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.