Sometimes I Regret It All

The room is unfamiliar. I don’t know how I got here. The day started ok. I wasn’t even late. It was my last day on service, last day before vacation, and it should have ended gently. 

The admission pager went off at 0632, exactly two minutes after I had taken over from the night team, and that should have been my warning. The night resident Allison, always a team player, offered to take it, but I waved her off. That was our culture - she had to offer, and I had to refuse the offer. 

I went down to the Emergency Department to meet the patient. Whenever I had time, I took the stairs down from our fifth floor ICU. I liked the solitude of the staircase, the echoing concrete spiral. On my walk down I regretted forgoing a third cup of coffee. I thought about the new patient - grim case, throat cancer with some sort of bleed from the tumor. 

“Mr Nichol?”

He was in one of those ‘rooms’ staked out by curtains in the hallway, the hospital overflowing with patients like all the hospitals in the region. A man on the edge of middle age, teetering toward elderly, gray hair still flecked with brown and brushed determinedly over a balding dome. 

He waved at me. 

“I’m Dr Adams. I’m one of the residents on the ICU service, here to get you admitted to the ICU. What brought you in today?”

He moved his hands as if trying to convey something, then grimaced a bit. “I ‘an’t ‘alk ‘e’y ‘ell.”

I moved the syllables around in my mind but couldn’t interpret. He nodded once and pointed vigorously toward the chair beside his bed. I saw a notebook and a pen and handed them to him. Mr Nichol wrote briskly. 

My jaw is locked. Can’t talk very well. 

The interview was abbreviated, him writing out his answers in a neat hand, spelling and punctuation flawless. Throat cancer, for which he had received chemotherapy and radiation. The bleeding had started last night, bleeding from both nostrils. Unable to stop the bleeding, he had ultimately come to the Emergency Department, where a combination of interventions had stopped the bleed about an hour ago. They had gotten a CT scan and recommended admission for ongoing workup, though he was not sure what the CT scan had shown. I watched him deflate as I told him what the CT scan showed - progression of the tumor; failure of the chemo and radiation. He had been through this for long enough to know how grave that was. I hadn’t even had breakfast yet and I had already delivered soul-crushing news. I thought of the many years of pre-med and medical school, of how trussed up I was in student loans. 

My son is on his way in. Will you tell him when he gets here?

He tapped on his phone and held up a picture, a brown haired young man in a Cubs jersey. 

“Of course.”

For a while the day proceeded well. We checked in on all of the already admitted ICU patients. My favorite charge nurse, Melissa, played a clip from a Chappell Roan song at morning huddle. The attending intensivist Dr Petersen brought in bagels and we mercilessly teased the intern when she dropped her bagel, cream-cheese side first, on the floor of the team room. We started rounds, and I watched from the other side of the ICU as they brought Mr Nichol up and into room 7.

We were rounding on room 4 when Adam, the nurse for room 7, poked his head into the hall. “Can y’all come in here? He is starting to bleed again.”

I had seen the CT scan and I knew how serious a re-bleed could be. Dr Petersen knew too. We moved with alacrity, the rest of the team a little slower. Mr Nichol held a paper towel to his nostrils and pinched the bridge of his nose. A slow trickle. 

Dr Petersen caught my eye. “Let’s call ENT. And it’s probably time to get anesthesia to evaluate him, just in case. We can do inhaled thromboxane in the meantime.”

In case he needed to be intubated later, for airway protection, if the bleeding became more brisk. It would be difficult with his locked jaw. The experts, the anesthesiologists, should evaluate him now, before it was an emergency, to come up with a plan in case things deteriorated. 

I paged anesthesia and the ear, nose, and throat surgeons. I ordered the inhaled thromboxane, to slow the bleeding. We resumed rounds, back at bed 4. We had just finished talking about bed 5 when I saw first the ENT team, then the anesthesia team, arrive to Mr Nichol’s room. 

It could not have been more than 5 minutes later that Adam shouted, “We need you in room 7, please!”, decorum jettisoned. Dr Petersen was halfway to the room before Adam had even stopped talking, the rest of us on his heels. 

Whatever was bleeding in Mr Nichol’s nasopharynx had opened up. Blood streamed from his nose, too much, enough to choke on. It soaked the bed sheets and his shirt, drifted down his chin in globs. He leaned forward, oddly calm. I wanted to scream for him, to claw at my own neck. Do not go gentle. 

Everybody was shouting. One of the nurses fumbled with suction tubing, cranking the lever on the wall to turn the suction off then on to clear out the clots. Somebody called for blood products. The anesthesiologists argued about intubation through the mouth (locked shut) vs the nose (hemorrhaging). The ear, nose, and throat surgeon had a hand on Mr Nichol’s neck, palpating landmarks, planning for a tracheotomy. Framed in the doorway, I saw Mr Nichol’s son. 

I made it through the crowd as Dr Peterson, voice surging over the rest, called, ‘Does he have a pulse?’ In the silence that followed I put a hand on Mr Nichol’s son’s elbow. The face he swung toward me was white. There were no lines on his face, and I realized he was younger than me. 

“Call a code blue. Start CPR.” Dr Petersen called, in his practiced calm tone. 

I was supposed to lead the code. It was my day to hold the code pager. To stand at the foot of the bed and direct the resuscitation. 

“Come over here,” I said. I led him around the corner, to a set of chairs tucked beside the back stairwell. He dropped into a chair like his joints didn’t work, a puppet operated by a novice. I was overcome at the thought of how many family members had sat in these chairs while their loved ones died. 

“What’s your name?” I sat down next to him, as the overhead voice called ‘Code Blue, ICU, bed 7. Code Blue, ICU, bed 7. Code Blue, ICU, bed 7.’ 

There was a pause. I heard Dr Peterson call for epinephrine, 1mg. “Jackson.” Soft, hoarse. He cleared his throat and tried again. “Jackson.”

My role was to explain it to him. Well, today my role was to lead the code, to be in the room and leave this part to someone else. Failing that, my job was to narrate the code to him, to explain what was happening and to set expectations. 

We sat quietly. 

“I have a pulse!” One of the nurses. Adam? 

Jackson picked at a hole in his jeans. He leaned on his forearms on his knees, back hunched, head down. He wore only a t-shirt and I could see the goosebumps on his upper arms.

“We need to get him to the OR!”

I knew a tracheostomy was his best chance, and that this was better done in the operating room in a controlled setting than at bedside. But it would be a long few minutes wheeling him down the hall, waiting in the elevator, pushing through the double doors into the operating room. I kept my gaze on the far wall and didn’t look at Jackson. 

In the room, the shouting crescendoed. And then people spilled around the corner - Melissa pushed the crash cart out of the way, followed by Adam with two trash cans and the adjustable bedside table on wheels. The pharmacists, the respiratory therapists, the anesthesia intern, the two float nurses, flattened themselves against the wall as the foot of the bed emerged around the corner. The head of the bed was obscured by bodies, pulling a thicket of IV poles, portable suction, a ventilator. They had gotten an airway, then - I wondered where. I closed my eyes. When I opened them I saw Dr Peterson, at the head of the bed leading the procession down the hall. He looked over his shoulder and caught my eye with no expression on his face. 

Jackson got unsteadily to his feet and followed the crowd. 

When they were through the double doors leading out of the ICU and the halls were quiet again, I stood and went into the now-empty room. It was one of the nicest ones - through the windows, the city skyline glittered in the sun, and beyond, the Pacific unfurled to the horizon. The floor was littered with debris, plastic wrappings and half-used flushes, crumpled masks, gloves. Someone had stepped in blood and bloody footprints led toward the hall, each step fading until there was no blood left on the shoe and the floor beyond was clean. 

“Code Blue, service elevators, fifth floor.” The overhead speakers. “Code blue, service elevators, fifth floor. Code blue, service elevators, fifth floor.” 

I made it to the chair by the computer in the corner of the room. I sat down and cradled my head in my arms against the desk and shut my eyes tight. I pictured Jackson’s white face. 

The room is unfamiliar. I don’t know how I got here.