The Walk Across the Bridge Entering Ella''s room that morning, I had expected to find her resting peacefully with a nasogastric tube sucking bile from her stomach. What I had not expected was to find her parents and grandfather seated in a semicircle around her with their own tubes sticking out of their noses and taped to their foreheads. I was a third-year surgical resident at Brigham and Women''s Hospital, making rounds with the senior resident-technically my boss that day-on my first rotation in pediatric surgery at Boston Children''s Hospital. Both the Brigham and Boston Children''s were teaching hospitals affiliated with Harvard Medical School-many of their doctors taught at Harvard, and Harvard Med School students went there for training and to do their residency. Crossing the bridge between the two hospitals, I had felt the senior resident''s mood shift from gruff to decidedly grumpy. Now, as we stood in Ella''s room trying to make sense of the scene, I felt he was about to erupt. He was not the first colleague to show frustration in a pediatric environment. After two years of residency at Brigham and Women''s, I had grown accustomed to the regular complaints of my peers as they crossed the bridge to Boston Children''s, one of the first and best pediatric specialty centers in the nation.

I suppose at some level it was to be expected: they were mimicking an attitude common among the famous doctors who were training us. Most of my fellow residents were aspiring brain surgeons, cancer researchers, orthopedists, and heart surgeons. They had little time or energy for anxious parents, let alone for the quirks and tantrums of children. The previous day the senior resident had brusquely informed Ella''s parents she would need a nasogastric tube, which we would have to insert through her nose down into her stomach. Her intestine, which we had untwisted in a relatively common but quite invasive surgical procedure, was still not functioning properly, and we needed to relieve it of all stress to give it a chance to heal. Ella''s parents had been patiently waiting for weeks to see some progress, and the news of the tube had visibly crushed them. The prolonged hospital stay was taking a toll on their four-year-old daughter, and they worried the tube would further damage her spirits. The senior resident didn''t seem to register their concerns.

He silently examined Ella one last time, then wrote out the order for the tube to be inserted. I wanted to reassure them somehow but couldn''t think of what to say or do that wouldn''t seem insubordinate. Ella''s parents moved in closer and spoke more emphatically. "She is not ready for this," her father said, his voice not so much stern as weary, almost pleading. "She''s been through too much. We have to be able to explain-in her own language-why she needs this." My colleague looked up and mumbled, "I''m sorry," and then we were off, leaving them with a look of disbelief. So the following morning when we entered the room, I was struck by the majesty and outrageousness of their gesture.

"We told you we would do whatever it took to make this easier for her," Ella''s father said matter-of-factly. Her mother stood up and moved closer. I will never forget the willfulness-the sheer, animallike protectiveness-that she exuded. The senior resident blushed and didn''t even examine the girl before saying, "This is against hospital policy." I had to do all I could to keep from wincing. Ella''s mother saw that her daughter was registering the tension in our voices and motioned for us to step into the hallway, but the chief resident would not budge. "You are going to have to remove the tubes immediately or we will ask you to leave the hospital," he said. The grandfather folded his newspaper and frowned.

He looked at his granddaughter, then shook his head and closed his eyes. "Immediately," he repeated, and out he went, before they could respond. I trailed after him despondently, angry at myself for doing nothing to intervene. I knew he would follow through on his threat, and I could tell the parents understood this. But if it helped the girl, was it really such a problem? Over the course of my first pediatric surgical rotation, the trips across the bridge had had the opposite effect on me as on most of my colleagues. I loved working at Children''s. It felt a bit like going home. I was raised in North Carolina, earned my undergrad degree at the University of North Carolina, and went to Duke medical school, and I was still recovering from a culture shock that had less to do with the infamous rigors of residency at Brigham and Women''s than with the gruffness and wear-it-on-your-scrubs ambition of life among hard-chargers up north.

The care and results at the Brigham were excellent, of course, but the coolness and professionalism there, the dispassionate approach to patient interaction, left me wanting. In three short months I had grown to cherish the heightened authenticity I felt every day at Boston Children''s. In my first year as a resident, I had made the trip across the bridge a few times during rotations in plastic surgery and neurosurgery, specialties in which there were no separate pediatric departments, but it wasn''t until now, in my third year, that I was doing a full rotation in pediatric surgery. In the end, Ella''s parents removed the tubes from their foreheads, and their daughter''s intestines began functioning properly soon thereafter. Her digestive system had been given the respite it needed to recover completely. My boss, having done the right thing in the wrong way, departed a year later for a very successful career in adult surgery, and I was left with nagging questions about the system and my future. Why couldn''t hospital policies be adjusted to consider the emotional needs of children and their families? Young parents are so desperate to see their children heal. Shouldn''t we adjust our ways to address their needs, too? I began to see the bridge connecting the Brigham and Boston Children''s as a passage to a different form of medicine, one that accounted not just for the unique psychology and biology of children but also for the concerns of their families.

A few months later I was back on adult rounds in a general male ward at the Brigham that was typically made up of uninsured patients. One night one of my patients, a man we had nicknamed Mr. Pibb, was feeling uncomfortable. HeÕd had stomach surgery a week before, and the surgeons had placed a nasogastric tube in him, just as they had done with Ella. They wanted his stomach to rest and heal; draining it was key. The senior resident had directed me to make sure the tube stayed in place all night. Mr. Pibb was notoriously feisty and craved soda pop-hence his nickname, which rhymed with his real name.

The painkillers were making him restless, and he was a prime candidate to thrash about and rip his tube out. The first time the nurse paged me, about midnight, I knew immediately what had happened-the tube had come out. I rushed upstairs and tried to calm Mr. Pibb. Then I gave him all the little extras that I understood to be the hallmarks of a good nasogastric tube insertion. I numbed his nose a little bit to make the placement more comfortable, put the tube on ice to stiffen it a bit so it would be easier to place, and calmly asked him to cooperate with his swallowing as I ran the tube down his throat. Then I taped it in place about as gently as I had ever seen the kindest nurse tape a patient. An hour and a half later, while I was on my cot catching my first shut-eye of the night, the nurse paged me again.

I was by this point, as my mother used to say when I did something wrong, "clearly perturbed." I called upstairs, and the nurse told me that Mr. Pibb had kept thrashing and had pulled the tube out again. This time I didn''t numb his nose or call for ice. I taped the hell out of the tube. I even ordered that he be placed in restraints. Exhaustion and frustration had gotten the better of me, but at least I was certain that he would not be able to dislodge the tube again. But he did.

I had just lain down again when the call came in. A medical student named Robert Sackstein was resting on the cot across the room from me. "Okay, your turn, Robert," I recall saying. "Nothing like learning on the job." I craved sleep, and having Robert give it a try would buy me a few winks. "But you''ve got to get them to restrain him completely this time." The procedure normally takes half an hour with hard cases like Mr. Pibb, so I closed my eyes as Robert got up, and I drifted off before he even closed the door.

But Robert was back ten minutes later. I sat up and asked him what happened. "What do you mean?" he asked with surprise. "What happened up there-why are you back so quickly?" "I put the tube back in and ordered that he be fully restrained," he said. "That quickly?" "Well, yes," he said. "He didn''t fight it? He didn''t give you a hard time?" "Well, no," Robert said, obviously trying to get me to shut up so he could get some sleep himself. He turned over, and I suspected he was smiling in the darkness. "Mr.

Pibb did say something to me when I got there," he offered. "What was that?" "He said, ''Son, I don''t care what you''re going to do-just don''t call that bald bastard back in here!''" And with that, Robert broke out laughing. I was, at thirty, already going bald, professional anxiety no doubt expediting genetic destiny. I chuckled.