One morning Dr. Freeman woke up in somebody else’s bed. Well, at least it wasn’t his bed. It smelled like bleach, and the mattress inflated and deflated at sporadic intervals. The sheets were thin and scratchy, and his feet poked out from under the blanket. He could hear a familiar beeping noise that didn’t immediately register. He also heard a thumping sound that occurred with the regularity of a heartbeat. He was able to half open his eyes, but everything was out of focus. What was most concerning, however, was the tube coming out of his mouth. It was pushing air into his chest, and right as his chest wall began to relax, the tube delivered another gust. He tried to blow his air out, but burst after burst of air forced its way into his lungs, until he felt they were going to explode. He started to gag forcefully in an effort to expel the tube, but it was in vain. He heard a loud alarm sound from the machine to his left, and a short woman in a white shirt quickly came into the room, pushed some buttons on an IV pump, and then Dr. Freeman felt very sleepy.


“Tom,” someone said. Dr. Freeman stirred. “Tom, can you hear me?” Dr. Freeman recognized the voice. It was his colleague, Dr. Quincy. “Tom, I know you probably can’t hear me, but our intern is going to quickly update me about your hospital course, okay? Go ahead, Dr. Jensen.”

Dr. Freeman heard a squeaky voice, “Mr. Freeman, ahem, I mean, Dr. Freeman, is a 73-year-old man with a past medical history of hyper- tension, dyslipidemia and alcoholism, who was found down in front of his home 4 days ago. He was transported by EMS to the hospital, where he was found to have an anterior ST-elevation myocardial infarction. He was taken to the cath lab emergently and received two stents to the left anterior descending artery. His course has been complicated by cardiogenic shock requiring dobutamine, norepinephrine and vasopressin and an intra-aortic balloon pump. He has also developed respiratory failure, alcohol withdrawal and an upper gastrointestinal bleed. In the last 24 hours . . .”

Heart attack? thought Dr. Freeman. You’ve gotta be kidding me! I’m a cardiologist! Who does this bozo think he is? And I am NOT an alcoholic!

 “Okay, Tom, we’re just going to examine you now,” said Dr. Quincy. Dr. Freeman felt the cool rim of a stethoscope rest on his bare chest.

“Did you hear the S3 gallop?” asked Dr. Quincy. “It sounds like ‘Ken- tuck-y, Ken-tuck-y, Ken-tuck-y.’ Coincidentally, it also sounds like the introduction to the U2 song, Beautiful Day. What does an S3 sound indicate, Dr. Jensen?”

Dr. Freeman heard that same squeaky voice. “It means the patient has heart failure.”

“What did the echocardiogram show?” asked Dr. Quincy.

“He had an ejection fraction of 20%, with an aneurysm of the apex,” replied Dr. Jensen.

“What other exam findings suggest that Dr. Freeman has heart failure?” asked Dr. Quincy.

“Well,” squeaked Dr. Jensen. “He has cool extremities with poor capillary refill.” Dr. Jensen squinted like he was thinking hard. “He has narrow pulse pressure too.” Then a light went off in his eyes. “He also has jugular venous distention to the angle of his jaw.”

“How would you describe that distention in millimeters of mercury?” asked Dr. Quincy.

Who the hell cares? thought Dr. Freeman. You sound like a raving lunatic, Quincy. I’m on a balloon pump for crying out loud. Stop torturing that idiot house officer.

“Let me teach you a trick that Dr. Freeman actually taught me when I was a cardiology fellow. You take the elevation in jugular venous pressure in centimeters of water, divide by 1.3 . . .”

Look, Quincy, thought Dr. Freeman, I’m touched that you were so moved by my exposition of jugular venous pressure, but seriously, what is going on here? I’m on inotropes and pressors and a ventilator. How about you skip to the part where you’re going to cure me.

Several minutes passed as Dr. Quincy reviewed exam findings, labs, electrocardiograms, and imaging with the residents and fellows. Fi- nally the exhausted Dr. Jensen got to the pinnacle of the presentation, the “assessment and plan.”

“In summary, Dr. Freeman has cardiogenic shock secondary to a transmural infarction. He is not improving on the balloon pump, inotropes or pressors alone. His systolic pressures are low and his urine output has dropped off over the last two days. He needs more mechanical support, like a left ventricular assist device. However, given his age, alcoholism and lack of social support, the LVAD team does not feel he is a candidate.”

Whoa, whoa, whoa! Given my age?! I’m only 73, you moron! I’ve got YEARS of life ahead of me. And why are you perseverating on this alcoholism thing? I’m not some low-life junkie out there drinking hand sanitizer. So what if I like the finer things in life?  I’m a connoisseur, not a wino! As for my “lack of social support . . . “

“Has anyone been in touch with his family?” asked Dr. Quincy.

“Dr. Freeman is single. Di- vorced times three. He has one estranged daughter back east, but no one has been able to reach her,” replied Dr. Jensen.

“Well, team, you’re doing everything you can,” started Dr. Quincy. “You are to be com- mended for that. It’s rather tragic, really. Dr. Freeman was a great man. But let’s not give up yet. It’s not time to pull the plug. Why don’t we go up on the lasix drip and add chlorothiazide. Do we have any room to go up on the dobuta- mine?”

Dr. Freeman didn’t hear the intern’s response. The team shuffled out of the room, reaching for the hand sanitizer by the door on their way out.  Dr. Freeman lay motionless.  The only sound in the room was the constant thumping of the balloon pump and the breaths of the ventilator. He thought back to the night eleven years before when his daughter, Rebecca, had told him she wanted to marry a man she met in law school. He had made some offensive remark about the man’s ethnicity. “He probably just wants to marry you so he can stay in this country.”

He remembered seeing the hurt in her eyes, but he didn’t stop. Re- becca patiently waited until her father’s diatribe was over, and then walked to the front door. That was the last time he had talked to her. He thought about the wedding invitation still sitting on his dresser at home, and the apology letter he had written, but never sent. He had never met his two granddaughters, and now it looked like he never would. R


An internal medicine resident at the University of Utah and will be joining their hospitalist group in the summer of 2017. He lives in Salt Lake City with his wife and two children.