DIARY ENTRY #1

June 4, 1996

Stanford, California

  Well, here it goes.... Hello out there in MedWorld!

   I'm writing this from San Francisco, 3 weeks before I graduate from Stanford Med School and head off to Beantown (that's Boston) to start internship. I've never done anything like this before (that is write a diary that anyone will read!), and it feels a bit intimidating, but a good challenge to share , keep track and reflect upon myself and my experiences throughout internship. We're in for an amazing year!

For those of you used to succinct presentations, here's a "Bullet" biography summary...

Read on in the H.P.I. from here if you're interested: 

  I'm London Born, D.C. area bred, Brown University Class of '90. Headed West for Stanford Med school '96. Spent 3 years in Med school as a Howard Hughes Med Institute Research Fellow in immunology. Took an extra year before internship to explore tropical medicine in Central America, participate in research and a medical expedition to Nepal, do my -Gyn rotation in Tel Aviv, start an on-line internet company, and complete work in aerospace medicine with NASA. Free time passions and pursuits include flying small airplanes, music (sax, keyboards and clarinet), skiing, tennis, running, diving , travel, photography and a good book here or there. In three weeks I give all that up (or at least much of it!) to become an intern in the combined Harvard Medicine/Pediatrics program. I'm looking forward to the transition and experience, mildly terrified and excited at the same time.

HPI: 

  So a bit more about me... London Born (A perfect Apgar!), but left as a wee tot (though I still love British Smarties- especially the orange ones, anyone out there who knows where I can get some?), and grew up within the Washington D.C. Beltway in Silver Spring, Maryland along with my younger sister, Dina, and of course my parents (Hi Mom!). In case you were wondering my Mom is from New Zealand and Dad from Michigan, but they met while working as a teacher and journalist (respectively) in London. Had a great childhood, as best I can tell- I remain successfully toilet trained, but still won't eat Broccoli. (I won't bore with stories of "playing doctor" as a 3 year old with my cute little nursery school mate Lisa from up the street... but lets just say those were my first experiences in physical examination.) 

SYMPTOMS CONTINUE...

  It was somewhere in early high school that the kernel of becoming a physician/scientist began to form. I'd always enjoyed and done well in science classes, finding out how things worked, dissecting frogs and such. Integrating science with real people and their experiences, woes and problems seemed to be challenging and rewarding. The science world opened up with a summer high school internship at the clinical immunology lab at the National Institutes of Health (NIH), in nearby Bethesda, Maryland. I spent the summer learning how to make solutions, run gels, culture cells, and make monoclonal antibodies. When in 11th grade, I had to do the dreaded science fair project, and thought; "hey why not do it at my old NIH lab". I had helped make some of the first monoclonal antibodies to the IgE receptor, being used to examine the receptor structure. In a moment of inspiration, I thought, why not use these anti-IgE receptor monoclonals clinically, to block the receptor thereby inhibit IgE binding and IgE mediated histamine release. Too make a long story short, I tested many monoclonals, found one that beat the socks of IgE, and would knock off IgE and prevent IgE mediated histamine release, both in-vitro, and later in-vitro. A cure for allergies! So, I won science fairs locally and internationally, and my scientific research career had begun. Turns out that two Biotech companies have now submitted patents based on this idea of blocking IgE binding (if I only knew how to start a biotech company back then...) Won trips to the London International Science fortnight, and a summer at the Weitzman Institute of Science, in Israel, and even a week with the Navy in San Diego. I can say that I drove a nuclear powered submarine at 1000 feet. These were exceptional summers where we certainly partied more than studied science... In retrospect, I feel lucky to have gone to some great public schools and had some good/caring teachers, while never feeling a huge pressure to get into a great university, go to medical school, or do anything in particular. There was just an internal expectation to do well.

PMHx:

  I landed at Brown University as an undergraduate (In Providence, Rhode Island). I fell in love with Brown the moment I first walked onto the college green as a pre- frosh. Had a fantastic 4 years there. Although my diploma says I majored in Biochemistry, I always felt it was in extracurriculars. The pre-medical scene was relatively mellow, and allowed me to develop other interests while out of the library. I had great fun as a sophomore being sophomoric as the conductor of the off-beat Brown Band, earned my pilot's license and ran the two airplane Brown flying club. Singing groups, jazz bands (I play Sax, piano, and clarinet), and membership in a co-ed fraternity (Alpha Delta Phi) were all great experiences.

  During several school breaks I was back at the NIH, in a lab of neurophysiology. For my honors thesis I worked on the molecular biology of HIV (tat) as a Ford Foundation fellow at Brown, and determined which human chromosomes encoded the co-factors needed to facilitate HIV pathogenesis.

  Another valuable and initial clinical experience at Brown was earning my Emergency Medicine Technician (EMT) license, and working for Brown EMS, eventually as a Ambulance Crew Chief. We were the dashing figures (or so we thought) riding around campus in our ACLS ambulance, mostly responding to drunk students and twisted ankles, with occasional car accidents and major medical emergencies. I got the "Emergency Medicine" bug, always waiting for a good call to come in, and for the sirens to wail and adrenaline to flow on a "Code 3" call in between Dunkin Donut runs. The EMT job had its perks. We were hired to work 'Grateful Dead' and 'The Who' stadium concerts. Wandered confidently back stage before the shows (wearing a uniform helps) and met the bands- Pete Townsend even signed my ID badge.

  After graduating from Brown, I took the summer and trekked through Europe with a backpack, friend, Eurail pass and the Back Door Guide to Europe in hand. Then it was off to Stanford for Med school. I had never conceived of coming west for medical school, and had no concept of Stanford Medical school, until I saw a "where are they now" spot about Eric Heiden, the 5 gold medalist speed skater, who was a student at Stanford Med. At the time, In the middle of a New England winter, a change of venue, complete with palm trees seemed enticing. So I checked the box on my AMCAS application...

  For me, Stanford was a very good choice for medical school. It offers a flexible curriculum, a small class (86 per year), pass/fail grading system (a big plus!), and an amazing wealth of research and other opportunities. I enjoyed being attached to the main campus where one has the ability to take non-medical classes and interact with undergrads and a large population of diverse and talented graduate students. Stanford also made the burden of financing med school reasonable, with generous grants, and research assistantships pay extremely well. Combined with a Howard Hughes research fellowship I'm fortunate to have a relatively small debt load coming out of school. The San Francisco Bay area is also a fantastic place to live, and I'll really miss the city, the Sierra mountains, and the good weather. I shall return!

HEAD IN THE CLOUDS...

  One of my long term interests has always been aviation and space. I remember following the Apollo/Skylab missions (I was even at the Apollo 17 launch when I was 5). Though my eyes weren't 20/20 and dashed my hopes of jetting about in F- 15's, I managed to get my pilots license in college and have been flying ever since. While in medical school I've flown many of my classmates over the Golden Gate bridge and Alcatraz (and gotten a few of them air-sick in the process). I've piloted on several trips with a medical relief group called "Los Voladores Medicales/The Flying Doctors", where we've flown small planes into remote villages of Northern Mexico and set up weekend clinics. 

  On the aerospace side of things, I was able to combine my biology and space interests for the first time in high school, when I worked on a "Get-Away-Special" project which was selected to fly on the space shuttle. We were looking at the ability of planarian worms to regenerate after sectioning in microgravity. After my sophomore year at Brown I was selected to participate in the 1988 NA SA Space Life Sciences Training Program, and spent 6 weeks at the Kennedy Space Center in Florida. We worked on a variety of space life sciences related projects ranging from regenerative life support systems to countermeasures to muscle de-conditioning. This experience opened my eyes to some of the connections between space flight and medicine. During my first year at Stanford Med school, I joined a group of engineers and for two years worked on the Space Systems Engineering - Stanford-USSR Manned Mission to Mars design project. As the only non-engineer I had the good fortune to design all the medical requirements and physiologic parameters for the mission. The project was published, made the press, even Dan "Space is Really Big" Quayle got to hear about it. 

  I spent the summer after my first year of med school in Toulouse France, at a program called the International Space University. This was an amazing summer- with 130 students from 28 countries. The Life Sciences Dept. Chairman was Oleg Atkov, a cosmonaut- physician who had flown on the Salyut Space Station for 7 months. We designed another International Mars mission in great detail, and learned to appreciate fine French wines. Just last month I was one of 4 medical students at the Johnson Space Center in Houston on an aerospace medicine clerkship. Highlights included meeting 2 Apollo astronauts, flying the Space Shuttle full motion flight Simulator with a crew in training, and 2 flights aboard the infamous KC-135 Vomit Comet. On this airplane you achieve 30 seconds of weightless with each giant parabola in the sky (they filmed much of Apollo 13 aboard). This explains the picture of me floating by the G-meter.

  I'm not really sure how all this fits into a medical career, its just been fun, interesting and broadening in a multi-disciplinary sense. There are many medical spin-offs from the space program, ranging from the Cell culture bio-reactors, to telemedicine, and microtelemetry units now used for intrauterine-fetal surgery. I'll try and keep my hand in it, and in my excessive free time during residency hope to join the Air National Guard as a flight surgeon (F- 15 flights included).

  Another thread on the medical side has been that of research in immunology. Since my experience at the NIH, I have always been intrigued by the concept of immunotherapy, and the impact of the immune system on virtually all aspects of the human health. After the NIH clinical immunology and neurophysiology (looking at stress hormone effects on NK cells), and HIV research at Brown... I started in the lab of Dr. Irving L. Weissman, a well known immunologist, and a very nice guy as well.

  Another long story short: I worked on human T-cell differentiation, using the SCID-hu mouse model (a SCID mouse (no innate T or B cells) with surgically implanted human immune tissue). I took the traditional extra year at Stanford (75% of students here take 5+ years to finish) and was awarded a Howard Hughes research fellowship for my 3rd year of med school. Through this work I discovered and published new intermediate T-cell population (CD3- 4+8-) which is part of T-cell maturation in the human thymus. Since this was the earliest population to express CD4 in the thymus, it was a likely source of HIV entry and Thymic infection. I was asked to spend some time at SyStemix (a biotech company examining HIV pathogenesis, and with HIV infected SCID-hu mouse models), where I helped look at HIV in the human thymus. Sure enough this new population was infected, though bystander and non-CD4+ cells underwent apoptosis as well (a large percentage of which were not infected cells).

A YEAR MOSTLY AWAY

  More on this later in future entries, but I spent much of this last year pursuing medicine in other places. I had begun the residency application process in my second clinical year. While planning for my final couple of months of medical school, I ended up with more than 6 months of great things to do and only 2 months in which to do them! I figured that I won't have this time and flexibility in my life for some time, and that a year in the grand scheme of things is not great- so I deferred residency applications for a year. There is a big world out there and I wanted to explore some of it while relatively young and unburdened by major responsibility. So last summer I joined 30 med students and physicians on a course in tropical medicine, in Costa Rica. We also spent some time seeing patients at an Indian reservation there. I spent 6 weeks in Central America, including some time in Guatemala, where I worked on my espanol. In Antigua, Guatemala, beneath a volcano, $100/week will buy you room and board with a family and 20 hours of individual Spanish instruction. I highly recommend it!

  I spent much of last fall in the Kingdom of Nepal. I had joined up to participate on a medical expedition with a group of several Docs and Nurses, called "Helping Hands". Had an incredible 3 weeks in the beautiful hill town of Bandipur, where we ran a very busy clinic, and saw around 2,000 patients. Incredible pathology, from advanced TB, to chronic (6 years!) otitis media, and lots of parasitic infections. We had a Nepali surgeon with us, and in rather a rather primitive O.R. did over a hundred outpatient surgeries. I removed several large sebaceous cysts on my own, and first assisted on cleft lip repair and a hernia repair under local. I also trekked up to Annapurna Sanctuary (up to 16,000 feet), and spent the rest of my time living as an expat in Kathmandu and working at the CIWEC clinic , where I ran a research project on the health and immunity of expatriates and travelers in Nepal. The hospitals in Kathmandu were incredible places. Nepal is a very poor country, you (or a friend) have to bring your own suture material, chest tube etc. and lidocaine to the ER if you want to be patched up. In other adventures, met a Sherpa starting a trekking company. Met Buddist Lamas, rafted the Bhota-Khosi and attained enlightenment (well, still working on that part).

  I flew out of Kathmandu and headed for Israel, with a stopover in Dubai, United Arab Emirates (lots of Sheiks driving Mercedes and speaking on Cell phones), and a several days in Jordan. Hung out with the Bedouins and visited the famous site of Petra (where they filmed the end of Indiana Jones and The Last Crusade). Completed my Obstetrics and Gynecology at Tel Hashomer Hospital via the Sackler Medical School (an American medical school) in Tel Aviv. Caught lots of babies and said 'Mazel Tov' alot. 

January of this year was a blur of interviews for residency. The research mini-postdoc job I had lined up with an immunotherapy group at Genentech fell through when the head of the lab I was to join decided to change jobs. This gave me the opportunity to hang out in San Francisco for a couple of months, and start an on-line internet company, the idea for which I had for some time, but never had time to pursue. 

SO HOW DID I END UP IN MED/PEDs ANYWAY?

  I had a terrible time deciding what area of medicine to go into. I basically enjoyed all the clinical areas, and the thought of giving up many fields to choose just one area was difficult and painful. Ask my friends and house mates, I was always changing potential futures. After a pediatric surgery month at UCSF I was off to be a peds or transplant surgeon. I really love working with kids. After spending more time on trauma surgery , and more long hours pulling retractors in the O.R., I realized I really like surgery, but wasn't in love with it to the point where it was the only thing in life I wanted to live and breath. Tried ortho, but found it wasn't my calling. I will miss being in the O.R. and will probably have a bad case of surgeon envy for some time.

  Emergency medicine remains a strong appeal, and I had fantastic rotations at UCLA-Harbor and at San Francisco General. I really enjoy E.R.- the diversity, pace and action. I also applied in Emergency Medicine Programs, and would like to have the ability to practice E-med in the future. I am hoping that a combined Med/Peds residency, with some additional electives in Trauma will prepare me for this as well.

  So how did I end up in Med-Peds? I had done an elective rotation in Pediatric Hematology at Boston Children's, and also had done a pediatric sub-internship on the Bone Marrow Transplant unit at Stanford. I liked the mix of clinical work and research application. Again, while I really enjoyed Pediatrics, I liked working with bigger folks as well, and didn't want to give up treating adults. 

  When I heard about the combined Med/Peds program at Harvard, and later met one of their residents while in Costa Rica, it seemed like the ideal mix for me. For one extra year of training I'll be board eligible in two fields. The 8 incoming folks spend our residency rotating between the Mass General Hospital, Boston Children's, and Brigham and Women's. So we are officially part of 4 residency classes, though we are split between a dominant home base at the MGH or Brigham/Boston Children's side.

  While a combined Med/Peds program can have a primary care slant, I anticipate utilizing this training to pursue clinical work and translational research which has crossover and synergy between pediatrics and internal medicine. While I am not sure I want to sub-specialize in hematology/oncology, I may pursue fellowship in a field such as heme/onc or clinical immunology. Hopefully this will enable me to synthesize a career in clinical and translational biotech research with crossover between pediatrics and internal medicine, in which I can pursue creation of novel therapies which treat both kids and adults. (Whoah- sound like an application essay. Sorry. )

  Congrats on surviving a far too long, and unsuccinct first Diary intro entry. As Shakespeare once said: "Brevity is the soul of wit" So, having failed miserably on the brevity part, as well as the wit, I'll sign out here, until next time. In the meantime then, I have to survive graduation, and make the West to East Coast move...

June 24, 1996
Boston, Massachusetts



DIARY ENTRY #2

   Well, I'm here. As of 7 days ago, I'm an M.D. officially, and officially dangerous. I'm in Boston and about to start internship at the Mass General. The name tag with my name followed by "M.D." sits before me. Reality is about to begin.

   The last week has been quite something. The week before leaving full of trying to finish up last minute things, pack five years of accumulated junk, deal with my visiting (and helpful) parents and other family in for graduation. Plus, saying goodbye to friends and to Stanford and warm Northern California.

   Sunday, June 16th was graduation. Made my way in my newly rented flowing gown, with the Green/Red M.D. hood and funky mortarbard, to the Stanford Stadium for part 1 of graduation. We lined up with the other professional schools. A classmate brought a box of surgical masks and gowns, which we donned for the ceremony, a token jest compared to some of the Stanford undergrads wacky outfits. Speeches, pomp circumstance, all that stuff. A good talk by Mae Jameson M.D. , the first African American female astronaut. Part 2 was more intimate and at the med school.

   Handshakes and hugs. Diploma case (we got the real thing when we turned in our gowns...)
   After graduation, yet more pictures and goodbyes. Had dinner with family and friends, back for final packing, and to the airport to catch a redeye flight that very night to Boston. For Monday (the very next day) I started orientation. As I was about to take off from San Fran airport, and the engines revved-up, I opened a card from my a good friend and housemate of 4 years. As he was writing the card to me, Elton John's "Daniel" came on the radio. My friend transcribed some of the lyrics- "Daniel is leaving tonight on a plane..." There I was, on the plane, red tail lights and all, waving goodbye, and for the first time over this hectic weekend, the emotions of loss and leaving swept over me.

   Arriving the next morning - Hauled my over the limit baggage (car and rest of stuff coming next week by movers) to The Mass General, where I met my new housemate, and we made the short drive in my rental car to my new pad. An awesome place, right on Beacon street, a few doors down from the "Cheers" bar and across the street from the Boston Commons park. Wonderful place, complete with fireplace, large rooftop deck. And most importantly- laundry and dishwasher. I'm sharing a place with Ben, a 3rd year resident, (starting urology after what sounds like 2yrs of pretty brutal general surgery), and Yago, Ben's cat. I'm already working on plans to get a hot tub for the roof deck.

   Made it after having my 1st hellatious parking experience in Boston, to our first orientation to the Med-Peds program. There are 8 of us starting the program this year. We met with all the respective program directors from MGH and Brigham medicine programs, and Boston Children's Peds. All very fine folks. It was weird sitting around that table at first, looking at all these people I knew I am soon to know so well, and for so long.

   We started off with a discussion, as did the Boston Children's orientation, by sharing our "hopes and fears"... There was a common theme of 1. I don't know/remember anything... 2. I won't have time for a life, to hopes of 1. Becoming a great doc, and 2. Having some semblance of a balanced life outside of the hospital. The residency directors reassured us, told us not to sweat it. Sure...

   Part of the unique distinction of being in the Med/Peds program is that we are part of four internship classes. This has made for a rather crazy orientation, to a couple of different hospitals, and lots and lots of new people- all seem to be rather nice and interesting. Getting ID badges, jackets, figuring out health plans, taking both Pediatric and Adult ACLS courses. Plus, the bonus of over 4 different welcoming lunches, picnic/barbecues and formal dinners, including Mass General (MGH) medicine, MGH pediatrics, Brigham medicine dinner, Boston Children's picnic, MGH medicine picnic.

   My schedule for the year...
July-Medicine Bigalow Wards
August-ICU (2weeks)/Oncology wards(2weeks)
Sept-Pediatric Wards at the Mass General
October-NICU (Neonatal Intensive Care) 
November- Adult Emergency Dept. at MGH
December- Bigalow Medicine Wards
January- 2 weeks ambulatory care, 2 weeks Private medicine service,
February- Ambulatory care- 2 weeks/ 2 weeks vacation (Finally after 8 months!), March- Emergency at Boston Children's ER,
April- School Age Ward at Boston Children's,
May- Ambulatory care/ 2 weeks vacation
June-Northshore hospital pediatric hospital/ER (near Salem, Massachusetts)

   I'll also have a combined internal medicine and pediatrics outpatient clinic each week in Chelsea, a poor, ethnic and diverse section just north of downtown Boston.

   Tonight was the "last supper" with the Boston Children's group of interns. For tomorrow- I become an intern for real. I start on the infamous "Bigalow" medicine ward service at the Mass General. By all accounts its a great place to start, thrown into the milieu, though the support system seems to be strong, with lots of help if /when we need it. Call every 3rd night.

   I feel ready to finally start, though not neccesarily ready to be a doctor. The trepidation hit today while the medicine chief residents were discussing the realities of schedule and admitting sick patients.

   I'll let you know if I survive the week (or better yet if the patients survive me).

Until then- Here I go...
Daniel 


Beacon Hill...July 10th 1996

   Its 11.30 pm and I've just rollerbladed home from the Mass General through the gaslit streets of Beacon hill. Two weeks into internship. On the main medical service team-The Bigalow service. I have to be in the hospital in a few more hours. I'm on call, tomorrow, again. I was just on call two days ago....

   I am an intern.

   I am sleep deprived.

   I have survived 5 nights on call

   I have slept an average of 15 minutes each call night, and that came on from one night.

   I have not killed anyone

   I have admitted every third day, and night

   I have been on call, post call, and swing

   I have admitted chest pain

   I have diuresed CHF, 

   Pushed the morphine

   Treated Chest Pain on the floor, transferred to the unit

   Ruled in MIs, ruled out MIs.'

   I have seen heart failure.

   Pneumonias, TB, Urosepsis, stroke, DVT

   The obnoxious drunk. The affable Alzheimer's soul. The sweet, the terminal.

   Terminal AIDS at full court press. 

   Had cute great great grandmothers call me sonny

   4am in the morning drawing blood cultures for spiked temps.

   I have learned how to heparanize, how not to heparanize.

   I have gotten lost.

   I have learned I had better learn how to read EKGs

   I have rounded.

   I have rounded.

   We have rounded and rounded.

   I have fallen asleep standing post call while rounding, (holding up the wall).

   I have tapped knees, tapped bellys, tapped backs.

   I have been clueless.

   I have been paged.

   I have been overwhelmed, underwhelmed, and just plain out of the loop.

   I have been paged again.

   I have stayed late.

   I have missed at least 5 good social functions by staying late, and getting in early.

   I have had fun, had the feeling that I just can't wait to get away.

   I have become a pretty good phlebotomist.

   I have had one day off.

   I have laughed, and I have cried-Its been better than "Cats".

   I've seen the code called, and the call called.

   I have written 27 SOAP/progress notes in a morning.

   I have gram stained.

   I have been in the groove.

   Definately been out of the groove.

   I have increased my caffeine tolerance.

   I have been toxic.

   I have had my beeper.

   I have become my beeper.

   I have barely unpacked.

   I've seen the Esplanade and the 4th of July fireworks.

   I've met good people, and great people. 

   I have had no time.

   I have had my first medical students. (Its nice to have someone on the team who knows even less than I do.)

   I have learned by osmosis.

   I haven't had time to read.

   I have been at this for two weeks

   I am tired.

   I am an intern.

   I am going to sleep...

July 25, 1996

Beacon Hill, Massachusetts

Well- I've just about finished/survived my first month as an intern. On the main medicine ward, its been Team 'A', 3 interns, a junior resident, 2 first year Harvard med students and a fourth year student sub-intern. It has been the busiest July at the Mass General in recent memory. Averaging 5 admissions per call per intern on the public service. Every third night call comes around quickly, especially if you've left the hospital pre-call the night before at 11pm, and are returning the next morning for another 30 hours. 

   Unlike most traditional ward medicine teams, the MGH Bigalow public service is more team oriented, where we all follow patients. Every third day you are on call for your team, writing progress notes on all the patients (we usually have between 23-28 patients), and admitting patients new patients to the team from the Emergency Ward, or on transfer from one of the Intensive care or step-down units. Usually don't sleep on call, trying to write admission notes, running the cases by the one junior covering all four medical teams (A-through D), and keeping the teams' patients alive and kicking until morning.

   Post-call days one's job is to stay awake on rounds and present the new patients. By noon its a sense of relief and off to home to sleep (or try to enjoy the day- I made it sailing on the Charles river once with one of my clinic attendings I ran into while rollerblading home down the Esplanade, and also went to my first Red-Sox game (though I slept through a couple of innings). The 3rd day you are the "Swing" intern, and the job is to get all the scut done for the day- calling the consults, getting the tests run, checking the labs and reading the charts, writing all the orders, dealing with decompensating patients, chest pain etc. Its a crazy, hectic, stressful job. 

   We round as a team each 7:30 am. We meet with the attendings, have X-ray rounds, and go over and see new and talk about old patients from 10-noon. Then noon conference marks the end of the formal day (gotta get there early to get food- often pretty good Indian/Mexican/ or greasy pizzas). Then its trying to get the work done and get home (averaging around 10 PM) when on swing duty, to come in the next day on call.

   Some of our current patients...

   Ms M is starting the IV Morphine drip to oblivion. The family is pushing it. The nurses are pushing it. Nothing more done. Diagnosed with metastatic lung Ca after being admitted for TB and diarrhea. Dwindled fast. Always looked like shit. Now she is sure, wants it done and over. No hospice for her. 45 pack year smoker she is 52 for a while longer.

   Declared my first patient dead the last call night, or was it morning around 5:30. Much of the extended family was there, which was nice , but painful as they watched their sister mother, grandmother on the C-PAP positive pressure breathing mask, taking her final breaths over a 16 hour period. The ravages of advancing rheumatoid lung despite high dose steroids. Each night it was getting harder to keep her sat above 80%, to high flow to CPAP. A Do Not Intubate (DNI) declared. In on rounds she was struggling... a blood gas came back with a CO2 in the 70s. Called the family in. This time she wasn't going to pull out of it. Filled out the forms. Called the admitting office for the discharge to the big man upstairs...

   Mr D. left today. Our Jovial overweight, Italian chef had pancreatitis, despite the fact that he doesn t drink. His lipase, amylase were down, and he'd stopped spiking temps. We "The A Team" now have a gift certificate to his Italian restaurant. 

   Mr M., some excitement the other day on call, when he had elevated S-T on his ECG. Big MI? ... all leads. Turns out to be pericarditis. Good thing we didn't heparanize him. The echocardiogram confirmed it. His chest tube is in place and draining what is probably a malignant effusion. Seems like we have the lung cancer ward this month. Nice Italian man. Family there to translate. I'm getting better at my, Bonna Sera, and converting my Spanish to Itanglish.

   Drawing blood on the neurotic woman from NYC with an infected vein graft harvest site, 3 months out from her quadruple bypass CABG. A real laugh riot.

   4am- taking Mrs. M, a 75 yo women with metastatic angiosarcoma to the MRI to r/o cord compression as mets to her spine rendered her acutely nuerologically impaired. Had to snow her with over 30 mg of Haldol to get her through the scan.

   Mrs. S, 48 yrs old from the Hills of Maine, who let an ear infection with puss coming out his ear brew for a month until he developed facial palsy, and osteomyelitis of his skull- comes to us from the ICU, for hyperbaric oxygen and antibiotics. 

   Mr Joe . Our team's darling mascot. Very pleasantly, and most amusingly demented, and always pulling out his suprapubic catheter, he is full of congenial confabulations to the questions we pose to him. He returned to us from the nursing home after a fall. Doesn't eat much but chocolate Ensure and sit, poseyed to his chair by the nursing station so we can keep an eye on him.

   Timmy, the 23 year old chronic vegetative state patient transferred over a month ago from rehab with pneumonia, status post MVA (car vs. pole), now ventilator dependent. The parents take shifts, and one is always there... since April. Poor poor prognosis. Poor family.

   The end stage AIDS patient transferred from the ICU with an almost brain herniation from a large brain mass, either toxoplasmosis or lymphoma. Comfort measures only. Though now he is coming out of it a bit, despite being on a morphine drip at 10mg an hour. Barely touches this heavy IVDA heroin user. No brain Biopsy... like our other similar patient a week or so ago. Went for brain bx. Showed lymphoma, STarted radiation treatment. but why. Had a huge GI bleed. Died that night. The first death for our team. Not unexpected. Not too tragic?

   Got AIDS from a needlestick working in a lab. Does that make it any more tragic at 42 yrs old?

   Signed out tonight at 10pm . Tomorrow on call. Never-ending. 

   Next week. Its on the to the Intensive Care Unit.

   Ciao for now-

   Daniel

September 10, 1996

Boston, Massachusetts

On Call, early morning Sept. 10, 1996

   Just back from a code at the Mass Eye and Ear Hospital (connected to the Mass General). Someone, somewhere had little heartbeat and little breath to speak of. The sundry members of the code team had their beepers squawk, and rushed from various corners of the hospital. 

   Its been a relatively quiet week on the Pediatrics ward. The Code call announcement came on overhead speaker. My medical student and I, high up the 16th floor pediatrics floor, looked at each other, and having nothing better to do at ten to midnight, made the not insignificant treck from the Mass General over to the connected but otherworldly Mass Eye and Ear hospital. As interns, if its not our patient, we certainly aren't expected or usually needed to go to codes. More a moribund curiosity and opportunity to help when possible and see how they are run-as I will be the one running the codes in a year or so. The flavor of a code changes dramatically if you know (as happened to me when one of my patient coded while at radiology) , or are responsible for the patient, which fortunately , we weren't. 

   The strangely surreal but becoming familiar scene of many residents and nurses crammed into a room greeted us. CPR in progress. Someone was trying to put in a central groin line. It was worse than usual- the patient, an 80 year old, who was fine 30 minutes early when checked by the nurse, had just undergone a reconstructive facial procedure following a carcinoma removal, and had what the anesthesiologists would call a " a difficult airway". Having just been operated on about the neck- normal endotracheal intubation was not an option. After a few rounds of epinephrine, a few shock with the defib- and very little ventilation going by via the bag mask into the lungs- the ENT senior resident tried for the bed-side surgical airway (a first for him). I held a couple of flashlights to light the impromptu surgical field. Tracheotomy incision- and the endotracheal tube shoved tight directly into the trachea. A weak pulse on the monitor but nothing palpable. The arterial blood gas came back with a pH of 6.9 (acidic), and a oxygen level of 6 (normal is >50) and Carbon Dioxide of 140 (way high). The situation was obviously futile. Any brain was long past salvage 25 minutes into the code. Finally the senior medical resident "called" the code. It was over and the patient was now without a return ticket to the netherworld. 

   Five seconds after she said "lets call it" and CPR and respirations were halted... The patients phone rang.

   Everyone, about to leave, froze in place.

   "I don't think we'll answer that one" said the ENT resident.

   I'm back online and up for air. Now I've survived 2 months of internship (that's 1/6th of the year) (though who is counting?) 

   After the 1st 5 weeks on the general medical wards- it was out of the frying pan and into the kitchen- to a stint in the Medical I.C.U., which I recently completed.

   Intensive Care Units are intense in more ways than one. Intense medicine, intense living, intense dying (and lots of it), intense attendings, tense tense tense. The place where patients which are medical disasters come to be 'flogged' and in a few cases great 'Saves' are to be made. 

   All in all- it was great fun...

   The Team: A senior resident, and three paired sub-teams consisting of a junior resident and an intern. There is a pulmonary and critical care fellow who helps out, and an attending whose name is on the chart and rounds with team each morning Every third night call. One of the other residents kept a moribund tally of Hits (admissions), Patients on each sub-team, Deaths, and Saves (i.e. someone who really benefited and made it out of the ICU) 

   Every third night it was me and my junior, alone, taking admissions and running the unit with the fellow and attending somewhere asleep at home.

   The patient my resident and I picked up the morning we started had been in the unit for a week already and was pretty amazing. Ms P. , an otherwise healthy 36yr old mother, had a gum infection which spread down to her neck, and into her chest. Required an operation to debride the infection. Post-operatively she developed "ARDS"- adult respiratory distress syndrome while on the ventilator. Her lungs were shutting down and despite the best ventilator and other tricks in the books she was about to die. In comes the ECHMO (extracorperal membrane oxygenation) team. Two big catheters placed in the groin take out blood, which is oxygenated in a big contraption with many tubes, and pumped back in. Basically a bypass bypass used while the heart is still pumping. It allows us to essentially turn off the lungs to allow them to heal and get a break from mechanical ventilation while the blood is oxygenated outside of the body. Until very recently this was only done on premature babies, but now has been tried on less than 2 dozen adult patients. To make a long story short, Ms. P was a true ICU 'Save', and in my time in the ICU we got her off the ECHMO, then extubated and breathing on her own off the ventilator. And finally after 5 weeks in the ICU, to the general medical floor- and finally home.

   Our first day/night on call we had five admissions. My junior resident (who had all of 2 weeks as an intern in the ICU), was terrified.

   Our first patient: a very large chef from New York- a true heart attack victim with a very nasty EKG, who had received thrombinolysis to break up the clots in his coronaries while in the emergency dept. He was finally pain free after loads of morphine in the ER, but required full IV doses of Nitroglycerine and Esmolol drip to keep his pressures below 150. The high blood pressure and heart rate monitors kept ringing and I'd have to run into his room and give him extra slugs of IV Beta blocker to bring his heart rate down. Then his chest pain came back... He made it out of the unit to the Cardiac care unit a couple of days later after having cardiac catheterization.

   Number two: A suicide attempt- 38 year old who had taken 2 bottles of his anti- Tuberculosis medicine (INH). A poor choice for suicide- he'd been found confused, taken to the ER, stomach pumped with charcoal, intubated for airway protection. And then sent up to me, very combative despite 100mg of Haldol (enough to snow a horse). We sedated him with propofol ( a short acting benzodiazapine) gave him the antidote (vitamin B6), and sure enough in the morning he was extubated and sent wide awake and talking to the medical floor.

   Number 3: A 58 year old with widely metastatic lung cancer- with trouble breathing. With his unstable respiratory status they thought that he might "buy the tube" as its called, and since per family wished he was a 'Full Code' ie. everything from intubation from CPR was to be done (essentially futile in end stage cancer patients) he came up to the MICU. I put my 3rd arterial monitoring line in after a couple of sticks. This allows us to follow blood pressure and heart rate in real time (and makes the alarms go off when parameters are out of wack). By the next day, he remained actually quite stable and was transferred to the oncology unit, where after appropriate consultation with his oncologist, he was made DNR (Do Not Resuscitate) and sadly, died a few days later.

   Number 4: 3am up from the ER, a unidentified 60ish year old male, who was found down at a subway stop without a pulse. After 45 minutes of CPR and grams of epinephrine etc. in the ER, they got a pulse back. Now ironically, he had maintained his weak pulse on full pressors, and hadn't died as expected. The attending ER physician needed the room in the ER, so up to the ICU the nameless patient went with a systolic blood pressure of 60-70. My junior handled this one. Despite full IV meds, his pressure fell. There was nothing left to do. And he died. What my resident resented most about this lousy admission, was that she would have to dictate the entire admission, and discharge (to the morgue). More futile paperwork.

   That was only the first night of many sleepless in the medical ICU. We survived the night to bagels and coffee brought in by the relief team the next morning. I left to a glorious summer afternoon in Boston, and the past 30 hours of rounding, bells, whistles, ventilator settings, sedation orders, DNR orders, beepers, thick charts, tragedy, triumph and stale coffee were left behind as I rollerbladed home to sleep.

Daniel