4/21/15

This story is not my own, but I find it so evocative that it feels like mine.  It was told to me and a few other students by Dr. Richardson, a cardiology attending who was filling in for our regular one.  These approximate his words.

When I was a cardiology fellow working the night shift in the ER, we were always excited when we got a referral from Martha’s Vineyard.  There was a really sharp GP (general practitioner) there named Loxie and when he missed something it was because it was a real tough nut to crack.

Anyway, one night around ten I got a call from Loxie telling me that he was sending me a patient with acute episodes of shortness of breath.  He could not hear any heart sounds, and interestingly the man did not have an increased jugular venous pressure (a particular interest of Richardson–he always pronounced the initial “u” with a long sound like  “you” or “jujubee”.  Everyone else always said “jug” like “little brown jug”.  Anyway, the word means yoke.)  He had an enlarged heart.

The patient, Mr. Smith, was flown in to Boston by helicopter and arrived before midnight.  Immediately a team of cardiologists, fellows, and residents pounced on him and began to gather data.   He was a muscular, well-developed man in his seventies, with a big mane of hair and a winning personality.  He indeed had no audible heart sounds of any kind, and his neck veins were sure enough flat, unusual for someone going in and out of congestive heart failure.  His EKG showed an enlarged heart, as did an M-mode echocardiogram.

While they were working on Mr. Smith, he died.  He began to breathe rapidly with great difficulty, then he keeled over.  His monitor showed VTach (ventricular tachycardia), but shocking him did not help.  His heart just kept going back into it.  After over an hour of resuscitation, Richardson “called it”.  With a feeling of failure, he called Loxie back. (For some reason I’m flipping from first to third person.  I’m going to stick with it.)

“We lost your guy.”

“I’m sorry, I’m sure you did your best.”

“I have a favor to ask you.  Can you get permission for a post? (autopsy)  I really want to know what happened to this guy.”

“I can sure try.  I have to drive out to the other end of the island so it will take a little while, but I’ll get it for you.”

Richardson was overcome by a wave of tiredness mixed with depression, and went to the call room to try and catch some sleep.  It was two o’clock.

About an hour and a half later his phone rang.  It was Loxie.  “You have your post,” he said.

At four in the morning the pathologists had the answer: critical aortic stenosis with a pinhole valve opening.  The hole was closing off so much that not even the characteristic murmur of aortic stenosis could be heard, much less the slapping together of valve leaflets.  The neck veins were flat because the issue was not high blood volume but low blood flow.  The heart was enlarged from years of straining against the tiny opening.

At four thirty I called Loxie back.  “It was critical aortic stenosis.”

He could almost see Loxie shaking his head over the phone. “Missed it, and it was right there.”  Long pause.  “Well thanks for your help, doc.  Hey, ya wanna hear something great?”

“Yeah!”

“While I was on the other side of the island I delivered a baby girl!  Eight pounds, four ounces!”

“That IS great,” I said.

As I hung up the phone I realized, Loxie really had something there, working on an island taking care of friends in a close-knit neighborhood.  And me being a cardiology fellow at a prestigious Boston hospital, but now I’m depressed and he just delivered a baby.  Go figure.

This story has stayed with me over decades, and changed my way of thinking about what I do.

Thanks for reading.

4/20/14 & 10/16/2022

For some reason today this story came to mind, and I told it at lunch to my son and his wife.  I think it was prompted by the thought that I had always wanted my two sons to know more about my work and the challenges that I faced. First, a few doctor  jokes (which were not part of the telling today): 1) A medical student one week from graduation is accosted by a nurse in the hallway. “A man down the hall just grabbed his chest and collapsed, and now he is having a seizure.  What should I do?”  His answer: “Well call a doctor for God’s sake!” 2) Question: What do you call the person who graduates last in his med school class?  Answer:  “Doctor”

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Two weeks after my graduation from medical school I was doing my internship, a baby doctor some might call it.  Usually my responsibilities were not too hard to handle, for example pushing the rolling chart rack up the hall during morning “chart rounds”, but as the junior member of a two-person team I sometimes had to step up to the plate when my senior partner was called away.  He was called a JAR (junior assistant resident), but he was a year and two weeks out of medical school and he “ran the ward team”.

On the day in question we couldn’t get through rounds because our JAR, Bob Trautman, kept getting called down to the ER (emergency room) with “stat” pages to deal with a patient who kept going into VTach (ventricular tachycardia), a deadly heart rhythm.  I ended up going through a cursory type of chart rounds with the two medical students, who had the honor of pushing the chart rack since I had been temporarily promoted.

When Bob returned, he said “he’s getting admitted to you.” “To me?  Shouldn’t he be going to the ICU (intensive care unit)?” “He doesn’t want to go to the ICU.  He also doesn’t wanted to be coded (resuscitated) if he should arrest.  He doesn’t even want an IV (intravenous).  He just wants to go to a regular floor bed and let Nature take its course.  Hey, cheer up!  There’s nothing for you to do.  You’ll like him.  He’s from Maine.”

I consulted my handbook. IV Lidocaine? He doesn’t have an IV.  Is there an IM (intramuscular) treatment for VTach?  What a ridiculous question.  But there is, a gram of Pronestyl (procainamide) IM, there it is.  I guess if you’re having trouble getting an IV in? When I went in to meet Walter I did indeed like him.  He was tall and muscular, and dressed like a farmer in a red plaid shirt.  He told me that he started feeling funny today when he was chopping firewood. (!)

He had a strong handshake.  I confirmed with him his treatment (or non-treatment) preferences.  Then I decided to take a positive approach and said to him, “I am going to go over you with a fine-toothed comb!” He got a big, winning smile on his face and said “Let’s do it!”

First I listened to his heart.  I could not hear his heart sounds, but I did hear an enormous diamond-shaped murmur like nothing I had ever heard before.  I looked up at the heart monitor and saw large regular complexes, then a sawtoothed pattern, VTach, then a wiggly chaotic line, VFib (ventricular fibrillation).  Walter slumped back on the bed, unconscious.  He was dying. The monitor was alarming, and I heard the sounds of many people rushing down the hall toward me.  Then I heard Bob’s voice say to them “He’s a DNR. no code. DNR (do not resuscitate).”  The footsteps slowed down, then dissipated.

“What do I do now?”  I asked one of the senior nurses.  “Well, Doctor, you have to wait until all electrical activity is gone, then note the time as the time of death on the death record. Sometimes it takes a while.”  I slumped down into an orange lounge chair against the wall and looked at the monitor.  The VFib pattern had become finer and finer and finally reverted to “flatline” or asystole.  However, every ten seconds or so there was a wide-looking beat.  I needed to wait.

My friend and fellow intern Jen came in to keep me company and sat on the green lounge chair next to me.  She was supposed to be off today “post call”  but she was having trouble getting herself to leave the hospital because a thirty-five year-old patient of hers had died on her watch, of malignant hypertension, and she was too shocked and stunned to finish her paperwork and leave.  We talked about our feelings.

“Did you ever imagine it would be like this, Jenny?” “No, I didn’t.  This was supposed to be the ‘gentleman’s internship’  with only one in four call, night floats, etc. etc.” “I didn’t either.  Only two weeks out of medical school and it already feels like an eternity.” We both sighed and continued to watch Walter’s EKG (electrocardiogram) as the wide complexes spaced out wider and wider.

Finally, twenty minutes later I signed my name on the death certificate. “Time of death 14:34”. I left the room as the nurses came in to wrap up the body, and one of them told me that the patient’s son was in the solarium and would I go talk to him?  Sure. I went into the bright room and saw a stout man with a goatee who was taller and older than me.

Walter was in his eighties, and his son looked to be in his late forties.  He shook my hand and said “Doc, I know you did everything you could for him” and reached out with both arms to hug me.  At that, I started to cry in his arms with my face in his plaid shirt.  “I’m sorry there was nothing I could do.  I’m so sorry.” For a moment a part of me stepped back to see a comical scene,  a man whose father had just died, with a stoical look on his face, comforting a crying twenty eight-year-old baby doctor who had just “lost” his first patient.

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That night I called my parents.  They asked me what was wrong.  “My patient died today!”  I said.  “Oh, Edward, that’s too bad. I’m sure you’re very sad.  How old was he?” “Eighty two”  There was a long pause on the line, and then the booming voice of my dad.  “Oh, let him go!!!” Didn’t I know yet that no one lives forever?  No, they hadn’t taught me that one in medical school.

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The next day I was paged out of rounds by the pathologist.  He asked me to come down to the morgue and see something on my patient’s autopsy.  I went down and there was Walter’s heart, with a large round blood clot lodged into his aortic valve.  Pathologist: “This guy was walking around with a pinhole for an aortic valve, and finally this clot got stuck in there and that was all she wrote.  I even tried to force it out with a garden hose, but no luck.  The only thing which would have saved this guy was emergency heart surgery, which…” “he didn’t want”, I said, completing his thought. As I left the morgue I felt a weight lifted from me.  There was nothing I could have done. It was not my fault.

I count this day as the beginning of my life as a doctor.

Thanks for reading.

Harvard traditionally starts its academic year very late, in the last week of September.  Meanwhile, I was itching to get out of the house and off to college, but I had to wait.  Yale was starting the week before, and was only a bus ride away, and so I ended up slumming at Yale’s old campus, their freshman quadrangle, looking for some action, or at least some activity, to keep me occupied.

My family had many connections with Yale.  Through a connection with Undersecretary of state Walt Whitman Rostow (his brother Eugene V. Debs Rostow was the provost of Yale Law School), my dad and mom were offered a one-year position teaching a seminar on East Asia.  My dad was a double law school graduate (in Korea and at Harvard) while my mom had a PhD in sociology from Boston University, which she had earned while raising three young kids.  So we moved from Washington DC (another yet-to-be-written post) to New Haven CT so that my parents could take this job.  Even though the job was only for one year, my parents were eager to establish a connection with a top-notch American university, and in Korea “Yae-il” was only second to “Ha-bo-duh” in status.

And so we rented houses on West Rock Ave. (from the Wm. Veales), Alden Ave., and finally Yale Avenue, which was located only two blocks from the Yale Bowl.  Clearly this was meant to be.  Several years later, when my older brother Howie applied to colleges, he ended up going to Yale, which started the next generation’s association with this tradition-laden school.

So during my senior year at Hopkins, Howie was a freshman at Yale, living in “TD”, Timothy Dwight College, singing in the Yale Glee Club, and spending time with his roommates.  I envied him his newfound freedom as a college student.  I remember that during my senior year I had a meeting with my college admissions advisor, who was also my math teacher.  He asked me what I expected college to be like, and I answered “Heaven!”  He chuckled and said, “Well maybe you shouldn’t start off with your hopes too high.  Although I’m sure that you’ll find it an eye-opening and enjoyable experience.”  The meeting was brief, given that I knew where I wanted to go, we both took as a given that Harvard would accept me, and my work and activities at Hopkins were exemplary.

Back to the old campus.  The old campus was a city block-sized quadrangle with a brownstoned archway (the Phelps gate–okay I cheated and googled it) as its main form of entrance and egress.  (The superintendent’s office was located there, and arriving freshmen (freshpersons? That was the first year that women matriculated at Yale) and their families all checked in there to get directions to their dorm rooms.  I hung out there and struck up conversations with these newcomers (I, being a townie of course, was an old hand), and I quite naturally fell into the role of helping new staudents carry their luggage to their rooms.  In the process I would ask the students and their parents, and in some cases siblings as well, where they were from, what were they planning to major in, what sports they played, and all of the usual conversation-starters.  For their part, they assumed that I was an upperclassman who had been assigned this duty, and I did nothing to disabuse them of this misconception.

I found that this was the perfect way to let off my nervous energy in starting my own freshman year, and I spent the entire week performing this unappointed function.  The officials at the gate didn’t seem to mind or even notice my work as a greeter, and by the end of the week I knew twenty or thirty freshmen by name.  I would run into them in the street, and they would say “Hi Ed! How are you doing?”  Even a few months later, during the Thanksgiving break, I would go downtown and invariably run into a few of my freshman-week friends, who would greet me warmly and say “Hey, Ed! Haven’t seen you around too much!  What have you been up to?”  At this point I usually ‘fessed up and told them that I wasn’t a Yale student, and in fact was a freshman at Harvard.  They registered surprise but were good-natured about it.  After all, I had helped them move in.

The following week, when my parents brought me up to Cambridge to start two weeks of orientation, I found that I had spent my meet-new-people energy at Yale, and was starting my time at Harvard with an empty tank, so to speak.  Or perhaps it was just the fact that I had no obligations or expectations at Yale, while Harvard was going to be my new home, come hell or high water.  Funny, this is the first time that I’ve made that connection.  I had always chalked up my behavior to impatient exuberance.  Another example of how writing things down leads to new insights…

(to be continued)

So far the pieces of my life which I have presented in this blog have no coherent thread, except perhaps in the mind in which they come bubbling up.  In a way they are like puzzle pieces waiting for some connections to be made.  I will break with this “tradition” now by picking up the thread from my presidential scholar story, which took place in June of 1970, the summer before I went to college.

I frankly don’t remember much of that summer, except for one (ironically) unmemorable experience occasioned by a phone call from a woman who had a radio show in Hamden CT.  She had heard that I had been selected as a presidential scholar, and she wanted to interview me on the air.  I remember going there (I probably hitchhiked) wearing a tan army shirt and carrying a backpack (did I actually own a backpack then?  I hadn’t yet bought my handmade leather shoulder bag.  That was later…), climbing a shallow knoll up to the station, which was in a small building at the foot of a tall radio tower.  The woman was an appearance-conscious person who carried herself with a show business air.

The show was disappointing.  I had resolved to tell truthfully about the experience and my misgivings about it, but whenever I was about to say something significant, she would cut to a commercial.  This happened many times, and when we came back from the break she would “summarize” my previous statements in an entirely inaccurate way,  making me seem to be a very conventional student.  I left the interview feeling that I had not expressed a single one of the real thoughts and opinions which I had resolved to share.

So much for that incident.  Besides that, I went to visit Kate (this time with a car) at her house, and we took a short hike to an isolated and beautiful lake.  She showed me her special spot to sit and look out at the water, and told me that she had written a poem about this special lake.

I felt drawn to her, but had been crushed the year before when I learned that she had started going out with a senior, a tall boy with long blonde hair and an aristocratic (certainly not Jewish) sounding name.  So I let her take the lead, and the visit stayed platonic.  We talked about the strange experience in Washington, and she spent some time consoling me for my shame in accepting the award.  She had accepted the award too, but had been resigned to the fact early on that resistance would be futile (to quote the Borg from Star Trek).

The rest of the summer I worked again in the chemistry lab at Yale where I had worked the previous summer, and made a splash as the pimply-faced prodigy who was doing graduate level work as a 15 year-old.  (The grad student I worked with actually included my name as a co-author on the paper he published, although my contribution had been that of a highly-trained monkey more than a collaborator.)  I found myself being annoyed by my advisor, who I found to be self-centered and odd, and I ended up accidentally breaking the same delicate, expensive piece of equipment (it was a mercury-based Toppler pump which was designed to create a near-perfect vacuum) not once, but multiple times.

I remember when I was doing an experiment (a Grignard reaction) which was highly exothermic (heat-generating).  I was under the hood wearing protective goggles and gloves, quite nervous about the prospect of messing something up.  When everything was set, I started started the reaction, but just before doing so I decided to put the ice bath, which I had prepared to slow the process in case of an emergency, under the reaction vessel (a round Pyrex flask).  The reaction started up, and as it bubbled up it started to get out of control.  I immediately reached for the ice bath, but found it already underneath the flask, the ice already melted by the heat.  I panicked.  At this point the boss yelled “it’s gonna blow!” and ran out of the room.  Sure enough, the reaction exploded out of the top of the flask and shot into the ceiling of the hood.

I was saved by Jack, one of the grad students, who, cigarette in hand, came over and turned off the magnetic stirring bar, which was promoting the reaction.  “Maybe we should slow this down” he said in his understated Midwestern way.  The reaction immediately came under control.

After this embarassing experience (which no one but me blamed me for) I found myself keeping a low profile in the lab.  I had proven myself the previous summer, and was going to be starting college in a couple of weeks, and my emotional energy started to direct itself there.

(continued in “I make a load of friends at…Yale!)