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

"Please."


THE RESPIRATORY TECH ARRIVED after an interminable period during which Mrs. B refused again and again to wear the mask. Eventually we found a compromise. She would hold it a few inches below her chin. It bumped the pulse-ox to 88 percent. But her respiratory rate continued to climb. I couldn't tell if it was hypoxia or anxiety. A blood gas would have told me, but I was reluctant to try. I didn't know what I would do with the information. When the tech arrived and fitted her with the bucket, I stood at the door watching. It seemed to be doing something.

The next page from twenty-six came around four. I had gone into the call room fifteen minutes before, but the moment I lay down it was clear there was no chance of sleep. I lay rigid in the lower bunk, unwilling even to turn out the light, bracing against the sensation of my pager at my hip. My thoughts were an incoherent jumble: scraps of medical education— the innervation of the hand, the watershed areas of the mesenteric circulation, drugs to avoid in supraventricular tachycardia—none of which was relevant to any of the calls I had gotten that night. I was thinking of anything but the patient in twenty-six, two floors overhead. The next page was, of course, about her.

The nurse picked up on the first ring. "Doctor? I think you'd better get up here."

I was out of the door without a word.

The scene in twenty-six was superficially unaltered. But from the bed I was hearing small whimpering noises, rhythmic, paced almost to the beating of my heart.

She was sitting bent over, the exaggerated movements of her chest and shoulders making her head rise and fall, rise and fall. I counted, but lost track in the twenties, somewhere around half a minute. At least forty.

"Mrs. B?" I laid a hand on her shoulder. She didn't turn. Just the rapid rise and fall of the head. Her shoulder was clammy, her gown damp. Was she febrile? Was there something I'd missed? Should I have gotten cultures? Hung antibiotics? Was she having a PE? The body on the bed wasn't telling. Only the same carrier wave of distress, up and down, up and down. I looked to the door, where the nurse was standing.

"Get Respiratory up here." She started to go. "And get me two of morphine."

The patient didn't resist this time. I don't know if she was even aware, but as the plunger went down on the syringe I could see a change in her; she settled and her breathing slowed. The pulse-ox, which had been in the mid-seventies, climbed up a notch or two, settled in the low eighties. I had no idea if that was something she could live with. I stood at the bedside and watched. Her respiratory rate was in the low thirties. An eye opened, swiveled around the room until it met mine. The mouth moved, no sound came out.

"Mrs. B," I said, and my tone was frankly pleading now, "you've got to let me help you."

The eye held my gaze for a long moment, the dim gleam of the nightlight streaking across the cornea. A hand made a brief sweeping gesture, fell. Away.

Somewhere in the course of the night I had developed a fixed idea: if I could get her to morning, it would be okay. I had no idea where that notion came from. Years later, after what seems like countless midnight vigils, the trust and hope of it chill me. But then I clung like a child to the thought of morning. In the morning, her primary team would be on hand; someone would know what to do. By the light of the morning, ill spirits flee. In the morning, it would be off my hands.

The respiratory tech was at the door.

"It isn't working," I said.

The tech didn't actually shrug. "You don't think you can tube her?"

"I can't," I gritted out. "DNI."

"BiPAP?"

"I can't get her to wear an ordinary face mask."

"Why don't you just snow her?"

It was a thought. She hadn't refused the morphine. I could try adding on sedation until she would let me put a mask on her—perhaps even a tight-fitting BiPAP mask, the next-best thing to intubation. It could be done.

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.