Entry 1

Entry 1

Entry 1
A weeklong electronic journal.
Feb. 9 2004 5:05 PM

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Alexi (left) and Ingrid in the CCU
Alexi (left) and Ingrid in the CCU

Some people are born knowing they want to be doctors, but it took us longer to realize medicine was our calling. I spent a few years working in public health in Baltimore, Paris, and Vietnam. Alexi worked as a journalist, making a documentary film on East Palo Alto, Calif., and doing a few stints for National Public Radio and the New York Academy of Sciences. Both of us went back to school to complete our premedical requirements, and we met when I was taking a tour as a prospective student at the University of Pennsylvania. Alexi showed me around the anatomy lab, impressing me by pointing out the skinny lateral rectus muscle on her cadaver. She would later say that I wasn't nerdy enough to be captivated by her anatomical prowess, but fortunately we had a lot of friends in common and ran into each other often over the next few months. Eventually, we fell in love. Unfortunately, we started dating a few weeks before I moved across the country to begin medical school at the University of California at San Francisco. Two years later, Alexi moved out to join me and we swore we would never do the long distance thing again. After four long years of medical school, we applied for residencies as a couple.

Leaving San Francisco brought us deep sadness, but we were thrilled to be embarking on a new adventure. We were fortunate enough to find a home at a Harvard-affiliated hospital in Boston, where we were welcomed into the tightknit fold. As part of a process called "The Match," we entered as a couple, ranking our top choices of programs while the programs simultaneously ranked their top choices in candidates. While we were the first gay couple ever to apply for The Match into internal medicine at most of the medical schools we visited, we were pleasantly surprised by the support we received, not only from our peers but from the "Old Guard" as well.

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I think back to that time almost a year ago, and it seems infinitely more innocent. Our youthful idea of what it meant to be a physician has been replaced by a complexity I never could have imagined. This week we will be writing to you from the cardiac intensive care unit. We hope to offer a glimpse into the training of young physicians and into our lives as a couple navigating this intense journey together.

After being up for a 30-hour shift covering the CCU, I passed off to Alexi, who will be up for the next 30 hours, so that I could come home and begin today's entry. Being in the unit, I find the distinction between morning and night blurs. Often, I know it is morning only when the nurses change shift. During the change of shift this morning at 6, my pager started going off. I reached down to stop the blaring noise and see what new order was headed my way. As a medical intern at one of the busiest teaching hospitals in the country, my life is dictated by what appears on this matchbox-sized device. My all-time highest number of pages is 30 in 15 minutes. The vast majority of these pages are sent from nurses, reminding us of orders that are outstanding and need our authorization. These can range from medication updates to renewal of restraints for sedated patients so they cannot fall out of bed. In my darkest hours, I have wanted to strap a pager on a nurse to return his or her reminders with some of my own. Instead, I have succumbed to intern defeat, accepting the stream of unremitting interruptions of my thoughts and activities.

Yesterday, however, I knew before I looked down at my screen that it was bad. One of my patients was incredibly sick. All day long I was expecting to hear the overhead "Code Blue" page that assembles a vast crew of the house staff to a dying patient's bedside to do whatever it takes to bring him or her back to life. I felt a lump developing in my throat when I looked down to see the words "Come STAT—your patient is SOB [short of breath] and needs immediate help."

Patients can be neatly lumped into two general camps: those who come in sick and get better and those who get worse. Mr. J.—my 65-year-old patient with advanced congestive heart failure—was unfortunately in the latter. His decline had been quick. When he arrived at the hospital, he was talking with me, taking an interest in my life. This is often a good prognostic indicator. Yet instead of improving on the regimen of diuretics and medications we gave him to help his heart pump more efficiently, his health had been deteriorating.

I jumped out of the call-room bed that I had used only briefly and ran to his room. I knew that it would be up to me to figure out the next move. Since interns are usually the first to see and assess a patient, we often decide if a Code Blue should be called. Not calling in a grave situation can be truly life threatening. However, one tries not to "call" if it is possible to manage a situation on one's own or with the help of nurses and nearby residents. Mr. J was gasping for breath and rapidly turning blue even while receiving 100 percent oxygenation on a full-face mask. The next step would have to be intubation—this means we would stick a tube down his throat to help him breathe. "Mr. J," I screamed, "can you hear me?" I watched him as he tried to greet me with his usual smile but instead offered only a grimace.

I did a rapid assessment of Mr. J. and quickly knew that I needed assistance. I alerted my resident, the next up in the chain of command, and we managed to stave off calling a full Code Blue by paging the anesthesiologist to come and immediately intubate our dying patient. It was only a matter of minutes before she arrived, and Mr. J. was able to get the necessary oxygen he needed. His daughter and wife held onto me. There was anguish in their eyes. How could this man they loved be dying here in front of them? I found myself welling up, trying to provide comfort when I felt myself falling apart. Despite receiving aggressive treatment, the patient died.

I tend to be much more emotional with a patient's family than I am with the dying patient. Those in need of my active care rarely move me to tears, but their loved ones often bring me to my knees. I cried with the family who lost their father, husband, and nurturer. When I left the room, I started entering a page instinctively knowing where I could turn for solace. "My sweet one—I have lost him tonight—I am wrecked. Please come." She was there in a matter of minutes. She let me shed my own personal tears full of exhaustion and grief. She put me back together again while I collected myself. "May I buy you a hot chocolate?" She knew, without having to ask, all I had experienced and all that was still to go.

Ingrid Katz and Alexi Wright are physicians completing internships at a major teaching hospital in Boston. They are currently rotating through the cardiac intensive care unit and are the authors of Interns' Diary, an online journal.