When a Single Choice Is Life or Death for Your Patient
A doctor is faced with a devastating decision.
Every medical case, to paraphrase the writer Viet Thanh Nguyen, is lived twice: once in the wards and once in memory. Some of what follows is still intensely vivid, as if it were shot in high-def video. Other parts are blurry — in part because I must have subconsciously deleted or altered the memories. I was 33 then and a senior resident at a hospital in Boston. I had been assigned to the Cardiac Care Unit, a quasi I.C.U. where some of the most acutely ill patients were hospitalized.
In mid-September — it had been a moody, rain-drenched month, as I recall — I admitted a 52-year-old man to the unit. I’ll call him by the first letter of his given name, M. As medical interns, we were forewarned by the senior residents not to identify too closely with patients. “A weeping doctor is a useless doctor,” a senior once told me. Or: “You cannot do an eye exam if your own eyes are clouded.” But M.’s case made it particularly hard. He was a doctor and a scientist — an M.D., a Ph.D., like me. He must have been about 15 years ahead of me in his schooling; I could imagine him returning to my class in med school to teach us “Patient-Doctor,” in which students are taught how to deal with real-life patients. He’d trained as a medical resident and then as a fellow in cardiology at another hospital across town. He was now an assistant professor — it seemed like such a victory to have that title — and ran a small laboratory. I knew a student who once worked with him. Six degrees of separation? There was barely one.
Earlier that year, in March or April, M. became short of breath in the middle of his run. (Was his running route the same as mine? Across the Longfellow Bridge at Mass General, looping around the river and then back again by Storrow Drive?) His legs turned cold and blue. He had dizzy spells and lost words in mid-sentence. He saw a cardiologist — presumably one of his own colleagues — who diagnosed heart failure. A series of scans must have revealed a sluggish heart. In place of the regular, intentional motion — jellyfish pulsing in a tank — there was an eerie wobbliness, just jelly. A biopsy was performed, and the diagnosis was amyloidosis, a mysterious condition in which misfolded proteins begin to be deposited in the organs of the body. Sometimes the proteins come from cancer cells; sometimes from poorly understood sources. The deposits choke the organs: heart, liver, blood vessels, kidneys. “And then, bit by bit by bit, I was all pro-te-in,” he said dryly, paraphrasing the Tin Man in Oz. We laughed.
M. needed a new heart. I’m writing this casually, as if you go to the used-heart salesman on Long Island and pick one up on a three-year lease. Hearts are notoriously hard to find; someone has to die for you to get one. About 3,000 hearts are available in the United States every year. Many come from youngish men and women who’ve had accidents or drowned, leaving them in a peculiar limbo — brain-dead but heart-alive. But there are never enough: At any given moment, about 4,000 patients are waiting for a heart. Many of them will never find one.
M. was on this list of supplicants. His own heart, meanwhile, was failing so precipitously that he needed constant medical monitoring. Weird, deadly electrical rhythms arose out of his dying cardiac muscles, like ripples on a stagnating pond, necessitating defibrillating shocks to reset his rhythm. Fluid pooled in his feet, and the skin on his calves came off in strips.
There was a second reason to monitor M.’s status. Hearts are so rare that patients have to be under constant surveillance to ensure that they continue to “qualify” for the transplant. Transplantation is a touch-and-go procedure; a patient on the wait-list must be in the best possible condition before receiving the donor organ. An innocuous-seeming infection, or kidney failure, can spiral out of control after the transplant. “If it’s bad now, it’ll only be worse later,” the transplant nurse told me, grimly. She was efficient-looking, dressed in a white nursing smock. She noted M.’s vital signs and then disappeared down the corridor with her book.
And so we watched him. Every vital sign — temperature, respiratory rate, heart rate — was dutifully recorded in the log books and on the resident’s notes. I was on call every third night. I would stop by to say hello to M. and wait for the transplant nurse to come around. He would be puzzling over 40-across on the Sunday crossword. She would check his numbers. “Maybe there will be one tonight,” she would say, before signing off for the day.
It must have been on the third or fourth week of M.’s hospitalization, sometime late in the evening, that the transplant unit called up to the I.C.U. A kid had dead-ended his motorcycle on a concrete barrier on the expressway. He was declared brain-dead shortly after the accident, but his heart was intact. M. was on the top of the transplant list. I half-ran, half-walked to his room to bring him the news. He had been dozing through most of the day and night — a sign, perhaps, that he was having trouble pumping blood to his brain. He woke up, smiled wearily and then drifted off to sleep again.
Around midnight, I was paged to the unit. “He’s spiked a small fever,” the unit nurse said. She tried to look at me blandly. “It’s nothing,” she wanted me to say. “It’s not real. Nothing to see here, folks. Get back to work.”
“Well, let’s retake the temperature.”
She measured it again. 101.
His systolic blood pressure had also dropped ever so slightly — a few, barely discernible notches. But his pressures had always been low.
I paused for a moment, weighing my choices. “Try another thermometer. And check the pressure again. Actually, let’s wait and try in 10 minutes.”
She brought another instrument out from the nurse’s station. M. began to sense the slowly building hubbub in the unit. He sat up woozily.
“Do you feel anything wrong? A chill?”
“Nope,” he said. “Nothing.”
I examined him, pore by pore, looking for a potential source.
The nurse entered the room and made a tiny motion to see her outside. I met her by the nurse’s station. “Should we record the temperature?” she asked, whispering, as if the intercom might be eavesdropping.
The stakes could not have been clearer to both of us. If we put the number in the chart, M. would temporarily fall off the list for the next morning. The transplant surgeons at this hospital, I knew, would never risk taking a febrile, potentially septic, patient to the operating room.
I felt paralyzed. Medicine depends on looking at data objectively, dispassionately; a decade of training had taught me that. But it also depends on understanding that tests can mislead us, that data can deceive: What patient ever fits squarely into an assigned box? My fingers hovered above the computer, where I was meant to write my note and record the fateful temperature spike, but I found that I couldn’t type a word.
At 1 a.m., I called the attending physician. I felt foolish: I imagined her scuffling around her nightstand for her spectacles, anticipating a question about an acute cardiac crisis. Instead, there was a mumbling, hesitant resident trying to decide whether to write a note. But she understood immediately. She walked through the details of the case. Had I really evaluated the infection? Yes, yes, I reassured her — or rather, tried to reassure myself.
“It’s really your decision, Sid,” she said. “But you’ve got to consider that in some other hospital, there’s some other young guy — a doctor, with a Ph.D. — waiting for that same heart. If your patient goes to the O.R. infected, he’s not going to make it, and the new heart is going to die with him.”
I put the phone down and turned to the nurse. The fever had come down to 100 degrees. What if we hadn’t measured it in the first place? What if we’d forgotten to take the vitals on one shift? How about all the things we don’t measure? Muscle tone? Wakefulness? If a temperature spikes in a forest. ...
I returned to the computer, tried to type my note, hesitated and stopped again.
I wrote my final note at 2 in the morning. Temperature: 101 degrees, currently 100. No obvious source of infection. A chest X-ray showed no signs of a pneumonia. A complete history and physical exam was unrevealing. Awaiting blood-culture data.
At rounds the next morning, I felt as if I had let the team down. I presented the case quietly, feeling the eyes of my co-residents burning holes into my skull. No one had any questions.
There were just a few more days left in the rotation, and I went to say goodbye to M. His fever had subsided on its own after that overnight spike. “I’m sorry,” I said, and he nodded.
M. died of a fatal arrhythmia a few weeks later. No other heart became available. The fever never returned.
Siddhartha Mukherjee is editor-at-large at Tonic. He is the author of The Emperor of All Maladies: A Biography of Cancer , winner of the 2011 Pulitzer Prize in general nonfiction, as well as 2016's The Gene, and The Laws of Medicine. Mukherjee is an assistant professor of medicine at Columbia University and a cancer physician and researcher.
This piece originally appeared in the New York Times magazine.
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