BECOMING A DOCTOR

an excerpt from singular intimacies: becoming a doctor at bellevue

by danielle ofri

this scene takes place just after the narrator has graduated medical school. she's in her first month of internship, doing night-float duty at bellevue hospital.

one night during my third week of internship, i was paged at 3:00 a.m. "elba rodriguez's blood count just dropped 13 points," my resident barked. "go do a rectal exam and see if she's bleeding from her gi tract." my pocket was already stocked with gloves, petroleum jelly, and test cards to check for blood in the stool. i strode into the room-crack night-float intern-ready for battle.

mrs. rodriguez was a tiny, wrinkled dominican woman, with frizzy gray hair amassed on the pillow. she was wearing a worn, floral housecoat and cardigan sweater over her hospital gown. her husband, son, and a few other relatives stood gathered around her bed. they all turned and looked at me with concern on their faces.

i cleared my throat. "hi, i'm dr. ofri." i hoped that sounded convincing. "i'm one of the night doctors taking care of mrs. rodriguez. i'm just here to do the rectal exam." yep, dr. ofri, rectal specialist!

the grandson stepped forward. he was slim and amber-skinned. a small moustache graced his upper lip. "i understand what you have to do. i'm a nurse. if you don't mind, i'd like to stay here while you do it."

my grip on the metal railing of the bed tightened. stay while i do the rectal? i gestured somewhat inanely in the air and shrugged my shoulders. "whatever you want, i guess."

the rest of the family left the room. i pulled the curtain so that mrs. rodriguez, the grandson, and i were separated from the three other sleeping patients. the grandson stood to mrs. rodriguez's right, and i stood to her left. we rolled her toward the grandson, and i fumbled with her housecoat, cardigan sweater, and hospital gown to get down to her skin. i fished around in my pockets to unearth the necessary equipment and suddenly realized that i was missing the little bottle of developer fluid to do the test for blood in the stool.

i looked over to the grandson who was balancing his mother on her right side. "umm, could you hold her there for just one minute? i need to get one more thing." i dashed out of the room, studiously avoiding eye contact with the family members waiting in the hall.

i ran into the 16-north supply closet but there wasn't any developer fluid on the shelf. all the other interns had probably pocketed them. i raced out of the supply closet, down the hall, around the corner to 16-west. i dug through the drawers and the storage bins but i couldn't find any.

the cardiac care unit! they were always well stocked. i knew the nurses guarded their supplies like hawks, so i snuck into the ccu from the back door where the bedpans and dirty laundry were kept. i tiptoed over to the supply shelf in the far ivs, chest tubes, iodine swabs, glycerin swabs. aha! tucked behind the 1 cc syringes was a yellow bottle of developer. i snatched it just as a nurse yelled, "hey, those are ccu supplies." i jammed the bottle in my pocket and dashed out of the ccu with my head down. from the back all interns looked alike, i hoped.

i was panting when i got back to mrs. rodriguez's room. her grandson was still balancing her on her right side. his face was calm, and he didn't say a word.

i gloved up and slathered my right index finger with petroleum jelly. i bit my lower lip as i concentrated on my assigned task. i felt around, hunting for any abnormal masses. i'll just finish this quickly, i thought, and maybe i'll be able to get some sleep before the nurses do their 6 a.m. vitals and start calling me with the next round of fevers.

"i think mamy is no longer with us," the grandson quietly announced.

i froze in mid-exam and looked up at the grandson. his calm expression hadn't changed. my heart began to pound inside my ears. no longer with us? what was he talking about?

with his free hand, the grandson crossed himself thoughtfully and murmured something in spanish.

no longer with us? mrs. rodriguez was dead?

the grandson let out a soft sigh. "mamy didn't want any extraordinary measures. it's the way she wanted it- drifting off in peace. we just need you to pronounce her dead, doctor, then we can take her home."

i stared at the grandson, blinking repetively as my mind blanked out to nothingness. the window beyond him was pitch black. there was no moon. a few faint lights twinkled from across the east river. i couldn't remember where i was or what i was doing here. i could only hear my heart thud rythmically.

dead! that's right, mrs. rodriguez is dead! i tore the glove off and my mind began to race-how do i declare a patient dead?

pupillary reflexes. that's it. a dead person doesn't have pupillary reflexes. i pulled out my flashlight and shone it confidently in mrs. rodriguez's eyes. to my dismay, she had huge cataracts. she wouldn't have pupillary reflexes anyway.

respirations. a dead person won't breathe. i whipped out my stethoscope. by now the whole family had come in from the hallway and followed my every move as i carefully planted the bell on mrs. rodriguez's chest. suddenly a vibrating twitch ran through her body. i jumped back and the family looked at me with worried eyes. was this rigor mortis, or might she still be alive?

it suddenly dawned on me that i'd never had a lecture in medical school on how to tell if someone is 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, that's it. dead people for sure don't have a pulse. i ran my fingers along her carotid arteries. of course, the only way you know you've found the pulse is when you find the pulse. how do you document the absence of something when its presence is defined by hunting until you've found it? maybe it was a half-inch to the right. maybe it was deeper, or maybe i was pressing too hard.

another shiver ran through her body and the family looked at me, their eyes gathered in a single longing stare. how could i say anything? what if i got it wrong?

an ekg. that's it. if i get a flat line on the ekg then i'll have proof that she's dead. i excused myself and dashed back to the supply closet to get the ekg machine. i wheeled the dilapidated machine to mrs. rodriguez's bedside. i struggled with the tangled cords, twisting and pulling, muttering curses under my breath at whichever intern had used the machine last.

i pinched the red rubber suctions cups to stick them onto mrs. rodriguez's chest and ancient electrode jelly, from ekgs gone by, slithered out in crusted blue clumps. as soon as i fastened one suction cup onto her chest, the previous one i'd placed would pop off. i applied more jelly and then re-squeezed the suction cups. pop! another one flew off. the grandson and family bent in closer and followed with their eyes back and forth as i chased down the obstreperous suction cups. the more jelly i applied, the more they popped off. i wiped away the hair that had fallen in my face and a slimy gob of electrode jelly slid down my forehead.

finally the ekg was set up and i hit the start button. we all stared at the skinny strip of graph paper snaking out from the machine. please, i prayed, be a flat line.

the paper emerged with unreadable squiggles. between the air vents and the three iv pumps running in the next bed over, there was too much background noise. i jiggled around the ekg leads, but i could not get a stable baseline. two more suction cups popped off.

the grandson curled his hand around his grandmother's wrist. "she's dead, doctor," he said softly. "she has no pulse. you don't have to do any more tests."

my face was burning and i could only stare at the ekg electrodes that continued to pop off her chest.

"mamy lived a long and wonderful life," he said. "we are grateful that we could at least be with her at her last moments." the family joined hands and began to recite a prayer in spanish.

i stood in silence while they prayed, coaxing moisture from my throat to wet my parched mouth. the weight of my white coat, laden with its instruments of medicine, pulled at my neck. my shirt was damp with sweat. five feet of ekg strips were crumpled in my sticky palm.

when they were done i unhooked the ekg leads and wiped the blue jelly from mrs. rodriguez's chest. i grabbed the ekg machine and started out of the room. "i, um?i'm sorry," i whispered hoarsely. "about your grandmother, that is. if need anything?don't hesitate?" the back wheels of the machine abruptly swerved left and i collided with the doorframe.

i collapsed into a chair in the nurses' station; my face rippling with heat and embarrasment. how could i not figure out whether or not mrs. rodriguez was dead? wasn't that what doctors did-pronounce the time of death? how could i ever be a doctor if i couldn't tell a dead person from a live one? i had my medical diploma; i had those 'md' letters after my name-and i couldn't distinguish life from death? when were all these magical medical skills supposed to materialize?

the mountain before me seemed impossibly steep. i thought i'd already climbed so high after all those years of college and medical school. but it seemed that i was at the beginning again, craning my neck upward toward an insurmountable slope of knowledge. i brushed the hair out of my face and blue electrode jelly snagged under my fingernails. what was i going to write on the death certificate as the immediate cause of death?rectal exam?

in the morning i staggered home in the brilliant july sun. a hot shower washed away the last of the electrode jelly. a cup of tea and warm toast eased some of the aches. i crawled into bed, grateful for the soft, clean cotton sheets. i drifted off to sleep, thinking of elba rodriguez. i imagined her as a young woman, a fresh immigrant to america with her three children. i thought of her ninety years of life, of growing old in her brooklyn neighborhood. i imagined that she'd been a regular patient at the bellevue clinic all her life, coming every year to the old brick building for her annual physical. maybe she'd given birth to her children at bellevue. maybe she expected that she would die at bellevue. i hoped that wherever she was now, she forgave me for the indignities she suffered at the hands of an inexperienced intern.

"i'll do better next time, mrs. rodriguez," i whispered aloud as i drifted off to sleep, the morning traffic report bleating from the radio. "for the next patient, i'll do better. just give me some time."

singular intimacies by danielle ofri copyright &Copy; 2003 by danielle ofri reprinted by permission of beacon press, boston dr. ofri, up close danielle ofri is an attending physician in the medical clinic at bellevue hospital, assistant professor of medicine at new york university school of medicine, mother of three, author of two books and learning how to play the cello. she is also the co-founder and editor-in-chief of the bellevue literary review, a journal relating to themes of health, healing, illness, the mind and the body. ofri found time between rounds to talk about her writing. the following transcript has been edited for clarity.

q: in your first book singular intimacies, which documents your medical training at bellevue, you connect your situation with many archetypal figures: the outcast, the innocent, the helper, the underdog and quite often the hero. is this the experience of everyone entering the medical field? a: interns are the workhorses of the hospital, the jack-of-all-trades. technically, logistically and psychologically they assume all of these roles. you become everything for the patient out of necessity. it's just the way of the job.

q: when did you decide to write about your experiences at bellevue? a: after my residency i took a break for about 18 months, working as a freelance physician. distance-geographically and emotionally-gave me the perspective i needed to think. when i came back all that was available was a three-day-a-week job. suddenly i had two free days, so i started writing more. then, when a full time position opened up, i realized that the one thing i would want to buy with the raise in salary would be the one thing i couldn't buy: time. so i still work three days a week and write on the other two.

q: what do you think on your morning commute? a: i live in the neighborhood, so i have almost no commute, but i'm thinking of all the things i have to remember on my to-do list. i have three kids-8, 6 and 3-so i have to be efficient with my time.

q: the bellevue literary review came out in 2001. how did it start? a: i asked my students to write narratives about their patients, and soon we decided to turn these stories into a journal. but there's a national interest-at some point our bodies will fail us, so we're all connected to health and medicine. we opened it up to the public and immediately had about 1,000 submissions for the first issue. now we're getting 3,000 a year.

q: what's next? a: i'm writing a new book, medicine in translation. it's about immigrants who are entering our medical system. all of my patients are immigrants. we have a program for survivors of torture with many patients who are seeking political asylum-a booming business. there is a parallel between the emigration from one country to another, and from health to sickness. it's a journey we all have to make.

-nick broad