burden that Gonzales’s was dealing with, and would most likely carry him into the next life before he got out of the ICU. It was incumbent on Ann to measure his fluids with the catheter for his systolic blood pressure would not ease into the eighties despite flooding his veins with two liters of normal saline. Despite the fluids, despite the antibiotics, and despite the vasopresors, we could not get his systolic blood pressure higher than eighty. For Mr. Gonzales, I thought that the Almighty had punched his card. On physical exam, all the findings were there, the fever, the low blood pressure, the rapid heart beat and the obvious infection. Once Ann had inserted the guide wire into the subclavian vein, and had taken the central line out, she slid the Swan-Ganz catheter over the wire. At the end of the Swan-Ganz catheter, there were three ports. Finally, with the catheter in one of the pulmonary arteries, his wedge pressure was low, and so too was his cardiac output. All the catheter findings were consistent with sepsis, and they were also consistent with a fluid deficient state. I suggest to Ann that she press ahead and keep him on the antibiotic and vasopressors while giving him more fluid. His blood pressure, currently, was 76/44 mm Hg with wide open liters of normal saline pouring through IV tubing into his veins in both his arms, and norepinephrine going in one IV to raise his low blood pressure. Gonzales was barely responsive and he was drifting farther and farther out to sea. While we performed the procedure, Joan Duffers, the nurse helping us, held both Ann’s and my beeper. Leaning over the bed, in my sterile gown, Joan, showed me the number on the dial. It was for the emergency room. “Jesus, they’re coming out of the woodwork today.” Ann just nodded. By now we were through, and I took my beeper back from Connie. I called the emergency room and asked to speak to Turley. I was told that she was through with her shift. Paul Perkins, another of the emergency room interns, picked up the other end of the line and informed me that he had a GI bleeder who needed to be admitted.
“Who’s on call for gastroenterology?” I asked Jennifer, the ICU secretary. Every day they are handed a list of the different services and who is covering for them. “It says Jim Valdez is.” This would be my third ICU admission, and it was not yet four. I still had my two admissions on the floor, as well as the patients who were already on my service.
“Turley had told me the GI bleeder was fairly stable when she called you,” said Jennifer. Julie Turley had been one of my interns in July. Her competence impressed me. That she was an emergency department resident, I didn’t hold against her. But I didn’t care for a lot of the interns from the program. They were too proud. Beginning my third year of internal medicine, the university medical center started an emergency medicine residency, taking in a half dozen residents each year. They were the top students in their classes from across the country. Unlike the rest of the residents at UNM Medical Center, they wore bright, blue emblems on their white lab coats, signifying that they were not only residents, but that they were residents in the Emergency Medicine Department. No, they were too proud. While we were busy managing patients in the internal medicine, general surgery and pediatric departments taking care of patients, the cloth emblem exuded an attitude that bespoke a bias saying: “We’re here saving lives.” Just what were we doing? Their interns in the emergency department residency program spent a couple of months doing their internship on the internal medicine wards. And that was how I knew Julie.
I nodded at the secretary and thanked her as I watched Ann suture the Swan-Ganz catheter to the patient’s skin with thick, black silk thread so it would not slide out, nor farther into subclavian vein. I looked up and out of the window of Mr. Gonzales’s room. The rain that began that morning, had turned to sleet and the weather was all aslant. Sleet balled up on the windowpane and dripped down in thick rivulets. The cold front coming through central New Mexico was turning into a tempest. So many of the homeless with any ailment would be presenting to the emergency room and the urgent care, searching for a warm bed, clean and dry, rather than under nature’s tempest. Though days like these seemed endless for a resident, I couldn’t help but feel sorry for the homeless. For those so down-on-their-luck, they had no roof over the heads. And God knows there were enough of them in this city slung in the swale of the Rio Grande Valley. “You’re did fine, Ann,” I said as she checked the balloon at the tip of the Swan-Ganz catheter one more time. Now once an hour, the nurse attending Mr. Gonzales would inflate the balloon long enough to record the wedge pressure while taking the rest of his vital signs.
Feeling someone at my shoulder, I looked up from Mr. Gonzales chest to find one of my other interns. It was John Naylor. He was known to the other residents and the medicine interns as “The Terminator.” He had earned this appellation from so many of his patients succumbing from their medical problems under his care. But the nickname was unfair, for John was a good intern. Live had just dealt him the sickest patients. In the internal medicine rotation, each intern gets their patients in the order they present to the resident from the emergency room or the urgent care. John couldn’t help the fact that the deck seemed loaded to him. “John,” I said. “I have another admission for you. A GI bleeder. I have to go down to see him when Ann and I are finished here. Then you can see him when we move him up to the intensive care unit. I looked back down at Mr. Gonzales. As Ann finished attending to Gonzales, I took the back stairway that led down to the emergency room, the emergency department in the medical center being directly below the intensive care unit.
But if my nerves were set on edge by all the beeping telemetry units, the groan of the ventilators, the constant ringing of the telephone, I was even more dismayed when I entered the emergency department from the staircase from the ICU. It looked like a Fellini film, each gurney holding someone deep in misery, from the elements, and from some medical or surgical emergency.
Now that Turley was no longer on, I sought out Paul Perkins, the intern who took her place in the emergency department. Turley had gone off shift not more than an hour ago, not long after she had beeped me. Unfortunately, so too had the nurses who had taken care of Jose Garcia, my GI bleeder. That was all too typical for an emergency room in a busy medical center like UNM. But she had signed out Paul Perkins, and I sought him out. When I found Paul Perkins, he was wearing that white lab coat with the emblem that I detested. “Paul, tell me about this guy?”
“I only know what Julie told me about him. She said the nurses put an Ewald tube down him and it was positive for blood. Apparently, Albuquerque’s finest brought him in after he complained of abdominal pain. That caught him driving drunk. He’s on a police hold.” He handed me his ER chart. On it were his complaints, his exam and his labs. On the emergency room record, Julie wrote he had been brought in by two police officers complaining he had abdominal pain and then thrown up blood. The nurses put an Ewald tube down his throat and into his stomach, the return looking pink, which they believed consistent with a bleeding ulcer. I perused his notes quickly. His hematocrit, the percentage of blood in the blood after one lets them settle out in a tube, was 39%. Yet his last pressure recorded on the notes was 99/60 mm Hg, and his pulse was one hundred and twenty. I looked for a nurse who had taken care of him, hopefully the one who had put the Ewald tube into his stomach. None was to be had. He had been in the emergency room for almost three hours according to the log sheet.
As the saying goes: When in doubt, ask the patient.
I strode over to Jose’s gurney. His eyes were shut and he was moaning. “Mr. Garcia,” I asked. “I was told you were throwing up blood and that’s why we’re admitting you to the hospital.”
“I never threw up any blood.” Pain sparkled in misery in his eyes. He looked startled. It appeared as though he was not trying to move; as if it hurt too much to move, as if death would bring welcome relief. The nurses had prudently hooked him up to a cardiac monitor and place two intravenous lines. Though it was clear that he was inebriated when he was brought to the emergency room, he seemed quite sober now.
“Here it says you were throwing up blood.” I held the ER record upside down so he could see it.
“No man, that’s not it at all. I was drinking. I was drinking more than I should have been. I admit that.
