Graduation: the Fifth Floor

This address was given for an Internal Medicine residency graduation event on June 3, 2021. It is lightly edited for clarity and the scripted portion is below.

What does it mean to graduate in the year 2021? Future generations of residents will undoubtedly ask you, “What was it like to train during a moment in history so significant that the very institution you began at was fundamentally transformed, that was so disruptive that even the way you entered the building itself was different?” And undoubtedly you will respond, “Yes, I know exactly what you mean… I too did not know what to expect when Wilmington Hospital got its new parking garage.”

It may seem a small thing. But I am terrible at remembering where I park and so had developed the habit over years of simply parking in about the same spot on the 4th floor. Sure, there were variations during the early days of Covid, during active construction, with the ebbs and flows of hospital volume. But generally I got used to hurrying down 4 flights of stairs to get into the hospital and climbing 4 flights of stairs to get back to my car, to get home to my family, and to literally leave the hospital behind.

And then I got Covid. Of all the things I feared bringing home from the hospital – the sadness and grief of human suffering, the exhaustion and worries of clinical medicine, the ghosts of mistakes and dead patients and regret – this was what I feared bringing home the most, what I carried home with me in December of 2020 to my young children, to my wife who was pregnant at the time. Was the disease mild? Technically, yes. Were we hospitalized? No, we were not. Did we make a full recovery? I had thought so. I returned to work several weeks later and to teaching service. Rounding was the same. Patient care was the same. The building itself was the same. But parking… that had changed ever so slightly and, for whatever reason, I had to park on the 5th floor every day that week. And so at the end of each day, when I finished with the work and went through my usual routine of coming home and of climbing those stairs in the parking garage, I found myself struggling to make it to that 5th floor.

To graduate in the year 2021 means that you have survived the year 2020. It means you have made it through every cliché worth repeating: you were a healthcare hero during a pandemic; you were on the frontlines in the ICUs, on the floors, in the clinics battling a novel and terrifying disease in addition to all the old ones reinvented; you watched the world transform through protests and insurrection and courtrooms through those grainy bedside TVs; you adapted; you survived. You made it and now here we are, ready to celebrate, ready to move past from the abnormal new and terrifying things to move on to the normal new and exciting things. You are ready, perhaps even looking forward to parking again on the 4th floor.

But that is not where you are headed. You are not returning to the 4th floor. You are going to the 5th floor where everything should be the same; it is, after all, just a parking garage floor. It is simply one flight of steps higher, just a few steps further, just a little different. For some, the difference may feel trivial and perhaps even a welcoming challenge and change, an opportunity to grow and strengthen. And that is what I told myself every day that week I returned to work after Covid: it’s just one flight of stairs, just a few new steps. But by the end of that week, on that 5th floor, halfway across the nearly empty deck, I simply had to stop. I felt weak and fatigued. I was breathing harder. I felt my pulse go up, my legs get weak, and a concerning lightheadness. I sat down on the concrete, ripped off my mask, and found myself gasping for breath, alone, and dyspneic.

What is dyspnea? We describe it as shortness of breath, we characterize it relative to exertion, we have a broad differential that flashes through our mind when listening for rales at the bedside or for wheezing in the clinic or when staring at vent settings in the ICU. I found myself thinking about this recently when talking with a patient who was struggling to describe exertional dyspnea from simply walking across the room. She paused, searching for words to describe just how disturbing and terrifying the experience was, this feeling like you were going to die doing the most mundane of things. I asked her, “Did it feel like you were drowning in air?”

That is what change sometimes feels like: why the tasks you used to do without thinking may suddenly feel more laborious, why an outside observer may only notice the subtle signs by listening to you carefully, why you may feel different, why you may suddenly feel more conscious of all the details of all the things that were once invisible and ordinary. They say that culture is like the water that fish swim in or like the air that you breathe: you don’t think about how important it is and how much you take it for granted until you are flopping around, gasping for breath.

I remember the first time I felt dyspneic. It was shortly after graduating from college. I had no medical knowledge then and only remembered feeling acutely short of breath, scared, drowning in air. I remember being in the Emergency Department and being asked a long series of questions by the resident. I told him I thought maybe I had a collapsed lung, in part because I had recently heard a sermon in church describing the tragedy of a young man that had died from one. The resident was thoughtful but looked at the monitor showing 99% saturation on room air, examined my lack of distress, performed a cursory physical exam, and told me he thought it was dyspepsia from the bad Chinese food I had eaten earlier in the evening. Two hours after I had entered the Emergency Department, I got a chest x-ray. Ten minutes later, the attending strolled into the room and asked, “How are you feeling?” I was actually feeling better. With rest, I was no longer dyspneic and actually feeling quite sheepish at coming to the ED for acid reflux, and so I said, “I think I’m feeling better.” He replied, “No you aren’t. You have a 90% collapsed lung. You are getting a chest tube and staying in the hospital.”

This was a moment which began a series of changes that would alter the trajectory of my life. During that time, I was indecisive about pursuing seminary as compared to pursuing medical school; you can see now how that turned out. I have since had several pneumothoraces and three chest tubes. I have had two video-assisted thoracoscopic surgeries, one on each side of my chest. Even so, I would have periodic moments of dyspnea and anxiety. I went to the ED several times for these episodes. The most important of these was X years ago. It happened during an intern retreat; as I was playing frisbee with some random kids in the park, I began feeling short of breath, like I was slowly drowning in air. Most of my fellow residents thought I was joking at first when I stumbled up to them saying I was dyspneic; the one who was paying attention and happened to have a stethoscope in her car is now, appropriately so, my boss and I am grateful to her for not just hearing but listening to me. I spent the rest of that retreat admitted under observation for a small pneumothorax.

Because of that incident I began carrying around a 14G angiocath in case I needed to emergently decompress myself. This took place in tandem with a series of ways in which my life was reshaped by the things that were wrong with me, or, in the language of trauma informed care, the things that had happened to me. I was often afraid: afraid of the randomness of these episodes, afraid of being trapped somewhere far from medical help, afraid of going to sleep and never waking up, afraid of dying dyspneic. In fact I changed my travel plans for attending a conference and so, rather than fly, I switched into a carpool that planned to drive the 15 hours instead. I met up with the group at a rest stop somewhere along the Pennsylvania Turnpike and there, greeting the trip coordinator for the first time, I said to her: “Hi, my name is Dave. If I look like I have trouble breathing or am unconscious, this is a 14-gauge angiocath you can stick right here, probably into my left chest.” She told me she was a therapist and didn’t do anything medical and so I suggested one of the medical students we were traveling with could help. This was probably what should have warned her that I was not quite okay because, as we all know, I shouldn’t have asked her to trust medical students to perform needle decompression. To this day I remain surprised that she ever agreed to marry me.

That was also the year I moved into the North Side of Wilmington, near 23rd and Pine street. It was the year I became friends with my neighbor Dwight. The age of my father, we became good friends as he loved to tell stories and I loved to listen to them. He grew up under very different circumstances in a Wilmington that was also changing: he remembered running to bring a bottle of Coke for a young and aspirational Joe Biden, he lived through desegregation, he was in high school when Martin Luther King Jr. was assassinated, he watched the city burn in the time that followed, he remembered the occupation by the National Guard for over 9 months (which remains the longest any American city has ever been occupied by a military force since the Civil War). He served in the military briefly and had an honorable discharge, but because of a brief stint incarcerated made a better living as a contractor than through other employment. He had watched the neighborhood around him change over decades, swept up in the violence we often heard through gunshots in the middle of the night.

He was also a smoker, and over the years that we were neighbors I watched his coughing turn into wheezing and dyspnea. I dragged him into the office to become my patient so I could prescribe and pick up the nebulizer treatments he was too sick and too alone to get on his own. And as we lived through those years and the many “social determinants of health” together as friends, we talked about life, survival, and the sickness and death that could come at any time as it did for our neighbors who were shot, stormed, cancerous, unwell.

I’d like to say that we came to peace with death, and in a certain way we did. At least, he told me as much as his dyspnea worsened while mine improved. I had already moved out of the neighborhood and helped him to do so as well, though to very different places within the city we loved. The last time I helped him move was just a few weeks before his death and I remember watching him struggle to cross the room, remember putting the albuterol MDI by his bedside, remember organizing his medications in the bathroom, remember exchanging with each other, “I love you.”

I often think about how he would have responded to the events of the past years. I imagine he would have beamed with pride in having known Joe Biden long before he was President Biden, that he would have been afraid of the virus but more hurt by being alone, that he would know exactly what it felt to say, “I can’t breathe.”

What does it mean to graduate in 2021?

The rest of the speech is unscripted.