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On Medicine : The Rules of the Doctor’s Heart

M. was on this list of supplicants. His own heart, meanwhile, was failing so precipitously that he needed constant medical monitoring. Weird, deadly electrical rhythms arose out of his dying cardiac muscles, like ripples on a stagnating pond, necessitating defibrillating shocks to reset his rhythm. Fluid pooled in his feet, and the skin on his calves came off in strips.

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Photo illustration by Cristiana Couceiro

There was a second reason to monitor M.’s status. Hearts are so rare that patients have to be under constant surveillance to ensure that they continue to “qualify” for the transplant. Transplantation is a touch-and-go procedure; a patient on the wait-list must be in the best possible condition before receiving the donor organ. An innocuous-seeming infection, or kidney failure, can spiral out of control after the transplant. “If it’s bad now, it’ll only be worse later,” the transplant nurse told me, grimly. She was efficient-looking, dressed in a white nursing smock. She noted M.’s vital signs and then disappeared down the corridor with her book.

And so we watched him. Every vital sign — temperature, respiratory rate, heart rate — was dutifully recorded in the log books and on the resident’s notes. I was on call every third night. I would stop by to say hello to M. and wait for the transplant nurse to come around. He would be puzzling over 40-across on the Sunday crossword. She would check his numbers. “Maybe there will be one tonight,” she would say, before signing off for the day.

It must have been on the third or fourth week of M.’s hospitalization, sometime late in the evening, that the transplant unit called up to the I.C.U. A kid had dead-ended his motorcycle on a concrete barrier on the expressway. He was declared brain-dead shortly after the accident, but his heart was intact. M. was on the top of the transplant list. I half-ran, half-walked to his room to bring him the news. He had been dozing through most of the day and night — a sign, perhaps, that he was having trouble pumping blood to his brain. He woke up, smiled wearily and then drifted off to sleep again.

Around midnight, I was paged to the unit. “He’s spiked a small fever,” the unit nurse said. She tried to look at me blandly. “It’s nothing,” she wanted me to say. “It’s not real. Nothing to see here, folks. Get back to work.”

“How small?”

“101.”

“Well, let’s retake the temperature.”

She measured it again. 101.

His systolic blood pressure had also dropped ever so slightly — a few, barely discernible notches. But his pressures had always been low.

I paused for a moment, weighing my choices. “Try another thermometer. And check the pressure again. Actually, let’s wait and try in 10 minutes.”

She brought another instrument out from the nurse’s station. M. began to sense the slowly building hubbub in the unit. He sat up woozily.

“Do you feel anything wrong? A chill?”

“Nope,” he said. “Nothing.”

I examined him, pore by pore, looking for a potential source.

The nurse entered the room and made a tiny motion to see her outside. I met her by the nurse’s station. “Should we record the temperature?” she asked, whispering, as if the intercom might be eavesdropping.

The stakes could not have been clearer to both of us. If we put the number in the chart, M. would temporarily fall off the list for the next morning. The transplant surgeons at this hospital, I knew, would never risk taking a febrile, potentially septic, patient to the operating room.

I felt paralyzed. Medicine depends on looking at data objectively, dispassionately; a decade of training had taught me that. But it also depends on understanding that tests can mislead us, that data can deceive: What patient ever fits squarely into an assigned box? My fingers hovered above the computer, where I was meant to write my note and record the fateful temperature spike, but I found that I couldn’t type a word.

At 1 a.m., I called the attending physician. I felt foolish: I imagined her scuffling around her nightstand for her spectacles, anticipating a question about an acute cardiac crisis. Instead, there was a mumbling, hesitant resident trying to decide whether to write a note. But she understood immediately. She walked through the details of the case. Had I really evaluated the infection? Yes, yes, I reassured her — or rather, tried to reassure myself.

“It’s really your decision, Sid,” she said. “But you’ve got to consider that in some other hospital, there’s some other young guy — a doctor, with a Ph.D. — waiting for that same heart. If your patient goes to the O.R. infected, he’s not going to make it, and the new heart is going to die with him.”

I put the phone down and turned to the nurse. The fever had come down to 100 degrees. What if we hadn’t measured it in the first place? What if we’d forgotten to take the vitals on one shift? How about all the things we don’t measure? Muscle tone? Wakefulness? If a temperature spikes in a forest. …

I returned to the computer, tried to type my note, hesitated and stopped again.

I wrote my final note at 2 in the morning. Temperature: 101 degrees, currently 100. No obvious source of infection. A chest X-ray showed no signs of a pneumonia. A complete history and physical exam was unrevealing. Awaiting blood-culture data.

At rounds the next morning, I felt as if I had let the team down. I presented the case quietly, feeling the eyes of my co-residents burning holes into my skull. No one had any questions.

There were just a few more days left in the rotation, and I went to say goodbye to M. His fever had subsided on its own after that overnight spike. “I’m sorry,” I said, and he nodded.

M. died of a fatal arrhythmia a few weeks later. No other heart became available. The fever never returned.

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