Randall S. Stafford, MD, PhD
Stanford University, California, United States
To be summoned to pronounce the end of a patient’s life is always unnerving and he was my first death during my Massachusetts General Hospital internship. The task required a physician, no matter how inexperienced. My patient, the eighty-one year-old Mr. H., was one of the privileged class of old time Mass General employees from its golden age. His dementia and Parkinson’s had precluded direct verification or even a cursory medical history, but the high stack of medical record charts revealed a full career working at MGH from the 1930s until his retirement in 1981. Supposedly, this status afforded him perpetual free care at Man’s Greatest Hospital, a fitting reward for witnessing the hospital’s twentieth century ascendency to international prominence. For me, he was a bridge between the old and the new MGH.
In the early 1930s, the hospital encompassed an impressive cluster of patient care buildings: the original four-story Bulfinch Building completed in 1821, the Surgical Building from 1890 (later torn down), the eight-story Phillips House built in 1917, and finally the then new, but now gone, Baker Memorial Building. In 1992, I arrived to a far larger hospital, a compact constellation of activity newly anchored by the 24-story, just completed Ellison Tower with its skin of sparkling blue-green glass and the matching 15-story Blake Building.1
After visiting his room several times in hopes of reversing his worsening shortness of breath and falling oxygen saturation levels, I realized the situation had grown desperate. The phone call came at 2 AM, later than I had expected. Awaiting my arrival, the nurse had left him on the floor where he had fallen. His eyes were open, staring motionless towards the doorway, his body was contorted uncomfortably. I approached cautiously, acutely aware of the absence of his wet, guttural breathing.
It was early September and I had been an intern for eight weeks. This was my first 36-hour on-call shift for the Founders House, grueling for even the younger interns. Mercifully, my internship began in the emergency department under the constant guidance of the watchful senior attending physicians. I had moved to Boston in late June, not only newly graduated from medical school, but also newly married. With my wife in San Francisco finishing her PhD, I split my waking time unequally between long hospital shifts and a lonely routine of wandering through Back Bay on available evenings. Mass General had been my first choice. While in medical school at UCSF, I had grown weary of its edge of self-promotion. The defensive west coast reactions that invariably accompanied my questions about hospitals on the “other coast” left me intrigued. Having spent nearly my entire life in California, I was ready to give New England and its older traditions a try at the nation’s third oldest hospital. Started as an institution to provide care to the poor, MGH’s founding dated back to 1811; its first patients seen in 1821. Always closely affiliated with MGH, the Harvard Medical School was located next to the Bulfinch Building for 36 years in the mid-19th century.2
The Founders House was eight brick stories of anachronistically remote hospital wards nearly a quarter of a mile from the hospital entrance. Originally known as the Phillips House, when it opened it must have afforded tranquil views of the wide Charles River.1 The over-sized windows now overlooked adjacent Storrow Drive, vibrating from its constant automobile hum. Once, Founders had housed only the special private patients who received this privilege due to social status, donations to the hospital, or, later, a willingness to pay beyond what insurance would cover. This function, however, had migrated to other, more fashionably modern quarters, most recently the excessively appointed top three floors of the new Ellison Tower. The new luxury rooms featured dark wood paneling, panoramic views, and near wall-to-wall Persian rugs fit for the occasional visits by Saudi royalty.
Well past its prime, Founders House was now a destination for those patients unlikely to need immediate medical attention: either those cases, like Mr. H., slowly dying, Do Not Resuscitate patients, or those whose slow recoveries would progress just as quickly without undue scrutiny. The twelve-foot wide, grand corridors were an oddity, the large patient rooms, lacking sinks and bright lights, were out of compliance with modern hospital building codes. But the old, comfortable opulence still shone through despite deferred maintenance and sloppy layers of thick paint. Each room had a brick fireplace with a solid stone mantle, ornate molding trimming the doors, its own private bathroom, and elegant high ceilings. I imagined that in its early years before prohibition, claret and brandy had been on the Founders formulary. These days the smell was a less delicate mixture of disinfectant, urine, and baby shampoo.
Mr. H. had been a patient in the hospital for nearly three months, admitted from a nursing home for aspiration pneumonia, urosepsis, and worsening mental status beyond his baseline dementia. Even after a long course of antibiotics, his breathing never returned to baseline, but instead took on an animal-like, gurgling quality punctuated by his feeble attempts to cough. He responded to questions between noisy breaths, but his answers were never appropriate, even when decipherable. We had failed in our search for next of kin. He was fed through a pliable gastric tube placed through his left, upper abdomen. He was tenuously stable, but over the past month had required increasing oxygen delivered into his nose.
Into the evening, by nightfall, his noisy breathing had worsened from another likely aspiration of saliva down his trachea into his lungs. His condition continued to deteriorate despite new IV antibiotics and more breathing treatments from the respiratory therapists. Finally, I saw him again at midnight and prescribed 3 mg of IV morphine to be repeated twice more as needed to ease and slow his breathing, acknowledging the possible consequences of this comfort care. I am not sure it helped, given his desperate climb over the sturdy, foot-high metal bed railings.
I rarely slept when on-call. Although a room full of bunk beds was available for the interns, the pace of nighttime tasks never allowed more than thirty minutes of sleep at a time. When I did have free moments, I investigated the hospital’s curiosities, including the Ether Dome, the Bulfinch Building’s peculiar surgical amphitheater. Its steeply angled, terraced seating took up nearly thirty feet, its height extended further upwards into the building’s windowed dome. Forty-four feet below the dome was a small, claustrophobic stage of a floor.1 Originally used for the clearly non-sterile surgical procedures of the mid-1800s, here inhaled anesthesia was first demonstrated publicly on October 16, 1846 for an operation to remove a neck tumor.1,3 It had been more than a century since the hall had been used for clinical care. For a time, the Ether Dome was redeployed for Medicine Grand Rounds, the house-staff relegated to the upper seats, including the curious top row of leather bicycle saddles mounted atop heavy pipes arising from the floor. The bicycle seats reminded me of Dr. Paul Dudley White, an ardent cyclist and advocate for vigorous exercise, one or several MGH clinician-investigators who in the 1940s reinvigorated the hospital’s worldwide prominence in the new era of scientific medicine.
Another late night internship pastime was reading through the ancient admission notes located in first volumes of multi-volume medical charts. As with Mr. H.’s 30 lb seven-volume chart, we often found fountain pen notes from the 1960s, quaint in their simplicity, lack of sophisticated tests, and bold absence of modern ambiguity. Quite often, we came across notes by our more senior attendings that dated back to their days as MGH house-staff.
Before coming to Boston, several patients I had followed as a medical student had died, but always in a crowded operating room or while I was away from the hospital. Unsure of what this new situation officially required of me, I went through the obvious with Mr. H.: no breathing, no pulse, no heart tones, fixed, non-reactive pupils, absent response to a sharp tap of my knuckles on his sternum. His skin was even waxier than before, his bald head and grizzled face much paler. He was taller than he had seemed when he was confined to his hospital bed. With effort, I pushed his heavy legs into a more natural position, arranged his floral print hospital gown, and pushed his lids down to stop his staring.
I wanted to speak, to pronounce his passing with words beyond “rest in peace;” to say something more profound, worthy of MGH, its traditions and legacy. All I could think of was how, save his trip to the floor, Mr. H. had experienced a reasonable death and that at last his suffering was over. Unable to prolong the process so as to make it seem less perfunctory, I slowly walked back to the nursing station. The lone nurse handed me the half-completed death certificate. With evident experience, she pointed to the lines left blank for me to complete. I filled out the time of death, its causes and contributing factors. I signed the form, marveling at my learning curve for official actions. As I handed her the form, the nurse telephoned the morgue and asked them to send two strong orderlies for the heavy task of lifting Mr. H.’s body off the smooth marble floor. In the pre-dawn darkness I was now free to explore the hospital as I waited for the next call, more than ever connected to the rituals and ambitions of the Massachusetts General Hospital.
- Personal communication. Jeffrey Mifflin, Archivist, Massachusetts General Hospital Archives and Special Collections. Boston MA. January 7 and 22, 2015.
- Harvard Medical School. The Early Years. Boston MA. http://hms.harvard.edu/about-hms/history-hms/early-years. Last accessed 1/31/15.
- Massachusetts General Hospital. History of Mass General: History Trail Online Tour. Boston MA. http://www.massgeneral.org/history/exhibits/history-trail/. Last accessed 1/31/15.
Randall Stafford received a PhD in epidemiology from UC Berkeley and an MD from UC San Francisco prior to beginning his Internal Medicine residency at Massachusetts General Hospital in 1992. Following his clinical training he remained at MGH and Harvard Medical School as an Assistant Professor at the MGH/Partners Institute for Health Policy. In 2001, he returned to his hometown of Palo Alto to direct Stanford University’s Program on Prevention Outcomes and Practices. In addition to clinical practice and research on chronic disease prevention, Dr. Stafford is an avid cyclist, father of two teenage daughters, and advocate for physical activity.