tube in, and taking him away. She tells me he'd had a previous heart attack, and had been complaining of being tired the last few days but otherwise seemed all right. I try to convey the gravity of the situation to her, but over the phone there are no physical cues, so I can't tell if she understood or if she was still in denial or shock. I ask her to come in for a meeting, to prepare for what may be a negative outcome. Vulnerable families can't be expected to absorb an inundation of medicalspeak, so I put it in the plainest language I could: “He's our sickest patient in the cardiac intensive care unit.” She says she will come in the next morning.

I stay overnight, help put in the central line and the arterial line, and get two hours of sleep in the on-call room. By morning I'm not looking or feeling too fresh, and I am in need of a shower and clean clothes. But I'm in no position to complain; the important thing is that we have managed to stabilize Mr. Werdna and that he is showing small signs of improvement. His blood work is improving, his kidney function gets better, and his elevated liver enzymes start to drop. His heart does not seem to have sustained catastrophic damage, which suggests that perhaps it wasn't his heart but possibly a seizure, some kind of aspiration, or a major neurologic event such as a stroke that caused his collapse.

There are less promising signs, though. Mr. Werdna is on a breathing machine without sedation. Normally, being on a breathing machine is both unnatural and uncomfortable. Having a tube in your throat is a decidedly unpleasant sensation; many patients thrash or open their eyes when they are intubated, necessitating the administration of sedatives for safety and comfort. But Mr. Werdna is showing no such physical responses—no jerking motions, nothing. And he has a continually low heart rate. This suggests that he might have an anoxic brain injury, which occurs when oxygen flow stops, starving the brain so it fails to perform. Hypoxic is partial oxygen deprivation; anoxic is total deprivation. The greater the deprivation, the worse the damage is to the brain, including potentially permanent loss of cognitive and physical skills. Recovery is possible but is determined by the brain parts affected, unpredictable at best, particularly at these early stages.

Dr. Martin comes in, and as the resident presents the case, I scrawl a little drawing on a scrap of paper. At the end, Dr. Martin asks what I think we should do. I hold up my rudimentary sketch of the brain. He nods. We aren't being irreverent. It's a picture of the situation; nothing else takes priority over the brain. And all of Mr. Werdna's organs seem to be recovering except his brain. I walk the team through a plan for the next twenty-four to forty-eight hours, explaining to the resident and the nurses that we have what appears to be perhaps an irreversible brain injury. Our job is to keep the brain alive and to give it its best chance at recovery under admittedly challenging medical circumstances. The other organs are secondary concerns at this point.

Afterward, I explain to Dr. Martin that I'd called the patient's wife the night before to set up a meeting for today; he agrees to join us. I meet Mrs. Werdna by the unit desk when she and her neighbors, who drove her, come in. I recognize her immediately—something about the catch in her gait, an older demeanor, and a frail voice. I go up to her, and her first question—“Is he getting better yet?”—makes it plain that she didn't fully comprehend our phone conversation. This makes a sit-down meeting—before she sees him with a tube in his lungs, IVs, a central line in his neck, electrodes on his scalp to monitor seizures—even more crucial. As I walk her down the hall, I make a combined medical and “neighborhood” diagnosis of how to deal with the situation. It isn't prejudice or gut; it's science. We turn into a small conference room and sit.

In the room are Dr. Martin and the CICU nurse, along with Mrs. Werdna, her neighbors, and me. I begin, “Mrs. Werdna, when we talked last night, I threw a lot of information at you, so I think we should go over it.” I can tell she doesn't want to hear it; she knows it's bad. Meanwhile, Dr. Martin is watching me to see how I handle it. He mentioned before the meeting that he wanted me to start by setting the stage very realistically. Mrs. Werdna's husband is not likely to recover. With severe neurologic injury, the best he can hope for is to remain on life support for a few days. She's trembling, and I start to worry that she may fall apart. I go slowly, but not too slowly, because I don't want to drag it out. “Your husband is very sick, critically ill.” I let my words sink in and then say, “We're providing him with life support right now. When you see him, he's going to be hooked up to a lot of equipment.” I purposely use terms such as
critically ill
and
life support,
and I look for comprehension in her face.

In fact, Mr. Werdna had not suffered a massive heart attack (as his cardiac enzymes have returned to normal levels). The unhappy truth is that Mr. Werdna's body and brain had already begun to die on the kitchen floor, a process that was interrupted only temporarily by the paramedics. The body has remarkable resilience, an ability to recover in almost every organ system—lungs, kidneys, liver, even the heart. The one organ that begins to die quickly, with little chance of bouncing back, is the brain. And blood flow to Mr. Werdna's brain had been cut off for five or more minutes—the danger zone.

When his wife asks, “Is he awake at all?” I know she's beginning to understand. I tell her, no, he probably won't know that she's in the room. Then she asks the inevitable—what happened and why. What did I do? He was fine two days ago. What should I have done? The bottom line is, we don't really know. I tell her, “What we know, based on the testing in the last eighteen hours, is that he's a man with serious medical problems, and people like that can get very sick, very quickly.” More important, I add, “Sometimes there aren't clear warning signs. You didn't miss something. It isn't your fault.” Dealing with the likelihood of his death is enough; there's no reason she should be blaming herself. Her friends listen and hold her hands. Though only in their fifties, they aren't pictures of health themselves. Mrs. Werdna's support team seems as weak as she is, gathered for a vigil over the one who'd, at least to them, seemed the strongest.

Dr. Martin, who has been quietly monitoring the scene, leans forward now and looks at Mrs. Werdna. “Sweetheart, how are you holding up?” Her face says, “As well as I can.” He goes on: “I have to tell you, we doctors are not miracle workers. There are some questions we don't know the answers to.” With these plain phrases, he resets her expectation levels to reality. We don't have all the answers. Sometimes there are no answers. He then reiterates the medical plan. “As Dr. Muñoz said, at this point we're most concerned with his brain because he went too long a time without oxygen to the brain.” The choice of words, “too long,” was again simple but strong, perfect communication, so subtle an outsider might miss it. The last thing we want to do is provide false hope, nor should we label a tragedy prematurely.

I'm taking mental notes on every nuance. This is not something med school, residencies, or fellowships necessarily teach. Our time is filled cramming knowledge and experience into us, and little is left for human subtleties. We're supposed to pick them up on our own, which means that some people never do. I've seen academically brilliant colleagues who talk to patients and families as if they were spouting data into a digital recorder. “This is stage IV melanoma. There are treatments but no cure. Expected survival is from four to thirteen months….” Arguably, it cannot be taught. Either you're someone who is sensitive to people or you aren't. That's why when you come across a Dr. Martin, you know you should pay attention. We're here to treat people, not charts.

Mrs. Werdna asks Dr. Martin if her husband is in pain. He leans in, speaks softly, slowly, and compassionately, and puts his hand on hers. “I can tell you, he is not. Your pain is far greater than the pain he feels. I know you hurt right now.” Her husband is not suffering. Because his brain is not working properly, it will not allow him to sense pain. Dr. Martin conveyed all that without relying on cold medical words. I am blown away. I've never heard another doctor communicate this way.

Mrs. Werdna looks at Dr. Martin and gets teary but doesn't break down: She is physically frail, but rock solid in character. Then she says something that I've heard before, but that always amazes me. She thanks us. We've just told her that her husband is hanging on to life by a kite string, and that his brain has likely already let go. But she says, “Thank you all for everything you're doing for him. He couldn't be in better hands.” Families invest their confidence in our medical knowledge, but evaluate us on our ability to connect. If you can connect, you're a good doctor. If you can't, you aren't. It isn't rational, but it's not crazy either. Oftentimes, patients and family members can gauge only the human elements. Do you hear me? Can you feel my distress? Do you care? Mrs. Werdna says she and her husband couldn't be in better hands, an opinion that is largely based on Dr. Martin's communication skills, not actual proof of his clinical ability. In theory, we could all be mediocre. But that's what a lot of good medicine is about—reaching the patient or family so you can practice good medicine. If the adage “Ninety-five percent of success is showing up” is true, the medical corollary is, “Ninety-five percent of being a good doctor is the ability to look the patient in the eye.” I am not ashamed to say I will try to memorize what Dr. Martin said, how he said it, his pauses, even his facial expressions. He is a master at this, and this is one of the most indelible lessons of my career.

After the meeting, we guide Mrs. Werdna and her friends to her husband's room. Dr. Martin backs out: “I want to give you time to yourselves. We're just down the hall outside if you need anything.” She sits by her husband, but in reality, she's alone. He's not there anymore. I stay a few more minutes, then leave. An hour later, I see the neighbors escort her out.

At the next meeting about Mr. Werdna, I set the plan. We'll wait a day on the remote chance things might improve, but our next meeting with Mrs. Werdna will almost inevitably involve telling her that her husband isn't going to make it. Dr. Martin says only, “Sadly, I agree,” which surprises me a bit. From someone as understated as he is, that brief comment is a vote of confidence.

In the ensuing hours, Mr. Werdna's organ systems improve but his brain does not. He's just not waking up, although he occasionally exhibits jerking, seizure-like movements, episodes that are understandably troubling and confusing to his family. We speak to the neurologists involved to help manage these sporadic movements, but they are most likely the result of faulty electrical firings in his injured brain. It's now Thursday, two and a half days after Mr. Werdna was admitted. He displays no primitive reflexes, but he is not technically “brain-dead.” His brain waves have not flatlined. His jerking motions show up as little blips on his EEG (electroencephalogram). But his chances for recovery are as close to zero as you can get. All of this brings up another major medical dilemma: At what point does keeping a patient alive because there is a very small chance then cross over into keeping the patient alive when there is no hope? There isn't a specific moment in time—say, day two at 11:15 in the morning—when a patient's fate is sealed. There's no test that says, as of right now the brain will never recover. The judgment isn't black-and-white; it evolves from gray.