You Can Stop Humming Now

Nearly halfway through my first year as a doctor, I became Facebook friends with a young man who was dying in the cardiac intensive care unit.

Sam Newman was twenty-eight years old and his heart was failing. When his doctors realized that he was too sick to be cared for in the New Jersey community hospital close to his home, they had started to make phone calls to surrounding hospitals, hoping to send the young man out to the nearest tertiary care medical center. I’m not sure how long it took for them to find a willing institution with the necessary specialists and an open bed. But what I do know is that one night that winter, an ambulance carried Sam Newman, his fear, and the vague hope of a heart transplant to the cardiac intensive care unit at New York Presbyterian Hospital, where I was in the midst of my cardiac ICU rotation. I had been a doctor for just shy of six months.

I wasn’t on call when Sam arrived. I was at home in my apartment, trying to sleep, but failing. I was so tired that year—an anxious kind of tired in which I could doze off despite being squished between strangers in the middle of a crowded subway car and miss my stop, but when I finally got into bed at night, all I could do was toss and turn. Those sleepless nights were so frustrating that I was half relieved when I saw my watch tick toward 5 a.m., because it meant I could officially wake up, get into the shower, and start readying myself for the day. That morning, when I arrived at the hospital, I took my place in the semicircle assembled outside one of the patient rooms to begin our daily ICU rounds. We always started with the sickest or most complicated new admission and finished with the patient who required the least of our waning energy, the person who had been in the unit for days and was simply awaiting a bed on the general medical floor or transfer to a rehab hospital. Sam Newman was both the sickest and the most complicated one on our list that morning, so the room we stood in front of was his.

The bleary-eyed intern who had admitted Sam overnight stood slightly forward, in the middle of the group. A few eager medical students clustered nearby, hoping to have the opportunity to show off what they’d memorized. A perky, well-dressed pharmacist was poised at attention, ready to block our inadvertent attempts to overdose our patients on antibiotics, potassium supplements, or sedatives. I took my place with the rest of the first-year doctors and our second-year supervisors in our uniform of white coats with yellowed collars, T-shirts, and rumpled scrub pants. We faced what seemed to me to be an impossible task of trying simultaneously to listen to our new patient’s history, place orders for the meds he’d need throughout the day, field corrections on the meds from the pharmacist, and tune out the noise.

Sometimes the background noise of critical illness was all I could hear. There was the strangely melodic crescendo-decrescendo do-do-do-do-do of the ventilator, the rhythmic staccato of heart rate monitors, the whooshing of the Zamboni-like vacuum that seemed programmed to clean the floor during the most emotional moments of a hushed family conversation. Every now and then a nurse would come by and pluck one of us interns away, to clarify a medication order or to transport a patient to a CT scan or even to declare a person dead. The best I could do, most of the time, was to hope I’d absorb the highlights. I’d been a doctor for nearly half a year, and I had almost forgotten what it might be like to hear a person’s story in its entirety. In its place, I’d learned to distill each patient into a set of check boxes on a to-do list called the Scut List that we would plod through over the course of the day. There was no before or after; there was just the Scut List and the tasks that we needed to finish before I could go home. Narrative, like full nights of sleep, had faded into memory.

But that day I heard “twenty-eight years old,” and the beeping of the ventilators and heart rate monitors, the whooshing of the Zamboni, and the dank smell of human sickness all faded to the background. This patient and I were nearly the same age. And so even though my co-intern launched into our new patient’s history in the clipped tones and terse language we’d perfected throughout that summer and fall—“This is a twenty-eight-year-old man who was in his usual state of good health until one year ago, when he developed lower-extremity edema”—I found myself, for what seemed like the first time since medical school, actually listening and creating a story.

Sam Newman was putting in long hours as an investment banker when he started to notice that his ankles were swollen at the end of the day. He wondered if it was because he was spending too much time sitting. Or maybe it was from drinking. With all that stress at work, he had been going at it a little hard. He’d cut down on beer and get back on the basketball court if he ever found the time. But then the swelling got worse. He woke up in the middle of the night, sweaty and gasping for air as if he were suffocating. He had to sit bolt upright before he could breathe again. “His lower-extremity edema increased, newly accompanied by orthopnea,” my co-intern recited. Sam thought it might be panic attacks. The job was really getting to him. He must have been so scared, I thought as I stood outside his door that morning. A buddy at work told him he was fine and he should stop acting crazy, but gave him the name of a local doctor just in case. Sam waited a few weeks before finally squeezing in an appointment one morning. The internist must have assumed, as I would have, that this young guy with a demanding job was just stressed. He would have heard Sam’s story and nodded reassuringly. I imagined how he must have placed the stethoscope against Sam’s chest to listen to his lungs, casually at first, the way you do when you know it’s fine, fully expecting the lungs to sound clear. But instead of the strong, unencumbered breaths of a young man, he heard a crackling through his stethoscope, like the sound hair makes if you rub it between your fingers. Fluid had filled the lungs’ delicate air sacs. The doctor’s expression would have changed ever so slightly, his jaw tightening and the room going still.

“Just give me a cough,” he might have instructed his patient, still disbelieving, hoping the sounds would clear and things would proceed as he’d expected them to—a quick exam, a healthy young man. Sam coughed. He felt nervous without knowing why. “Is everything okay?” he asked. But his doctor was quiet. He was already listening, his face intense and eyes unreadable as his mind shifted into focus. He leaned down again and felt the legs. The slight swelling, so easy to dismiss moments before, now took on a whole new meaning.

The doctor did not tell Sam the extent of his worry, not at first, because there was no point in upsetting the young man before gathering more information. Sam was scared, too scared to ask questions because he did not even know what he should be afraid of and he didn’t want the answers, so their conversation was brief. Sam would get a chest X-ray the same day. When the image came back hazy with fluid that had filled his lungs, Sam returned for an ultrasound of his heart, which revealed that the muscle was beating at only half of the strength predicted. The doctor called Sam with that news and told him he would have to go into the hospital. When he heard Sam’s breath quicken on the other end of the line, all he wanted was to reassure his patient, and so the doctor kept talking, filling the silence. He told Sam that it was probably just a virus that had affected his heart, and if that was the case, then it could pass, as viruses do, and Sam would get better. So Sam focused on this idea of a virus and told his boss at work that he would have to take a couple of days off, something about a virus, but that he would be fine. He called his mother, too, and though he spoke in generalities, she understood enough that her stomach sank and her hands shook and she started to cry, even when he told her it was probably just a random virus, that he’d get better soon, and so she shouldn’t worry.

He didn’t get better. He left the hospital with a set of prescriptions, and his mother bought him a pillbox and brought it over to his apartment. She arranged her adult son’s medications by morning and evening for the seven days of the week. Two weeks of meds passed. Then there was a biopsy. Sam lay on the cardiac catheterization table, feet dangling over the edge, cold and scared and uncomfortable. His doctors placed a thick catheter into his neck, into the large internal jugular vein that sits next to the carotid artery. They threaded a smaller catheter with little jaws at the end down to his heart to steal a microscopic piece of the muscle for the pathologists to inspect. Finally, there was a diagnosis. It wasn’t a virus at all. It wasn’t something that would pass. Sam’s immune system had decided to attack itself, and none of the pills he kept in the box his mother had bought for him, not the high-dose steroids his doctors prescribed nor the host of other meds—each with its own side effects that he tolerated wordlessly, belly pain and numbness and infections—could stop it.

His heart grew so sick that instead of working in sync to pump blood through his body, the chambers started to move in a dangerous rhythm called ventricular tachycardia. The doctors gave him improbably high doses of medications to calm this storm inside him, and when that did not help either, they implanted a machine under his skin, called a cardioverter defibrillator, so that when his heart slipped into this potentially lethal rhythm, a jolt of electricity would shock it back into its normal pattern. The first time it happened, it felt as if a bomb had gone off. Now the shocks were coming more and more frequently, and so he had been sent from the hospital near his home to our medical center in the hope that our team of experts could take care of him. He had been shocked by his defibrillator three times since he had arrived the night before—he might have died, that is, three times before being brought back with jolts of electricity. And we were to keep him alive while he waited for a heart transplant.

My father is a cardiologist, and when I was growing up, I liked to play with his model of the heart. It was heavy and intricate, and each of the heart’s four chambers opened with a silver latch that allowed me to look inside. My father taught me the name of each part. I learned how blood travels from the body to the right atrium, through a valve to the right ventricle below it, and then out to the lungs to pick up oxygen before returning to the left side, where the pattern continues again—atrium, ventricle, out to the body. Years later, in medical school, when we cut open a cadaver and lifted the heart from its silent cage, it was beautiful and unreal. But that morning, standing outside Sam Newman’s room, it was clear to me that there would be no poetry or metaphor. There was only this.

As my co-residents pored over our twenty-eight-year-old patient’s electrocardiogram, jockeying to see who could name the most arcane of abnormalities in the simple tracing of his heart’s rhythm, I glanced around the half-drawn curtain into the young man’s room. I watched our patient lean over and pull out a laptop from the drawer next to his bed. I felt my own heart pounding, regular and insistent. Three times overnight this young man could have died, and yet there he was, alive and trying to navigate the hospital’s wireless network to get on the Internet.

Sam Newman was hands down the most interesting patient in the ICU. “A great learning case,” my attending pronounced that first morning. Sam was young and had a particularly nasty form of a rare disease, so I should have fought for the opportunity to be involved in even the most banal aspects of his day-to-day care. But this young man scared me. And so I avoided him. It was easy to do, at first. When we split up the daily Scut List tasks, I simply claimed the blood draws and transports and phone calls for the other patients. But one day my resident told me that the intravenous line in Sam’s neck needed to come out. He had started to spike fevers, we didn’t know where they were coming from, and since the catheter could represent the entry point for bacteria, one of us had to pull it. I was the intern in charge of procedures that day, so the job was mine. I put it off all morning and through our lunch of tuna fish and chicken salad sandwiches, hoping that the fevers would subside or the empty “Pull Line” box on the list would somehow disappear. But by 1 p.m., that box was still empty. “I’m going to go pull the line now,” I announced to no one in particular. I grabbed one of the pale yellow gowns we wear over our clothes to keep us from transferring antibiotic-resistant bacteria from patient to patient, and stepped into his room.

I had seen him on rounds each morning, but those exams were brief, and he was often half asleep. Now, for the first time, I took in my patient. His face was swollen and his arms were bruised from the steroids that had done nothing to stop his heart’s self-destruction. He was wearing a hospital gown and compression devices on his legs to prevent blood clots. Hopeful get-well cards bearing inspirational Hallmark-style messages covered the bedside table.

“Hey,” I said. “I’m Daniela, one of the interns. I’ve seen you on morning rounds, but you’ve generally been sleeping.”

He was typing on his laptop and barely looked up from the screen. I told him that we needed to take out his central line because it might be the source of his fevers. He shrugged, which I took as assent.

“So, here’s what I’m going to do,” I explained. “I’m just going to cut out the stitches. That might hurt a little. And then I’ll pull out the line and hold pressure on your neck until it stops bleeding.” He might bleed for a while—the fluid that his heart couldn’t pump had settled in his liver, and as a result, his body wasn’t working well to make his blood clot. I didn’t tell him this. Instead, I told him that I was going to ask him to help me out by doing something.

“When I pull, I’m going to ask you to hum,” I said.

He looked up from his computer. “Hum?” It was the first time I’d heard his voice. He sounded so regular that I felt my heart break a little. I explained that by humming, he would increase the pressure in his chest. This would decrease the chance that in the moment I pulled out the intravenous line, before I covered the tiny hole it would leave with a piece of gauze, an air bubble might enter his body, travel to his heart, and kill him before his disease would.

“Okay,” he said. “Hum.” He looked amused. We had asked so much of him, and this must have seemed silly in contrast. He closed his laptop and set it down on the bedside table. “I can do that.”

I leaned over and gently peeled off the dressing that covered the spot where the line entered his neck.  I used tiny forceps to lift the stitches and then cut them, one by one. I had to lean in so close that I could hear him breathing. He smelled warm and a little bit like sweat, but not bad. It was time to take out the line. I lowered the head of his bed. “You all right with that?” I asked. “Uh-huh,” he said.

“One, two, three. Okay now! Start humming.”

“Mmmmmmmm…”