By Any Other Name

Her name was Star, and I never met her. I was probably hiding from her in an on-call room, my residency having transformed me—through nights when sleep was obliterated by blood draws and questionable admissions, and days where my presence was required not so much to provide healing but to relieve the workload of the attending physician sub-specialists who could then move on to the next patient and continue to bill—expanding my cynicism to the point that I could now conflate a beautiful newborn with work and suffering. A baby was no longer a treasure you held in your arms or lightly kissed on top of the head while breathing in that downy smell of skin but something that roused you from sleep so you could poke it with needles and make it cry and induce sweat to bead on its brow. As determined as I was to speed home each night I could, eager to embrace my own baby (my head nodding against the window glass on the D train all the way from uptown to Columbus Circle), that’s how intent I had grown to run away from an infant on a hospital ward.

This particular night I was in my last year of residency. I was the senior in-house, a position in which I served two masters. When the emergency department attending called to inform me that a child was being admitted, it was my duty to find her a bed somewhere up on the floors. But it was also my social obligation to act as The Wall, to block as many gratuitous admissions as I could and thereby protect my fellow residents, overworked on the floors already, reinserting intravenous lines that had fallen to the ground and hand-writing orders for chemotherapies they knew little about for patients of whom they knew even less. Addressing both the demands of tenured physicians and the basic needs of my fellow residents highlighted the impotence of my position, the disconnection between my efforts and their outcomes. My struggles to moderate competing forces were pointless, only serving to burn me out faster, as they inevitably were resolved in favor of the attending physician, a shift worker who would be going home in a few hours.

Occasionally, the job involved medical care. The senior in-house might be called upon to help the floor residents with simultaneous admissions or advise on the handling of a patient whose status was changing on the floor—as if my whole additional year of training, in comparison to those I oversaw, conferred on me some silverback wisdom. Sometimes, it was the job of the senior in-house to increase the acuity of care, to transfer a patient up to the ICU in the middle of the night (and therefore move another patient, deemed “critical” up to that moment, down to the floor at the same time to make room in this game of musical beds) and with a telephone call rouse from sleep all the parties (the chief resident, the intensive care attending) who must approve these wee-hour requests. But at its core the senior in-house was mostly an administrative post: coming in at 5 p.m. and doing my best to clear the floors of all who didn’t need to be there, whatever that meant, and then finding bed space as a new batch of overnight patients came through the door.

Star was only a few weeks old, and to me, she was just an admission statistic, a matter of disposition. I didn’t need to see her face, or the fixation of her eyes, or the pleated philtrum above her lip beat rhythmically as she fed from her mother’s breast, or from a bottle at her father’s hand, or propped up against a grandmother’s bosom, or any of the other details I thought I didn’t need to know. All I needed was her date of birth, so I could assign her to the appropriate floor (our wards were distinguished by three age ranges: infants, children, adolescents) and her admission diagnosis so I could prepare my fellow residents for the work they had ahead of them. Through training, through conditioning, I had fashioned myself into a cold and efficient administrator.

Though fine upon her arrival at the emergency room, Star’s parents had rushed her over because they thought she had stopped breathing at home. After an unremarkable evaluation, she was labeled an “ALTE” (apparent life-threatening event, pronounced ALL-tee), as one of the poison fruits of our training was the tendency to distill each child into a diagnostic category: ALTE, sickler, wheezer, FIB (fever in baby). But there was an efficiency with this method of categorization, for each depersonalized category came with a protocoled diagnostic and therapeutic course, like task boxes to check off on a to-do list. When completed it signified that our work on behalf of the patient was done, whether or not we determined the problem or relieved her suffering—an uninspired goal for healing artisans so early in their apprenticeship, for sure, but it was remarkable how many of us, by our third year of training, accepted without protest such lame aspirations.

I still remember my knee-jerk thoughts from that middle-of-the-night call about this faceless Star—the first being that her case, like the dozen other ALTEs I had presided over in my first two years of training, was going to yield nothing but a battery of negative studies, with the exception being those diagnostic procedures that address gastroesophageal reflux. We would begin by asking, in the form of high-tech equipment and analysis, all the right questions: Was this a cardiac event? A near-SIDS? Was this an apnea—maybe an obstructive apnea, perhaps a central one? Or was this only a case of reflux, something benign where the baby just looked like she was choking to death? We would hook the baby up to cardiac monitors that would catch nothing (no dysrhythmic accessory tracts, no blockade of electrical conduction); to pulse oximetry probes that she would swipe off her fingers and kick off her toes, despite our best attempts to secure them with paper tape; and to impedance devices on her chest wall that would produce inconclusive data—a sleep study that essentially kept everybody up at night except the baby and yielded little in the way of objective conclusion.

When all else failed, the reflux-focused studies were guaranteed to provide an answer of sorts. The swallowing study was sure to catch some “deep penetration,” as the speech therapists would call it, of the nasty barium formula we fed the baby, its white, milky film moving in the wrong direction through a series of x-ray plaques. Or we were certain to observe, in the baby’s chest, the prolonged scintillation of the radioisotope we placed in her milk during esophageal transit scintigraphy—a nuclear medicine study whose name has a misleadingly benign sparkle. And if neither study captured the invisible enemy, then we would torture her with the placement of a pH probe through her nose, advancing it down to her gastroesophageal junction, and leave it there for hours. Invariably, a spurt of acid from the stomach would cling to the esophageal wall and lower its pH, providing us the Eureka! we needed to close the case and prescribe some therapies (thickened feeds, antacids, elevated positioning in the crib) that might or might not work.

The relationship between the patients’ presenting symptoms and our neatly packaged final explanations always gnawed at me: Of course we find reflux in these kids—all babies spit up, not a single one doesn’t, and we don’t need to irradiate a newborn to learn that. But that wasn’t the point of these diagnostic gymnastics. Rather, the goal was to come up with an answer when, through no fault of our own, we didn’t really have one. So, we conveniently tagged an official diagnosis of reflux on these babies, as it was the objective finding upon which we knew we could rely. But all this diagnostic technology ignored the more likely explanation, and this comprised the second automatic thought my brain synthesized about Star’s admission: that the true diagnosis was going to be nervous parents—nervous, first-time parents, young and scared and living in a world without resources, without support, with perhaps only that thin sense of safety that their own parents might provide in a world that otherwise doesn’t care about them. We were going to find a normal baby, I knew, with an anxious, inexperienced mother and father, who misinterpreted all the weird sounds and physical jerks that a neonate makes as something other than the normal phenomena they are—and then we were going to send them home with a diagnosis that had nothing to do with why they arrived.

I never went up to the floor to meet Star. Like I said, she was an ALTE, her workup protocoled and predetermined. There was nothing that I could add to the process, the pre-set dominoes had already begun to fall the moment she had been labeled in the ER with an admission diagnosis. And I was the senior in-house, anyway, a once-every-fourth-night interloper who would have nothing to do with her management once she was tucked into her metal crib. During the days in between my overnight calls, I would be working at one of the hospital’s out-patient pediatric sites, caring for other patients in a neurology clinic, in an oncology infusion suite, in a primary care office an entire bus shuttle away from Star, of whom I’d likely never hear again.

But I did hear about her, through my grapevine of fellow residents, sharing our war stories from our call shifts the nights before. Star’s father had been a little difficult during her hospital stay, I heard from my colleagues over lunch in the hospital cafeteria, and during the sign-out from my chief residents four days later, when it was again my turn to act as senior in-house. He was frustrated, I was told, that no one could come up with an explanation for the life-threatening event that he perceived Star to have had. Our tests and technology, as usual, had yielded little in the way of answers, and anger had begun to seethe, as it so often does, out of unresolved parental worry. For my part, I gave it little thought. It was a new night, with a new list of scut before me, my attentions turned toward the next wave of discharges and admissions, and I had little interest in a stable patient who slept through the night hooked up to monitors, waiting for the requisite diagnostic battery of the next day, hostile parent in tow. Besides, I could divine the eventual answer to Star’s diagnostic riddle: nervous parents, likely reflux.

It was several days after that second night on call when I heard that Star’s father had rushed into the hospital in an emotional fury and threatened violence to the staff on the infants floor. Star had been discharged home a few days earlier without any dramatic explanation for her initial admission, and that morning her parents had found her lifeless in her crib. No doctors on the wards knew that Star had died; they learned as the tragedy unfolded before them from the tearful, enraged words of a grieving parent. In mourning and shock, Star’s father sought revenge, retribution, a last inadequate cry to finally be heard. Security guards were called to contain him, perhaps the police, too, and when the story got back to me I was consumed by the horrible truth that I had never met Star. I knew of her existence, I knew of her parents’ concerns, but I had never bothered to stop by and say hello. If this story were her final cry for me, it was too late—by the time I had chosen to hear her wails, they were coming from her grave.

I was exhausted, of course, physically and emotionally, working during the days and pulling a night shift every fourth, coming home to my own infant and toddler and working wife. And I was detached personally—detached from the patient, whom I viewed as an admissions statistic; detached from the emergency department, which every resident views as the enemy in the middle of the night; and even detached from my own training, as I felt like some combination of an orderly and a medical assistant but never the clinician that I was ostensibly being trained to be. I had also lost any feeling of accomplishment, of any sense that I could change anything, that anybody would listen to what I had to say. I had cultivated this bias, experiential and empirically derived, that none of these weeklong, arduous workups ever yielded an actionable result. And so, what was the point in meeting Star?

So here I am now, nearly two decades later, the past rushing into my present as it always does, like a creek during a spring thaw, and I’m thinking about Star again. What if I hadn’t been so tired? What if I hadn’t felt protected by personal detachment, hadn’t been tainted by the notion that intimate attachment put me at odds with my own best interests? What if I had still believed that I could change something, accomplish something, do more than check a box or cross a line off a scut list or balance a hospital census?

What if I had just gone to the floor and said hello to Star’s father, and asked him how he chose her name?

DOUGLAS KROHN

Douglas Krohn is a primary care physician in Westchester County, New York, and a Clinical Assistant Professor of Pediatrics at New York Medical College. His fiction and essays have appeared in The Westchester Review and other publications. He lives in Westchester with his wife and four sons.