Night and Day

The morning report room smelled like chicken tikka masala, pizza, and sweat. I cleared off several cardboard cartons from the table, sat down next to the chief resident, and gave her my team census.

“I see you've been eating well,” she said. “How was your night?”

How was my night?

The usual stuff, really. After the other residents had gone I became the senior most physician in charge of the headaches, heartaches, dyspneas, decubiti, fevers, and falls of the day. Not bad for a second-year resident in December. At 8:00 p.m. my pager sounded; 4 South wanted me.

“Are you on call for medicine?” asked the nurse.

“That's me.”

“Your patient has arrived.”

“What patient?”

“Your patient from the outlying hospital.”

“I don't have a patient from an outlying hospital.”

“Yes you do.”

“Look, no one told me about any patient from another hospital,” I said angrily. “You're making a mistake.”

“No I'm not. Your patient's here, and you need to come see him right now.” She hung up.

I stormed down the stairs to 4 South. The clerk, who had just heard half of the preceding conversation (and likely a few additional words from the nurse), handed me a thin manila envelope and pointed to Room 473. “His name is Baker.”

I briskly entered the dark room. “Mr. Baker, I'm Dr. Warm. Why are you here?”

Silence.

“Mr. Baker,” I repeated quickly, “why are you here?”

More silence.

My eyes adjusted to the dim light. Looking up at me with a vacant stare was a gaunt, ill-appearing man. He had a ratty patchwork of hair, tape on his nose where there had been a nasogastric tube, and a bony chest beneath his gown. No matter how old he is, I thought to myself, he appears older than stated age. “Mr. Baker, I am here to help you. Could you please tell me what's going on?” He would not talk. I felt an urge to give him a sternal rub.

The manila envelope contained a copy of his chart from the outlying hospital and a hastily scribbled transfer note. He was a 28-year-old homeless intravenous drug user (he lived under a bridge) admitted to the hospital after coughing up blood. A chest x-ray had revealed bilateral upper-lobe infiltrates as well as patchy densities elsewhere, and he had been empirically started on seven antibiotics. Initially his lab work was normal, but his sodium level had dropped from 140 to 120, and then quickly rose to 140 again. After this, he became mute and lost intravenous access. The outlying physicians promptly requested transfer.

I backed out of the room and did the most logical thing: I called the chief resident to complain.

“Do you know anything about a Mr. Baker coming from another hospital?” I asked her.

“Oh, I'm sorry. I forgot to let you know about him. Is he there already? He sounded sick so I accepted him for transfer.” In the background I heard glasses clinking and music playing, and I could tell she was at a holiday party. The physicians from the outlying hospital would probably be joining her any minute.

“Yes he's here already, and yes he's sick.”

“Do you need any help?” she asked.

“No thanks.” I hung up the phone.

Further evaluation of Mr. Baker revealed he would need several procedures, including a central line. Inserting catheters into uncooperative patients who might be HIV positive is an inevitable hazard of residency. Every resident knows at least one trick to come through the experience unscathed. I have seen teams of limb-sitting doctors, elaborate systems of bed-sheet restraints, and imaginative meshworks of tape used to create a controlled enviroment. My friends laughed at me, but all I needed to put in a central line was a kit and an empty garbage can. My work field was sterile and immaculate. I did not want to reach under a piece of central line detritus and stick myself with a hidden needle. Removing the garbage as it was generated gave me a sense of calm, and for this I required an empty garbage can. Mr. Baker's room did not have an empty garbage can.

I stepped back into the quiet stillness of the hallway to find one. Walking deliberately, I looked left to right, room to room: no garbage can, full garbage can, no garbage can, no garbage can, full garbage can, dead man on the floor, no garbage can, full garbage can.

I stopped and stared out the window at the end of the hall. Darkness anchored the clean white reflection of the hospital floor, and a draft moved through the window pane. I turned around and leaned backward on the heating vent below the window, burning myself slightly. Dead man on the floor? Now?

I stood motionless for some time. All was quiet. There was a dead man on the floor in Room 465, and I wasn't moving. On the first day of residency I would have been in his room, grabbing his shoulder, yelling, “Sir, are you okay?” On the first day of residency I would have pounded on his chest and asked questions later. On the first day of residency I would have broken ribs. But not this night. My family would ask me later, “How did you know he was dead?” Second-year residents know these things.

I pulled out my cross-cover cards. Room 465 was marked “sick.” I vaguely remembered him from previous call nights—he had cancer and was always in a great deal of pain. The card did not indicate code status. I slowly made my way back up the hallway, careful to only look straight ahead. I found a thick chart labeled 465 and thumbed through the pages. He was admitted 23 days prior. He had cancer. He was DNR.

I closed the chart. The nurse I spoke to earlier glared at me.

“Hey,” I said, “the guy in Room 465 is dead.”

“Really?”

Wordlessly, we walked to his room. The man lay in a crawling position on the floor, like a Pompeii victim without the ash. He must have climbed over his bed rails and fallen. Did he know the end was near? Did he try to make a break for it? The overhead heat lamp shone down and he glistened in the light. He was dead. The nurse grabbed his torso, I took his bare legs, and we lifted him back into bed. Edema fluid leaked out onto my hands. I wiped them on the sheets, tucked the body in, and turned off the heat lamp.

I phoned the family from the nurses' station. “I'm sorry to call you this late, but I'm afraid I have some bad news. … No, no, he didn't die in pain. … Yes, he looked comfortable. … Yes, I was with him at the end. …”

After I hung up the phone it occurred to me that I hadn't even looked. I walked back to Room 465 and found the perfect empty garbage can next to the bed. I grabbed it and slid the central line into Mr. Baker. It went well.

“Eric? Eric? Are you in there?” The chief resident nudged my arm. “I was asking you what happened yesterday? How was your night?”

“How was my night?” I grabbed a piece of cold pizza out of one the boxes on the table. “Oh, you know, the usual stuff.”

That day in morning report we discussed hyponatremia.

• Copyright ©2004 by the American College of Physicians