Woe, destruction, ruin, and decay; the worst is death, and death will have his day (Shakespeare, Richard ll)

Authors note: Part 1 is a fictional vignette designed to set the table and soften the topic of AIDS before we delve into Dr. Gottlieb's life story.

He awoke with a start and sat bolt upright in bed in one swift, disorienting movement, placing both hands on his forehead like a drunk with a raging hangover. It was pitch black save for a thin strip of light seeping from under the call-room door. The beeper chirped again. It was only then that he knew where he was and what had awoken him. He silenced it, read the message and for the hundredth time restrained himself from flinging the beeper against the wall. Oh, the satisfaction of that one simple act. One day. Standing up, he tightened the draw strings on his scrub bottoms and tucked in his shirt. He was losing weight. Stress, he thought. His skin was sticky, and the room smelled like body odor mixed with stale donuts and spilled coffee, even though the room appeared clean. The nausea hit him, like it always did this time of night, and he placed a soothing hand over his stomach and rubbed. He checked the time. He had been asleep for little over an hour.

Sometimes it’s worse to sleep, and this is one of those times, he knew, as he ambled over to the wash basin and splashed his face with cold, refreshing water and then began the long, lonely trek over to the ICU.

“Hi, Dr. Smith,” said the charge nurse, a short, rotund woman of notorious ill-temperament. Her words seemed a little too rosy for 3 AM. “Those charts you need to sign are still in the corner over there,” she said, nodding her head at the pile. He glanced over at the charts and acknowledged them, just to be polite. The absurdity of asking someone to do charts at this hour. No wonder they stuck her on the night shift, as far away from others as possible. There was a commotion inside ICU 5 and instinct told him that was his destination.

He stood in the doorway and took in the scene. His eyes flicked over the data streaming on the monitor, which was alarming due to a faster than normal heart rate and a lower-than-normal blood pressure. He noticed the oxygen saturation was extremely low, just 84% despite the 15 liters of oxygen flowing out of the wall unit, through the tubing, and into the face mask strapped around the patient’s head. His eyes shifted to the RN, Carli, and they lingered there a bit. She had on loose fitting scrubs that were trying, and failing, to hide her curves. God, what a doll, he thought, and she knew it, too. She also knew he was married, but that hadn’t stopped her inquiring where his call-room was a few months back. He had ignored her. It was the best way to put an end to that kind of stuff before it even began.

She could tell, without looking, in that weird way girls know, that he was staring at her. “Trainwreck. Just arrived an hour ago from the ER. Going down the tubes real fast the last 15 minutes or so,” she said, pursing her full lips and blowing long, wispy, brown bangs off her face. Two other nurses were busy at bedside, one helping start a new large bore IV despite the movement of the patient's arm and the other was trying to hold the patient’s torso down while Carli reconnected the telemetry leads. The patient was agitated, and ripping the leads off just as fast as Carli could replace them. The alarms continued their menacing shriek. Her body language suggested she was getting flustered.

As if reading his next thought, she said, “Intubation tray is just to your right, all ready to go if you need it, Dr. Smith.” It was said as a suggestion, but Smith knew it was just short of a command, but it was also obvious and needed to be done and fast. Her tone was also saying, wake up and let’s get a move on, Dr. Smith. He tuned out Carli, her curves, and the alarm bells, then took in the patient for the first time: Young. Maybe 35, tops. Hispanic. Very agitated and short of breath. Lips and fingernails cyanotic, or blue. The patient was gripping the beds handrails as if he were desperately trying to remain attached just a little longer, to this very bed, in this exact room, and on this very planet. His face was thin, with a panicked visage that rivaled the expression in Edward Munch’s The Scream. His brown eyes were sunken into deep, shadowy sockets, temples concave and wasted. He was emaciated, and he hadn’t gotten that way overnight, concluded Smith. Simple gold stud earring, right ear only. Left is right, right is wrong, he thought. Well, this is LA.

The patient’s chest was heaving violently up and down, even the neck muscles were at play, recruited by the brain in a desperate measure to help the struggling chest muscles expand the ribs and inflate the thorax. The tissues needed oxygen, and they weren’t getting enough. He placed his stethoscope over the chest and heard diffuse crackling in both lung fields. Abdomen was soft, scaphoid, or hollow, like a canoe. No enlargement of the liver or spleen. Something purplish on the left side of the abdomen. Curious. He peered in and dragged his hand over the lesion. Slightly raised. Not a birthmark. You could see the xiphoid close by puckering the skin. Taking it all in, he concluded he was like a skeleton that someone had stretched a layer of greyish-hued skin over. Christ! Like a camp victim. What does this guy have? No time to think about it now. Time to intubate. Carli stood by, waiting patiently and ready to assist.

Smith got behind the patient, lowered the head of the bed, and felt the neck. Supple. No evidence of meningitis or obvious cervical spine disorder. Before he could ask, Carli was handing him the Versed. He traced the clear tubing to the right arm and injected the drug into the side port. The patient relaxed immediately and let go of the handrails. Next came the succ’s, or succinylcholine, a strong paralytic agent. Same IV port. Done. Carli followed it with a saline chaser. The patient’s chest muscles relaxed, and the chest deflated. He could no longer breath on his own. He was fully paralyzed but still cognitively aware, and that was where the Versed fit in. Smith had to act fast, as the patient was no longer capable of oxygenating. With experience and fluidity, he extended the neck and inserted the laryngoscope into the oropharynx in one smooth motion, gave pressure to the cricothyroid area, and extended the scope further down into the laryngopharynx, where he slipped it under the vallecula and through the vocal cords. The cords showed no evidence of swelling or inflammation to suggest they were the cause of the patient’s respiratory distress. Given the snap, crackle and pop he heard on the lung exam, he already known this. With his free hand, he inserted a number 8 plastic endotracheal tube as far down as the carina, or bifurcation of the trachea, and then pulled it back 5 centimeters. He inflated the balloon to hold the tube in place, removed the laryngoscope, but as he was removing his hand, his finger nicked a chiseled tooth or sharp filling.

“Ouch!” A red dot began to enlarge on this pad of his finger. Carli saw the bloody finger tensely gripping the scope. Smith stepped back and away from the bed.

The respiratory therapist stepped in to suction and attach the patient to the ventilator. Smith listened to both sides of the chest for breath sounds, a confirmation the endotracheal tube was in good position. Satisfied, he hung his stethoscope back around his neck.

“Steve, at least put a pair of gloves on next time. I mean, did you see the gunk in that guy’s mouth?”

“I know, I know. It’s just that this is the way I trained. I like to feel the instruments in my hand. It’s hard to explain,” he said, demurely. She handed him a gauze and an alcohol swab and peered over. It was just a small puncture. “It happens.”

“Seriously, we are in the middle of LA. You don’t know what these people could have. They come from all over the world bringing whatever they have with them. You have to be more careful.”

“I promise,” he said, a little irritated.

“I mean, you’re the married one with the kid on the way.” She gave him an meaningful look before glancing at the monitor and titrating the norepinephrine drip upward to help raise the blood pressure to a mean arterial pressure of 55mmhg.

“Touche,” he said over his shoulder, as he walked out of the room and toward the sink to wash his hands. Carli would take care of the rest, and he would sign the orders in the morning as if he had ordered it all. She was incredible.

He got halfway to the sink, and she was calling him back in an urgent voice and he hustled back over to the room. The oxygen saturation, which had just come up with the intubation, had plummeted again. The respiratory tech was busy suctioning the lungs. “I think he just aspirated,” the tech said.

“I’m sucking up all this fluid from his lungs that wasn’t there just a minute ago. It looks like gastric juice.”

“Bradycardia, Dr. Smith.” Before he could say Atropine, Carli bellowed “Flat line. Code blue,” Carli yelled out to the monitor tech at the nurses station.

The PA system sparked to life. “Code blue, ICU 5. Code blue, ICU 5.” It was protocol. All the major players were already in the room but now the other ICU nurses poured in to help. “Get the back board. Let’s get it under the patient,” the charge nurse barked. “Let’s move people! Roll him on the count of three. One, two, three!” They heaved the patient onto his side and slid the backboard under him to create a firm surface for the CPR to follow. A big, burly male orderly began pumping on the frail chest. The red crash cart, which housed all the necessary medicine and equipment for a typical code, was being wheeled in and a continuous cardiac rhythm strip began to flow out of the defibrillator machine and curl onto the floor like a giant paper snake.

“One amp of EPI, Dr. Smith?” asked the bulldog-like charge nurse.“Yes, one amp, please. What do we have on the rhythm? Looks like a fine V fib. Let’s shock him.”

Carli finished pushing the epinephrine into the IV port using the meat of her palm for extra force and began to attach the defibrillator pads, right upper chest and left upper abdomen.

“Pads are on,” she said in a loud voice meant to stand out over the chaos of the code.

“Charge the paddles,” said Dr. Smith.

“Charging.” Then, “Charged, doctor.”

"Set to 100 Joules, please,” said Dr. Smith. “100 joules,” someone echoed in acknowledgement.

“Everybody clear,” barked Dr. Smith. Immediately everyone took a step back and looked up and down the bed, making sure no one was touching the patient or the bed. Dr. Smith discharged the paddles with a THUMP. The body jumped a good six inches off the bed. “Feel for a pulse,” commanded Dr. Smith.

“No pulse,” came the reply. Monitor still showed Ventricular fibrillation.

“Let’s do it again. 200 joules,” ordered Dr. Smith. “All clear.” THUMP. The body jumped again.

“Pulse?”

“No pulse.”

“Give me 360 Joules and an amp of lidocaine.”

“Paddles still charging. Hold on.”

“Lidocaine in. Still no pulse.”

“All clear.” THUMP. “Feel for a pulse.”

“No pulse.”

“Rhythm is asystole, Dr. Smith,” Carli called.

“Okay, let’s give another EPI and give an amp of Atropine. Let’s add an amp of bicarb while we’re at it.”

The code went on like that for another 20 minutes until everyone was weary and exhausted. At this point, Dr. Smith worried that in the unlikely event they were successful at reviving the patient, he would be a vegetable given the prolonged hypoxia, or lack of oxygenation to his brain. He hated to do it, especially with someone this young, but he finally said “Okay, people. That’s it. I’m calling it.

Time of death 3:46 AM.”“Note the time of death on the record,” said a weary looking charge nurse. Carli stayed to clean up and the other nurses scattered. They needed to check in on their own patients. Carli shut the monitors down and the room became silent, the chaos gone along with the patient. She helped him close his eyes for the very last time. His struggle, however it started, was over. He was no longer suffering. He was at peace.

A few hours later, Steve Smith was sitting in the doctor’s lounge waiting for his relief. He managed another hour or two of sleep before his beeper chirped and he again awoke with a start, sat bolt upright, and began the whole process all over again, nausea and all. He settled a little further into the beat-up couch and sighed. The ICU was hopping this morning but in 5 minutes it would no longer be his problem. He closed his eyes and thought about the emaciated young man from last night, which already seemed like a few days ago. Chest X ray was strange, not typical. Abnormal yes but didn’t look as bad as the degree of hypoxia, or lack of oxygen, suggested. The thick, tan dots of thrush filling the oral cavity. Don’t see that much except in chemo patients, he mused. The purple lesion on the abdomen. The wasted body. Why did he wait so long to come in? It was hard to understand these people, sometimes.

Just then, his relief came bounding through the door, chipper and energetic, and bopping to music only he could hear on the Sony Walkman propped around his head.

“The Police,” he said a little too loudly, pointing to his ear with equal exaggeration. He tossed his backpack onto the couch and sat down across from Smith looking fresh. “You’ve got to listen to this stuff, man. It’s far out. I know, I know. You like that Bee Gee’s and stuff but, man, disco is dead!

Haven’t you heard? No one’s diggin’ that anymore. It’s the 80’s now, man. They smashed up all those disco records at Comiskey Park two years ago, back in ’79. Didn’t you hear about that?” He looked at Smith and pulled his headphones down around his neck. “You look like crap! Seriously, Steve. You’re working like a resident!”

“I feel like crap, Peter, and I know, but Sarah’s tired of renting. We need to buy and moonlighting is the only way to scrape up the down payment.”

“Was Carli on last night,” he asked, changing the subject, a devilish smile creeping over his cherubic face.

“Yeah,” he replied, nonchalantly.

“Was she looking good?”

“Better than good. She had this thing going with her bangs.”

Peter looked at the ceiling and sighed.“We had a tough case, Carli and I, last night.”

“You see, you’ve got this surfer thing going. The tan, the vibe. God, I wish I were you. Life would be so much easier.”

“Pete, look at me. Does it look like I’m having an easy life.”

“Good point.”

“Besides, you would hate to be me. I love Barry Manilow; you love punk rock. I love to surf the

wave’s; you love to surf the shelves for Dostoyevsky and Tolstoy and Solzhenitsyn. I’m working days AND nights, and you’re boppin’ in here fresh and diggin’ life; you’ve got a great big smile on your face, you have energy, and I’m sweaty and sticky and I got that call-room odor that I know even a hot shower won’t take off my skin when I get home. Plus, I’m a big time capitalist and you’re a commie pinko!”

He thought it through. “Right on,” he conceded. “You need to get out there today, on the waves, at Manhattan or Dohany.”

“It’s…Doheny, Pete, not Dohany. Doheny.”

“So, you had a tough case last night?”

“Yeah, tough and weird. Had a young guy code. Came up from the ER in pretty bad shape. Surprised they didn’t tube him down there, although Carli said he looked bad but not that bad initially. Hispanic guy. 35. Profoundly hypoxic. Rales all the way up bilaterally. Chest x ray with diffuse interstitial infiltrates. Emaciated. Skin and bones. Tubed him. Then he aspirated and coded. Couldn’t bring him back. Oh, and had a mouth full of the worst thrush I’ve ever seen.”

“Interesting,” replied Peter. “Almost sounds like a guy I had a few months ago, except he wasn’t that emaciated. Young guy, early 40’s, also came in with a weird interstitial pneumonia that nobody could really figure out. Also had thrush. Threw the kitchen sink at him as far as antibiotics were concerned. Continued to deteriorate. Tubed. The works.”

“What happened to him?”

“I was off the next week but I think he passed away. Wasn’t there when I got back, anyway. I guess these cases are for better minds than us, my friend." He noticed the bloody bandage on his friend’s finger. Smith acknowledged his glance and said “Cut it in that guy’s mouth during the intubation. Maybe I cracked his tooth with the scope going in, I don’t know. If I did I wasn’t aware of it.”

“You’ll live.” Peter’s beeper chirped. He looked at it and sighed. “Well, time to go.”