Hopkins Medicine Magazine - go home
Current Issue Past Issues Talk to Us About the Magazine Search
an online version of the magazine Fall 2007
Features
No One Dies Tonight
 
  Every July 1, the new physicians arrive book-smart, filled with the finest hopes. Now comes the real world. Which patient wants to go first?

By RAMSEY FLYNN
Photograpy by Keith Weller
 
 
 
 

As if on cue, nearly all 40 of the new medical interns are paging each other at the same time. Odd, since they’re all in one room. “Here,” says one intern to another, seated close enough to feel the man’s breath. “Page me.”

Doo-oo-oo-oot!

And so begins the annual flocking of short white coats to a room on the Hospital’s fourth floor—with brand new pagers proclaiming the births of brand new physicians. It’s 7:38 on a Sunday morning, the first day in July, traditionally the first day of active residency for fledgling physicians at teaching hospitals all over the country. And, also in accord with tradition, all the interns are clad in noticeably abbreviated hip-length lab coats that denote their status as first-year residents. Within 10 minutes, a handful of senior residents will arrive—all cloaked in the coveted knee-length lab coats that show seniority—to usher their chosen beginners to the bedsides of sick people.

The room is fully bursting with earnest would-be healers, all super-bright, all hand-picked. They have been drawn here by a feverish desire to save the world, of course, and they are sublimely fine students; by dint of their medical school performance, at least, they are masters of books.

But what about the real world of fulminating complications that awaits them, where qualities like character and stamina will become paramount? And what of their patients, many teetering on the edge, whose lives will rest in the hands of these fresh-faced first-week doctors?

The intern year has become the stuff of classic medical humor. One popular online residency forum has lately circulated an iconic poster. Under the heading “New Interns,” it shows a young boy of about 8, swaddled in an over-size white coat and decorated with a stethoscope. The tag line: “Don’t go to a hospital in July. Ever.”

 

Gathered in the inner sanctum on Osler 4 where they’ll spend much of their first year, one small cluster of interns is briefed by a senior resident about a patient with an attitude. “This one’s a bit ornery,” says Peter Benjamin. The man’s 82 and seems to know that new interns are now flooding the halls. The patient questions every visitor in a white coat. “What year are you?” he asks. “I want to see your badge.” The inquisitions so impeded the man’s care that an outgoing resident had laid down the law for him the previous evening. “Sir,” said the resident commandingly, “if you die tonight, it’s your fault.”

The interns in this group raptly absorb the litanies of horrifying details on each of their 20 patients. Virtually without exception, the patients suffer from a riot of chronic problems—lots of heart failure mixed with hypertension mixed with addictions mixed with infections mixed with diabetes mixed with renal failure. Most are elderly, many unemployed, some non-verbal. “They’re all sad stories,” says Patricia Ross, a pharmacist who has served this residency training unit for four years. She has seen her share of them.

The patients are divvied up among the four interns, typically five patients each. In an arrangement rare among major teaching hospitals, the interns are imbued with instant responsibility. Their patients “belong” to them. If any of these patients dies tonight, it’s the intern’s fault. Or, at least, they’ll probably feel like it is.

 

Sara Keller is about to officially introduce herself as a physician to one of her very first patients. The 25-year-old intern with striking red hair lingers over the man’s progress chart outside his room, calmly studying and jotting notes for nearly 15 minutes at the compact “wallaroo” fold-out writing tablet in the hallway. “Mr. Hartline?” she asks brightly upon entering. “My name’s Dr. Keller.”

So far, so good.

Mr. Hartline is a 56-year-old soft-spoken sort with a droopy mustache and bushy eyebrows—and a deep-vein thrombosis that has swollen one arm to painful proportions. It probably came from his new angioplasty and recent dialysis. More dialysis is coming. He’s got heart disease, renal failure and diabetes. He has battled constant pain for years, with mounting layers of high-end medicines steadily losing impact. His blood pressure careens wildly, defying the will of drugs that would dictate otherwise.

The young Doctor Keller can’t wave a magic wand, but she can manipulate Mr. Hartline’s chemistry and alter his course. “Where, exactly, has it been hurting?” she asks, placing her hand gently on his forearm and studying the intravenous lines and then proceeding to probe his torso for the source of sharp pain storming through his belly. “I’m sorry you’re in such pain,” she says, tapping him on the hand. “Maybe we can take off some of the edge.”

It’s a smooth beginning. If Keller has knots in her stomach, they don’t show from the outside. She appears utterly poised. Yet the day is young. She has learned of a 50-year-old patient on the third floor who’s facing end-stage heart failure. His lungs can’t cope. Sweet man. Talkative. Married to a physician. There’s no sugar-coating this one; both the man and his wife know exactly what’s going on. The challenge for Keller, and for the man’s private physician—who also serves on the faculty of Keller’s residency group—is to see if they can squeeze a few more months out of the declining patient’s vital organs. Could they bridge him to a heart-lung transplant? Keller stops at the wallaroo outside the patient’s room to study her most acutely challenging case.

Back in the 15-by-15 room on Osler 4 that serves as the world headquarters of the so-called Thayer Firm, 26-year-old Adam Gerstenblith has checked into one of the eight Dell computers to enter orders for one of his new patients. Suddenly a dialog box pops up: “Are you sure you’re entering orders for the correct patient?” In the modern provider order entry system, even the computers are patrolling to keep physicians at all levels on high alert.

In a month of especially intensive vigilance, Gerstenblith might be the most alert July intern in the hospital. The son of cardiologist Gary Gerstenblith, Adam is a Hopkins Medical School graduate who has previously assisted this same training unit. His patient interactions and presentation skills have been startlingly flawless. Up since 6 this morning, Gerstenblith has been designated the first intern to take the overnight call—actually a 30-hour shift that will keep him on deck through the night and into Monday morning, finally releasing him from its iron grip late in the afternoon the following day. A senior resident will track him through the nighttime hours.

Instead of relying on caffeine, the dynamic young doctor says he’s propelled by “the sheer joy of medicine.” In the coming days, he will become comically notorious for trying to admit new patients during his overnight shift despite his senior resident’s efforts to “protect” him from the extra workload by steering them elsewhere. “What’s the big deal?” he asks good-naturedly after one such interception. “He was an interesting patient!”

 

It’s Monday morning. Day two. The firm’s chief resident and two senior residents are on the floor, making the rounds with their four interns—along with the team pharmacist and four medical students. As the entire white-coated tribe weaves through the hallways as one, they inevitably cross paths with other roving tribes of medical firms with July interns, clotting up the morning halls with traffic jams. It feels like a high-energy hive. It’s been 24 hours. No one has died overnight. No patient has even crashed overnight. The new kids are making it look suspiciously easy.

At one point, Gerstenblith leads the troupe into the room of an 84-year-old man with jammed arteries and sleep apnea and chest pain. Attending Chief of Service Timothy Scialla, a bespectacled 30-year-old true believer from a three-physician family, has already armed his group with a lecturette on the art of diagnosing chest pain. Now in the patient’s room, he insists that all 12 people introduce themselves to the patient by name and position.

And then, for Gerstenblith, comes one of the most dreaded tests in a new intern’s life—“presenting” a patient case, live, after 28 waking hours, in front of peers, all of whom are judging your every word. It’s showtime.

With a nod from the chief, he launches into a textbook-perfect presentation of the complicated case. He cites lab values, blood numbers, pressures, “I’s and O’s” (for fluids in and fluids out), and more, with almost no reference to his handheld notes…. Until it’s time to guide his colleagues through the man’s EKG tracing back in the hallway, where he detects a tracing pattern “characteristic of a right bundle branch block.”

After an X-ray study and some case-related lessons from the two senior residents, chief Scialla turns back to Gerstenblith: “Bring it home,” he says, prompting the young doctor’s diagnosis and care plan. Scialla rejoins: “Are you worried about pericardial effusion?”

No, says Gerstenblith, confidently explaining why.

Scialla can barely contain his smile. “It’s a great workup for someone with chest pain,” he says. “Fantastic.” He checks his watch. He notes that the discussion took 45 minutes, much longer than the desired 15 to 20, “but  he’s a great patient.”

In the coming days, with the steady unfolding of each new intern’s disarmingly coherent presentations, Scialla’s celebrations become more emphatic, graduating to outright victory pumps with his left hand. “Yes!” Whenever an intern presents a patient who has improved to a key threshold, the chief applies a golfing term for pronouncing the job well done; the patient can be sent home: “Let’s tee her up.”

Scialla had forecast chaos for these early days. He expected the interns to display fear, confusion, even some occasional hand-trembling amid procedures like on-the-floor injections. This quartet is almost too good to be true. Surely some must be in for a bigger trial by fire.

 

 

On their first gathering in the Thayer
                                              Firm office, interns listen as
                                              their new chief shares thoughts
                                        about first-day jitters.  
> WELCOME TO THAYER:
On their first gathering in the Thayer Firm office, interns listen as their new chief shares thoughts about first-day jitters.

In the Thayer Office, it is suddenly Monday tea time. Just before 5 p.m., the firm’s guiding alpha doc quietly slips into the room, peering over his bifocals to take in the ragtag gathering of five white coats before spotting senior resident Peter Benjamin, who looks slightly startled to see him. “So, Peter,” says Thomas Traill with a trace of his British accent (“pee-tah”)—“are you surprised?”

“It’s been a year and a half since we’ve both been in this room,” smiles Peter.

“Well, then,” says Traill, “maybe we should put the kettle on.”

At 60, cardiologist Traill is right at the sweet spot of middle age. He’s sought-after for his teaching prowess, but also sees up to 300 new heart patients a year. He holds weekly “Traill rounds” with interns in his outpatient office, along with pivotal social functions for residents throughout the year. His frequent tea time visits to the office are the Firm’s most constant character trait.

While the other young physicians pause amid their duties to greet their faculty leader—and Benjamin sends out an all-points-bulletin on his pager to alert other colleagues that it’s tea time—Traill sets about washing cups in the nearby sink. He stops to lift the foil cover off a plate of aging food. “What’s lurking in here?”

“Dr. Traill, can I ask a question?” inquires medical student Sahael Stapleton, who at 6-feet-8 towers over everyone else in the room. “Should we be able to see delta waves after an ablation?”

“No,” Traill answers, measuring out “three and a bit” scoops of his favorite Bengali tea. When Sara Keller walks in several minutes later, Traill greets her with a warm mug.

“I like tea!” she gushes. “Thank you very much!”

It is here, in this sequestered space, where the firm’s deepest tribal bonding unfolds. The office can be playful, intense, even confessional. Mistakes are caught and corrected. Brownies are shared. The refrigerator’s merits are debated. Communal cleaning is announced. Up to half a dozen conversations can unfold all at once. Teaching arises both formally and spontaneously, 24 hours a day, 365 days a year.

For all of the intense corrective guidance, the office can become a womblike refuge of support, much of it orchestrated by the chief and his three seniors. The words Thayer Love are splashed across the room’s whiteboard. Scialla has stood before it and warned his charges that people outside this room “will want to make you cry. But you guys’ll be great,” he told them. “Listen to your seniors.”

Thayer’s three senior residents constitute a nearly steel-trap backup that’s partly invisible to the patients. While the interns might visit their patients solo, their diagnoses and care plans are carefully vetted by their senior, often here in the firm’s office. At key moments a senior can even take pressure off an intern by quietly shifting into the role of functionary. In one case, while intern Joyce Sanchez was deeply caught up in the minutiae of entering orders on multiple patients, senior resident Hansie Mathelier silently walked Sanchez’ patient’s fluid samples to the basement pathology lab,  just to ensure the rigorous chain of custody.

Splashes of humor are evident around the room. A pair of giant green rubber fists is tucked away on a shelf, in case someone needs to relieve stress. Above it rests a simple face-mask of Mike Weisfeldt, the head of Medicine. The eyes are cut out, so anyone can don it if they’re in need of extra authority.

“This is a really merry office,” beams Traill, who suddenly looks up to see an old colleague entering.

“Joseph!” he exults. “Good to see you!”

Joe Cofrancesco is the physician for the 50-year-old man with end-stage heart failure, Keller’s patient. Cofrancesco wants to get Keller up to speed for the looming challenge. “What we’re really looking at here is what happens to a person 30 years after heavy cancer radiation,” he begins, pulling up a swivel chair.

As a lad of 12, according to Cofrancesco, the patient was sent to a dentist who suspected the boy’s tooth problem was not related to his teeth. After a series of tests, an oncologist detected  lymphoma and immediately admitted him for heavy radiation treatments. In the late 1960s, physicians weren’t quite sure of the optimal levels. Their thinking at the time, says Cofrancesco, was that “the boy’s not going to live unless we blast him.”

At the start of his first 30-hour
                                              shift, intern Adam Gerstenblith
                                              will forgo caffeine for “the
                                        sheer joy of medicine.”  
> PUMPED AND READY:
At the start of his first 30-hour shift, intern Adam Gerstenblith will forgo caffeine for “the sheer joy of medicine.”

They saved the boy’s life but “fried” his vital organs. He’d gotten a three-vessel bypass and a metal heart valve in recent years, but now the heart is failing and the lungs can no longer assist with clearing bodily fluids. The man is puffing up. At best, says Cofrancesco, “we’re looking at either a new valve, or new organs. This case is enormously complicated,” he adds, now staring sympathetically at Keller, whose expression would seem to confirm that she has absorbed every detail. “Welcome to internship!” he says, patting her on the hand.

 

The great cliché of the intern year is that young doctors typically arrive with romantic notions of saving worthy lives but end the year exhausted and cynical. Thayer is not immune to the syndrome. “It’s grueling,” says Ed Ostrin, slumped over with exhaustion after an end-of-year soiree at Traill’s home in Sparks. “It’s toxic.” Other graduating interns describe similar feelings (though the funk seems to lift as they decompress in the post-intern weeks.) “But by the end of the year,” admits Ostrin, “you can handle anything.”

It’s not just the volume of patient complications that wipes the interns out, says Thayer’s recent ex-chief Joshua Schiffer, but the recycling of patients on the Firm’s service who can’t seem to follow the medical advice intended to keep them well. “By February,” says Schiffer, “these guys will all know who the ‘frequent fliers’ are.”

Adam Gerstenblith may already have one. In his first week, he presents a 40-something man who arrived with acute chest pain. As he presents out in the hallway at morning rounds, Gerstenblith takes on a carefully neutral monotone. The patient’s pain came after he snorted five vials of cocaine. He has HIV. “Previous job,” the doctor recites, “‘I was in jail.’ Diet: ‘Living off graham crackers.’” The man funds his drug habit with disability payments. It’s the sort of twisted list of self-destructive horrors that might prompt dark humor, but all of the gathered white coats are poker-faced. The only essential question is whether the man should still be referred to drug rehab. He’s already been through it repeatedly.

Scialla doesn’t think the question is even worthy of debate. “Your chances always improve every time you go to rehab. So never give up. Ever.”

And then come the cases where interns in the medical service must think like those in the emergency room. Just after 8 a.m. during her first Friday as a doctor, Keller arrives in the room of a 68-year-old woman whose heart rate has soared to an alarming  160 beats per minute and stayed there. Keller is accompanied by Peter Benjamin, who asks nurses to set up an EKG monitor.

The woman’s eyes bulge, glaring at the two young doctors. She says nothing. In the course of a few requests by Benjamin, it becomes apparent that the woman can’t communicate at all. She responds to none of his requests. After quickly studying the woman’s heart rhythm, the two doctors opt to give the woman a dose of adenosine. The drug will intercept the signals of the heart node that drives her racing pulse. They must “push” the dose into the vein in the patient’s neck, stat.

 With the second patient in her new
                                              career as a physician, Sara Keller
                                        probes for the source of pain.  
> PATIENT TWO:
With the second patient in her new career as a physician, Sara Keller probes for the source of pain.

“Sara,” says Benjamin, “have you ever pushed anything through an I.V. before?” She has, but nothing of the potency of adenosine. Benjamin says he’s only done it once.

In moments, Keller has the I.V. access to the woman’s neck.

“Are you ready?” she asks the patient, who registers no awareness of what’s going on. Sara depresses the plunger. The woman winces, grimacing as the tendons in her neck rise in a spasm. The woman squeezes the nurse’s finger as her heart comes to a complete halt. Then, steadily, the heart restarts. The rhythm pattern on the monitor settles into an easy 60 in the span of about 10 seconds.

“This may only be temporary,” Benjamin cautions, as he takes the printout in his left hand and scrolls across the strip with his right. “But I think we’ve broken her,” he says, studying the pattern. The rhythm stays settled for 30 seconds, then 60, then 90. “Beautiful,” he says at last. He and Keller exchange the most guarded of smiles. “Let’s keep this strip,” he suggests to the nurse, “so we can save it for Sara’s file.”

Wordlessly, the patient’s wide eyes relax. Her attention shifts to the various tubes that attend her, which she tends and adjusts as she settles in for her sustained return to a normal heart rate.

As Keller walks back into the Thayer office, she tries to tame the long strip of paper that will serve as a memento of one of her first finest moments during this crucible of a first week.

“That’s a lot of rhythm strips you’ve got there,” says Patricia Ross.

“It was exciting,” smiles Keller, as Scialla compliments her cool in pushing the adenosine to cut the patient’s heart rate. Then Keller presses her own heart. “But I’m still doing 120,” she says. *

 
 
 
 
Features
 A Silver Bullet for Blake
 Desert Bloom
 'No One Dies Tonight'
 
Departments
 Circling the Dome
 Medical Rounds
 Bench Press
 Annals of Hopkins
 
Class Notes
 The Stobo Touch
 
Opinions
 Learning Curve
 Post-Op
 
Johns Hopkins Medicine

© The Johns Hopkins University 2007