Tiny Medicine

Don’t give up! I believe in you all.
A person’s a person, no matter how small!

– Horton, from Horton Hears a Who by Dr. Seuss

***2019 Update – Now an excerpt from Chapter 2 of the book Tiny Medicine, available for pre-order now at Amazon or your favorite online bookseller!***

When I tell people I’m a neonatologist, they usually nod and smile in the awkward way people do when they have absolutely no idea what you’re talking about. I’ve learned to follow this up with “you know, the kind of a doctor who takes care of really small and really sick NICU babies.” Most people’s eyes then immediately brighten as they identify with a niece, cousin, or friend whose baby had to stay in the NICU for a couple of days. Then they invariably talk about how amazing the nurses were and how small the other NICU babies were in nearby isolettes.

Premature infants are small. Very small. They’re so small that our normal physical understanding of the world just doesn’t make sense. Calling them “small” is like describing a galaxy as “big” or the sun as “heavy.” Words simply cannot do the real thing justice.

If you really want to grasp NICU small—and you’re not up for volunteering in your local NICU as a cuddler—you’re going to need some props. I recommend that you put down this book, go to your kitchen, and get a gallon of milk, a soda can, a straw, a spoon, and a grape.

Start by picking up the milk. A full gallon of milk weighs plus or minus 8½ pounds, varying just a flicker whether you prefer slightly heavier whole milk or the slightly lighter skim variety. Close your eyes and really feel the weight, imagining a newborn crying in your arms while you gently rock her back and forth. An average newborn actually weighs just a little less than the gallon of milk (closer to 7 pounds), but two of my three kids weighed more than the gallon you’re holding, so it’s a close enough approximation for our purposes.

Now transfer the gallon of milk to one hand and pick up the soda can with the other. In America, most soda cans contain 12 ounces of your favorite carbonated sugary beverage, which (including the mass of the aluminum can itself) weighs about the same as the smallest NICU babies I’ve cared for as a doctor. An adult’s weight fluctuates more than 12 ounces—or just under 400 grams—over the course of just a few hours. Yet 400 grams is more than enough to contain the sum total of the smallest person I’ve ever met. You’ll get to meet her in Chapter 7.

Imagine the contrast as you walk down a hallway in the NICU, passing the soda-can-sized baby hunkered down in her isolette (also called an incubator), sandwiched between two giant infants of diabetic mothers, each over 12 times her size. To put this massive size discrepancy in perspective, if I was next to another human being 12 times as big as me, he would stand 72 feet tall or about the length of an average blue whale. He would also weigh nearly a ton and his palm could fit me, my wife, and my three kids all lying together in a line head-to-foot while still being able to close his fingers in a fist. It shouldn’t then be a surprise that caring for babies 12 times smaller than other newborns requires really, really tiny medicine.

Now put down the drinks and pick up the straw. Most grocery store drinking straws have an interior diameter of about 6 millimeters, or just a quarter of an inch. (Yes, I actually measured a sample of straws for the sole purpose of this comparison.) I want you to pick up the straw and look through its hole—hold it really close to your eye, and try to really appreciate how hard it would be to breathe through such a tiny passageway. Despite incredible advances in care over the past century, the smallest and most premature babies invariably need a breathing tube and specialized high-frequency ventilators for some period of time to support their immature lungs. The breathing tubes that doctors and other providers use in the NICU to intubate their windpipes have an interior diameter of only 2.5 millimeters. You could easily fit two of them inside the straw you’re looking through with room to spare.

Learning to intubate babies this small was one of the most harrowing experiences I’ve had as a doctor. For obvious reasons, only the most seasoned providers are called upon to place such a tiny breathing tube in such a tiny baby, usually only seconds after the infant is born and only moments after cutting the umbilical cord. I first learned how to intubate on larger babies during residency under very controlled circumstances and with exceptionally close supervision. It wasn’t until my NICU fellowship that I was given an opportunity to intubate a preemie.

Imagine holding a tube half the size of the straw in your right hand while using a glorified spoon with a flashlight on its tip to open a baby’s mouth and peer inside. You’re looking for a structure no bigger than the tube you’re holding—the vocal cords, which look like thin white strips of dental floss standing out against the back of the baby’s flesh-colored throat. To slide the tube through the cords you have to time it just right, catching the baby just as she’s breathing and not trying to cry, while doing your level best not to push too hard or accidently bounce off the vocal cords and dip into the esophagus (the food pipe) that lives right below the trachea (the windpipe).

Providers are downright religious about how they prepare breathing tubes and the stylets placed inside of them to give the flexible tubes a temporarily more rigid shape. Some believe that a perfectly straight breathing tube is best, while others curve the stylet to give the breathing tube a shape reminiscent of a crescent moon. Personally, I’ve always been a fan of the “hockey stick” bend, which looks exactly like it sounds with a gentle curve at the top followed by a sharp bend up toward the tip that looks like you could use it to whack a microscopic puck. Since most of the tiny babies’ vocal cords I’ve found are toward the front of their throats, using the hockey stick bend allowed me to gently rotate the tube into place along the side of a baby’s mouth while maintaining the ability to still see where it’s going in a space no bigger than a marble.

Should you succeed in passing the tube gently through the cords, you then have toƒ pinch the tube with your right hand, drop the laryngoscope blade from your left, very carefully pull out the stylet, and connect the tube to the respirator without moving it more than a millimeter. Should you inadvertently move it 2 millimeters, the tube might slip out of the windpipe and either drop into the esophagus or fall into the back of the baby’s throat, meaning you have to start the process all over again. Oh, and you have exactly 30 seconds to complete the entire process from start to finish or risk the baby dropping her heart rate or her oxygen saturation levels. It’s a high-wire act for even the most experienced intubators, especially on the tiniest of tiny babies.

Now put down the straw and pick up the spoon. Like straws, spoons vary greatly in size but a standard teaspoon can hold about 5 milliliters of liquid. Open your soda can and very carefully fill up the spoon. You may actually need to use the straw to very slowly drip it in.

When the smallest NICU babies need a blood transfusion, we give them about 10 milliliters (or 2 teaspoons) of packed red blood cells for every kilogram of their body weight. That tiny sip of soda you’re holding in the teaspoon—barely enough of a taste to hazard a guess on the brand of carbonated sweetness that’s in the can—is more than the amount of blood a 400-gram baby receives in each blood transfusion. And because we transfuse blood extremely slowly to protect extremely premature infants from a host of potential problems that could come from transfusing it too fast, that single teaspoon takes nearly four hours to complete its trip into the baby’s bloodstream. At a speed of give or take 1 milliliter an hour, the blood is at such a high risk of clotting during the transfusion that we routinely need to place an extra intravenous line somewhere in a preemie’s body to avoid losing her main intravenous lifeline for medications, hydration, and nutrition.

Presuming you’re an average-sized human adult, you probably have around a thousand teaspoons of blood flowing through your heart, lungs, and bloodstream right now. A 400-gram baby has approximately 7, meaning the now minimally emptier soda can you’re holding still has enough liquid to replace the baby’s entire blood volume 10 times over with almost an ounce to spare. Preemies this small often need many transfusions over the course of their NICU stay, both to make up for the blood we have to draw to test their labs and to support their bone marrow, which doesn’t pick up its own pace of red blood cell production for several weeks after birth. Each time you donate blood, the single unit you give (once fully processed) yields about 300 milliliters of packed red blood cells, enough to fully replace more than eight 400-gram babies’ entire blood volumes or give 75 of them one transfusion.

Finally, put down the spoon and place your right hand on your heart. With your left hand, pick up the grape and carefully make a fist, closing the grape gently within your left palm. An average adult human’s heart is about the size of its owner’s fist and beats 70 times per minute. Look down at your left hand and imagine your own heart beating, feeling its rhythmic thump inside your chest against your right hand.

Now open your left hand. The heart of a 400-gram baby is smaller than your grape, yet contains exactly the same atria, ventricles, valves, and vessels and works in almost exactly the same way as the heart you feel now pounding against your right hand. What’s more, despite its incomprehensibly small size, a preemie’s heart beats on average well over 160 times per minute. This is why it takes so many adult hearts to care for just one NICU baby, and these extraordinarily small humans touch nearly every grown-up heart in the NICU during their many, many month-long stays.

Even with a good set of props, NICU small is something you truly cannot appreciate until you see it, feel it, and live it in person. I truly had absolutely no appreciation for what NICU small meant before I went to medical school. I thought I did—my younger brother was born around four weeks premature, and at under 5 pounds he seemed tiny when my parents finally brought him home from the hospital a few days after my mom was discharged. He had some yellowing of his skin, known as jaundice, and we kept his bassinet by the picture window in the front of our suburban New York home. For years I was afraid that even the slightest bump would break him into pieces.

That changed when I went to medical school. As a second-year medical student, I remember briefly setting foot in the NICU while on my pediatric surgery rotation. Everything about the place seemed intimidating. First of all, unlike other hospital units, every doctor was stopped at the front door by someone who forced you to remove your white coat, put on a hospital gown, and wash your hands up to your elbows for a full minute. Even the Chairman of the Pediatrics Department didn’t get a pass—anyone who didn’t spend 100% of their time in the NICU wasn’t considered “clean” enough to get past the formidable head unit clerk without a thorough decontamination.

On this particular occasion, after our mandatory disinfection, my team of other medical students and surgical residents throttled through the NICU in typical surgeon fashion. We passed row upon row of isolettes, seeking the relatively large baby in whom we’d placed a gastrostomy tube—a specialized feeding tube that allows the team to pump nutrition directly into a baby’s stomach—the day before. We finally found the baby, the most senior surgical resident examined his new G-tube, and upon finding everything to be healing satisfactorily we hightailed it out of there as fast as possible.

The NICU is simultaneously an intentionally intimidating place to outsiders and an incredibly welcoming place for those who enter its folds as family. I’d experienced the former—born out of an overwhelmingly parental need to protect the smallest, sickest, most vulnerable patients in the hospital—as a medical student. I’d learn the power of the latter soon enough.

My wife was pregnant with our first child when I started residency. I worked an enormous number of hours over the first six months of residency, covering different inpatient services, outpatient clinics, oncology, the general pediatrics wards, and cardiology. But thankfully I didn’t reach the NICU until well after my wife gave birth in late December. I don’t know how we would have made it through her first pregnancy knowing just enough about preemies to be dangerous but not enough to really understand prematurity after being exposed to how terribly things could go wrong during pregnancy without any warning. While that reality made it easy for me to practice medicine with a seemingly endless well of compassion for both mothers and babies, it would fundamentally change my appreciation for how lucky we were that everything went well for us. Fortunately, Reese was born healthy, on time, and didn’t have to visit the NICU, and we had a month of an easy elective rotation to get to know our first baby.

Somewhat ironically, my first real rotation back on service the month after Reese was born was the well-baby nursery. I spent four weeks partnered with another intern and a general pediatrician seeing 25-30 healthy newborns a day, churning through reams of paperwork, and learning very little. Sometimes we’d need to bring babies who were breathing fast or having a hard time feeding into the nursery to monitor them, and a few times I had to call the NICU fellow to come take a look at a baby who wasn’t turning the corner. I was incredibly intrigued with what happened once a NICU fellow decided the baby needed to go across the hallway, through the double doors and into the NICU’s all-encompassing embrace. As luck would have it, my next rotation would finally bring me into the NICU on service, so I was about to find out…

I am NOT Steve Jobs.

Technology is nothing. What’s important is that you have a faith in people, that they’re basically good and smart, and if you give them tools, they’ll do wonderful things with them.
– Steve Jobs: Rolling Stone Magazine, 1994

This may come as a shock to you, but I am NOT Steve Jobs.

I know… I’ll give you a minute to let this sink in.

I’m a doctor, and at HIMSS on February 12th I get to deliver the conference’s first ever SPARK session on my big idea: Technology does NOT have to suck the humanity out of the practice of medicine.  Rather, I think that with shared purpose and the right approach to design, development, and deployment, today’s generation of AI-powered health IT tools can actually return some humanity to healthcare.  To understand how though, we need to start with why today’s approach is failing.

Take medical records as a simple example.  I am 100 percent certain that today’s medical students are much slower walkers than me.  Why?  Because the days of sprinting on rounds to get ahead of the white coat phalanx, pull down a cabinet and open a three-ring binder chart to the next blank page before the intern reaches the door ended a decade ago.  Today’s medical students are instead both blessed and cursed with electronic medical records (EMRs) and patient care technologies that track and trend every aspect of the inpatient and outpatient course, demanding hours of tedious, field-driven data entry while yielding treasure troves of mineable new information.

With technology is now integrated into nearly every aspect of the patient-provider relationship, it’s crucial to note what patient care technology can’t do: it can’t replace our humanity.  No EMR can ease the despair of parents whose child you’ve just diagnosed with cancer, or with parents-to-be whose baby is being born weeks too early to survive. These conversations require human compassion, and sharing compassion is core to our humanity.

In centuries past, this human-to-human connection was all healthcare had to offer (beyond perhaps blood-letting).  As a result, the human connection came to define the practice of medicine from Asclepius to Osler.  Today’s technological transformation has opened panoplies of new treatment doors to walk through with our patients, yet too often detracts from instead of supports such a vital part of the practice of medicine as sharing our humanity.

This challenge begs THE Jobsian question, the main subject of the SPARK session – can we, with great intentionality, use AI as a tool to actually return some humanity to healthcare?

The answer is YES.  Read more at my HIMSS blog post or join me on the 12th at 3PM in room W300.  Also, given the structure of the SPARK sessions – specifically, without designated time for Q&A – feel free to drop me a note below if you’ll be attending so we can connect on your questions, comments, or other thoughts after the talk!



Our American Idea

On February 8th 1963, President John F. Kennedy addressed a small crowd in the tidewater city of Greenville, North Carolina. In truth, he actually didn’t speak to the crowd that day in person – his remarks were pre-recorded and played for the dedication of a United States Information Agency radio transmitter, designed to broadcast the “Voice of America” to an eager world.

Despite the nondescript nature of the day, one line from his speech lives on in the canon of American rhetoric:

“A man may die, nations may rise and fall, but an idea lives on.” 

These fourteen words – emblazoned forever on the walls of the JFK Library in Boston, MA – carry as resonant an echo today as they did fifty-five years ago for one simple reason: they neatly capture the truth underlying America’s greatness. The truth that America is more than a nation, more than even the sum of its people – America is an idea. An idea conceived in a crucible of freedom, born and repeatedly defended in the crucible of war, and surviving still today in a crucible of division, fear, and invective.  

What exactly is our American idea? That we can always, always, always get better.

In the opening lines of our Constitution’s preamble, the framers didn’t write “We the People of the United States, in Order to form a perfect Union….” Rather, they wrote “We the People of the United States, in Order to form a more perfect Union….” To insure this idea against future skepticism, the same founders even imbued the Constitution itself with the ability to be amended, proclaiming from the outset an expectation that future generations must find ways to make the Union better.

For over two hundred years we have in fact recursively made it better, tackling America’s structural imperfections one-by-one and strengthening our country’s foundation generation by generation. Our progress has rarely been linear, yet progress we have made and ultimately, inextricably, towards justice.

Today’s generation faces no different a task – a task not defined by striving to “Make America Great Again.” Instead, borrowing the late Catherine McAuley, our national identity itself demands that we strive to make America “good today, but better tomorrow” and leave our children a more perfect union.

To do so, we must first acknowledge that – while we are intensely proud of our United States of America – we remain imperfect. Division, fear, and invective too often characterize our national conversation – we must confront them. Oppression still persists in public and in private – we must defeat it. Cycles of poverty, violence, and hunger persist despite a decade of nearly unprecedented economic expansion – and we must end them.

Most importantly, we must realize that these cracks in our nation’s foundation need not be permanent. Like those encountered by past generations – including slavery, suffrage, and segregation – they can be mended, but we must mend them together.

We must do these things – indeed we can, and we will. Because a man may die, nations may rise and fall, but as long as there are Americans there is an America. And as long as there is an America, an idea – our American idea – lives on.

Dr. Chris DeRienzo is a physician from Asheville, NC and author of the upcoming book Tiny Medicine – One Doctor’s Biggest Lessons from His Smallest Patients. Follow him @ChrisDeRienzoMD and sign-up for the book’s pre-release here.

Thank You!

It took five months from the day I first posted at DrDeRienzo.com for the site to reach 1,000 views.  Late last year, the site’s most popular post – Bartlet’s Lessons – reached 1,000 views on its own in less than 3 weeks.  This month DrDeRienzo.com crossed the 10,000 view mark, and it seemed fitting to pause for a moment reflect back on the last two years and express my deep sense of gratitude.


I started writing here as a kind of personal outlet, a way to release years of pent-up literary energy and share my thoughts and stories with whomever would listen.  Back in December 2016, I would never have believed 34 simple posts on healthcare, hope, and humanity would reach thousands of people across so much of the globe.

In 2018 alone, WordPress tells me that people (or at least IP addresses) in 43 countries visited the site, including Canada, Brazil, Poland, Ireland, Australia, Ghana, Fiji, Hong Kong, Turkey, and Iraq.  That’s six of the world’s seven continents.  I’m perhaps most proud of the two views I somehow got from Pakistan and the single view from Myanmar, both of which make Wikipedia’s list countries with “pervasive” or “substantial” internet censorship.  Perhaps my stories about NICU babies and pound puppies represent a small contribution to the 21st century version of ping-pong diplomacy.

With all this in mind, as 2018 winds to a close I want to thank-you for visiting DrDeRienzo.com, engaging with the content, and engaging with my stories.   With the promise of Tiny Medicine hitting the shelves in fall 2019, I am grateful for all of your support, feedback, and encouragement, and wish you a very Happy New Year!

Dr. Chris DeRienzo is a physician from Asheville, NC and author of the upcoming book Tiny Medicine – One Doctor’s Biggest Lessons from His Smallest Patients.

Facebook Live

I was honored to join Lianne Fagnant from the Mission NICU on a Facebook Live this week. It was a great opportunity to share some of the Mission NICU’s incredible stories, and help viewers really begin to appreciate just how Tiny the NICU’s tiny medicine *really* is.

Tune in at the link below and see if you can figure out what the prop in the screenshot (1 milliliter of liquid pulled from a 12 ounce soda can and dripping very, very slowly) have to do with caring for preemies!


What Ironman Louisville Taught Me About Gratitude

This post has been a long time coming.  Back in 2003, I volunteered as a first year medical student at the Blue Devil Ironman.  As exhausted and elated triathletes crossed the finish line, I worked the medical tent and escorted those who were dehydrated, hyponatremic, or obviously suffering from altered mental status into the tent for fluids.  I remember thinking you’d have to suffer from significantly altered mental status at baseline just to sign up for such insanity, much less complete one.  And I was totally right.

For the uninitiated, an Ironman is a very, very, very long race composed of the three classic disciplines in triathlon.  According to triathlon folklore (and Wikipedia), its ridiculous distances descend from combining three 1970’s era Hawaiian races – the 2.4 mile Waikiki Roughwater Swim, a 115 mile Oahu bike race, and the Honolulu Marathon – into one massive race.  When in 1978 the first competitors shaved 3 miles off the original bike race’s course to create an easier Transition Zone from swim to bike and bike to run, the now iconic “Swim 2.4 miles! Bike 112 miles! Run 26.2 miles! Brag for the rest of your life!” ethos of Ironman Triathlon was born.

I had trained for my race – Ironman Louisville on October 14, 2018 – for over a year, having barely finished a half-distance Ironman 70.3 race alive in 2017.  Shortly after crossing the line in Raleigh that summer, profoundly dehydrated and unable to stand up, my wife had to whisk me into the medical tent for intravenous fluids and something called “salted Gatorade.”  It tastes just as bad as it sounds.  Midway through the second liter of intravenous saline I promised her that if I was crazy enough to ever try a full Ironman I’d hire a coach and train hard enough to finish the race and remain on my own two feet.  Turned out that within a month I’d decided I was just that crazy.

Late in the fall of 2017, I hired coach Steve Brandes who started prescribing my daily training sessions. We worked around hospital, travel, and family commitments to build the endurance and power needed to withstand 12-14 hours of racing.  By the summer of 2018 I was up every weekday morning at 4:30AM to train for an hour.  I trained almost every day for 6 months, with weekend sessions reaching out at their longest to over five hours of cycling one day and three hours of running the next.  Throughout the summer, my incredibly supportive family built our weekends around my training and I finished nearly every training session Steve prescribed to the letter.

Finally the day came, and October 14th wound up being ridiculously cold for Kentucky in early fall.  The thermometer registered a balmy 48 degrees as a cold rain fell on the starting line, and I jumped into the Ohio river for a current-shortened swim.


This is what I looked like after getting just a brief taste of the Ohio River during the frigid practice swim the day before the race.

It was just as cold when I finished the swim, waved to my wife and kids in Transition, and hopped on my bike to start the 112 mile journey around northwest Kentucky.  With the rain still falling and the thermometer stalled at 50 degrees, my clothes were soaked through within minutes and I started to shake.  My face shook, my fingers shook, my arms shook, and every time I steered the bicycle down a hill my whole body shook so hard I had a hard time controlling the bike’s aero-style handlebars.  I honestly believed that if I kept going I’d sooner or later lose control of the bike speeding down a hill and crash.  Not willing to risk dying somewhere on a highway outside of La Grange, I knew there was no way I could finish the race without catching some kind of break.

It came just after mile 26, where I stopped at a high school with an aide station.  A volunteer grabbed my bike, pulled me off, and directed my shuddering frame through the school’s front doors.  I walked into the lobby and found fifty other triathletes all quivering from the same hypothermia as me, caused by a combination of cold wind, cold rain, and a total lack of waterproof clothing.  A second volunteer sent me into the men’s restroom under the hot hand-dryer vents, which began to rewarm me from the core out.  It took 20 minutes for the shaking to subside, after which I found a seat in the makeshift field hospital.

I’d spent hundreds of hours in the pool, on my trainer, and pounding the pavement over the last year training for that day.  I had a crew of friends and family rooting for me at home and watching my progress on the Ironman race app, which at that moment just said I had gone “off course.”  And somewhere out on the race course my wife and kids – who had sacrificed just as much as I had to make this day a possibility – were shivering themselves, waiting to root me on and cheer as I crossed the finish line that night.  I desperately needed some kind of break.  It turned out to be Mylar.


Most people only experience Mylar in balloon form, but like generations of endurance athletes before me I’d been wrapped in a Mylar blanket as soon as I entered the school.  Its reflective coating had helped warm me up from the inside-out by preventing heat from escaping my body.  Mylar blankets make for a terrific a field hospital tool, but aren’t particularly practical for riding a bicycle.  That didn’t stop the volunteer at my table though, who said “Well why don’t we just totally wrap you in it mummy-style?”  Why not indeed.

She left for a moment and returned with more Mylar, a pair of scissors and some tape.  I unzipped my race jersey, and we wrapped the Mylar completely around my skin from chin to belly button, over each shoulder, and down each arm to my fingers.  She then taped up all the seams and I zipped back up my jersey.  I looked like the Tin Man and sounded like Jiffy Pop every time I moved, but it worked.  Once I hit the course again I found could ride the downhills without shivering – my face, fingers, and feet were numb, but my core was warm and that’s all the mattered.

As you’d expect, the rest of the race brought a few additional obstacles.  Around mile 80 I face-planted outside of an aide station when my bike ran over a Gatorade bottle.  Mercifully I was going close to zero MPH, and with the small laceration on my leg just as numb as the rest of me it didn’t take much extra resolve to push on.  Seven hours after leaving Transition to start the bike leg I finally rolled back in, high-fived my kids again and hit the run course.

With a little more luck, a lot of perseverance, and more Mylar than the Macy’s Day parade, I ultimately crossed the finish line after finishing the marathon another four and a half hours later at 4th Street Live in Downtown Louisville.  I was so deliriously overcome with emotion that I didn’t even hear the iconic “Chris DeRienzo – You Are an Ironman!” announcer’s call until my friend Shannon sent me the video below that she’d recorded live on her phone.  I crossed the finish line on my own two feet, and walked with my wife and barely-awake kids back to the hotel to celebrate.




I learned several lessons in the 12 hours, 32 minutes, and 2 seconds I spent swimming, cycling, and running around the Greater Louisville metro area – here are five of the most meaningful:

1. You race the race you get.  I’d trained for a full 2.4 mile swim and sweltering heat.  I got a current-shortened swim, 48 degrees and rain.  The universe didn’t care, so that’s what I raced.  More often than not life works the same way.

2. Never clip into your pedal when there’s a Gatorade bottle standing between you and the road.  Self-explanatory.

3. Runner’s GI distress is a real thing – it’s unstoppable, and like most unwelcome and unstoppable things in life it’s best to deal with it and move onNo further comment.

4. Just stay in the game long enough to catch a break.  No amount of grit, determination, and perseverance is more valuable than a little bit of luck at exactly the right time.  That said, it sometimes takes a ridiculous amount of grit, determination, and perseverance to not just give up until you happen to get lucky.  I got incredibly lucky to find a volunteer at the field hospital who thought Mylar-wrapping my entire body might be a good idea, and I’m convinced there’s no way I would have finished the race without her help.  I’m also convinced that it took an enormous amount of motivation to stay in the race long enough to make it to that aide station alive, not throw in the towel while shaking like a maraca on a high school bathroom floor, and remain open to finding an unexpected opportunity.  Which brings us to number 5…

5. Having a lot of people counting on you is an absolutely incredible motivation.  Some say triathlon is a lonely sport.   It’s true that no one else can swim, bike or run for a triathlete, and riding 5+ hour training sessions on your own is monotonous at best and torture at worst.  That said, it’s not possible to finish an Ironman without an enormous universe of other people’s help.  From the legions of volunteers, to my friends and family cheering me on in-person and back home, to the thousands of other triathletes supporting, comforting, and cajoling each other ever forward towards the finish line – it may be possible to feel lonely on an Ironman race course, but it’s impossible to ever really be alone.

Before the weekend of October 14th, I didn’t even know Ironman had an app that lets you track athletes during a race.  But my friends did.  As a result, throughout the day I knew I had people from all four corners of the country watching my progress.  I also had my wife and three kids braving the elements and twelve-plus hours of total boredom in the wilds of Kentucky just to be there for me and with me.  Knowing they were all watching me, counting on me, and believing in me meant I just could not let them down.  It’s hard to explain, but the fire that lit felt just like the lines from the song Jim Henson’s Muppeteers sang at his memorial service:

And when all those people believe in you, deep enough and strong enough, believe in you, hard enough and long enough, it stands to reason you yourself will start to see what everybody sees in you… and maybe even you… can believe in you too.

I am deeply grateful for the chance to have trained, traveled, raced, and finished my first Ironman.  I am grateful for the volunteers, the police, the organizers, and the other triathletes who all helped make October 14, 2018 a special day in my personal history.  But more than anything else, I am now and forever grateful for having so many people believe in me that failure was simply not an option.  It was at once the most humbling and most exhilarating experience of my life.


A Big Announcement…

About a year ago, I floated the idea of writing a book across my social media communities.  You responded in ways I could never have imagined, nearly universally encouraging me and spurring me on.

There were of course also a handful of trolls.  Like this one:

Screen Shot 2018-09-25 at 7.36.56 PM

Ignoring the trolls and buoyed by your support, I marched on as the realities of writing a book and actually getting it published set in.  I read up on agents, connected with editors, and sought advice from anyone willing to share it.  I even cold emailed Jim Collins, who I found to be both incredibly responsive and incredibly insightful.

After a full year’s worth of effort, all I had to show were 20+ literary agent rejection letters, three failed book proposals, and the experience of having two publishing houses electronically laugh in my face.  But I also had people like Nate Klemp reminding me that my writing didn’t totally suck and I had to keep trying.  And I had stories.  Lots of them.  Real human stories about practicing medicine that still felt like they needed telling.

So today, I am incredibly proud to announce that I’ve signed an actual book deal, one where I write the book and someone else pays to bring it to life.  I’m working with a spectacular editor at Big Eye Books and, if all stays on track, we expect to have Tiny Medicine in print and on bookshelves in the Fall of 2019.

While the journey isn’t over, this is a big milestone for me and I wanted to share it with you, my friends and connections who’ve unfailingly provided both honest, constructive feedback and constant motivation.  Thank-you for being there – I am deeply grateful for your support.  And if you’d like an update when we get closer to the pre-release, please drop your name and email in the form at the end of the post and I’ll make sure to touch base again next spring.

Oh, and to “Major LinkedIN Troll” – and anyone else bent on putting and keeping people down – I have but this to say:


Pre-Release Opt-in Contact Info:



What Books Changed Your Life?

This summer I’ve been fortunate to read some great books. Among others, I read Jon Meacham’s The Soul of America on the beach, flown cross-country while audio-booking Beneath a Scarlet Sky, and indulged a (wishful-thinking) Teddy Roosevelt kick by powering through both River of Doubt by Candice Millard and The Bully Pulpit by Doris Kearns Goodwin. While I’ve enjoyed them all, none hit my list of the top 4 books that have shaped my life.

We’ll begin with Number 4…

4. Grover Goes to School

The only one of the quartet I’ve already passed down to my kids, I must have read this book hundreds of times in kindergarten. My original 1980’s copy had long ago disappeared, but incredibly my wife found a copy of this childhood memory in a used book store soon after our oldest daughter was born.

For the uninitiated, Grover Goes to School is unsurprisingly about Grover’s first day of school and his efforts to find friends. While elementary in its storytelling, the book’s message is even more important in today’s world: namely, that we don’t have to change who we are or what we believe for other people to like us. In the end, it’s better to unashamedly be ourselves rather than risk winding up with no cookies, a broken truck, busted crayons, and someone else’s baloney sandwich:


3. The College Book of Verse: 1250 – 1925

As a teenager, I pilfered this small volume from my grandfather’s basement library when I was just beginning to awaken to the power of words. Its weathered title page read “Copyright 1927” making the 650-page text seem like it contained ancient secrets I’d liberated from years of neglect. I read from Wordsworth and Milton, Frost and Whitman, and dog-eared page after page from the poets of the Romantic Period. I was young and excitable, all promise and potential, and their words spoke to me with a power I had never before experienced.

I used to carry the book with me everywhere, but when its nearly century-old spine finally began to break I parked it on a shelf in my own library for fear of disintegration. Of all the book’s mystic chords, it was this poem by Keats that stood above the rest to a smart, awkward kid who took refuge from chaos (then and now) in the quiet comfort of an ordered mind:


2. It Worked for Me

The first time I read Gen. Powell’s treatise on life and leadership, I was only a month into my tenure at Mission Health. I came to Mission straight out of fellowship, and my role as Vice President and Chief Patient Safety Officer was my first formal opportunity to lead a big team. The concrete, practical principles in this book resonated with the way I wanted to lead, and I’ve returned to them at least once a year ever since. From maintaining weekly in-person team huddles to regularly see the whites of my direct reports’ eyes all at once, to focusing first on defining purpose before jumping to tactics, to building a great team and directing most of my energy towards enabling them to do great things, I haven’t gone wrong in applying Powell’s wisdom in life or leadership.

Since most of my leisure reading since college has been via audiobook, I didn’t actually own the hardback copy of It Worked for Me until this year. When I finally bought it, I mailed the book to the publisher to secure a signed bookplate and included a letter of gratitude expressing how much the book meant to me. I also asked, without hope of reply, what the General’s one-sentence guidance would be for a leader still early in his career and bent on improving the health of Americans nationwide. His reply will forever hang framed in my home office – while I can’t say I’m succeeding on the no-weekend work (and I’m not totally sure he did either… you know, with the whole war thing and all), I couldn’t agree more about strength through family:


1: The Spirit Catches you and You Fall Down

Believe it or not, Anne Fadiman’s tome on the intersections between western and traditional Hmong medicine is actually one of my least favorite books. I read it once as an undergraduate student and somehow found a way to skip out on the author’s mandatory lecture. I was then required to read it again as a first year Duke medical student, and figured that was proof I simply could not escape Ms. Fadiman’s grasp. Why then, you ask, would such a book make it to Number 1 on the list of books that shaped my life?

Late in my second year of medical school I had the best Chief Resident in the history of the hospital. We had been on-service together for about a week, and around noon on a Tuesday he looked me in the eye and said “Christopher, you are a fantastic medical student, you work hard and deserve some rest. Give me your pager and go take a two-hour lunch break.” Before he could change his mind I thanked him profusely, handed him my pager, and sped off the ward.

Medical students have a preternatural ability to sense free food anywhere in the hospital, and that day for me was no exception. I followed my nose down to the lecture halls on the hospital’s second floor, where indeed there was a talk in the main hall accompanied by a free lunch open to medical students. An author was speaking… and of course, it was Anne Fadiman. She had come to Duke to deliver some version of the mandatory lecture I’d skipped in college, a final stroke of karma smacking me upside the head.

And that’s when I saw what the other lecture hall had planned for the day.

Outside the smaller room was a table filled with more free food and copies of a book written by a double-amputee who had climbed Mount Kilimanjaro. And surrounding the table were countless nursing students. My eyes met those of one particularly attractive twenty-something who was wearing a white patterned scrub top and navy pants. She was standing with a few other nursing students and smiled when she caught me looking at her. The first thought that hit my brain was “Whoa.” The second was “What the hell Chris, give it a shot.”

I walked up to her, introduced myself, and we chatted while she worked her way through the lunch line. I asked her to save me a seat in her lecture hall and said I would sneak out of mine as soon as I could to join her. She agreed, and as soon as Ms. Fadiman took the stage I snuck over the back row of chairs, shuffled past a cluster of sleeping medical students, and silently exited the room. Sure enough, there in the very back row in the very back corner was my nursing student, saving me a seat. I have absolutely no memory of the lecture, my attention instead fixed on a pair of blue-green eyes unlike any I’d ever seen before. We’ve been together ever since.

I am certain that Anne Fadiman is a terrific speaker. Her books have won countless awards and her critical acclaim will far eclipse anything my writing will ever achieve. Yet it’s only because I’ve never connected with The Spirit’s content that I find myself today happily married, a father of three, and two-for-two on skipping mandatory lectures.

Concluding Thoughts

Be who you are, build a strong mind, lean on a strong family, lead with purpose, and sometimes just take the risk and skip a mandatory lecture – five basic lessons from four books that form much of the core of who I am as a doctor, a father, a husband, and a leader.

While I can’t promise these books will have the same transformative effects for you as they’ve had for me, I am sure there are certain books that have become touchstones for you in your journey through life as well. And because words only increase in power when shared with others, I invite you to share this article with your friends and connections and add to the comments at least one book that’s had a defining influence on your own life!

About the Author

Dr. Chris DeRienzo is a dedicated husband, a proud father, and a mediocre triathlete. He’s also a doctor dedicated to improving the health of all Americans and striving to live like a spectacle of the human engine driven at full speed. You can read more about him at www.drderienzo.com or follow him here on Twitter.

Weaponized Fear and Our Health

On a warm June day in 1950, 53-year-old Senator Margaret Chase Smith stepped to the rostrum in the chamber of the United States Senate. With a steady, measured tone, she delivered her “Declaration of Conscience” warning America and her Senate colleagues of the dangers of riding “to political victory on the four horsemen of calumny—fear, ignorance, bigotry, and smear.”

She was of course referring to McCarthyism, the widespread campaign of fear spearheaded by Senator Joe McCarthy who sat just yards away as she spoke. And while that June day was comfortably warm in Washington, the summer to follow would rage in the heat of the “Red Scare” fever that infected the nation.

Nearly 70 years after Senator Smith’s speech, America’s success in heeding her admonitions can be best summed up like this:


Fear has in fact become a lodestone of today’s America. From the global fear of a nuclear exchange with any of several belligerent dictators, to the hyperlocal fear that neighbors feel for each other, our era and its politics are dominated by fear. And as Simon Sinek notes, “when fear is employed, facts are incidental.”

As a clinician, I deeply appreciate how hard it is to resist the physiology of fear. Our brain’s response to fear originates within our most id-like reptilian neuroanatomy – the amygdala. When faced with a fear-inducing stimulus, the amygdala dutifully beckons upon the hypothalamic-pituitary axis and activates our “fight or flight” reaction. This squeezes our adrenal glands, flooding the bloodstream with enough cortisol and epinephrine to send our bodies into overdrive and help us escape chaos.

But when chaos is ever-present and inescapable we wind up living each day in a state of ongoing fear. Our bodies strain under the stress of a chronically-activated fight or flight pathway, wreaking havoc on our health. The toll of this unrelenting stream of fear upon our nation’s health is already well-documented in reductions in life expectancy, dramatic increases in substance abuse, and a rising risk of dying from “deaths of despair.

And yet medical school also taught me that no matter how deeply ingrained the fear response lives inside our brains, we can still choose to respond differently. Despite an increasingly hostile and increasingly ubiquitous rhetoric of fear, we are not inextricably bound to responding to fear with fear. We can instead choose instead to take control, respond with truth, compassion, and understanding, and again be inspired to trust each other.

Trust, like compassion, is grounded in truth and biologically linked to oxytocin. It takes much more effort for our brains to cultivate trust than it does to react to fear with fear, as oxytocin appears to only exert its trust-building effects under just the right social circumstances. But when it works it shouldn’t be surprising that increases in oxytocin are linked to decreased activity within the amygdala. Physiologic proof that we can (and perhaps must) actively work to convince our brain to overcome reptilian fear.

That’s exactly how McCarthyism met it’s end. On another June day, this time in 1954, Senator McCarthy stood questioning Army Counsel Joseph Welch in the midst of the nationally-televised Army-McCarthy hearings. Having spent the better part of a month attacking the Army for being “soft on communism,” the Senator lit into one of Welch’s young associates who wasn’t present to defend himself. Welch, and the rest of America for that matter, had finally had enough:

“Until this moment, Senator, I think I never really gauged your cruelty or your recklessness… If it were in my power to forgive you for your reckless cruelty I would do so. I like to think I am a gentleman, but your forgiveness will have to come from someone other than me… At long last, have you left no sense of decency?”

As FDR once said, fear is a “nameless, unreasoning, unjustified terror which paralyzes needed efforts to convert retreat into advance.” While the threads of fear run deep, we are not slaves to the fight or flight response. We can instead choose how we respond to the world, and how we choose to respond through both word and action reinforces our physiology.

We must choose to stop allowing ourselves to fall victim to those who use fear as a behavioral weapon. Instead, we must choose to take the harder path; a path that requires speaking and confronting hard truths, and investing the time required to understand each other and allow the seeds of trust and compassion to grow.

Our own health, and the health of our nation, depends upon it.

About the Author

Dr. Chris DeRienzo is a dedicated husband, a proud father, and a mediocre triathlete, striving to be a spectacle of the human engine driven at full speed. He’s also a physician executive dedicated to improving health for all Americans. You can read more about him at www.drderienzo.com or follow him on Twitter

Ten Years in Medicine

On May 9, 2018, just after 8PM, I marked the end of my first decade as a doctor.

Without question, the past ten years have challenged both my technical and diagnostic skills… for what either are worth.  I’ve had to irreparably bend a pair of iris forceps to cannulate an impossibly small infant’s impossibly small umbilical artery, a willful destruction of hospital property whose cost was thankfully not deducted from my resident salary.  I’ve manually provided positive pressure ventilation to a baby in the back of a screaming ambulance with a broken ventilator, counting “one-two-breathe, one-two-breathe” at least 1,200 times on the hour-long ride.  Once after spending hours with a partner trying to place a central line I remember looking over my mask and up to the heavens, saying a Hail Mary, and twisting the catheter in one last pass before throwing in the towel.  We both stared in amazement as the line slipped effortlessly into the infant’s umbilical vein, as if all along it was just waiting – quite literally – for a wing and a prayer.

Yet the most defining moments of my career to date aren’t those that pushed the limits of my technical or diagnostic prowess.  Rather, the moments most deeply etched in the marble of my mind are those that pushed the boundaries of my humanity, forcing to grow not just as a doctor but as a person.

Moments like the countless nights I’ve spent parked at the bedsides of babies with pulmonary hypertension.  Persistent pulmonary hypertension of the newborn is a wily and relentless adversary whose war obeys no clock.  As a fellow, for the most severe cases I’d perch next to a warmer bed like an owl in the night, coffee in hand, eyes on the monitor, prepared to pounce.  These battles were my first experiences in staring down death, fixed firmly as the shield between his sickle and a newborn’s soul.  Toeing that last line of defense requires a combination of audacity and humility and has a way of engaging man with his own mortality.  For what after all defines our humanity if not the deepening of one’s personal relationship with the fragile space between birth and death?

On a different night I remember being called to Labor and Delivery to speak with parents whose infant was about to be born too early for our team to resuscitate.  I walked to their room, sat next to the bed, introduced myself, and asked them to share their understanding of what we faced.  The father talked about his wife’s labor, the raging infection in her uterus, and why we could not stop her labor.  We then talked for an hour about the kinds of things we normally try to save a premature baby’s life, why we could not begin resuscitating a baby born near 21 weeks, and why a single week matters more in the womb then at any other point in a human’s life.

As the conversation drew to a close, he looked up at me with his hands clasped so tightly that his knuckles were as white as the bedsheet.  He was a little younger and much more muscular than me, and the veins in his forearms looked about to burst.  His eyes reddened and locked on mine as he finally said “Doctor, is there really nothing at all you can do to save my daughter?”

I can hear his words as clearly today as I did nearly a decade ago.  I thought then as now about my own kids, about the depths to which I would go to save their lives, and about the warped relationship between powerlessness and things over which we most want to have power.  My hands trembled, not from nerves but because his words had pushed me to the edge of my own humanity.  I knew I had to step into a darkness I’d never before tread and had no idea what, if anything, would be there to catch me.

I’ve never fought harder to hold back tears.  It didn’t work.  My eyes watered, my voice wavered, and I said “It is my job to bring all that medicine has to bear to save babies.  If there was literally anything I could possibly do, I would do it.  But I can’t.  And I am infinitely sorry.”  There is nothing more human than the realization that, no matter how powerful we become on earth, there will always be things we are powerless to change.

In truth, I was first drawn to our profession by the rawness of the humanity etched into the person-to-person practice of medicine.  What I didn’t expect, and have now grown to cherish, is how my practice has pushed me to learn and grow as a person.  I’m a more complete, more human version of myself because moments like these keep nudging my capacity for humanity.

While healthcare is always changing, and today’s waves of population health and rapid-cycle technological advancement will without question make my practice look different a decade from now than it does today, I am confident one fundamental will remain constant: it’s the humans at the center of this most human endeavor that make medicine most meaningful.

About the Author

Dr. Chris DeRienzo is a dedicated husband, a proud father, and a mediocre triathlete. He’s also a doctor dedicated to improving the quality, safety, experience and sustainability of healthcare for all Americans. You can read more about him at www.drderienzo.com or follow him on Twitter