Danielle Ofri - July 1st

 

The most ominous day of the year, if you’re becoming a doctor, is July 1st. On July 1st, everything turns over in the medical world. So, medical students become doctors. They're now interns. Interns become residents, residents are now fellows, fellows become attendings. You're not supposed to remark on the bizarreness of being ratcheted up a notch at the stroke of midnight. No. On July 1st, you walk into your untested role, cool as a cucumber, and you act as though the world of June 30th and before never existed. [audience chuckle] Or, as the interns say, when in doubt, pretend. And so, on June 30th, I was a measly medical student. And on July 1st, I was now one of those interns.

 

I had been scheduled to start internship on night float, four weeks straight of night shift only. At 10 o'clock at night, I walked down First Avenue in the pitch darkness for my first day of internship. Now, night float is supposed to be the direct continuation of medical care from the day teams. But as a night float intern, I had the patient load of four other interns, so this wasn’t possible. My beeper never stopped. “Mr. Rivera, 19 south needs a new IV. Mr. Soto in 16 east is having chest pain. Mrs. Ahmed in 17 north has a fever. Mr. Hallal's daughter’s here and wants to talk to a doctor. Mrs. Rashid fell out of bed. Mrs. Kwan’s refusing her meds. Mr. Nolan’s having a blood transfusion reaction. Mr. Rivera’s IV is out again.”

 

And so, night float turned out to be 10 hours of damage control. I raced from one ward to the next, patching things up, putting out fires, just hoping to keep everyone alive until the sun came up over the East River and the day teams [audience chuckle] came back. So, one night, in my second week of night float, I get paged by my resident around 3 o’clock or 4 o’clock in the morning. “Elba Rodriguez’s blood count just dropped 13 points. Get over to 16 north, do a rectal, see if she’s bleeding from her gut.” 

 

Now, you should know that in the human body, there are only a few places where you can bleed briskly enough to drop your hematocrit to 13 points. And the GI tract is the prime suspect. And if you bleed anywhere along that line, from mouth to esophagus, stomach, small intestine, large intestine, rectum, there will be traces of blood in the stool. So, the way you check for a GI bleed is you get a stool sample, you put it on the card and you put a few drops of the special developer fluid on it. If it turns blue, that’s blood. And the way you get a stool sample is you send an intern over to do a rectal exam. [audience laughter] [audience applause] 

 

And so, at this point in my career, I was very adept at taking orders. I didn’t ask questions. I did what I was told. Mrs. Rodriguez was a tiny, wrinkled Dominican woman with layers and layers of family at the bedside. So, I walk in and say, “Hi, I’m one of the night docs. I’m not her regular doctor, but I’m just here to do the rectal.” [audience laughter] And I’m thinking, Dr. Ofri, rectal specialist. And so, the grandson steps forward. He says, “Well, we understand what you have to do, doctor. I’m actually a nurse. And if you don’t mind, I want to stay with Abuelita while you do the exam.” “Stay while I do this?” And I’m thinking, what is the protocol for this situation? I’ve been a doctor now for two whole weeks, and I have no idea what to do when the family wants to stay. But I say, “Okay, you know, whatever.”

 

So, the rest of the family goes out to the hallway. We pull the curtain for some privacy from the other three patients. The grandson and I roll Mrs. Rodriguez on her left side, and I start disgorging my pockets, the gloves, the lubrication fluid, the test cards. And then, I realize I’m missing the bottle of developer fluid. So, I say to the grandson, “Can you just hold on for one second? I need to get one more thing.” So, I dashed out of the room, and I avoid the gaze of the family members there, and I run to the supply closet and start rifling through the shelves and the bins. No developer fluid. So, I raced down the hall to 16 west to their supply closet. And of course, none there, all the other interns have pocketed them. 

 

The CCU, the cardiac care unit, was always well stocked, but I knew the nurses guard their supplies like hawks, so I crept in from the back door of the CCU-- [audience laughter] You know, where they keep the dirty laundry and the used bedpans, and I tiptoe over to the supply shelf. I start going through the shelves and there’s gauze pads and IVs, blood tubes, culture bottles, glycerin swabs and Betadine swabs. Right behind the chest tubes is a single yellow bottle developer fluid. I snatch it just as the nurse yells, “Hey, those are CCU supplies.” I cram it in my pocket and I run out with my head down, because from the back all interns look alike, [audience chuckle] or so I hoped. 

 

So, I get back to 16 north, and I’m out of breath and I’m flustered and sweaty and the grandson is still calmly balancing Mrs. Rodriguez on her left side. [audience laughter] And so, I undo the floral housecoat, the cardigan sweater, and the patient gown, I get down to her skin. While I’m doing the exam, like a good night float intern, I’m running my scut list in my head, all right, I’ve got to do those blood cultures on 15 North. I’ve got to do the chest X-ray to follow up on 17 West and that guy in 19 South keeps pulling out his IV. And so, I’m doing the exam, running the scut list, and the grandson says, “I think that Abuelita is no longer with us.” “No longer with us? What was he talking about?” 

 

With his free hand, the grandson crossed himself and murmured something in Spanish. I’m still frozen in the middle of the exam, “No longer with us? Mrs. Rodriguez is dead?” The grandson sighed. “Abuelita lived a long and wonderful life. She didn’t want any heroic measures or machines. She just wanted to drift off in peace. We just need you to pronounce her dead, doctor, and then we can take her home.” I’m staring at the grandson. Suddenly, my mind begins to race. I tear the glove off and I’m thinking, okay, okay, how do I declare a patient dead? I’m running through the file cab in my head, thinking, okay, okay. Pupillary reflexes. That’s it. 

 

So, I whip out my handy pen light and I shine into Mrs. Rodriguez’s eyes. To my dismay, she has huge cataracts and probably wouldn’t have had reflexes anyway. [audience chuckle] Okay, okay. Respirations. Dead people do not breathe. And so, I whip out my stethoscope. By now, the family is filtered in from the hallway, and they gather around a watch that I put in one earpiece and the other, and I plant the bell on her chest. And suddenly, a twitch vibrates through her body and I jump back. Was this rigor mortis, or might she still be alive? 

 

Suddenly, dawns on me that we never had a lecture in medical school on how to declare a patient dead. I guess it was assumed to be pretty obvious, dead is dead. And if you’re not dead, then you’re alive, right? Pulse. Pulse. That is it. Dead people, for sure, do not have a pulse. And so, I run my fingers along her left carotid and then along her right. Of course, the only way you know you found the pulse is when you’ve found the pulse. [audience laughter] How do you document the absence of something when its presence is defined by hunting until you found it? [audience chuckle] Maybe I was in the wrong spot. Maybe I’m pressing too hard or not hard enough.

 

Was I supposed to go over her entire body to document the absence of a pulse? Another twitch runs through Mrs. Rodriguez’s body, and the family is staring at me, waiting for an answer. But how can I say anything? What if I got it wrong? Okay, okay. An EKG. That’s it. If I get a flat line on EKG, nobody could argue with that. So, I run out and get the EKG machine and wheel it back in. These old decrepit EKG machines that Bellevue had, all the leads are tangled up. These old machines have these red rubber suction cups to put on the chest. When you squeeze them, electro jelly for EKG goes by, slithers out in crusted blue clumps. 

 

And Mrs. Rodriguez, the skinny little woman, doesn’t have much bulk on her chest for the suction cups to stay onto. So, I’d squeeze one on, another one would pop off, and so I’d apply more jelly and put it on, another one would pop off, back and forth. The family is like watching, like a tennis match, back and forth [audience laughter] as I’m chasing down the obstreperous suction cups. Finally, finally, I get the EKG set up, all the chest leads, all the limb leads and I press the start button. We all stare at this skinny strip of graph paper that’s sneaking out of the EKG machine. I’m praying for something definitive. It emerges with completely unreadable squiggles between the rattling air vents and three IV pumps. the next bit over, I can’t get a stable baseline. I readjust the leads, and two more suction cups pop off. 

 

The grandson curls his hand around his grandmother’s wrists and he says, “She’s dead, doctor. You don’t have to do any more tests.” The family joins hands and begins to pray in Spanish, and I’m standing there, with EKG jelly crusted under my fingernails, burning with embarrassment, how could I not figure out whether or not Mrs. Rodriguez was dead? Isn’t that what doctors do, pronounce the time of death? How could I ever be a doctor if I couldn’t tell a dead person from a live one? [audience laughter] How could there exist so much to be ignorant of? When were these magical medical skills going to materialize, and what was I going to write on the death certificate as the immediate cause of death? 

 

The sun came up over the East River, as it always does, even after the longest, hardest night of night float. As I’m signing out to the day teams, I’m thinking about Mrs. Rodriguez. I imagine her as a young woman, a fresh immigrant, right off the boat to New York. Maybe she came to Bellevue every year for her annual checkup. Maybe she had her children at Bellevue. Maybe she thought she would die at Bellevue. Wherever she was, I hoped she forgave me for the indignity she suffered at the hands of an inexperienced intern. 

 

Now, most of us, when we go home at the end of the day, it’s the end of the day. The light is falling, twilight’s coming, dusk. But when you work at night, the end of the day, it’s brilliant morning sun. I did night float, the month of July, and so it was so bright. I remember I would go home every morning like this, with my eyes covered. When I look back at that time now, I realize that I spent so much of my medical training with my eyes closed. 

 

Learning medicine, so internally focused, cramming in all those facts, all those diseases, I always had my head in a book. But one of the things about becoming a doctor, is that you need to open your eyes. You need to open your eyes to the world around us, to the experiences that teach us medicine. But our truest teachers are our patients and their families, whose lives and experiences we are so, so privileged to be a part of. Thank you.