I got it Barry.”
Finally, Barry was at my side. “His wife had the ambulance bring him in. Said he was on a bender for the past two weeks.” Then I could see the ER nurse scuttling along the nurse’s station. Though Barry was not blushing as the ER nurse was, there were dewdrops of sweat gathering at his hairline. Neither did she bother to look at me nor did she say anything. “He was pretty agitated. I’d given him thirty milligrams of lorazepam more.
“No seizures, no hallucinations, no gastrointestinal bleeding?”
“Not to my knowledge.”
“Well, yes or no?”
“No.”
“Are you sure?”
I looked through his labs. Barry this time had done more of an adequate work-up than he usually did; what he hadn’t done was find a good excuse to put him in the hospital. Except for his liver enzymes being slightly elevated, nothing else was amiss. His chest X-ray was normal, his EKG displayed no abnormalities; even his stool didn’t have any blood. “What do you want me to admit him for?” Normally, mild alcoholic hepatitis can be handled as an outpatient on sedative agents like lorazepam. I had only two beds left on the ward and what if they needed to be filled?
“But I told the wife that we’d admit him.”
“Just how much has he been drinking?”
“One or two six-packs a day.”
“Has he ever had DTs or seizures before when he’s quit drinking?”
“Well, no.”
“Here’s what I’d do. I’d tank him up with sedatives, fluids, and vitamins. Keep him until the morning. Then call his wife and tell her that we can’t admit him because we have no beds. And never, ever make a stupid decision like that when I’m on call or I’ll tell Schuster (the chief medical officer of the VA hospital) that I caught you trying to play hide the salami with the ER nurse while a patient was sedated in the emergency room.”
“You wouldn’t?”
“You’re damned right I would.”
“You’re a real prick, Covington.”
“Coming from you, Barry, that’s really rich.”
The next time I had trouble with Krakauer came when I was in the second year of my fellowship of gastroenterology at the university. At the time – it made about as much sense to me as this crazy world affords – Albuquerque was awarded the Miss America Pageant. Someone on the pageant’s committee had the audacity to make Krakauer the official pageant doctor. The whole week, the doings of the pageant filled the pages of the Albuquerque Tribune. On Wednesday, three days before the pageant, Krakauer called me to see Miss Arkansas. He was admitting her to the hospital for what sounded like typical gastroenteritis and was going to fill her with fluids intravenously. He wanted a gastroenterology consult on her. A total waste of my time, but I did it without complaining. In his presentation of her over the phone, he mentioned she had a little bit of abdominal pain and went on to say that her pelvic exam was normal.
“What’s this with a pelvic exam?”
“She was having abdominal pain.”
“She has gastroenteritis. She should be having abdominal pain. Since when gastroenteritis ever required a pelvic exam? Have you ever heard of assault and battery? You’ve got a real problem, you know it, Krakauer.”
“Fuck you, Covington. You going to see her or not?”
So, I saw Miss Arkansas for gastroenteritis, a case a third year medical student could handle being performed by a second year gastroenterology fellow. She was quite a comely candidate who looked as pale as the sheets of her bed as she had IV’s running in both arms to resuscitate her fluid loss. I asked her if there was anything further I could do for her.
“Oh, no, that lovely doctor, Dr. Krakauer, he has done everything possible for me. He’s such a sweetheart.”
Black Are the Horses
It was late March, and the late afternoon light filtering through the blinds of the ICU bay were grim and grey. Water poured from the skies like someone wringing out a mop as the last winter cold front passed through Albuquerque. As a senior resident, I was helping my intern on the medical service, Ann Hodges, insert a Swan-Ganz catheter, in a diabetic patient whose name was Ernesto Gonzales. At the time, his temperature was raging at one hundred and three degrees, and his systolic blood pressure was sinking like the desert setting sun of the high plains of New Mexico. The interns had not reached journeyman status quite yet, and I was there to assist her in the procedure in which we would pass a the Swan-Ganz catheter from the subclavian artery in the the right side of the heart in middle-aged diabetic who was in septic shock from a skin and bone infection that had flowered in his left leg. When one pushed on the dorsum of his foot, it spit out horribly smelling pus. I was sure that for Mr. Gonzales, he would eventually have an amputation in order if he made it through his sepsis. Both Ann and I were in light blue paper scrubs to maintain a sterile environment. No sooner than she had made a small nick in the skin under his clavicle to ease the entry of the catheter into the subclavian vein, my beeper went off. The nurse helping us held our beepers should someone call. The nurse returned the call, telling the person on the other end of the line that I was in the midst of performing a procedure.
“It’s Turley in the ER,” said Connie, the nurse. She said to call back as soon as you could.”
“Okay, thanks. Be glad you’re not on the bubble, Ann. You’ve got enough on your hands with Gonzales. This one is for John. See if he can keep his lucky streak going.” Ann laughed. She had already scrubbed his right shoulder and neck with Betadine solution to sterilize the skin where the catheter would be placed, so as not to add to the infectious 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