White Coat Notes | Elbrecht's Corpuscle

Allen Street

Posted on July 28, 2017 by Elbrecht

Author: Dr. Lewis Thomas (1913-1993)
Reprinted from “The Youngest Science: Notes of a Medicine Watcher”

Canto I: Prelude

Oh, Beacon Street is wide and neat, and open to the sky
Commonwealth exudes good health, and never knows a sigh
S collar Square, that lecher’s snare, is noisy but alive
While sin and domesticity are blend on Park Drive
And he who toils on Boylston Street will have another day
To pay his lease and live in peace, along the Riverway
A thoroughfare without a care is Cambridge Avenue,
Where ladies fair let down their hair, for passers-by to view
Some things are done on Huntington, no sailor would deny,
Which can’t be done on battleships, no matter how you try
Oh, many, many roads there are, that leap into the mind
(Like Sumner Tunnel, that monstrous funnel, impossible to find!)
And all are strange to ponder on, and beautiful to know,
And all are filled with living folk, who eat and breathe and grow.

Canto II

But let us speak of Allen Street—that strangest, darkest turn,
Which squats behind a hospital, mysterious and stern.
It lies within a silent place, with open arms it waits
For patients who aren’t leaving through the customary gates.
It concentrates on pending results, and caters to the guest
Who’s battled long with his disease, and come out second-best.

For in a well-run hospital, there’s no such thing as death.
There may be stoppage of the heart, and absence of the breath
But no one dies!
No patient tries this disrespectful feat.
He simply sighs, rolls up his eyes, and goes to Allen Street.
Whatever be his ailment—whate’er his sickness be,
From “Too, too, too much insulin” to “What’s this in his pee?”
From “Gastric growth,” “One lung (or both),” or “Question of Cirrhosis”
To “Exitus undiagnosed,” or “Generalized Necrosis”
He hides his head and leaves his bed, and, covered with a sheet,
He rolls through doors, down corridors, and goes to Allen Street.

And there he’ll find a refuge kind, a quiet sanctuary,
For Allen Street’s that final treat—the local mortuary.

Canto III

Oh, where is Mr. Murphy with his diabetic ulcer,
His orange-red precipitate and coronary?
Well, sir,
He’s gone to Allen Street.
And how is Mr. Gumbo with his touch of acid-fast,
His positive Babinskis, and his dark lunatic past?
And what about that lady who was lying in Bed 3,
Recently subjected to such skillful surgery?
And where are all the patients with the paroxysmal wheezes?
The tarry stools, ascitic pools, the livers like valises?
The jaundiced eyes, the fevered cries, and other nice diseases:
Go! Speak to them in soothing tones. We’ll put them on their feet!
We’ll try some other method, some newer way to treat
We’ll try colloidal manganese, a diathermy seat,
And intravenous buttermilk is very hard to beat
W’ll try a dye, a yellow dye, or different kinds of heat
But get them on their feet
We’ll find some way to treat
I’m very sorry, Doctor, but they’ve gone to Allen Street.

Canto IV

Little Mr. Gricco, lying on Ward E,
Used to have a rectum, just like you or me
Used to have a sphincter, ringed with little piles,
Used to sit at morning stool, face bewreathed with similes,
Used to fold his Transcript, wait in happy hush
For that minor ecstasy, the peristaltic rush…
But in the night, far out of sight, within his rectal stroma,
There grew a little nodule, a nasty carcinoma.
Oh, what lacks Mr. Gricco?—Why looks he incomplete?
What is this aching, yawning void in Mr. Gricco’s seat?
Who made this excavation? Who did this foulest deed?
Who dug this pit in which would fit a small velocipede?
What enterprising surgeon, with sterile spade and trowel,
Has seen some fault and made assault on Mr. Gricco’s bowel?
And what’s this small repulsive hole, which whistles like a flute?
Could this thing be colostomy—this shabby substitute?
Where is this patient’s other half! Where is this patient’s seat!
Why, Doctor, don’t you recollect: It’s gone to Allen Street.

Canto V: Footnote

At certain times one sometimes finds a patient in his bed,
Who limply lies with glassy eyes feeding in his head.
Who doesn’t seem to breathe at all, who doesn’t make a sound,
Whose temperature is seen to fall, whose pulse cannot be found.
And one would say, without delay, that this is a condition
Of general inactivity—a sort of inanition—
A quiet stage, a final page, a dream within the making,
A silence deep, an empty sleep without the fear of waking—

But no one states, or intimates, that maybe he’s expired,
For anyone can plainly see that he is simply tired.
It isn’t wise to analyze, to seek an explanation,
For this is just a new disease, of infinite duration.

But if you look within the book, upon his progress sheet,
You’ll find a sign within a line—“Discharged to Allen Street.”

When I Grow Up

Posted on November 15, 2016 by Elbrecht

One of the most common questions I have received in Residency has been, “What do you want to be when you grow up?”

I have heard it from every level of the medical machine in which I have existed for the last two-and-a-half years.

Attending physicians have asked me.

Nurses in the ICU.

Respiratory therapists in the ED.

Janitorial staff in the hallway.

Pharmacists in the trauma bay.

Senior residents on a multitude of services.

“What do you want to be when you grow up?”

It has been the most infuriating question I have received in Residency; I’ve been asked it more times than I can count.

And it is not as if the question has been some derivative thereof; the wording has been exactly that.

It hasn’t been “When you have finished your medical training, is there a specific focus you would like to have?”

Or “what made you decide to choose Family Medicine?”

Grown adults have asked me, “What do you want to be when you grow up?”

I have grey hairs in my beard. If that weren’t a dead giveaway that I’m an adult, I don’t know what is…

For all except one of the occurrences, I have politely responded with something about my desire to provide primary care in the Behavioral Health patient population.

In the lone outlier, I made reference to my age, as I was clearly older than the person asking me and unbelievably sleep deprived, which kept me from overriding my primordial desire to psychologically eviscerate them.

I apologized after my verbal carnage ended.

My ego has been kept in check for most of Residency, mostly due to my need to survive without making a multitude of personal and professional enemies, despite my innate desire to respond with an exasperated,

“Do you realize how condescending of a question that is?”

It’s not meant to be a condescending question. Perhaps it has simply infiltrated the ice-breaking vernacular of the medical field.

Perhaps it is appropriate, as a fair number of medical school graduates are still coming straight from an undergraduate campus without an iota of life experience with which to share their patients, much less their colleagues.

Maybe I look young? But I know I don’t. I’ve seen pictures of me before I grew up. And I certainly don’t look as young as I did when I was 24.

When I showed up to the first day of Residency, I was 34 years old.

While it’s true that every single senior resident in my Residency had a far superior grasp on medical knowledge and patient care than me, a vast majority were four to six years younger than me.

Embedded in that seemingly trivial age difference, are the fruits of my labor.

If I conservatively look back on the six years from when I moved to Boston at 24 and when I turned 30, I wouldn’t know where to start in order to describe the multitude of amazing things I experienced.

Perhaps I sound like an incredible asshole by saying that. You may not be wrong. But for the most part it is true.

I came to Residency with an open mind about being taught by men and women with far fewer life experiences from which to draw upon than me.

The converse could not be said to be true.

For each successful completion of one year of Residency, it is as if a Purple Heart has been awarded by the Surgeon General.

Without a year under your belt, the Medical Degree for which you worked so hard was like a Participation Certificate a child would receive for making an exploding volcano at the Science Fair.

Respect is based solely on your capability to perform the medical task set before you as a resident; everything else about you be damned.

It didn’t matter if every other person outside of the medical field who knows you would explain with awe in regards to what you had created for yourself; no one within medicine could care less.

Medicine is a hierarchical beast. It has been that way for the past century since the dawn of modern medicine.

I am not perfect. I have fallen into that trap a few more times than I would care to admit during Residency, but I believe for the most part I have awarded everyone of my colleagues a Purple Heart for just making it to Residency.

Surviving the four years of Medical school without becoming disenfranchised, burned out, or overwhelmed by the cesspool of obstacles inherent in medical training, is an incredible achievement unto itself.

So each time I am asked “What do you want to be when you grow up?”, the part of my amygdala that houses my Pride, is set aflame.

I can imagine a PET scan of my brain glow bright red as each neuron would be firing at full tilt.

A sparkling fireworks display of my life flashes before my eyes:

I grew up a long time ago.

I’ve been taking care of myself for the past 20 years.

I worked at the #5 University in the world. I attended the #6 University in the world.

I worked at the #3 Hospital in the US.

I’ve presented my own research at Columbia University.

I traveled all over the world with an amazing woman at my side.

I have lived in Boston, Chicago, Miami, and New York City.

I’ve sat on the Board of Directors of a Non-profit organization.

I spent two years living on an island in the Caribbean.

I have grown up.

I did all of these things before taking one breath as a physician.

Each of them was critical in my development. Each of them have allowed me to make connections with people all over the world.

Each of them brought me closer to my patients and colleagues than I ever could have otherwise.

And my pride, which allowed me to overcome every barrier I found in front of me while transitioning from a 24-year-old Midwesterner to a 36-year-old world traveled physician, can’t help but take offense to the assertion that I have yet to grow up.

“What do you want to be when you grow up?”

I want to be who I already am. I’m comfortable in knowing that I have been fortunate to live a charmed life; a life that I created, despite getting knocked down a few times.

I don’t want to grow up.

I did that years ago.

As I transition from a Third Year Resident to an Attending physician, the number of times I have been asked the aforementioned question has picked up steam.

Each time, my Id screams, my Ego broods, and my SuperEgo kindly responds: “I plan to provide primary care to the Behavioral Health population.”

And now that I have my first job after Residency lined up, contract signed, and start date on the calendar, I can respond with an actual job title.

But I still wonder if people will expect to me grow up. Unknowingly overlooking everything that brought us to the moment where they felt it appropriate to ask:

“What do you want to be when you grow up?”

A Week in April

Posted on October 3, 2016 by Elbrecht

I had four patients die within one week.

When the totality hit me, I nearly lost control of my emotions.

On the Obstetrics service, a majority of all patient encounters are joyous and professionally reaffirming.

Each antepartum heart tone heard via ultrasound brings a sense of wellness and anticipation, both to the expectant mother and the caring physician.

But not every delivery has a pleasant outcome. Not every parent has a sense of anticipation. And not every physician can cope with those competing forces.

I delivered a 33-week-old neonate who precipitously declined within the first 24 hours of life. It had been an easy delivery, with the mother having given birth five times previously, and the fetus not yet having reached the period of greatest growth.

With one deep breath from her mother and a hearty push of the abdominal and pelvic musculature, the baby arrived, opening her eyes and taking her first breath while still cradled in my left arm.

She looked right at me. Deep into my eyes as she let out her first cry.

But despite our medical technologies and painstaking care, not every newborn baby survives.

She died in the neonatal intensive care unit 7 days later, an infection having made its way from the vaginal mucosa of her mother into her lungs and from there into her bloodstream.

The most aggressive antibiotics and procedures did not save her; there was nothing more we could have done.

Her death was unsettling. It came as the last of the four, but the one which nearly encompassed my entire being in darkness.

Two days after her birth, while awaiting another delivery on a quiet Friday night, the Code Blue alarms, indicating a cardiac arrest somewhere in the hospital, sounded overhead in the lecture hall.

My colleague, Dr O, was on medicine call that evening; she jumped from her seat across from me, immediately ending our conversation.

I glanced at my other colleagues remaining at the table and dutifully indicated I would join Dr O in case she needed back-up so they could complete sign-out.

The Code was called to a room at the furthest point possible from where we were seated, so rather than assuming I would eventually arrive to find Dr O having resuscitated the patient, I broke into a full sprint, clasping my stethoscope around my neck with my right hand to prevent it from flying off mid-stride, in case something went awry.

When I arrived a minute later, all hell was breaking loose, despite Dr O and a more senior physician, Dr B, deftly providing and directing life resuscitating efforts.

The woman, a 31-year-old mother of 6, who was admitted for nausea two days earlier, was accompanied in the room by her distressed and screaming 6-year-old son and her husband, who was shouting hysterically from her bedside, begging her to come back.

I stepped into hell incarnate and helped guide the husband and son to an adjoining room.

When I returned moments later, nothing had changed. She was still unresponsive. No heart beat was palpable; no rhythm identified on the cardiac monitor.

A deep sense of distress was evident in the room, despite the aggressive nature of our efforts.

The next hour lasted for an eternity, as Dr O, Dr B, and myself assisted the nurses in providing chest compressions, giving medications to stimulate cardiac contractility, and delivering electrical shocks to bring her back to life.

Nothing worked.

Her heart did not regain electrical activity. Her lungs did not attempt another breath.

Once we determined further efforts were futile, the husband, increasingly hysterical, was guided back into her room, to kiss the cheek of a lifeless body once belonging to the mother of his 6 children.

He begged us to try more. The despair in his eyes pierced everyone’s souls.

His son was sitting quietly in the adjoining room.

Physicians, nurses, security guards, and the chaplain cried; our emotions audible throughout the hallway.

I returned to the Obstetric floor after embracing my colleagues in a moment of silence. I stopped in the locker room to take off my sweat and tear-soaked scrubs and replace them with a new pair.

I delivered a healthy baby boy an hour later. His parents thanked me incessantly before I left the room.

I left the hospital the following Saturday morning having delivered several newborn girls and boys into this world.

All the while knowing a loving mother had unexpectedly died and another child’s life was being sustained in the Neonatal Intensive Care Unit.

When I returned to the hospital on Sunday night, I quickly scoured the electronic charts awaiting my signature.

A new electronic tab had appeared in the toolbar for me to click on. It read “Death Notice.”

I anticipated having to re-read the harrowing and emotional report of the unexpected death of the mother from Friday night.

Instead, I was blindsided by the account of another of my patient’s death, whom I had seen only a few weeks previously in the office.

He had been brought to my hospital’s Emergency Department on Saturday night, lifeless, despite the heroic efforts of the EMS and subsequent attempts by the Trauma Surgeons.

In the early evening hours of Saturday night, he had been found lying in a pool of his own blood, a trail of that blood following him for a reported 50 yards.

A bullet had pierced his femoral artery, the largest blood-carrying vessel in the leg; it had shredded the artery, leaving behind a capable exit path for the blood to flow from his body.

With each beat of his heart, more blood would gush from the wound in his leg, causing the heart to beat faster as it attempted to compensate for the missing blood.

Instead of a life-continuing effort, in its paradoxical nature, the heart beckoned the same death it hoped to avoid.

After scouring the internet for more information, I learned the 50-year-old man had been minding his own business in the parking lot of his apartment building when a man and woman approached him. They pointed a gun at him and demanded his wallet.

Having had several colorful conversations with him in the office, I could easily visualize him telling them to “Fuck Off”, his East Coast upbringing shining bright.

The following morning I received a phone call from my Program Director. She had also received notification of his death and wanted to check in with me.

I expressed my thanks for her concern. I did not tell her about the lifeless mother or the neonate only a few breaths from death.

A third patient died in the next 48 hours.

Honestly, I can not recall the details. None of them.

They have seemingly been erased from my memory, perhaps in a fitful effort to suppress the emotions death has brought to the forefront of my medical training so that I do not throw my heart up in the air and declare all is lost.

But I know another patient, someone for whom I cared, whose family loved them, succumbed to the only outcome known to our species.

Death.

So I will document that death here; despite my brain’s greatest efforts to forget it, I will forever know the impact it has had upon me.

When I received the call, I let out a deep sigh. I hung up as my eyes swelled with tears.

The fourth death. A seven-day-old child whose eyes I had stared into while holding in my left arm as she took her first breath.

Until the day I die, I hope to not forget the look I gave her. One of awe. And love. Excitement. And fear.

A gamut of human emotions, packed into one soul-penetrating experience.

I hope, despite her struggle for life, that in her final moments, the neurons in her brain grasped onto the emotions I transferred to her with our brief encounter.

That in the last beat of her heart and breath of her lungs, her mind went to the moment we shared; the look of awe and love and excitement drowning out the fear lurking deep in my eyes.

The Allies of Magneto

Posted on September 23, 2016 by Elbrecht

The Birth of Magneto

The Rise of Magento

The Opposition to Magneto

Residency is a right of passage (and requirement) in the development of anyone altruistic, sadistic, or narcissistic enough to pursue a career as a physician in America.

The progression of each individual, man and woman, from naïve undergraduate pre-medical student to naïve medical student to overwhelmed Resident to newly-minted Attending Physician is a long and tiring process; Residency represents the final and most taxing leg in this pursuit.

Depending on the field of medicine pursued, the training in Residency will span 3 to 5 years, potentially longer if one desires even more specialized training.

Each of these years brings with it new challenges, burdens, and failures; these are buttressed by the highlights, accolades, and patients who refer to you as “my doctor.”

None of these are equal or in proportion to the amount of time invested.

Not everyone who starts Residency finishes.

The product of each and every Residency is the Resident it transforms from medical school graduate into Attending Physician. This metamorphosis is akin to the sluggish caterpillar being reborn as the majestic butterfly.

Though each Residency has a “class of Residents” representing each year of training, the outcome for each of these members may not be the same; certainly the process will not be the same, as individuals have their medical knowledge and clinical skills carved out with every moment of their individual training.

Only on the very last day of Residency will every member of each Resident class have completed, in differing sequences, the requirements to achieve the status of Attending Physician.

They will have encountered different patients, performed a myriad of diverse procedures, and possess thousands of hours of clinical experiences.

The Residency program in which I find myself is no different. I am now a member of the PGY-3 (3rd year) class; the last year of our training.

At this juncture, I have cared for thousands of patients, spent nearly 7000 hours practicing my craft, and been bestowed with a persona I could have never imagined.

Amongst my peers, I have become Magneto; born from the cauldron of uncertainty brewed during Night Float; and then battling amongst the other aspects of my developing psyche, every day inching closer to becoming an Attending Physician.

But there are others like Magneto, each whom have been submerged in the icy depths of a Code Blue, roared into the uncertain waters of a Septic Shock, withstood the calamity of a bezerk office patient, and succumbed to the simultaneous terror and awe of newborn’s cry.

They are The Allies of Magneto.

In our program, The Allies of Magneto have the opportunity to train in all aspects of medicine: obstetrics, gerontology, surgery, trauma, cardiology, nephrology, critical care, gynecology, pediatrics, acute care, neurology, and chronic disease management.

We each develop strengths and weaknesses, preferences and avoidances, as a means to mold our calling as society’s guardians of health and wellness.

Red Panda, The Prince, Joker, Doc O, Big Red, Jane Grey, and BeastMode, amongst others, have shared moments of fear, trepidation, joy, anxiety, and solace with Magneto.

Each has toiled within the confines of a profession on the brink of meltdown and burnout. Each has contemplated a life outside of medicine. Each has longed for the ability to practice as they preach.

Each of them, now on the precipice of completing the journey to Attending Physician, having been taught to “Do No Harm”, have a host of decisions to make.

Who have they become amidst the countless hours of training?

How can they salvage their innate desire to do good, damn the barriers and obstacles placed in front of them?

Are they ready for what lay ahead?

For those who have joined Magneto on this winding journey, one chapter will soon come to an end.
But the author’s pen is patiently waiting, the next chapter slowly bubbling to the surface.

The Allies of Magneto, a group matured by the innumerable hours caring for those who seek their aid, hope to simultaneously shape their future and the future of those they serve.

No longer will the icy depths of a Code Blue, the uncertain waters of a Septic Shock, the calamity of a bezerk office patient, and the simultaneous terror and awe of newborn’s cry, cause them trepidation.

Instead, they will emerge from a 3-year-long cocoon to become the next generation of Family Physicians, forever remembered in my mind as The Allies of Magneto.