“Doctor!”
I didn’t realize until the nurse pulled on the sleeve of my white coat that she was talking to me. I was in the middle of rounds in the Cardiac Intensive Care Unit, going from patient to patient with the medical team presenting daily updates to our supervising doctor. Focused on the patient being presented at rounds, I hadn’t heard the nurse. Also, only two months into my time as a doctor, the title wasn’t something that registered in my mind. I quietly pulled away as the team continued to discuss the patient and followed the nurse to a bed in the corner of the room.
The patient in the bed was Ms. Williams. She was my patient, and I had finished speaking with her only moments before. This was the first day that we had been able to speak. Until today, communication had been somewhat complicated by the plastic tube down her throat. Her first few days of being my patient were spent exasperatedly shaking her head at my questions, and writing out answers in a notebook with a flowing cursive that I had difficulty interpreting. Only today had I been able to speak with her about what brought her to the Cardiac unit. Ms. Williams had been at home, standing on her balcony looking out at the ocean when she felt flushed, and began to feel extremely short of breath. She told me the feeling passed and that when she first arrived to the emergency room, everything was fine. Then, just before she was given her paperwork and sent home, her breathing had completely failed. Her breathing had not just become labored or shallow, her respirations had completely stopped. The emergency medicine doctors had then placed a plastic tube down her throat in order to control her airway and hooked the tube to a respirator that would support and maintain her breathing. They had saved her life. She had remained on the respirator for days before the medical team decided her breathing had stabilized. The medical team still had no answer for what had happened.
So when I arrived at bedside and she was gasping for air, my entire body tightened. The patient grasped my hand frantically. I looked at her monitor and saw that the oxygen saturation of her blood had dropped to 76%. This was so low in such a short time I couldn’t believe it, until I saw that her lips were starting to turn blue. I instructed the nurse to begin to bag the patient, so she placed a mask over Ms. Williams mouth and nose and began to rhythmically squeeze the attached plastic bag, pushing oxygen into her lungs. I sent another nurse to call for the medical team, and rapidly grabbed the intubation tray. I realized I would need to intubate, and began assembling the tools I would need. My heart racing, I began to visualize each step in my mind, trying to anticipate problems I might encounter. Then the team arrived. The senior medicine resident stepped forward, saw the level of the oxygen saturation, and promptly told the nurse to call for the airway team. I felt myself deflate. Almost blushingly, I stepped away from the head of the bed. This meant that the anesthesia residents and their team would arrive shortly, and intubate the patient. While this meant a slight delay in the intubation, my senior had made the decision to call for more experienced doctors to perform the procedure. I looked down at Ms. Williams, and saw the panic in her eyes. I grabbed her hand. As I watched the airway team arrive, I held her hand, feeling that there was nothing else that I was qualified to do.
The intubation was performed without incident. Afterward, the team discussed Ms. Williams’ case at length. Every reasonable suggested lab or study was ordered, and a multitude of consults to other services asking their expertise were made. As the intern, I ordered the labs the senior residents asked for, and I called the consults that the supervising Attending wanted. Though I had contributed nothing to the intubation, despite every desire to shine a light at the answer of what was wrong with Ms. Williams, I had no clever suggestions. I did not know what was wrong with my patient. The medical team continued with their rounds, and moved to the next patient.
Over the next few days, the sedation keeping Ms. Williams asleep while the medical team debated her case was lessened. She showed no further signs of respiratory compromise. So, Ms. Williams woke to find herself again with the tube in her mouth, and our in person version of pen pal resumed. However, I began to run short on questions. I was able to check her labs and respirations each morning, and I knew the full history of her present illness better than anyone on the team. So, I began to fill our time in other ways. In the morning, I would tell Ms. Williams jokes. At times she would chuckle quietly against the tube, at other times I do not know that she could have safely rolled her eyes any harder. In the afternoon, when I checked on her I would sit at the side of her bed and play tic-tac-toe. Despite my best efforts, she often won. In the evening, I would read on causes of respiratory compromise, looking for a solution.
The answer came from another intern. Interested in her case, the other intern had suggested Myasthenia Gravis. The disease was an autoimmune process that caused a weakness of muscles by preventing the neuron in charge of the muscle from working. The idea was that Ms. Williams’ respiratory failure had been a severe first time presentation of the disease. This was based on the fact that the muscle most critical to breathing, the diaphragm, was also the one affected in severe cases of myasthenia gravis. Turned out, the other intern was right. Ms. Williams’ mystery was solved, and she was transferred to another unit for further management. This all happened on my day off. I returned to the Cardiac Unit to find Ms. Williams’ bed filled with a new patient, was informed of the other intern’s great success, and I realized just how little I had contributed to the care of my patient.
Months later, deeper into the fatigue and frustration of my intern year, I was walking into the hospital.
“Doctor!”
I turned as someone shouted. I looked to see a woman running towards me. I didn’t know her. As I was walking into the emergency room, I began to fear that something terrible had happened. However, as she came closer I saw a smile on her face. I didn’t recognize her without the tube in mouth, or the patient gown. She laughed, told me I was terrible at tic-tac-toe, and I knew. She hugged me. Ms. Williams told me how much I had meant to her, berated me for not saying goodbye, and told me that I had saved her while she was trapped in that bed. I blushed. She hugged me again and said goodbye, said she was late for a checkup, but that she was doing fine. As she walked away, I paused. I smiled. Then I walked back into the hospital.
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Keep Scrolling down for Dr. Tetweiler’s Bio
Michael Tetwiler, MD
Michael Tetwiler grew up in a small town in Kansas. After completing his undergraduate studies in English Literature, he pursued his medical degree at the University of Kansas. During medical school, he was awarded a Fulbright Research grant that analyzed clean water initiatives in the Peruvian Amazon. His work in his medical school's free clinic led him to pursue an MPH in Health Management at the Harvard T. H. Chan School of Public Health. These experiences led him to a residency in Emergency Medicine at Harbor UCLA where his work focuses on helping underserved spanish speaking communities and initiatives for resident wellness.