We The Sleepers
Volume 22, No. 1, P. 16
Of all the patients I cared for during my internship, one group holds a special
place in my memory. I call them the sleepers – patients who lay motionless for
days or weeks at a time, their eyes closed and their arms resting peacefully at
their sides. These were my greatest burdens, yet caring for them gave me a sense
of transcendent power. Day after day, I attended to their every need, with no
clue from the souls who dwelled inside those still and silent bodies.
Maria Gonzales, the most beautiful of my sleepers, was six years old when I
admitted her to the neurosurgery service. She had dark eyes and magnificent dark
hair, but fate is seldom swayed by beauty. Vomiting and terrible headaches had
brought her to the hospital. My examination revealed choked discs, swelling of
the optic nerves caused by high intracranial pressure. Adrianna, the unmarried
aunt who brought Maria to the hospital, sat alone at the bedside for hours every
day, her face glowing with tenderness as she stroked the girl’s hair,
straightened her pillow, held a cup of water to her lips. I learned from a
social worker that Maria’s parents had deserted her soon after her birth.
The neurosurgery team had only an intern, a resident named Ron Goldstein, and a
tall, gaunt attending who had retired from the navy some years before. Ron and I
called him the Admiral. He carried a pipe, often chewed on the stem, though the
pipe was seldom lit. When Maria’s cerebral angiogram was completed, Ron laid out
her films on a view box. After a long, morbid silence, the Admiral spoke.
“Christ – look at that tumor blush in the left parietal lobe. It has to be a
“Yup,” Ron said, “no doubt about it.”
“We’d better start the Solu-Medrol,” the Admiral said.
“A hundred milligrams a day.”
We had nothing more to say. The child was doomed. Solu-Medrol, a form of
cortisone us for intravenous infusion, would lower her intracranial pressure and
relieve her headaches for a while, but no treatment known to medicine could stop
the tumor. It would soon devour the poor girl’s brain.
Maria’s headaches vanished. For a month, she ran up and down the pediatric ward,
spent hours watching TV and trading soft toys with the other kids in the
playroom. Every evening, Adrianna set the child on her lap to read a bedtime
story. When the headaches returned, Ron and I worked out the dosage of IV
morphine needed to control her pain, but this made her drowsy, and soon she took
to her bed. Adrianna now kept a round-the-clock vigil.
The nightmare seemed to go on and on. One morning while examining Maria, I
discovered lumps in her neck. The Admiral gently felt the lumps and shook his
head in amazement.
“I’ve never seen this before – the tumor has metastasized outside her skull.”
Two days later, Adrianna gave us more devastating news.
“Maria doesn’t wake up very often, but when she does, she says the headache is
terrible, and she claims she can’t see anything.”
The Admiral, his face grim as death, opened Maria’s lids with his fingers and
shined a flashlight into each eye. The light did not arouse the girl. Her
enormous pupils remained fixed and dilated.
“Yes,” he said, “I’m afraid the child is blind.”
Adrianna stood motionless, staring ahead as though blind herself. Silent tears
flowed down her cheeks. The Admiral gave her a hug. He seemed ready to speak
again, then shook his head and removed his arm from her shoulder. Ron and I
followed him down the hall to a conference room. He waited for us to enter, then
closed the door.
“Well,” the Admiral said, settling into a chair, “the Solu-Medrol doesn’t seem
to be working. We might as well stop it.”
“Yup,” Ron said. “That sounds like a good plan. I’ll write the order.”
Something about the idea bothered me. I probed my memory, seeking a fragment
retained from a textbook or a lecture.
“Ah, but wait,” I said. “Surely you don’t mean we should stop it all at once. A
hundred milligrams a day is enough to shut down her adrenals. If we just cut her
off cold, her blood pressure will drop like a rock. Shouldn’t we taper off her
dosage and give her adrenals time to recover?”
It was a proud moment. I had dredged up a gem, an erudite fact to save my
mentors from a dangerous lapse in their reasoning, but Ron and the Admiral
didn’t thank me. They gazed at me in silence. Perhaps they were embarrassed by
their lapse, or surprised by my precocious knowledge. The Admiral lit his pipe,
took a few puffs, grunted to himself and shook his head. Ron turned red in the
“Jesus Christ, Gamel,” he said. “How dumb can a man get? Did your mother have
any children that lived?”
The Admiral’s plan worked. Over the next thirty-six hours, Maria’s blood
pressure fell lower and lower. She died without regaining consciousness.
* * *
Granny Simpson, a seventy-year-old widow, distinguished herself as my most
bizarre sleeper. During the course of a week, she worked her way through a
cascade of life-threatening disasters, all the while urging us to stop the
treatments and let her die. Even her family opted for death, arguing that Granny
had suffered enough.
It started one night when ambulance attendants pulled Granny from her wrecked
Cadillac and brought her to our ER. She had ruptured her spleen on the steering
wheel. Lancy Allen, my senior resident that night, scheduled her for emergency
surgery, then typed and cross-matched six units of blood, but getting Granny to
the OR proved an uphill battle. She refused to sign the consent form, insisting
that she was a worn-out old woman with nothing left to live for. Soon her two
grown children showed up and gave Lancy the same story: Granny had been
depressed for years, insisting time and again she would be better off dead. Why
not let nature take its course?
Lancy was at his wits end. Since Granny smelled of liquor and had just suffered
a major trauma, she was in no condition to make a rational decision. The family
kept telling us the old lady was worn out and ready to die, yet before the
wreck, she had been in perfect health except for her depression. When Lancy
spoke to the hospital’s lawyer, he said we should go ahead with surgery. To do
otherwise, he insisted, would be nothing less than a mercy killing.
So we hauled Granny off to the OR kicking and screaming in protest. Her surgery
proved a close shave. The ruptured spleen had dumped pints of blood into her
abdomen, dropping her blood pressure to a critical level, where it stayed until
the anesthesiologist had given her several transfusions. The attending surgeon
thought her liver was enlarged, suggesting alcohol abuse. Lancy wouldn’t buy it.
True, she had liquor on her breath, but she had been well-dressed when brought
into the ER, and her children seemed solid members of the upper class.
Indeed, Granny didn’t look like a typical alcoholic, but on the third post-op
day, she went into florid delirium tremens. By the time I got her tremors and
hallucinations under control with a generous dose of intravenous valium, she
turned blue and began gasping for breath. A stat pulmonary consult diagnosed
shock lung caused by the prolonged drop in her blood pressure.
For any hope of survival, I had to put her on a respirator, but she would have
nothing of it. After she pulled out her endotracheal tube three times, an
anesthesia resident helped me set up a curare drip to keep her paralyzed
twenty-four hours a day. This turned Granny into a special type of sleeper. She
was awake yet couldn’t move a muscle, couldn’t even open her eyes, lying still
as a corpse except for the rise and fall of her chest in rhythm with the hiss .
. . clunk . . . hiss . . . clunk . . . of the respirator. Her children visited
the ICU every day. Now their protests reached a fever pitch.
“Poor Granny, why do you keep tormenting her like this? Why don’t you let the
old lady have her way? She’s miserable and wants to die.”
Every other day, Lancy was on the phone to the hospital’s lawyer, who still
insisted that so long as there was any chance the patient might recover and lead
a normal life, we should do all we could to save her. It mattered not that she
and her family fought our every move.
A week after these disasters began, Granny’s lungs cleared up. Rather than the
corpse she had hoped for, she was a healthy woman, sober and clear-eyed, with no
tremors and a recovering liver. Best of all, we could stop the curare drip. The
moment we took her off the respirator, allowing her to speak, Lancy and I were
astonished to find ourselves heroes. She grabbed my arm every time I came near
“Oh, doctor,” Granny said, “thank you so much. I just can’t tell you how
grateful I am. You saved me, and it’s wonderful to be alive. I’ve never felt
better in my life.”
Her family was even more effusive. They brought a huge basket of fruit for the
ICU staff and sent a card to Lancy and me, a flowery message thanking us for
saving their beloved mother. Most memorable of all was the gratitude shown by
one of the granddaughters, a young woman with long blonde hair who came to visit
one night wearing a halter top and skin-tight denim shorts. She grabbed me in
the hall outside the ICU, stunned me with a hug that cracked my ribs, then rose
on tiptoes to whisper a message. Our cheeks touched. I felt her warm breath on
my ear. She would do anything, anything in the world, to show her gratitude.
I’ve forgotten my mumbled reply, but I remember well Lancy’s outrage when he
heard of the encounter from one of the ICU nurses.
“You selfish jerk,” he said. “I’m the surgeon, the one who saved the old girl’s
life. If you had a decent bone in your body, you’d tell that babe she ought to
be hugging up on me. Besides, I’m single, and you’re married.”
In the end, the story fell short of the fairy tale one might hope for. I kept in
touch with Granny’s daughter, the mother of the affectionate granddaughter, and
she told me that for two months after Granny’s discharge, she seemed to have a
new lease on life. The old lady took up golf, joined AA, began keeping company
with a widower who lived next door in an upscale apartment near San Mateo. Then
she fell off the wagon. A few weeks later, the apartment’s manager evicted her
for drunk and disorderly conduct.
* * *
Greg Caraway was a forty-five-year-old airline pilot who lived in Cupertino, a
few miles from the San Jose Airport. When he developed progressive nausea,
fatigue and depression, his private doctor admitted him to a local hospital.
According to the records, the doctor found no abnormalities on physical exam,
but he described the patient as “lethargic and confused.” He ordered a battery
of tests, then went home for a good nights sleep. The next morning, all the lab
tests were normal, but he was disturbed to find his patient obtunded, almost
comatose. The doctor considered all the relevant details, including the fact
that Memorial Day weekend was coming soon, then dispatched Greg to Santa Clara
Valley Medical Center, where I admitted him to the medical ICU.
The first time I saw Greg, he inspired a strange thought: how could anyone give
up such a beautiful patient? Not that he was terribly handsome, but lying there
in coma, his arms resting at his sides, he seemed beatific, his face an
embodiment of peace and repose. The ICU nurses often stood by his bed, gazing in
wonder at his seraphic features. I examined Greg from head to toe and found no
abnormality except for his coma. Walter O’Conner, my resident on the medicine
service, had no better luck. Together we looked through the records sent over
from the private hospital.
“Damn,” Walter said, “here’s an EKG tracing, but there’s no report.”
“Ah, too bad,” I said, but my own heart fluttered with excitement. During a
cardiology elective, I had learned to read EKGs, and on the tracing I saw marked
shortening of the QT interval and a prolongation of the T wave. These were signs
of hypercalcemia, an elevation of the serum calcium, which can lead to
depression and coma. What a treat – Walter had missed the clue!
Rather than tell him of my discovery, I decided to wait for a measurement of
Greg’s serum calcium to confirm my diagnosis. This assay was not included in the
routine lab tests performed during that era, but I asked the pathologist on call
for special permission. Two hours later, report in hand, I set out to find
“Hey, take a look at this,” I said, thrusting my ace under his nose. “Mister
Caraway’s calcium is off the chart. That’s what put him in a coma.”
Walter glanced at the slip, then glowered at me. I was delighted to see that my
brilliant coup and obnoxious grin had pissed him off.
“Well, smartass,” he said, “you got any idea what’s causing this?”
“Uh . . . no, I don’t.”
“And treatment – any thoughts on that?”
“Uh . . . no.”
“Then you’d better get busy.”
Walter and I were pleased by what we found in The Merck Manual of Diagnosis and
Therapy. The section on hypercalcemia included a long list of possible causes,
and most were benign or amenable to treatment. Perhaps Greg had overactive
parathyroid glands. Perhaps he suffered from an inherited disease, or had taken
too much vitamin D or too many antacid tablets. The list also included
disseminated cancer, which could dissolve the calcium in a patient’s bones, but
the tests done so far had revealed no hint of malignancy. A few hours later, our
optimism collapsed when a radiologist paged Walter with devastating news. Greg’s
X-rays showed hundreds of dark spots scattered through his skull, his ribs, his
spine. The poor man was doomed.
This left us with only one question: where had these tumors come from? We
requested consults from oncology, gastroenterology, and urology. In the end, the
urology resident found the answer. After his first exam, he pronounced Greg’s
prostate unremarkable, but the next morning, I found him back at Greg’s bedside.
“I lay awake half the night thinking about this guy,” he said. “Since the
textbooks say those mets most likely came from his prostate, I decided to take
another look, and this time I convinced myself things don’t feel quite right.
There’s no obvious lump, but I don’t like the texture of the left lobe. I’ll be
back this afternoon for a needle biopsy.”
Bingo. The next day, I was at the ICU charting desk when a clerk delivered the
report from the biopsy. Greg had cancer of the prostate. It was a terrible
moment. Twenty feet away, his wife and two teenage children stood beside his
gurney, gazing down at his peaceful face. The wife was a frail, anxious woman
with dark circles under her eyes. I dreaded the speech I had to give: Ma’am, I’m
afraid we’ve got some news, and it’s not good . . . No, I had a better idea. I
paged Walter and told him about the biopsy.
“Look,” I said, “I had to tell Greg’s wife about the mets in his bones. Now it’s
your turn.” A few minutes later, he arrived in the ICU, gave me a look that said
I was a rotten coward and would owe him big time, then led Greg’s wife down the
hall to the hospital chapel.
Would that this had been the end of Greg’s story. What we needed to do was
obvious – let the poor man die in peace – but an enemy leapt upon us.
* * *
During my years at Stanford, the oncology department was both famous and
notorious, a collection of brilliant lunatics. They won millions of dollars in
research grants. They published dozens of papers in prestigious journals. But at
their worst, they tormented cancer patients with a consuming and irrational
passion, a passion that often served only to prolong hopeless misery. Dr. X, the
department’s chairman, was so aggressive in his treatments, a dark jest haunted
him throughout his tenure: Dr. X. rushes to a graveside just as the pallbearers
lower the coffin.
“Wait! Wait!” he shouts. “There’s still time for one more dose
of 5-FU.” Five-fluorouracyl is a toxic drug used to treat advanced malignancies.
When we first discovered the cancer in Greg’s bones, an oncology fellow from
Stanford had answered our request for a consult. Trained by Doctor X. and his
mignons, he did a thorough job, listing all the sites from which the tumor might
have spread and all the tests we needed to order. He also gave us a treatment
protocol for bringing George out of his coma by lowering serum calcium, but with
no hope for a cure, we decided to let nature take its course. A few days after
the consult, Walter paged me to the ICU. I found him fuming and red in the face.
“What happened?” I said.
“It’s that asshole from Stanford – the oncology fellow. He came back for a
follow-up exam and chewed me out. Called me a terrible doctor, threatened to sue
me for malpractice.”
“My god!” I said. “What the hell is he talking about?”
“He insists we have to treat Greg’s hypercalcemia, pull out all the stops so we
can wake him up.”
“Wow!” I said, buoyed by a surge of optimism. “You mean they’ve found something
new, a drug that might wipe out all of Greg’s mets?”
“Hell no. That moron made it clear – there’s nothing new for prostate cancer,
nothing at all. They’re still stuck with 5-FU, but this guy wants us to start
pouring it in right now. Maybe it’ll shrink the tumors by fifty percent, but
only if we give whopping doses. The best we can hope for is a few weeks of
survival, a month or two at best.”
I stared at Walter. My brain struggled to take in this lunacy.
“Wait a minute,” I said. “They want us to wake the man up so we can tell him
he’s a goner, tell him he’ll spend the last few weeks of his life writhing in
pain from his tumors and puking up his guts from the 5-FU?”
“Yea, that’s what he wants us to do.”
Despite the oncologist’s rant, all went well in the end. Walter sat down with
the ICU director and worked out a protocol. We gave Greg intravenous diuretics
and calcitonin, the standard treatment for hypercalcemia, plus a few milligrams
of 5-FU, but the doses weren’t enough to do the job. I wrote a standby order for
IV morphine in case he woke up screaming with pain, but it was never needed.
Greg remained in a coma for five days, his face calm and peaceful as a sleeping
baby’s, then died without stirring a limb.
* * *
My most prestigious sleeper was Michael B., a ten-year-old whose father had
served as the mayor of San Jose and the head of the county school board. The
trouble began when a pediatrician treated Michael with aspirin for what seemed a
typical case of influenza. He complained of a headache, developed severe nausea
and vomiting, then was admitted to a private hospital for intravenous
rehydration. At midnight, a nurse called the pediatrician to report that
Michael’s urine output had dropped to almost nothing. He had also become
confused and disoriented. These symptoms gave the final clue: Michael had Reye’s
syndrome, a mysterious affliction that devastates the brain and other vital
organs. There was no proven treatment. The pediatrician, reluctant to spend
fruitless hours at the bedside of a doomed child, shipped Michael to Valley
At three a. m., as ambulance attendants transferred him to a bed in the ICU, I
introduced myself to the parents. All three of us had been up for thirty or
forty hours. We sagged from exhaustion, but they had managed to dress for the
occasion in a suit and a stylish dress, as though on their way to church, while
I wore rumpled OR scrubs. Michael lay a few feet away, a beloved golden-haired
child, but he already had the jaundiced skin and urine-like stench brought on by
liver failure. The father was so distracted, I had to repeat my questions two or
three times before he could muster an answer. The mother remained silent. Again
and again, they turned to watch the ICU nurses as they tucked the boy into bed
and attended to his IV. He was delirious, screaming at the nurses, flailing his
arms and legs in a wild struggle. I had attended a lecture on Reye’s syndrome
during medical school and knew the dreadful truth: soon, the boy would be in
In 1962, Doctor Douglas Reye, an attending at the Royal Alexandra Hospital for
Children in New South Wales, Australia, described twenty-one cases of a
mysterious disease. All had occurred in children who suffered from what
initially seemed a routine viral illness, such as influenza or chicken pox. Over
the course of hours or days, they became delirious, fell into a stupor,
developed liver failure and renal shut-down. Seventeen of the victims died. Of
those who survived, some had permanent afflictions, including cirrhosis, brain
damage, and chronic renal failure. Doctor Reye, noting that all the autopsies
showed profound swelling of the brain, liver, and kidneys, named the disease
fatty degeneration of the viscera.
This paper was published ten years before Michael’s illness, and in the interim
no cure had been found. Thus when the boy entered our ICU, all we knew was that
he would soon suffer total organ shutdown, and his odds of survival were slim.
The best we could offer were educated guesses.
An hour after Michael’s admission, I saw a gray-haired man approach his bed. The
stranger was dressed in street clothes, but when he pulled a stethoscope from
his pocket, I realized he must be a doctor. This was Joseph Garvey, a senior
attending on the pediatric service. A few minutes later, in an office across the
hall from the ICU, I listened while he explained to my resident and me what we
should do for Michael. To keep his kidneys working, he needed diuretics. To
maintain hydration, he needed intravenous fluids. Most important of all, we
should give intravenous cortisone to reduce the swelling in his brain.
From their dour expression and subdued voices, I knew that neither Garvey nor my
resident expected the boy to survive. Reye’s syndrome was a cruel, inscrutable
beast that devoured organs one by one, transforming a healthy child into a
bloated corpse in a matter of days. Depressed and exhausted, I wrote out the
orders, then, while the nurses infused the appropriate fluids and medicines into
Michael’s veins, I explained our plans to the parents. Garvey had warned me to
not to give them false hope, but there was no danger of that. The tears
streaming down their cheeks made it clear they expected their son to die.
Perhaps fate was in a good mood that day. Perhaps Michael, unaware of the odds
against him, decided not to die. Twelve hours after we began our treatment, he
woke from his coma. His jaundice cleared. His kidneys poured pints of urine into
the bag hanging at the foot of his bed. A few days later, his mind was intact,
his blue eyes bright and clear.
On the day of his departure, the parents ambushed me. They bought a box of candy
at the gift shop and had the page operator summon me to the discharge desk. I
was weary from a night on call, curious why the discharge clerk had paged me.
The mother offered me the box of candy, then, before I could take it, she threw
her arms around me. I struggled against her embrace, trying to explain that it
was all a mistake – I was just the go-for, a glorified errand boy – but she
would have none of it. Doctor Garvey was the brains behind it all, yet I had
labored through the night at their son’s bedside. Before I could break from the
mother’s grip, the father embraced both of us, pressing his cheek against mine.
Tears flowed from their eyes, so many tears I wept myself. Michael sat nearby in
a wheelchair. His face turned red, but he kept quiet until the blubbering died
down. When everyone had blown their nose and dried their eyes, he stood up from
the chair and grasped my hand.
“Thanks, Doctor Gamel,” he said. “I was always glad to see you, especially at
night. Don’t you guys ever get to sleep?”
* * *
Of all the advice I have given and received during my medical career, this
dictum remains my favorite: if your fairy godmother wakes you in the night to
offer a choice between great skill and great luck, take the luck. In defense of
this philosophy, I present the case of Michael B. The history of Reye’s syndrome
shows just how great a role simple-minded pragmatism can play in the practice of
medicine. Over the decades after Doctor Reye published his famous paper, it was
discovered that almost all the victims had been given aspirin early in the
course of a viral illness. Though theories abound, to this day, no one has
discovered the mechanism by which aspirin interacts with a viral infection to
destroy every vital organ in the body. Yet despite our ignorance, an
international campaign to avoid the use of aspirin for treating febrile
illnesses in children has all but eliminated Reye’s syndrome.
As for treatment, pragmatism again saved the day. There is still no specific
cure, but now doctors know what to do – use common sense. The victims all suffer
from dehydration and renal failure and swelling of the brain, thus we should
give them IV fluids and diuretics and cortisone. Studies conducted since
Michael’s illness show that these simple measures, if performed early enough in
the course of the disease, dramatically improve the odds of survival and reduce
the likelihood of permanent damage.
On that desperate night when Doctor Garvey devised Michael’s treatment plan,
guided by principles known even then to any third-year medical student, he came
up with a regimen that remains the gold standard forty years later. Experience
has shown that if we can sustain the victim’s vital functions, the mysterious
disease will run its course without destroying the delicate intracellular
structures that sustain life. Thus a few simple measures have spared thousands
of children from the ravages of Reye’s syndrome. As with many other maladies
over the course of human history, when science failed, luck and common sense
saved the day.