Friday Reflection 60: The Brockton

RG was a 65-year-old man with obstructive sleep apnea (OSA). He came in on a Monday night for titration of continuous positive airway pressure (CPAP). The technician was unable to adequately treat his OSA with CPAP. The following morning, he was told that he would need to remain in the hospital until Thursday, when ENT was in-house and could place a tracheostomy tube.

I am hesitant to share essays that feel like a list of memories. I know that great memoirs can make readers nostalgic for experiences they never had; a feeling sometimes referred to as anemoia. I am not a good enough writer to achieve this, but the memories I’m going to write about are of medical training, so maybe there will be something in them for those who’ve experienced it, expect to experience it, or are vaguely interested in it.

The first rotation of my internship was at the Brockton VA Hospital. The intensity of my memories of The Brockton can partly be attributed to it being my first experience as a doctor. But the memories are so lasting that I think there was something special about the place.

Clinical Experience, Responsibility, and Learning

I ranked a few excellent residency programs lower than The BI because I got the impression that, when you showed up at those programs, the program director handed you the hospital keys and told you to lock up when you were done. I felt like I would need a little more support and nurturing. To paraphrase Captain Willard from Apocalypse Now, “I tried to dodge a mission, and for my sins, they gave me one.” My mission was to begin my internship at The Brockton.

My memory is that we were lightly supervised. This bred both fear and responsibility. The first night of my internship, I signed out a basic metabolic panel¹ to my co-intern. The patient had been admitted with cellulitis, and his creatinine had unexpectedly bumped. I came back the next morning and was informed that not only had the creatinine continued to climb, but that the urine sediment suggested post-strep glomerulonephritis. My fellow intern asked why I had not examined the urine before I’d left.²

That same week, my resident told me to increase a patient’s fluid from 75 to 100 cc/hr before I left. I forgot. These were pre-cellphone times, so there was a barrier to calling the on-call intern. I only fell asleep when I realized that 25 cc/hour for the 8 hours I’d be away amounted to less than a can of Coke. I made it up with a 250-cc bolus during pre-rounds the next day.

This independence led to mistakes, and probably some less-than-ideal outcomes, but I learned things I’ll never forget. One night, when I was a resident, we intubated a patient with a COPD exacerbation and ventilatory failure. After intubation, I struggled with his hypotension all night. The concept of auto-peep, explained to me the next morning, is one I will take to my grave.

Fun

While there were plenty of terrifying and humbling moments, I remember The Brockton fondly because we had a great deal of fun there. There was a bowling alley in the basement that we could use on quiet nights. On call, we had keys to the “widgets”, essentially golf carts, that allowed travel through the tunnels between buildings. Not surprisingly, widget racing was a thing.

As a snacker, I loved the commissary (now called a PatriotStore). I ate the ButterCrunch cookies almost daily. The ICU was stocked with chocolate Ensure pudding. I became a devotee of this rich snack until I realized each cup contained 550 kcal, explaining why it tasted so good.

Uncomfortable memories

There were experiences that make me realize how much things have changed, for the better, in the last 30 years.

• None of the patient rooms were private; one had six beds. It was common for patients to chime in about one another’s condition and plan.

• A patient once confided to me that he didn’t mind having an IJ placed because it meant that my intern, a young woman, would spend 15 minutes in close proximity to him.

• Dr. G, the attending in charge of the sleep lab, would not allow patients to leave if their CPAP could not be properly titrated. Instead, the patients had to wait until the subsequent Thursday, when ENT did their surgeries, to have a tracheostomy tube placed. As these patients had to be staffed by residents, they remained on our service. We referred to them as POGs. Prisoners of G.

• We sometimes commented that our patients seemed indestructible. This was said with respect, awe, really, but it reflected our concern that we were often in over our heads.

Camaraderie

The stress of The Brockton bound me to my fellow residents. Their support was unforgettable. My first resident warned me to beware of the intern shuffle, in which an intern would walk a few steps in one direction, then another, then another, because he was unable to prioritize his tasks. My resident insisted that I call him whenever I caught myself doing the intern shuffle.

This same resident once chased a van I was riding in across the entire VA campus to save me (and likely a patient). In the middle of the night, a cardiac arrest was announced at another building on the campus. Many of these buildings were residences for veterans with chronic conditions. During my orientation, I learned that when one of these codes was called, I was to report to the hospital’s entry, where a van would meet us and take us to the patient.

On this night, 5 days into my internship, I raced downstairs and hopped in the van, which quickly pulled away with a respiratory therapist and me on board. I said to the driver, “Wait, my resident is not here yet.” In a calm and measured tone, he said, “My instructions are to leave as soon as I have the respiratory therapist and a doctor.” Looking out the window, I saw my resident sprinting after us. He did not let up until we got to the code. For the rest of the month, I’d run downstairs and hide inside the lobby until I could jump on the heels of my resident when he passed me. I instructed my interns to do the same in later years.

Whenever someone finished their stint at Brockton, they were gifted a plastic thermal mug – mine was graced with an American Flag and the maxim, “America is Free, Thanks to our Veterans.” The rest of the house staff then gave a Brockton salute. The salute needs some explanation. Our pagers were radio receivers. When yours sounded, it alerted you to activate the broadcast, the page operator telling you whom to call. An unintended benefit of the system was that if your resident saw you reach for your pager, she could also listen in and monitor your activity. If the pager was activated when no message was being recited, it played only static. Hence, the Brockton salute. Everyone would raise their hand, holding their beeper, activating it to honor you with static.

There is much about our experience at The Brockton that would be unacceptable today. There was too little supervision, care often seemed less than patient-centered, and there was some inappropriate behavior. My time there was critical to my training.

1. We called the m SMA-7s at the time.

2. Now, 33 years later, I can admit that the reason was not laziness but ignorance. I knew neither the diagnosis nor the evaluation.