Excerpt from Internal Medicine by Terrence Holt, plus links to reviews, author biography & more

I remembered a patient I had taken care of during an ER rotation a year earlier, an old lady with pneumonia. I had gotten a gas on her, too, and it had come back essentially normal. The attending had asked me to interpret it. "It's normal," I said. "And?" the attending replied, directing my attention to the patient gasping on the gurney. I looked at her for a moment. She was breathing about forty times a minute. "You're about to tube her," I said. "Right," the attending said, and did just that. A normal gas on somebody working hard is a bad sign. A below-normal gas on somebody working hard to breathe on supplementary O2 is a very bad sign, especially if her chart carries the notation DNI. The letters stand for "Do not intubate."

It's the patient's order to her doctors and it draws an inviolable line. No breathing tubes, no ventilators, no call to the ICU for help.

I hurried back down the hall to the room. The sun had set, leaving the sky a dim purple. The room was dimmer still, the patient's face a sheen on the white pillow, her chest visibly stroking from the door. I stood in the doorway for a minute, watching her, trying not to match her breathing with my own.

Her face was turned to me. The eyes glittered.

"How are you feeling?"

"Not. So. Hot."

"I know," I said. "I'm going to get you some more oxygen." I reached for the regulator in the wall and cranked it up to six liters, the maximum you can deliver by nasal cannula. The nurse appeared at the door. "Do you want me to call Respiratory?"

"Yeah," I said. "That's good. Call Respiratory." Respiratory therapists know all sorts of tricks: complicated masks that somehow squeeze more oxygen into room-pressure air. I went back to the workroom and paged Keith. It occurred to me that I was displaying weakness. I told myself I didn't care.

He called back in a minute, cheery, calm. "What's up?" I told him.

"She's DNR? You checked the chart?"

I set the phone down and found her chart. There in the "Consents" section was the legal form, witnessed and signed. "Yeah. DNR/DNI."

"Well, that's it," he said. "If it's her time, it's her time. Just crank up her Os and give her some morphine. That's all you can do."

There was silence for a minute.

"Do you need me to come up there?"

"No. I'm on it. It's okay. I'll call you if I need anything."

"Okay. Have a good night."

It was eight-thirty. I went back to the patient's room. A respiratory therapist had arrived, bearing a tangled mass of tubes and bags.

"What do you want her on?" The tech eyed the woman in the bed speculatively. "Fifty percent?"

"Let's try that." I watched a minute as the tech unstrung his tubes, fitting valves together. The face on the pillow was blanker than ever now: she had closed her eyes. Without that glittering motion, her face looked as if it were simply waiting.


HALF AN HOUR L ATER, the nurse found me again.

"Do you want me to do anything for twenty-six?"

"Like what?"

"She won't keep her mask on."

"Why not?"

"She says she's claustrophobic."

I threw my pen down on the desk.


THE EYES WERE OPEN again, looking out through the plastic skin. She was holding the face mask in her left hand, about a foot away from her face, as if restraining something that had tried to attack her. Her chest was still rising and falling too fast.

I went to the bedside and crouched beside her. The eyes slanted down with me, the head immobile on the bed. "I won't," she said, and pushed the mask into my hands.

"Why not?"

She shook her head. "Can't."

"Is it uncomfortable?"

"Suffocating. Can't."

I bit back an argument. "How about I give you something to help you relax?"

"Why?"

"You need the mask. You're not getting enough oxygen without it. If we can relax you a little, maybe you'll feel better about wearing it."

Excerpted from Internal Medicine: A Doctor's Stories by Terrence Holt. Copyright © 2014 by Terrence Holt. With permission of the publisher, Liveright. All rights reserved.