Monday, September 5, 1988
The night shift nurse stopped Frank as he walked by the nursing station. “Hey, you’re the student working with Mr. Castela, aren’t you?”
“Yes.”
“He’s sundowning. Acting totally crazy. I put soft wrist restraints on him so he wouldn’t pull out his i.v. lines. I’ll need an order.”
Frank was almost done with his internal medicine rotation, and almost feeling like his inexperience wasn’t a danger to every patient. It had been a rough start, and he had questioned more than once whether he had what it took to be “a real doctor.” At least most of his patients asked him when he introduced himself if he was a real doctor or “just a student.”
Frank wrote the order, paged the intern to co-sign it when she could, and went in to see Mr. Castela. It was a slow call night, and Frank hadn’t seen sundowning. The hapless patient turned his eyes toward the knock at the door, and when Frank appeared, started yelling: “Get it out! Get it out!”
Frank took a half step backward, then caught himself. The desiccated septuagenarian lay tense, muscles quivering, hyperalert, sweating. He was trying repeatedly but fruitlessly to reach his right wrist with his left hand. His hospital gown was all askew and Frank, embarrassed, pulled one flap over to cover the man’s exposed groin.
“Get it out!” the old man yelled again.
“Get what out?” Frank asked.
“The snake! It’s eating into my hand. Get it out!”
Mr. Castela was pointing desperately at his right arm. Make that “right upper extremity,” Frank reminded himself. The arm proper is only from the elbow to the shoulder. It looked normal enough. An i.v. line entered just above the right wrist. He picked up the line. “Um … this is all I see, Mr. Cas—“
“You’ve got it! Get it out! Get it out!” The patient’s eyes were now even wider, and he was panting.
“I’m sorry, sir,” said Frank in his most professionally polite voice, “but this is just your i.v. line, and you really do need it for the antibiotics.”
“You’re with Them!” the patient screamed. “You’re in with whoever’s torturing me! You ugly sunnuva …”
The nurse skidded into the room and interrupted at this fortuitous moment with “Hi, Mr. Castela. Maybe I can help.” She shot an annoyed look at Frank and continued sotto voce. “I’d just calmed him down. Let’s see if we can repair the damage without snowing him.” While keeping up a soothing patter, she tucked the i.v. line into a makeshift pocket of sheet at the side of the bed and covered Mr. Castela’s right forearm with the sheet. The offensive clear plastic snake had disappeared and when the patient looked down it was no longer there.
“Thank you, honey,” he said. His breathing slowed. The nurse established that the patient thought he was in a warehouse and thought it was July, 1977.
After a minute or two, he closed his eyes.
“Wow. That was pretty amazing,” Frank told the nurse. “You’re good at this.”
She just grunted while arranging the sheets on the other side of the bed, but she looked marginally less grumpy.
“Just like a baby,” mused Frank. “Out of sight, out of mind. You hid the i.v. line and as far as he was concerned, the ‘snake’ magically disappeared.”
Unfortunately the patient heard the offending word and instantly resumed his hyperalert paranoia. “It’s you again!” he yelled, staring accusingly at Frank. “What are you doing here again! You’re the one with the snake!”
The nurse groaned audibly and started to shoo Frank out, but the door opened again and Frank’s intern appeared. Dr. Mary Pettit walked in briskly, with the “I’m-here-now-I’m-in-charge-of-the-situation” attitude that Frank had already begun to imitate. “What’s going on?”
Dr. Pettit had seemed more or less perfect to Frank for his first 6 weeks on the rotation. Not only did she have an M.D./Ph.D. behind her name, from Hopkins no less, not only did she seem entirely capable and unflappable, not only was she distractingly cute even in intern whites, but she somehow managed to show up every morning at 7a.m. with matching earrings and necklace and carefully applied makeup. She had earned grudging respect from the “real” internists after her first few months on service, even though she was a psychiatry resident just rotating through medicine. Frank had tried hard to impress her only to be caught out on numerous occasions in some rookie error or other. A couple of weeks ago he’d realized she was human too, when he found her in the report room crying after they lost their first patient together.
The nurse answered over the patient’s intermittent yells. “Your student here”—the omission of his name was one more proof that nurses, the hospital’s only permanent inhabitants, viewed the transient medical students as entirely fungible—“your student seems to have a positive gift for upsetting this patient.”
Dr. Pettit turned a cool gaze on Frank and asked for the patient’s vitals. Not thinking fast enough to ask the nurse for them, Frank admitted he had no idea.
“Do you know why they’re called vital signs, Dr. Kimball?” The nurse rolled her eyes at the honorific.
Frank desperately fished for some recollection from a second-year lecture on the physical exam, and came up empty-handed. He punted. “Well, vital comes from the Latin root for life.”
“Whatever. They call them vital because they’re actually important. For every patient.” She turned to the patient and felt his pulse.
Great, thought Frank. Three other people in the room and depending on which one you ask, I’m either evil, immature, or inept. He moved to stand behind the nurse to take advantage of the out-of-sight-out-of-mind phenomenon, and Mr. Castela quieted somewhat, calling “get it out” at intervals but somewhat half-heartedly now that the snake was no longer visible.
The nurse pulled out her rounds clipboard and read out his last set of vitals. “128, 160/100, 12, and thirty-seven three.”
Dr. Pettit never believed the respiratory rate. “The whole ward could die and the charts would show them all breathing in perfect unison at 12 per minute,” she’d said once. “Frank, count his respirations.”
He pulled out his watch and counted breaths for 20 seconds. A pen and a watch, the only two reasons that anyone ever wants a medical student, he reflected. “Twenty-seven,” he announced, after a quick 9 times 3 in his head.
“What’s a normal respiratory rate, Dr. Kimball?” asked the intern while auscultating the patient’s back, without looking up at Frank.
“Twelve to 20,” he reported, confident for once of the right answer.
“Close enough,” she said. “So what does that tell you here?”
The patient still looked terribly frightened, but was now quietly monitoring the conversation, looking confused like a head-injured spectator at a tennis match. The nurse gave up and left the room and to keep out of his line of sight, Frank retreated further, behind the corner that hid the bathroom door.
“Well, he’s breathing too fast. But he’s really anxious, after all. Paranoid, actually. Wouldn’t that explain the tachypnea?”
“Maybe, but this patient is here why?” asked Dr. Pettit.
“Community-acquired pneumonia.”
“Meaning he has a couple of other reasons to breathe fast,” she answered.
“Do you want me to get an ABG?” Frank volunteered.
“Frank. First tell me what else you observe about the patient without a needle or a lab.” Mary Pettit was a big Arthur Conan Doyle fan. “Take your time. Well, take 15 seconds, anyway.”
Frank commented out loud as he looked the patient over for a second time: 73-year-old man in a hospital bed, looking even older, general appearance frail, tachypneic, diaphoretic (like all med students, Frank had soaked up the fancy words that made you sound smart, like “diaphoretic” for “sweaty”), i.v. line in the right forearm, no redness above the i.v. insertion point, and so on. When he started to repeat the vitals they’d just discussed, she interrupted.
“Look here.”
“Oh. And a nasal cannula in place running”—he walked over to the wall—“2 liters of oxygen.” The patient started yelling at him again and Frank retreated once again around the corner.
Dr. Pettit shook her head slightly, took the two soft plastic nasal prongs from the man’s cheek and placed them in the man’s nostrils where they were supposed to be. “Now watch,” she said.
Frank watched from his post behind the corner. Mary waited one minute on her watch, then talked to the patient. “Can you tell me your name, please?”
“George Castela,” he said quietly.
Dr. Pettit beckoned for Frank to come out from behind the corner and he cautiously did so.
“Hi,” said the patient, and turned back to the intern. She continued.
“What’s today’s date?”
“I don’t know, honey. I think it’s early September.”
“And the year?”
“1988, of course.”
“Remind me what’s the name of this place?”
“Duke Hospital.”
“And do you happen to know your room number?”
“I think it’s 2315.”
“That’s right. Has anything been bothering you?”
“Well, I think I was having a nightmare where I was in a pit with snakes crawling all over me.” He looked over at Frank. “In the dream I was cussing you out. I hope I didn’t actually say anything out loud.”
By this time Frank’s eyebrows were riding high, but he managed to say, “Mr. Castela, please don’t worry about it. You’re here in the hospital and you’ve been pretty sick. When I’ve talked to you before, you’ve always been beyond kind.”
After they exited the room, Frank couldn’t suppress his wonder. “I can’t believe that, Mary. Are you telling me all that paranoia and the snake hallucinations and yelling at me were all cured by just putting his oxygen back on straight?”
“Yup. Look, it’s a slow call night. Ouch. Shouldn’t have said that.” Frank never tired of watching how incredibly superstitious residents and students were on call nights. The general theory was that if you talked about good luck it was sure to end. “Why don’t you go over to the library and do some reading on this.” She wrote out three phrases on a piece of medical record paper and handed them over. “Basically when somebody starts acting crazy for the first time when they’re in the hospital at age 70-something, it’s either drugs you’re giving them, drugs you’re not giving them—mostly alcohol and sleepers—or they’re just really physically ill. I read an article in med school that called it ‘acute brain failure.’ That made sense to me and it reminds you how seriously you have to take it. By tomorrow I want you to have a differential diagnosis and a prioritized list of diagnostic steps you’d want to take if his sensorium hadn’t cleared up after I moved his nasal cannula. Oh, and also look up the distinction between hallucinations and illusions.” She strode off to intern-land and Frank only with some effort stopped watching her walk. For some reason the children’s book, Where Do Butterflies Go when it Rains?, came to his mind.
He sighed, thought about calling home to Christine, looked at the note, and headed over to the library to look up “delirium,” “mental status changes,” and “acute encephalopathy.”