Sample text for My own country : a doctor's story / Abraham Verghese.



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SUMMER, 1985. A young man is driving down from New York to visit his parents in Johnson City, Tennessee.

I can hear the radio playing. I can picture his parents waiting, his mother cooking his favorite food, his father pacing. I see the young man in my mind, despite the years that have passed; I can see him driving home along a route that he knows well and that I have traveled many times. He started before dawn. By the time it gets hot, he has reached Pennsylvania. Three hundred or so miles from home, he begins to feel his chest tighten.

He rolls up the windows. Soon, chills shake his body. He turns the heater on full blast; it is hard for him to keep his foot on the accelerator or his hands on the wheel.

By the time he reaches Virginia, the chills give way to a profuse sweat. Now he is burning up and he turns on the air conditioner, but the perspiration still soaks through his shirt and drips off his brow. His lungs feel heavy as if laden with buckshot. His breath is labored, weighted by fear and perhaps by the knowledge of the burden he is bringing to his parents. Maybe he thinks about taking the next exit off Interstate 81 and seeking help. But he knows that no one can help him, and the dread of finding himself sick and alone keeps him going. That and the desire for home.

I know this stretch of highway that cuts through the Virginia mountains; I know how the road rises, sheer rock on one side, how in places the kudzu takes over and seems to hold up a hillside, and how, in the early afternoon, the sun glares directly into the windshield. He would have seen hay rolled into tidy bundles, lined up on the edges of fields. And tobacco plants and sagging sheds with their rusted, corrugated-tin roofs and shutterless side-openings. It would have all been familiar, this country. His own country.

IN THE EARLY EVENING of August 11, 1985, he was rolled into the emergency room (ER) of the Johnson City Medical Center-the "Miracle Center," as we referred to it when we were interns. Puffing like an overheated steam engine, he was squeezing in forty-five breaths a minute. Or so Claire Bellamy, the nurse, told me later. It had shocked her to see a thirty-two-year-old man in such severe respiratory distress.

He sat bolt upright on the stretcher, his arms propped behind him like struts that braced his heaving chest. His blond hair was wet and stuck to his forehead; his skin, Claire recalled, was gunmetal gray, his lips and nail beds blue.

She had slapped an oxygen mask on him and hollered for someone to pull the duty physician away from the wound he was suturing. A genuine emergency was at hand, something she realized, even as it overtook her, she was not fully comprehending. She knew what it was not: it was not severe asthma, status asthmaticus; it was not a heart attack. She could not stop to take it all in. Everything was happening too quickly.

With every breath he sucked in, his nostrils flared. The strap muscles of his neck stood out like cables. He pursed his lips when he exhaled, as if he was loath to let the oxygen go, hanging on to it as long as he could.

Electrodes placed on his chest and hooked to a monitor showed his heart fluttering at a desperate 160 beats per minute.

On his chest x-ray, the lungs that should have been dark as the night were instead whited out by a veritable snowstorm.

My friend Ray, a pulmonary physician, was immediately summoned. While Ray listened to his chest, the phlebotomist drew blood for serum electrolytes and red and white blood cell counts. The respiratory therapist punctured the radial artery at the wrist to measure blood oxygen levels. Claire started an intravenous line. And the young man slumped on the stretcher. He stopped breathing.

Claire punched the "Code Blue" button on the cubicle wall and an operator's voice sounded through the six-story hospital building: "Code Blue, emergency room!"

The code team-an intern, a senior resident, two intensive care unit nurses, a respiratory therapist, a pharmacist-thundered down the hallway.

Patients in their rooms watching TV sat up in their beds; visitors froze in place in the corridors.

More doctors arrived; some came in street clothes, having heard the call as they headed for the parking lot. Others came in scrub suits. Ray was "running" the code; he called for boluses of bicarbonate and epinephrine, for a second intravenous line to be secured, and for Claire to increase the vigor but slow down the rate of her chest compressions.

The code team took their positions. The beefy intern with Nautilus shoulders took off his jacket and climbed onto a step stool. He moved in just as Claire stepped back, picking up the rhythm of chest compression without missing a beat, calling the cadence out loud. With locked elbows, one palm over the back of the other, he squished the heart between breastbone and spine, trying to squirt enough blood out of it to supply the brain.

The ER physician unbuttoned the young man's pants and cut away the underwear, now soiled with urine. His fingers reached for the groin, feeling for the femoral artery to assess the adequacy of the chest compressions.

A "crash cart" stocked with ampules of every variety, its defibrillator paddles charged and ready, stood at the foot of the bed as the pharmacist recorded each medication given and the exact time it was administered.

The clock above the stretcher had been automatically zeroed when the Code Blue was called. A code nurse called out the elapsed time at thirty-second intervals. The resident and another nurse from the code team probed with a needle for a vein to establish the second "line."

Ray "bagged" the patient with a tight-fitting mask and hand-held squeeze bag as the respiratory therapist readied an endotracheal tube and laryngoscope.

At a signal from Ray, the players froze in midair while he bent the young man's head back over the edge of the stretcher. Ray slid the laryngoscope in between tongue and palate and heaved up with his left hand, pulling the base of the tongue up and forward until the leafshaped epiglottis appeared.

Behind it, the light at the tip of the laryngoscope showed glimpses of the voice box and the vocal cords. With his right hand, Ray fed the endotracheal tube alongside the laryngoscope, down the back of the throat, past the epiglottis, and past the vocal cords-this part done almost blindly and with a prayer-and into the trachea. Then he connected the squeeze bag to the end of the endotracheal tube and watched the chest rise as he pumped air into the lungs. He nodded, giving the signal for the action to resume.

Now Ray listened with his stethoscope over both sides of the chest as the respiratory therapist bagged the limp young man. He listened for the muffled whoosh of air, listened to see if it was equally loud over both lungs.

He heard sounds only over the right lung. The tube had gone down the right main bronchus, a straighter shot than the left.

He pulled the tube back an inch, listened again, and heard air entering both sides. The tube was sitting above the carina, above the point where the trachea bifurcates. He called for another chest x-ray; a radiopaque marker at the end of the tube would confirm its exact position.

With a syringe he inflated the balloon cuff at the end of the endotracheal tube that would keep it snugly in the trachea. Claire wound tape around the tube and plastered it down across the young man's cheeks and behind his neck.

The blue in the young man's skin began to wash out and a faint pink appeared in his cheeks. The ECG machine, which had spewed paper into a curly mound on the floor, now showed the original rapid heart rhythm restored.

At this point the young man was alive again, but just barely. The Code Blue had been a success.

In no time, the young man was moved to the intensive care unit (ICU) and hooked up via the endotracheal tube to a machine that looked like a top-loading washer, gauges and dials covering its flat surface. Its bellows took over the work of his tired diaphragm.

He came awake an hour later to the suffocating and gagging sensation of the endotracheal tube lodged in his throat. Even as the respirator tried to pump oxygen into his lungs, he bucked and resisted it, tried to cough out the tube. One can only imagine his terror at this awakening: naked, blazing light shining in his eyes, tubes in his mouth, tubes up his nose, tubes in his penis, transfixed by needles and probes stuck into his arms.

He must have wondered if this was hell.

THE MIRACLE CENTER ICU nurses who were experienced-at least in theory-with this sort of fright and dislocation, reassured him in loud tones. Because of the tube passing between his vocal cords and because his hands were tied to prevent his snatching at the tube (an automatic gesture in this setting), he could not communicate at all. With every passing second, his terror escalated. His heart rate rose quickly.

He was immediately sedated with a bolus of morphine injected into one of his lines. He was paralyzed with a curarelike agent, a cousin of the paste used on arrow-tips by indigenous tribes in the Amazon. As the drug shot through his circulation and reached the billions of junctions where nerve met and directed muscle, it blocked all signals and he lay utterly still and flaccid.

The respirator sent breaths into him with rhythmic precision at the rate dialed in by Ray, even throwing in a mechanical sigh-a breath larger than usual-to recruit and keep patent the air sacs in the base of the lung.

THE YOUNG MAN'S PARENTS now arrived at the hospital and were escorted up to their son's bedside. They had been waiting for him at home. Now they stood, I was told, in utter disbelief, trying to see their son through the forest of intravenous poles and the thicket of tubing and wires that covered him, asking again and again what had happened. And why?

By the next day the pneumonia had progressed. His lungs were even stiffer, making the respirator work overtime to drive oxygen into him. Ray performed a bronchoscopy, sliding a fiberoptic device into the endotracheal tube. Through the bronchoscope he could see the glossy red lining of the trachea and the bronchi. All looked normal. He directed the bronchoscope as far out as it would go, then passed a biopsy forceps through it and took a blind bite of the air sacs of the lung.

Under the microscope, the honeycomblike air spaces of the lung were congealed with a syrupy outpouring of inflammatory fluid and cells. Embedded in this matrix were thousands upon thousands of tiny, darkly staining, flying-saucerlike discs that the pathologist identified as Pneumocystis carinii.

The young man had no predisposing illness like leukemia or cancer that would explain this fulminant pneumonia caused by an innocuous organism.

His immune system had to be abnormal.

It was clear, though no one had yet seen a case, that he was Johnson City's first case of the acquired immune deficiency syndrome-AIDS.

Word spread like wildfire through the hospital. All those involved in his care in the ER and ICU agonized over their exposure.

The intern remembered his palms pressed against the clammy breast as he performed closed-chest massage.

Claire remembered starting the intravenous line and having blood trickle out and touch her ungloved skin.

The respiratory therapist recalled the fine spray that landed on his face as he suctioned the tracheal tube.

The emergency room physician recalled the sweat and the wet underwear his fingers encountered as he sought out the femoral artery.

Even those who had not touched the young man-the pharmacist, the orderlies, the transport personnel-were alarmed.

Ray worried too; he had been exposed as much as anyone. In the days to follow, he was stopped again and again in the corridor by people quizzing him about the danger, about their exposure. Ray even felt some anger directed at him. As if he, who had done everything right and diagnosed the case in short order, could have prevented this or warned them.

An ICU nurse told me that the young man's room took on a special aura. In the way a grisly murder or the viewing of an apparition can transform an otherwise ordinary abode, so cubicle 7C was forever transformed. Doctors and others in the ICU peeked through the glass, watching the inert body of the young man. His father was seated beside him. The hometown boy was now regarded as an alien, the father an object of pity.

Ray told me how the parents took the news. The mother froze, staring at Ray's lips as if he was speaking a foreign language. The father turned away, only the sound of his footsteps breaking the silence as he walked out into the corridor and on out into the parking lot, unable to stay in the building where that word had been uttered.

Much later, the father asked, "But how did he get it? How could he have gotten this?"

Ray pointed out that he had had no time to get a history: perhaps they could give him some information. Had their son been healthy in the past year and in the days preceding the trip? Lord, yes! (The father did all the answering.) Did he ever use intravenous drugs? Lord, no! And to their knowledge had he ever had a blood transfusion?


Was he married?


Did he live alone? No, he had a friend in New York.

A male friend? Yes . . . they had never met him.

"Oh Lord! Is that what you're saying? Is that how he got it? Is my son a queer?"

Ray just stood there, unable to respond to the father's words.

The father turned to his wife and said, "Mother, do you hear this? Do you hear this?"

She gazed at the floor, nodding slowly, confirming finally what she had always known.

THE MOTHER NEVER LEFT THE ICU or her son's side. And in a day or so, the father also rallied around his son, spending long hours with him, holding his hand, talking to him. Behind the glass one could watch as the father bent over his son, his lips moving soundlessly.

He balked when his son's buddies flew down from New York. He was angry, on the verge of a violent outburst. This was all too much. This nightmare, these city boys, this new world that had suddenly engulfed his family.

Ray tried to mediate. But only when it seemed his boy's death was inevitable did the father relent and allow the New Yorkers near him. He guarded the space around his son, marshaling his protection.

Library of Congress subject headings for this publication: AIDS (Disease) Social aspects Tennessee Johnson City