Читать книгу My Crescent Moon (A Collection of Short Stories) - Joseph Dylan - Страница 4

Coming from a long line of physicians, Barry Krakauer truly believed he had no other calling in this world than being a doctor. To him, it was his entitlement. Krakauer never quite admitted that to me when he was a third year resident in internal medicine at the University of New Mexico when I was a lowly medical intern, enduring my first month on the wards. But he implied it. One could sense it in him. Our medical team comprised of Laura Fairchild, who was the other intern, and three third year medical students doing their internal medical rotation. The first night that we – our medical team – was together on call, he exuded that very arrogance. From the cafeteria staff, we had been served the infamous white-on-white meals that the Albuquerque VA Hospital was notorious for: Tough, chewy turkey with white gravy, combined with soy beans and mash potatoes. Thinking of Gerber’s baby food, I gagged every time I tried to take a bite. I started to gag just thinking about it. I set my tray aside. Everyone in their turn did likewise. With such animal fodder, how were any of the patients supposed to get better. I listened as Krakauer rambled on. Given Krakauer’s rambling spiel, I think that Laura Fairchild, and the three medical students were also growing weary of it. Still he rattled on about how his father had gone to Hopkins and then practiced in the older section of Baltimore for his entire career. His father’s father, too, it seemed was a Hopkin’s man. Both practiced in the impoverished parts of Baltimore down by the docks where the North Baltimore Street served as an asphalt embrasure separating the whites of the city from the black denizens of the metropolis. Though the whites never crossed the boundary of this sanctuary, especially at night, his grandfather and father freely crossed into the black section of Baltimore for the blacks respected them, their profession, their care. Never were they molested or harmed. At least that was what Barry related to us while I wondered what I was going to do for dinner. If Krakauer had any reservations about going into medicine, he told us, it was simply that he didn’t feel like working as hard as they did. He didn’t want to feel like he was on call for the rest of the days of his life. Later, as I was to learn, no one who had spent anytime with Krakauer, were spared his disquisitions.

As he spoke, never once asking us where we had gone to medical school or where we were from, my stomach growled, while he kept the crowd enthralled with his own exploits. I simmered in indignation. I had been at the hospital before seven in the morning, trying to catch up on the students I was to inherit from the previous intern. I had a sandwich at the noon lunch conference, provided by one of drug company detail men, and hadn’t eaten since. It was now half past six. That first meal with the man, I kept wondering how I could keep up with the ongoing onslaught of patients, who wandered or were carried into the emergency room as if participating in some perverse, pathetic parade. All this while I fretted over some of the real sick patients belonging to the other medical interns on the other medical teams. And still Barry continued on in this vein, He ended it with the tale on how he ended up in Albuquerque in the Internal Medicine Program at the University of New Mexico. While an intern, I was in desperate straits for certain primal, needs, and I didn’t need the chutzpah of Krakauer’s rambling buzzing in the background.

None of the others seemed to have any heartier an appetite for the VA food. We all, in short fashion, got up, headed back to elevator and deposited our scarcely touched trays in the scullery of the cafeteria in the basement. Having done so, I went over to the vending machines and having put my quarters in the vending machines; they surrendered two Mars bars and one Coca-cola, while taking one of my quarters. So much for tonight’s fare. I would have to start making sandwiches to get through my ward rotations at the VA hospital. While collectively leaving the cafeteria, Barry was beeped again to the ER. He turned to me. “You’re on the bubble, Covington,” he said. I kept thinking of all of the things I needed to do on my nine patients on the floor, as well as the one in the ICU who had been admitted with a heart attack, who at the time was dropping his blood pressure. Meanwhile, I kept getting called over problems with the patients who had been signed out to me by the other medical interns. “What do I do with Jenkins?” I asked Krakauer. He was a difficult, very sick patient, septic with pneumonia, that Jerry Swerdlow signed out to me not yet an hour ago. Like Jenkins, the man with the heart attack, Marquardt was dropping his blood pressure in the ICU. To add to all that, Juan Garcia, a man never too far from a bottle, was bleeding into his gastrointestinal tract, the end result of years of drinking. He was my second admission to the intensive care unit.

“Did you read my note?” he replied. “It’s all in there.”

“I read your note, and I still don’t know what I’m supposed to do about his GI bleeding.”

“Read my note.” He began talking about how he missed the seafood of Maryland. For my first resident I had been dealt a real joker. “I’ll tell you what was in the note this time: notify the gastroenterologist on call. Have him take a look.”

“You know he’s vomited about half a liter of blood?”

“Keep his hemoglobin somewhere about seven or eight. Does that make you happy?” The GI department generally let an ulcer bleed down to a hemoglobin down to seven before they became unduly concerned. I had the foresight to transfuse him with two units of packed red blood cells, and I informed the lab to keep six units ahead. Juan was exsanguinating from eroding blood vessels in his esophagus; vessels that became engorged because his liver was cirrhotic.

Far from enlightening me regarding any new information, I nodded my head and took the stairs up to the ICU. Krakauer was going to be my cross to bear for the month. It was going to be a long night, a night in early July. “Have you checked his hemoglobin lately?” I heard Barry say behind me. I didn’t deign to answer him. He could read the chart. “Have you checked it lately?” he was storming up the stairs after me.

“I had them run one before we went down to dinner,” I said when pressed by Krakauer.

“Like I said, just keep it above seven. And call the gastroenterologist.”

That was about as much support from Krakauer as I had for the rest of the night. I felt like the engineer on a train running out of control that would convey me to the next world.

I had the temerity to ask him a question about another patient in the unit. His name was Tom Baker, an old smoker who had pneumonia in both lungs. He belonged to Dawn Fleming, another internal medicine intern. I was covering for her tonight. Baker happened to be the sickest patient on her medical team’s service. No sooner had she signed out to me, than his blood pressure bottomed out. “What should I do with Baker. He’s still spiking a fever and his oxygen saturation keeps dropping. Baker had me worried during the dinner we never ate, worrying about him while Krakauer was reminisced about Baltimore. Krakauer, of medium height but with long legs, was taking the steps two at a time.

“Should I change his antibiotics. If I do, what should I put him on?” I asked. Though having my medical degree for little more than a month, I doubted that Jenkins was going to make it out of the hospital – at least that was what my intuition was telling me – and I was scared to death that I was going to screw up. That pretty well encapsulated my feelings my first night on call – I was going to screw up and kill somebody.

“Read the resident and intern’s note. Then assess the patient. If you still don’t know what to do, call me. But have all your ducks in a row when you do Don’t waste my time.”

“I already called the ID resident on call. He wasn’t exactly helpful.”

“Look, Covington, if you want to make it through residency learn to read notes and call the appropriate subspecialist. Don’t be the weak sister.”

“Hey, wait a minute, mister. I’m a woman,” said Fairchild, “and I resent that.” She was marching up to the ICU with us, which was on the third floor of the old VA hospital, the cafeteria being in the basement.

“You go see Jenkins first, and I’ll give you a call when I get this admission sorted out. And for God’s sake.…”

“Read my note,” I added. Not since Lincoln addressed those at Gettysburg had a missive conveyed such import. So I headed to the medicine ward. Up on the wards as a brand new intern, it seemed like a trip to the haunted house at the traveling fair, with all the nurses coming up and asking questions on their patients and my beeper going off every few minutes. Trying to do everything that I had to do, I knew that Krakauer was in the emergency room seeing my next admission, another patient to take up a couple hours of my time.

Traditionally, when a patient presents to the emergency room, he is seen by the ER doctor who treats him, or decides he needs to be admitted to the hospital. If the ER physician decides the patient needs to come into the hospital, he notifies the resident of the medical team on call. Presumably, the ER doctor has obtained all the admitting laboratory tests, as well as the attendant EKG and chest X-ray. If the patient needs to be admitted, he beeps the resident on the admitting internal medicine team, who then goes down to see the patient in the emergency room. Once seen and written up by the resident, the resident calls the medical intern who is given the admission. From that point on, the intern owns the patient. Therapeutic measures, orders, and consultations all go through the intern. The intern, in picking up the patient, is responsible for all admission orders, his care on the ward or the intensive care unit, and – if the patient’s stars are still in a favorable alignment – his discharge home. If things don’t go according to plans; well, then – they drop like flies at the VA hospital from the vagaries of their illnesses or the corruption of the system. The scarcely consolable families ship the bodies of their loved ones back to Roswell or Clovis, Hobbs or Socorro, or other settlements scattered throughout New Mexico and the Four Corners region.

How I made it through that first day and night of dire and fright, I’ll never know. It was the most terrifying and taxing job I had ever performed. Admissions swarmed in like the Thoroughbreds at Pimlico. And I was the one standing in the middle of the finish line. I didn’t even touch the bed in the call room that first night. When I’d go down to the ER to meet Barry and see about an admission, I always had a question for him. He’d invariably turn to me and say, “It’s in my note.” But often it wasn’t. Krakauer was in no mood to answer any further questions.

Linda Fairchild, my cohort on the medicine team, was a striking woman, whose beauty was only surpassed by her exemplar knowledge of medicine for an intern, I’d turn to for advice. Then he’d slip out of the chaotic emergency room to go and see how the patients that Fairchild and I had admitted were doing. Linda had a winsome face and a pert body, and it wasn’t hard to figure out just which intern Barry was going to help more that night.

Once, about three in the morning, I passed Laura coming of the ICU as I was going in.

“How you holding up, Bill?”

“Read my note,” I replied. She laughed.

“Only if you read mine,” she retorted. “Where’s our resident extrodinaire? I had a question for him. And It wasn’t in his note.”

“The last I saw, he was flirting with the nurses in the emergency room.”

“I should have known,” she replied laughing again.

“Me, too. I come from a long line of slow learners.”

I took a short break, it was four-thirty in the morning. I still had one patient to finish working up, but I strolled out onto the roof of the hospital. I wanted to count the cobwebs connecting the constellations. I needed a breath of fresh air, cool, fresh air to rejuvenate me and catch my breath. Perhaps looking at them would guide me with some of the patients, help me in a way that Barry didn’t seem disposed to do. A nearly full waning moon was dissolving in the west horizon, but the pole star still shone. It shone where it was supposed to shine. I drank a Dixie cup coffee of coffee while I ate a Three Musketeers Bar. No sooner had I finished the coffee, than my beeper buzzed. The extension seeking me in my tiny universe was one in the emergency room.

But both Laura and I got through that first night on call. And the year proceeded apace, nothing without its miseries or woes: gradually, so gradually, it got easier to do as the long hours wore upon us like an old, broken record. So it must be the same for the thousands of internal medicine residents across the country in teaching hospitals every night of the year. But that month with Krakauer left a bitter taste with me, both for Krakauer and for residencies in general. Still, it was the hardest work I’d ever done. But Krakauer. Of all the residents I worked with, I detested him the most. There were times I be in the emergency room when Krakauer was there, that I’d see him arguing petulantly with the ER doctor on call in the emergency department whether the patient required inpatient treatment. By the sheer chance of irony, many of the New Mexico veterans had made and survived the Bataan Death March. They might have made it through the barbarous treatment of the Japanese, but they might not make it past the emergency room on a night when Barry Krakauer was the admitting resident. Or he would argue that the patient needed to be admitted to orthopedics or general surgery. Once he turned to me that first month, when we were admitted a COPD patient who was fighting to stay off the ventilator, “Covington, when a patient comes in the emergency room, they’ve got to show me that they really need to be in the hospital.”

On rounds, during that first month on the ward while Barry was my resident, he always seemed to see trouble coming before I did, and the minute he saw smoke on the horizon, he’d subtly stand out of the way. Once I didn’t know the blood count of a patient who had a bleeding ulcer after we transfused him. Barry took a step away from me as Mark Armstrong, our attending physician, asked me that very question. Things had been so fast and crazy, I hadn’t the time to obtain in the lab. Barry burst in. “It was 30.5%,” he replied, making me look both stupid and inept. I hated him for it, nursing my feelings close to my heart, adding that much more contempt that I had for the man. That hatred for the man is tattooed to my soul.

During that long first year, my feeling toward Krakauer I found were shared by many of the other residents. Krakauer’s sense of self-entitlement that grated most on his fellow house staff members. Neither did his narcissism nor his manipulative ways endear Krakauer to his fellow house staff members. There was more than a trace laxness and fecklessness in the way that Krakauer conducted his professional life. If Barry could slough an admission off upon another resident, he never hesitated to do it. None this was lost on the rest of the residents of the internal medicine department. None of it was lost on the residents in other specialists when Barry dumped a patient on them. He was not liked.

Picturing himself as a ladies man, with his hair of long black curls, a nose like a Russian wolfhound, his thin lips, and his lean frame he appeared to me like Long John Silver, readying to pirate a ship in calm water. Not every pirate sails the seas. But the women did seem to chase him, something of stupefying surprise to me, though in time, most of them recognized him for the sleaze he was. One modus operandi he used was to provide a shoulder to cry on when some nurse or resident had just been dumped by their boyfriend. During my internship year, there was an especially beautiful second year resident. She had moved to Albuquerque for her residency in internal medicine with her boyfriend, a well-known journalist, in tow. Coming off call one evening when she was still an intern, she found all her belongings strewn out on boxes on the cement patio in front of the main door of their house. That was the first and only notice that their relationships was over. Who was there but Barry when she needed a shoulder to cry on. And healing for Bruce was total only when it was in the Biblical Sense too. Every time I saw him after that, I could hear the soulful warbling of Marvin Gaye singing “Sexual Healing.” Proud of the fact, Krakauer circulated the story within the residency group. Chagrined, she regretted her intimacy with Krakauer for the rest of her residency. No longer would she even say “hello” to Barry in the hallways. Whereas Krakauer thought he was just ministering to the sick and needy in his satyric ministrations, he couldn’t understand the animosity that many of the women in the medical center held for him. Who could blame her?

As Krakauer was a third year resident when I was an intern, it was good to know that it was his final year in the program and I wouldn’t have to deal with him anymore when the year was up. But Barry surprised me. He surprised all of us. Instead of Barry disappearing, receding from our life like a conscientious butler – something that was too much to hope for – he became ever more entangled in it. Rather than going off and doing a fellowship, or going into private practice, he talked himself into a job in the emergency room first at the Albuquerque VA Hospital and then, finally, at the UNM Medical Center. He was living proof of the Peter Principle. There was a certain irony to it: where he had argued so much in the past with other ER attendings whether a patient had to be admitted, he was now admitting patients to the various services of the two hospitals. “I believe I have to have a good reason not to admit a patient to the hospital when they come in the emergency room. They’ve got to prove to me that they can go home.” The first time he pulled that one on me when I was an admitting resident, I reminded him of what he had said when I was an intern and he was the admitting resident. He denied making the statement. But the other residents remembered. Not a few of them called him on it when he tried to admit someone who truly didn’t need it. While he worked in the emergency room, he invariably wore surgical scrubs, the V-necked tops amply showing off his chest hair and his gold necklaces, with a white lab coat and his Littmann Cardiac Stethoscope draped around his neck. But he was still a fuck-up. One night when I was on call, he beeped me to admit a Navajo grandmother. Like many of her tribe, she was diabetic and hypertensive. Unfortunately, she spoke no English. But her daughter, who was with her, did speak English. She had shigellosis, having diarrhea for the last three or four days. Krakauer seemed to be proud of himself for finding the bacteria under a microscope. He had shown the slide on the microscope in the lab to the medical students who were in the emergency room that night and the ER residents. What he didn’t do, though, was take a thorough history. What was bothering her worse than the diarrhea was the chest pain she’d developed yesterday. To Krakauer’s chagrin, the EKG revealed tombstones across the precordial leads, evidence that she’d had a heart attack. Her cardiac enzymes almost reached a thousand. What would Sir William Osler have to say. I worried for the citizens of Albuquerque the nights he was in the emergency room. Barry circumvented some of my worries: contacting the resident on call for any speciality, he essentially shifted the responsibility to their shoulders. This infuriated me as much as anything. It proved how spineless he truly was.

During the second two years of my residency, I went out of my way to avoid Barry Krakauer. I dreaded the nights I was on call when Krakauer was in the emergency room. While the other emergency room attendings pulled their weight, Barry always seem to be more interested in any new nurses or residents he wanted to know better, or, in the winter, how the skiing was on Sandia Crest or in Santa Fe, a long hour away. When he I was down in the emergency room admitting a patient, he had not adequately worked up, I watched as Barry orchestrated the patient flow in the emergency room. As they wheeled one inebriated patient in asleep on a gurney, Barry said to me, “It looks like he’s going to need to come in, too.”

“Work him up, Barry. Then give me a call.”

That was Barry. The winds had changed. Those were, as my religious mother would say, “Saint Jude” nights, when one just have to pray for deliverance. When I saw on my calendar that I was due to be on with Barry in the ER, I’d just groan. And I’d slip the medallion of St. Jude she’d given me in my pack. Those nights, one of Barry’s girlfriends would drop him off at the emergency room entrance. He’d already be in his surgical scrubs. I’d go to bed early the nights before I knew that I’d be paired with him. Once Barry came on, I knew he’d repeatedly call me about patients who didn’t really need to come into the hospital; when they came into the hospital, he’d never have their story really together. Unlike the maxim he had given me when I was his intern: “He never had his ducks in a row.” Not infrequently, he’d never have done the appropriate work-up of their condition, nor would he have begun any basic treatment for it. Barry Krakauer, Talk show host and emergency room attending. Frankly, had I been Barry Krakauer I would’ve been embarrassed had my internal medicine skills as Barry’s had, to the point where they were at best tenuous when he had a medicine patient in the emergency room. He got to the point where he’d call one of the internal medicine residents down to the ER to interpret an EKGs that eluded his comprehension. Barry, having gone through the same medicine residency, was even more qualified to read them since he had become board certified in internal medicine. That was the way Barry got by: making someone else do his work. Things there were even busier than they were at the VA, and I dreaded to see his number come up on my beeper whenever I was on call as a second and third year resident. I never forgave him for the was he always made someone else take the blame for one of his misadventures.

Finally, on a godforsaken early spring night that brought rain and wind, thunder and lightning, towards the end of my second year in the program, he called me down to admit a man with alcoholic hepatitis. It was to the VA’s ER, which was much quieter than the ER at UNM. Normally, the resident of the medicine teams would go down to the emergency room by themselves to see the patient first before turning them over to their interns. When I descended to the emergency room, it must have been just after midnight. The ER seemed empty. There was a clerk at the check-in desk, but there were no nurses around and I didn’t see Krakauer among the gurneys, which were all empty except for the bed where the patient I was to admit was sleeping, life sucked out from under him after all the sedatives he’d received. I went over to the call room, which was in the back of the emergency department, down a long hallway. I slowly approached the call room. Emanating from it, I heard a girl giggling. I knocked on the door. That precipitated some quick scurrying in the call room. I heard whispers along with the sound of clothes being donned rapidly. “Barry?”

“Just a minute.”

“Barry?”

The door jarred open. It opened just a crack. Barry was putting on his scrub top; he had his bottoms on. In the thin cotton scrubs, it was impossible to avoid noticing his his erection. Behind him, I thought I saw something move. “Look, why don’t you go start seeing your patient. I’ll be right with you.” And so I did. I gleaned what I could from the ER chart and the patient’s old records. Finally, minutes later, Barry emerged from the emergency doctor’s call room more like a bear interrupted in hibernation, than a buck elk interrupted in coitus. “Just what didn’t you understand?” he said as he bent over the desk where I was gleaning the information from the notes of the ambulance crew, the nurses, and, lastly, from Barry. “I think I got it Barry.”

Finally, Barry was at my side. “His wife had the ambulance bring him in. Said he was on a bender for the past two weeks.” Then I could see the ER nurse scuttling along the nurse’s station. Though Barry was not blushing as the ER nurse was, there were dewdrops of sweat gathering at his hairline. Neither did she bother to look at me nor did she say anything. “He was pretty agitated. I’d given him thirty milligrams of lorazepam more.

“No seizures, no hallucinations, no gastrointestinal bleeding?”

“Not to my knowledge.”

“Well, yes or no?”

“No.”

“Are you sure?”

I looked through his labs. Barry this time had done more of an adequate work-up than he usually did; what he hadn’t done was find a good excuse to put him in the hospital. Except for his liver enzymes being slightly elevated, nothing else was amiss. His chest X-ray was normal, his EKG displayed no abnormalities; even his stool didn’t have any blood. “What do you want me to admit him for?” Normally, mild alcoholic hepatitis can be handled as an outpatient on sedative agents like lorazepam. I had only two beds left on the ward and what if they needed to be filled?

“But I told the wife that we’d admit him.”

“Just how much has he been drinking?”

“One or two six-packs a day.”

“Has he ever had DTs or seizures before when he’s quit drinking?”

“Well, no.”

“Here’s what I’d do. I’d tank him up with sedatives, fluids, and vitamins. Keep him until the morning. Then call his wife and tell her that we can’t admit him because we have no beds. And never, ever make a stupid decision like that when I’m on call or I’ll tell Schuster (the chief medical officer of the VA hospital) that I caught you trying to play hide the salami with the ER nurse while a patient was sedated in the emergency room.”

“You wouldn’t?”

“You’re damned right I would.”

“You’re a real prick, Covington.”

“Coming from you, Barry, that’s really rich.”

The next time I had trouble with Krakauer came when I was in the second year of my fellowship of gastroenterology at the university. At the time – it made about as much sense to me as this crazy world affords – Albuquerque was awarded the Miss America Pageant. Someone on the pageant’s committee had the audacity to make Krakauer the official pageant doctor. The whole week, the doings of the pageant filled the pages of the Albuquerque Tribune. On Wednesday, three days before the pageant, Krakauer called me to see Miss Arkansas. He was admitting her to the hospital for what sounded like typical gastroenteritis and was going to fill her with fluids intravenously. He wanted a gastroenterology consult on her. A total waste of my time, but I did it without complaining. In his presentation of her over the phone, he mentioned she had a little bit of abdominal pain and went on to say that her pelvic exam was normal.

“What’s this with a pelvic exam?”

“She was having abdominal pain.”

“She has gastroenteritis. She should be having abdominal pain. Since when gastroenteritis ever required a pelvic exam? Have you ever heard of assault and battery? You’ve got a real problem, you know it, Krakauer.”

“Fuck you, Covington. You going to see her or not?”

So, I saw Miss Arkansas for gastroenteritis, a case a third year medical student could handle being performed by a second year gastroenterology fellow. She was quite a comely candidate who looked as pale as the sheets of her bed as she had IV’s running in both arms to resuscitate her fluid loss. I asked her if there was anything further I could do for her.

“Oh, no, that lovely doctor, Dr. Krakauer, he has done everything possible for me. He’s such a sweetheart.”