Journal of Clinical Pharmacy and Therapeutics (1992)17,321-323
COMMENTARY
From %he Halls of Ivy to %hethundering horde L. Gutkind University of Pittsburgh, Pittsburgh, PA 15260, U.S.A.
Picture the typical middle-aged, middle-classAmerican, comfortable with their regular routine, dosing their eyes one evening in their own bed in Pittsburgh and then suddenly waking up the following morning in the middle of New Guinea. This is not too different from what happened to me when I began to research and write two books, one about the world of organ transplantation, the second focusing upon paediatrics, after spending the previous 15 years teaching in a university English department and writing books about sports, the motorcycle subculture, and backwoods America. I did not expect such a wrenching experience. I intended to ease myself into the health care field in a manner similar to a runner training for a long-distance race. A couple of hours one day in the out-patient clinic, rounding with the surgeons another day, visits with the chaplain, the head nurses, the day after that. There were social workers to observe, ethicists to interview, and many patients and family members to meet. My plan was to take it slowly and easily. When I began to know my way around the medical centre and understand the prevailing rhythm of life, I could pick up the pace. As it tumed out, this was an eminently sensible and totally implausible way to proceed. For one thing, in a medical centre, especially a place like the University of Pittsburgh, where nearly 1000 hearts, livers, heart-lungs and kidneys were transplanted in 1989, it is impossible to start slowly or ease into the action. Nurses and doctors work at three distinct speeds: fast, very fast and frantic. The notion of maintaining control of my schedule (even my life) was ludicrous. In such a frenetic setting, there are many more questions than answers, more puzzles than solutions. Around every comer is an emergency. Each half-hour brings a special and often unpleasant surprise. Just as Series editor ProfessorJ.H. Kilwein. Correspondence:L. Gutkind, Department of English, University of Pittsburgh,Pittsburgh, PA 15260, U.S.A.
any member of the transplant team, I never knew what time I would be home at the end of the day, or if I would be home before the following morning. Meetings and interviews were always tentative. For doctors and nurses, the concept of 'hospital time' means arriving at your scheduled meeting and/or appointment when (and if) you get there. In reality, a high-tech medical centre is a city (or a country) unto itself, with its own airport (helipad), power generators (most complexes can operate independently, in emergency situations), police force, maintenance department and administrative or 'executive' wing, 'gold coast' (the wealthy neighborhood) and 'welfare' wards or clinics (the other side of the tracks). The prevailing language throughout the medical centre, although English, is replete with the distinct idiosyncrasies of the profession, words and phrases with which I was at best only indirectly familiar. Listening to conversations and attempting to decipher what doctors and nurses were saying, on the spot, without constantly consulting my Tabers Cyclopedic Medical Dictionary, was often impossible. Interpersonal communication was further complicated by the fact that Pittsburgh's transplant team attracts faculty members and visitors from dozens of countries. O n any given day, one might meet visitors from Japan, Germany, Hungary, China, Egypt, Israel, Argentina, Australia [and from medical centres across the U.S.A., conversing (or attempting to converse) with patients who have also come to Pittsburgh from many countries: Argentina, Qatar, Bhutan, included] for lifesaving transplant therapy. During rounds, the patients announce to one another, 'Here comes the United Nations!' or 'Make way for the 'thundering horde!' " One startling difference between my old life in the humanities and my new world in modem medicine was the speed at which everyone worked and thought. Nurses, doctors, technicians walked rapidly, like
322
L. Gutkind
pedestrians in Manhattan during lunch hour, people who knew exactly where they were going and possessed a sense of immediacy about when they might get there. Strolling was anathema, as was the simple pleasantry of passing time. If you stopped to talk, the discussion would invariably centre around the status of patients, or laboratory results, or infectious disease conference, or the latest in-service. It was business with minimal pleasure. Reading, including patients’ charts, published research papers, newspaper articles, actually meant intensive ’scanning’. From as early as medical school, doctors have learned how to lift salient facts from text with little notice of style, composition or information unrelated to their immediate interest. As a non-fiction writer interested in characterization and story, most of my research is done on-the-scene, investing weeks or sometimes months, night and day, first with a few key people and gradually expanding my scope to understand and capture the global colour of the place or the experience about which I am writing. When I explained this ‘shadowing’ technique (sometimes called ‘total immersion’) to pioneer liver transplant surgeon Thomas E. Starzl, the pre-eminent figure in the transplant field, he looked me warily up and down, noting my professorial ‘tweedy’ sport jacket, crew neck sweater and graying beard, shaking his head in a bemused and reluctant protest: ‘You’ll never keep up’. Actually, I soon discovered that I could keep up with Starzl or anyone else on the transplant team for most of the day (the first 8 or 10 h) before I would begin to weaken, losing stamina and an intensity of concentration. Not that my ’subjects’ energized with the passage of time or the increasing pressure. But invariably they were able to maintain an incredible consistency, despite the long and arduous routine, which I found difficult to duplicate. If their backs ached and their feet throbbed and if they began to perceive patients, charts, conferences and constant emergencies in a whirling scrim of fog, as I sometimes did, they did not often show it: a fact that initially surprised me because they always seemed to appear, even at the start of the day, so weary and physically unfit. If I were first meeting these people, without having observed their physical and intellectual endurance, I would have bet a week‘s salary that I could run circles around every one of them. Despite their puritanical advice to patients concerning regular exercise and proper diet, health care personnel abuse their bodies unmercifully. It is not only the hours which make physical fitness so difficult, but
the hospital food, which tends toward starchiness and the many rich desserts offered in the cafeteria for doctors and nurses requiring quick sugar fixes for energy. In a medical centre, there are no standard hours for breakfasts, lunches and dinners; you eat when you have time or not at all. The nurses are especially guilty of poor eating habits, nibbling from patients’ uneaten dinner trays or devouring snacks grateful families (and other nurses) bring from home. Those toiling on the night shift will rely on midnight pizza delivery or some other fast food option because they are usually so understaffed that they sinply cannot indulge in their allotted 30 min dinner break. Free food is also an excuse for rare social interaction. Every Friday at 4:OO pm at the Children’s Hospital, the University’s paediatric clinical affiliate, ’fluid rounds (beer and snacks)’ for residents are announced over the intercom, while traditionally, ‘morning report‘ at Children’s will begin with pastry or, more frequently, chocolate chip cookies. In a typical teaching hospital, with hungry residents roaming the halls, there are never any leftovers. ‘Watch out for the stampede,’ one nurse remarked, as she took out slices of birthday cake remaining from a recent party. She added: ’If you want to meet an eligible resident, or if you just need a doctor to sign an order or see a patient, call for Chinese take-out or display a couple of dozen donuts at the nurses station on any unit, and you will suddenly be hosting a medical convention’. This is true even late at night, an eerie time in a medical centre in contrast to the frantic and ceaseless pace beginning about 6:OOam to the end of visiting hours at 9 3 0 pm. I once accompanied an officer from the Children’s Hospital Department of Public Safety on the graveyard shift-a very lonely experience. There were many children alone in bed, watching TV, cuddling and whispering to stuffed animals in the darkness. Parents wandered aimlessly through the halls, exhausted, but afraid to sleep, while others curled up on chairs and on the floor in corners, sneaking cigarettes, many softly crying. We went up and down from the eleventh floor tower to the sub-basement, checking doors, seeking fire hazards, listening to the intermittent crackle of conversation coming from the walkie talkies slipped into our side pockets, as the command centre communicated to the other officers on duty. I remember the intensity of my feelings of isolation and sadness at the sight of so many children and frightened parents fighting to maintain composure and steal a few needed hours of sleep through the scary
From the Halls of Ivy to the thundering horde 323
night-until we happened upon a group of residents and nurses huddled around a tray of food rescued from a late afternoon hospital board meeting. The cheese was old and dry and the crackers were soggy, but for a couple of minutes, we all stood together in the dimly lit hallway, talking. I cannot recall a word that was said during that conversation, or who else was there besides myself and the security officer on duty, but even now, two years later, the soothing feelings of comfort I derived (a reassuring moment that confirmed our mutual connection to the human race) remains a sharply focused memory.
Biographical note Lee Gutkinds book M a n y Sleepless Nights chronicles the world of organ transplantation. The author was presented with the American Heart Association's Howard W. Blakeslee Award for outstanding achievement in scientific journalism. A professor of English at the University of Pittsburgh, Gutkinds most recent book, One Children's Place, h i d e A Children's Hospital has recently been published in Japan and by New American Library (New York). Many Sleepless Nights has also been translated and published in Japanese and Italian.
COMMENTARY
From %he Halls of Ivy to %hethundering horde L. Gutkind University of Pittsburgh, Pittsburgh, PA 15260, U.S.A.
Picture the typical middle-aged, middle-classAmerican, comfortable with their regular routine, dosing their eyes one evening in their own bed in Pittsburgh and then suddenly waking up the following morning in the middle of New Guinea. This is not too different from what happened to me when I began to research and write two books, one about the world of organ transplantation, the second focusing upon paediatrics, after spending the previous 15 years teaching in a university English department and writing books about sports, the motorcycle subculture, and backwoods America. I did not expect such a wrenching experience. I intended to ease myself into the health care field in a manner similar to a runner training for a long-distance race. A couple of hours one day in the out-patient clinic, rounding with the surgeons another day, visits with the chaplain, the head nurses, the day after that. There were social workers to observe, ethicists to interview, and many patients and family members to meet. My plan was to take it slowly and easily. When I began to know my way around the medical centre and understand the prevailing rhythm of life, I could pick up the pace. As it tumed out, this was an eminently sensible and totally implausible way to proceed. For one thing, in a medical centre, especially a place like the University of Pittsburgh, where nearly 1000 hearts, livers, heart-lungs and kidneys were transplanted in 1989, it is impossible to start slowly or ease into the action. Nurses and doctors work at three distinct speeds: fast, very fast and frantic. The notion of maintaining control of my schedule (even my life) was ludicrous. In such a frenetic setting, there are many more questions than answers, more puzzles than solutions. Around every comer is an emergency. Each half-hour brings a special and often unpleasant surprise. Just as Series editor ProfessorJ.H. Kilwein. Correspondence:L. Gutkind, Department of English, University of Pittsburgh,Pittsburgh, PA 15260, U.S.A.
any member of the transplant team, I never knew what time I would be home at the end of the day, or if I would be home before the following morning. Meetings and interviews were always tentative. For doctors and nurses, the concept of 'hospital time' means arriving at your scheduled meeting and/or appointment when (and if) you get there. In reality, a high-tech medical centre is a city (or a country) unto itself, with its own airport (helipad), power generators (most complexes can operate independently, in emergency situations), police force, maintenance department and administrative or 'executive' wing, 'gold coast' (the wealthy neighborhood) and 'welfare' wards or clinics (the other side of the tracks). The prevailing language throughout the medical centre, although English, is replete with the distinct idiosyncrasies of the profession, words and phrases with which I was at best only indirectly familiar. Listening to conversations and attempting to decipher what doctors and nurses were saying, on the spot, without constantly consulting my Tabers Cyclopedic Medical Dictionary, was often impossible. Interpersonal communication was further complicated by the fact that Pittsburgh's transplant team attracts faculty members and visitors from dozens of countries. O n any given day, one might meet visitors from Japan, Germany, Hungary, China, Egypt, Israel, Argentina, Australia [and from medical centres across the U.S.A., conversing (or attempting to converse) with patients who have also come to Pittsburgh from many countries: Argentina, Qatar, Bhutan, included] for lifesaving transplant therapy. During rounds, the patients announce to one another, 'Here comes the United Nations!' or 'Make way for the 'thundering horde!' " One startling difference between my old life in the humanities and my new world in modem medicine was the speed at which everyone worked and thought. Nurses, doctors, technicians walked rapidly, like
322
L. Gutkind
pedestrians in Manhattan during lunch hour, people who knew exactly where they were going and possessed a sense of immediacy about when they might get there. Strolling was anathema, as was the simple pleasantry of passing time. If you stopped to talk, the discussion would invariably centre around the status of patients, or laboratory results, or infectious disease conference, or the latest in-service. It was business with minimal pleasure. Reading, including patients’ charts, published research papers, newspaper articles, actually meant intensive ’scanning’. From as early as medical school, doctors have learned how to lift salient facts from text with little notice of style, composition or information unrelated to their immediate interest. As a non-fiction writer interested in characterization and story, most of my research is done on-the-scene, investing weeks or sometimes months, night and day, first with a few key people and gradually expanding my scope to understand and capture the global colour of the place or the experience about which I am writing. When I explained this ‘shadowing’ technique (sometimes called ‘total immersion’) to pioneer liver transplant surgeon Thomas E. Starzl, the pre-eminent figure in the transplant field, he looked me warily up and down, noting my professorial ‘tweedy’ sport jacket, crew neck sweater and graying beard, shaking his head in a bemused and reluctant protest: ‘You’ll never keep up’. Actually, I soon discovered that I could keep up with Starzl or anyone else on the transplant team for most of the day (the first 8 or 10 h) before I would begin to weaken, losing stamina and an intensity of concentration. Not that my ’subjects’ energized with the passage of time or the increasing pressure. But invariably they were able to maintain an incredible consistency, despite the long and arduous routine, which I found difficult to duplicate. If their backs ached and their feet throbbed and if they began to perceive patients, charts, conferences and constant emergencies in a whirling scrim of fog, as I sometimes did, they did not often show it: a fact that initially surprised me because they always seemed to appear, even at the start of the day, so weary and physically unfit. If I were first meeting these people, without having observed their physical and intellectual endurance, I would have bet a week‘s salary that I could run circles around every one of them. Despite their puritanical advice to patients concerning regular exercise and proper diet, health care personnel abuse their bodies unmercifully. It is not only the hours which make physical fitness so difficult, but
the hospital food, which tends toward starchiness and the many rich desserts offered in the cafeteria for doctors and nurses requiring quick sugar fixes for energy. In a medical centre, there are no standard hours for breakfasts, lunches and dinners; you eat when you have time or not at all. The nurses are especially guilty of poor eating habits, nibbling from patients’ uneaten dinner trays or devouring snacks grateful families (and other nurses) bring from home. Those toiling on the night shift will rely on midnight pizza delivery or some other fast food option because they are usually so understaffed that they sinply cannot indulge in their allotted 30 min dinner break. Free food is also an excuse for rare social interaction. Every Friday at 4:OO pm at the Children’s Hospital, the University’s paediatric clinical affiliate, ’fluid rounds (beer and snacks)’ for residents are announced over the intercom, while traditionally, ‘morning report‘ at Children’s will begin with pastry or, more frequently, chocolate chip cookies. In a typical teaching hospital, with hungry residents roaming the halls, there are never any leftovers. ‘Watch out for the stampede,’ one nurse remarked, as she took out slices of birthday cake remaining from a recent party. She added: ’If you want to meet an eligible resident, or if you just need a doctor to sign an order or see a patient, call for Chinese take-out or display a couple of dozen donuts at the nurses station on any unit, and you will suddenly be hosting a medical convention’. This is true even late at night, an eerie time in a medical centre in contrast to the frantic and ceaseless pace beginning about 6:OOam to the end of visiting hours at 9 3 0 pm. I once accompanied an officer from the Children’s Hospital Department of Public Safety on the graveyard shift-a very lonely experience. There were many children alone in bed, watching TV, cuddling and whispering to stuffed animals in the darkness. Parents wandered aimlessly through the halls, exhausted, but afraid to sleep, while others curled up on chairs and on the floor in corners, sneaking cigarettes, many softly crying. We went up and down from the eleventh floor tower to the sub-basement, checking doors, seeking fire hazards, listening to the intermittent crackle of conversation coming from the walkie talkies slipped into our side pockets, as the command centre communicated to the other officers on duty. I remember the intensity of my feelings of isolation and sadness at the sight of so many children and frightened parents fighting to maintain composure and steal a few needed hours of sleep through the scary
From the Halls of Ivy to the thundering horde 323
night-until we happened upon a group of residents and nurses huddled around a tray of food rescued from a late afternoon hospital board meeting. The cheese was old and dry and the crackers were soggy, but for a couple of minutes, we all stood together in the dimly lit hallway, talking. I cannot recall a word that was said during that conversation, or who else was there besides myself and the security officer on duty, but even now, two years later, the soothing feelings of comfort I derived (a reassuring moment that confirmed our mutual connection to the human race) remains a sharply focused memory.
Biographical note Lee Gutkinds book M a n y Sleepless Nights chronicles the world of organ transplantation. The author was presented with the American Heart Association's Howard W. Blakeslee Award for outstanding achievement in scientific journalism. A professor of English at the University of Pittsburgh, Gutkinds most recent book, One Children's Place, h i d e A Children's Hospital has recently been published in Japan and by New American Library (New York). Many Sleepless Nights has also been translated and published in Japanese and Italian.
