“THIS is the medicine intern,” I said into the phone, “returning a page.” I turned on the lamp on the table next to my bed and squinted at my watch: 4:30 in the morning. I’d slept about an hour and a half. Not too bad, since I’d caught a couple of hours of sleep earlier in the night.
“You need to come declare a patient.” I didn’t recognize the voice. I was in my second month of a rotating internship in emergency medicine at one of the biggest hospitals in Pittsburgh: seven hundred beds and twenty-eight hundred nurses.
“Declare?” I yawned.
“Dead,” she answered. I heard someone in the background chuckle.
“What?” I shielded my eyes against the light, feeling sleepy and dim-witted.
“You need to declare a patient dead.” Her tone flattened.
“Oh, okay,” I said. “I’ll be right there.” We hung up. At that time of the morning my mind was a blunt instrument, so I was glad it was something simple, instead of a patient with acute chest pain, or shortness of breath, or some other problem I’d have to really think about.
I’d been in the hospital since six the previous morning, and wouldn’t go home until my work was done later that day, hopefully by five or six in the evening. Sally was a nurse and had seen what internship was like, so she’d forgive me for wolfing down supper and dropping straight into bed. But if I could knock out this problem and rack up another hour of sleep, I’d have enough reserve to stay up for an hour or so when I got home. I wanted to reconnect with Sally and play with Sarah, who by then had turned three years old.
I was doing a residency in emergency medicine rather than surgery, even though I’d always enjoyed working with my hands. Whether it was shaving off a thin curl of wood with a chisel, or getting a nut to thread on the bolt behind the starter of my MG, my hands seemed to understand things quickly. I’d worked diligently on my surgical rotations as a medical student, and knew I’d get good recommendations from the faculty. But I’d done poorly on the written exam, and finished the rotation with a pass instead of honors. Essentially, I’d made a C. The chairman of the department, Dr. Parini, called me into his office. “Paul, your grades on the clinical part of your rotation were excellent.”
I nodded.
He opened a file folder on his desk and read out loud: “Outstanding…Good work ethic…positive attitude…takes excellent care of his patients…shows keen interest in OR.” Dr. Parini glanced back down at the file on his desk. “But you almost failed the written exam.”
I nodded again. I knew I hadn’t studied enough. The book of practice questions my classmates had purchased in the medical bookstore had seemed less important than reviewing the anatomy for the cases I’d scrubbed in on, and I hadn’t expected the exam to be that hard.
“I understand that you’ve recently had some difficulties with your family…”
“I’ve tried not to let it interfere.” I sat straighter, feeling my face blush hot. I hoped I wasn’t in trouble, but I sure as shit wasn’t going to apologize for having a daughter with Down syndrome.
“No,” he said, shaking his head. “That’s not what I’m getting at. You’ve done well on your clinical rotation. But having a child with,” he looked back to the papers in front of him, “a child with Down syndrome, that’s bound to affect you.” He looked up at me. “And it’s why I’ve asked you to come by. I think you’d make a good surgeon.”
“Thank you.”
“We rarely do this.” He paused. “But if you’d like, you can retake the written exam.” He was giving me a second chance.
“Thank you, sir.” The idea of becoming a surgeon had appeal, but I didn’t want to squeak by on a second chance I’d been granted because my daughter had Down syndrome. I’d gotten into medical school by studying my ass off, grubbing for grades, and never missing a chance to get ahead. Surgery programs seemed to be the quintessential manifestation of that culture. Some surgery programs even had a pyramid system, in which there are fewer spots for the last years of residency than there are for the first year, requiring that every year a resident gets “cut,” after finishing just a portion of his or her training. Retaking the exam based on family problems seemed like a sign of weakness, and surgery seemed the one specialty in which signs of weakness wouldn’t be tolerated. “I appreciate your offer, but I think I’ll stick with the grade I got.”
“Okay.” He closed the file folder and leaned back in his chair. “Your decision.”
I’d been thinking about going into emergency medicine anyway. From what I’d seen, the ER docs just seemed happier than surgeons. Cooler, too. Maybe it’s because they had more time off, or maybe it’s because their work was more varied. And I’d felt drawn to the idea of being an all-round doc.
I yawned, and swung my feet off the bed. The on-call room was small and plain, about six feet by ten. The bare walls were painted eggshell white. A wooden chair sat at the foot of my bed, a Formica nightstand at the head. My white coat and stethoscope hung from a hook on the door. If Red Roof Inn were to design a monastery, my call room would be the result.
Had the nurse told me where I was supposed to go? I mean, where was the dead guy? And whose patient was he? Was he one of mine? Damn. I pushed the button on my beeper to show the last page received, and quickly punched the number into the phone. “Seven-one,” the ward clerk answered, identifying the floor and unit she was working on.
“Do you-all have someone who needs to be declared?”
“What?” She didn’t sound irritated, just confused.
“Did someone just page me to come declare a patient dead?”
“I’ll check.” She muffled the phone with her hand, and then came back. “Yeah. Mr. Brooks, room seven-oh-three.”
I hung up. Not one of mine. Good.
I’d never declared anyone dead and had never seen it done. I got out my Scut Monkey’s Manual, a chunky spiral-bound handbook that tells you how to do most of the tasks a medical student or intern has to do. SCUT stands for Some Common Unfinished Task, reflecting the countless unglamorous details that dominate a medical student or intern’s life. In the section dedicated to chartwork, there were examples of a delivery note, a pre-op note, an operative note, and a problem-oriented progress note. But there was no information on declaring a patient dead, or the paperwork involved. I’d have to wing it; but how hard could it be, compared to the other things I’d done since graduating from medical school?
I expected internship to be stressful, and it was. On most rotations we were on call every third night, which wasn’t too bad. Sometimes we were on every other, and would have to work thirty-six hours, catching sleep when we could. Our mantra was, “Eat when you can eat, sleep when you can sleep.” I quickly learned from the senior residents to sneak off to a call room every chance I got, no matter what time of day. I would lie on my back and carefully smooth my hair under my head so I wouldn’t get “bed head.” Since my face wasn’t pressed into the pillow, I never had the telltale pink wrinkles across my cheek or forehead. I can still sleep that way, flat on my back, arms to my sides. Snagging a thirty-minute nap in the afternoon was the mark of an efficient and savvy resident. Catching a few hours of sleep every night meant that you were good at getting your work done.
Residents are now limited to working eighty hours a week. The Accreditation Council for Graduate Medical Education made the decision in 2003, after a protracted national debate. A young doctor was quoted in American Family Physician, the journal of the American Academy of Family Physicians: “As a resident, it becomes exceptionally difficult to put forth the same amount of thought and offer the same emotional support to patients after a long 36-hour shift. The most disheartening feeling as a resident-physician is when you feel that your own patients have become the enemy. By enemy, I mean the one thing that stands between you and a few hours of sleep.” This quote was offered in support of stricter limits on resident hours. Taken at face value, there’s little room for argument. But I wonder how doctors will learn to take care of patients when their empathy has been exhausted if they don’t learn to do it in residency. Unless people are only going to get sick between nine and five, Monday through Friday, somebody’s going to have to do some late night doctoring, even when they don’t feel like it.
Across the country, hospitals are having difficulty finding specialists who are willing to be on call for emergencies. How many people would volunteer to climb out of bed at three o’clock in the morning to come into the ER to take care of a stranger, for free? In my hospital, just like hospitals across the country, the neurologists dropped their admitting privileges so they wouldn’t have to take call. They no longer come to the ER to help decide if a patient having a stroke should be given TPA, the “clot buster medicine.” That’s not a trivial question, since 3 percent to 6 percent of the stroke patients who get thrombolytics will have fatal hemorrhage into their brain. It has happened to one of my patients. An elderly lady came into the ER having a stroke. I discussed it with a neurologist over the phone, reviewed the risks and benefits with her husband, and gave her the TPA. A short time later, her blood pressure skyrocketed and her respirations became erratic gasps. I stuck a plastic tube down her windpipe and got another CT scan of her brain. I helped push the woman’s stretcher to the scanner, knowing she’d hemorrhaged inside the brain, but irrationally hoping she hadn’t. I stood behind the CT tech and watched as the computer screen flashed up the pictures of the ugly clots of blood blossoming inside the woman’s brain. If a neurologist had come in, I’m fairly sure that the same decisions would’ve been made, but we’ll never know.
Friends outside of medicine have suggested that working long hours was simply a form of hazing that the old doctors perpetuated—“I went through it, so you’ll have to as well.” But as I was pulling my call in residency, it seemed that working through the night to help sick people was just another part of becoming a doctor.
I adapted to the call schedule; but I never got over the feeling of shame for not knowing more. Nights on call exposed the things I hadn’t yet learned, things for which one couldn’t really study: how many units of blood to transfuse into a person with a gastrointestinal bleed? What’s the dose of a given antibiotic for a patient in kidney failure? How much oxygen should I give an elderly man with pneumonia?
Everyone realized that interns and residents were in the process of learning. That’s why we were there. But nurses, patients, and families all seemed to think the intern already knew what he or she was supposed to be learning. And not knowing what to do while a person is gasping, moaning, or pissing blood is a discouraging experience. That, not the long hours, was to me the most stressful aspect of residency training. I think that’s why so few people stop at car wrecks. Is there anything more miserable than standing in the presence of human suffering and not knowing what to do?
But after answering the page, I wasn’t worried. I wouldn’t have to make any important decisions, and I wouldn’t need to wake up Shannon Rogerson, my senior resident. I could just tell her at sign-out rounds in the morning. The culture of the hospital ward was, “Call your senior if you have to, but only if you have to.” If I called for help with every single problem that came up, the senior wouldn’t get any sleep, and I wouldn’t learn to think independently. Of course, whether or not I’d call depended on the personality of my senior as well as their specialty. As an ER resident rotating through the major specialties, I’d learned that the surgery seniors wanted to know of every potential problem as soon as possible, but got pissed if you hadn’t thought of a solution before you called. Medicine residents, on the other hand, seemed to enjoy working out the details of a medical puzzle, and wanted to participate in every step of the decision-making process. In this case, it wasn’t an issue; the nurse had already determined the guy was dead. My role was just a formality. I’d go upstairs, knock out the paperwork, and get back to my bed as quickly as possible.
I’d already learned that the hospital offered an almost endless pool of suffering, and if I was going to get through it intact, I’d have to limit how much of it I internalized. Maybe I had already started slipping down the “caring curve” our professor had drawn up on the blackboard back in the second year of medical school. It didn’t seem like it at the time—it felt as if I’d just learned to be a more cautious investor of my emotions.
Not surprisingly, medical educators have written about this. In the journal Academic Medicine, Jack Coulehan, M.D., M.P.H., and Peter Williams, J.D., Ph.D., published “Vanishing Virtue: The Impact of Medical Education” in June 2001. They pointed out that medical schools actually teach two sets of values, each of which is divergent from the other. The first set, to which there is an explicit commitment, includes the traditional values of doctoring—empathy, compassion, and altruism. The second set, to which there is a tacit commitment, includes an ethic of detachment, self-interest, and objectivity. These divergent values (empathy, compassion, and altruism vs. detachment, self-interest, and objectivity) can be confusing to physicians-in-training. Some of these young physicians resolve the conflict by rationalizing that they best serve their patients by concentrating exclusively on technical competence. Coulehan and Williams suggest that more classes in family medicine, communication skills, medical ethics, humanities, and social issues in medicine would help.
Maybe they’re right—maybe modern American medical education is producing crop after crop of uncaring physicians, and more classes would help. Perhaps traditional Chinese physicians are uniformly compassionate, but I bet after a long day of twisting needles into the skin of complaining, harping, miserable people, even they get a little testy.
Coulehan and Williams suggest that some young physicians may be immune to developing detachment, self-interest, and objectivity, and therefore more likely to hold to the traditional values of empathy, compassion, and altruism. This “immunization” could take the form of being a woman, having a strong personal belief system, or prior experience as a Peace Corps Volunteer or teaching in low-income-area schools. Maybe that is true—maybe non-traditional people are “immunized” against a loss of their compassion as they toil their way through medical training.
If that’s the case, I was in great shape as a non-traditional intern. In junior high school I read every biography I could find about my heroes: Mahatma Gandhi, Henry David Thoreau, and Dr. Martin Luther King, Jr. I spent my summers volunteering full time in a Head Start center. Every Saturday morning I spent an hour in a silent vigil for peace in Vietnam.
Non-traditional? In high school I drove a school bus to pay for a parcel of land in rural North Carolina. I dropped out of college to build a cabin on the land, and then went on to work as a pizza cook, trash truck laborer, and firefighter. If Coulehan and Williams were right, I should be fully immunized against any loss of compassion.
But at the time, I wasn’t worrying about any of this stuff. Emotional distance seemed like the only sane response to the burden of suffering I saw. My plan was to save up my energy, fill the gaps in my fund of medical knowledge, and sleep every chance I got.
I scratched my head, and yawned. My mouth was thick with the stale taste of having slept with my mouth open, so I walked down a short hallway to the bathroom, splashed my face, and brushed my teeth. Some interns wanted everyone to know when they’d been up all night, suffering. Not me. I always shaved and showered, and put on clean underwear and socks, first thing in the morning after being on call.
Riding up in the elevator, I wondered about the term “declaring” a patient dead. Why not “say,” (or “announce,” or “confirm,” or “assert”) that someone has died? The elevator stopped, the doors slid open, and I walked down the hall until I got to room 703.
The door stood ajar. I paused, and then tiptoed into the dimly lit room. I’d helped care for dead bodies as a nursing assistant, and had dissected one as a medical student, but being alone in a room with a dead person still made me uneasy. My eyes adjusted, and I could see well enough. An old man lay on the bed, the sheets folded neatly down just below his chest. He had white hair, parted on the side, not combed, but not particularly mussed.
I glanced around the room, unsure how to begin. In CPR classes we had been taught to firmly tap the mannequin’s shoulder, and loudly say, “Annie, Annie, are you okay?” But when declaring a person dead, how do you introduce yourself? Was it even necessary?
I could be in the wrong room, and if that were the case, an introduction could save some embarrassment.
I stared at the patient. His chest wasn’t falling and rising. I couldn’t hear him breathing.
I glanced around again, and then pushed his shoulder with my fingers. “I’m Dr. Austin,” I said in a conversational tone.
He didn’t respond.
I pushed harder, making his head jostle.
No response. I pulled the covers down and put my stethoscope on his chest, over his heart. There was no “lub dub” of a heart beating, no sound of air movement in the chest. I felt for pulses at the wrist, neck, and groin. Nothing.
I rubbed hard on his sternum with my knuckles. If he were alive, he’d be glad I hadn’t told the nurses to zip him up in a plastic bag. If he was dead, he wouldn’t feel it. But I felt bad, scrubbing my knuckles across his bony little chest.
I watched his face while I scrubbed. No expression.
I stood there, trying to find something deep or profound in the experience. But I couldn’t. He was an old, dead man, and I was a young, sleepy man. I was just the guy they called in to do the paperwork.
I quietly walked from the half-dark room into the chatter and light of the nurses’ station. “Who’s got the guy in room seven-oh-three?” I asked the ward clerk.
“Vickie,” the ward clerk called over her shoulder. “Intern’s here.”
A heavy young woman looked up from the chart she’d been writing on. “I got the paperwork ready for you.”
“Thanks.” I walked over and sat in the chair next to hers.
“Your pen have black ink?” she asked.
“Uh, yeah.”
“If you use blue ink,” she explained, “they send it back, ’cause it’s not legal.”
“Huh.”
“Something about photocopying.”
That didn’t make sense. Blue photocopies just fine; but why argue? I clicked my pen and squiggled out a line on a piece of scrap paper. Black ink.
She nodded and slid the form over to me.
I filled in each little block, until I got to the one marked “Time of death.” I looked over to Vickie. “Do I put in the time you found him, the time I got to the room, or the time right now?”
She shrugged. “Whenever you declared him.”
“I didn’t look at my watch.”
She looked at hers. “Just put in 4:52.”
The rest of the form was easy. I finished it, and slid it back to Vickie. “Anything else?” I smiled. Never hurts to be friendly.
“Nope,” she said. “That’s it.” She smiled back at me. “Thanks for coming so quick.”
“No problem,” I said. “Easiest thing I’ve done all night.”
Walking past the old man’s room, I paused—should I check one last time? I didn’t need to; I’d been thorough, and so had his nurse. I knew that if I went back into his room and put my stethoscope against the bony ribs of his chest, silence was all I would hear.
I stood in the darkened hallway, feeling that a fundamental insight stood outside my grasp. Something profound, about life, death, and eternity, but the only thing that came to me was a yawn.
I rode the elevator back down to my call room. Lying down, I smoothed my hair carefully behind my head and pulled the covers up to my chest, hoping to steal another hour of sleep—a down payment against the needs that the morning would bring.