Female Residents

Female Residents

Despite the bias against women in medicine, my period of training coincided with a time when women were just beginning to make great strides integrating themselves into the medical field.

However, to make it through the tougher disciplines of surgery or medicine, a woman had to have been born and raised without a thin skin. This is an attribute that happens to be an admirable quality in either gender; and works very well to help anyone succeed in life. That is unless it was the whip and the belt as opposed to loving discipline creating that tough hide.

Whips and belts create bitches, bastards, and psychos. Tough love creates successfully inspired over-achievers.

I had the opportunity to run into a few excellent female residents who can best be described as being good old fashioned “tough cookies.”

One female resident who supervised my fourth-year rotation in cardiology had those necessary brass balls and the guts that Italians call “stendine.” She was extremely talented, with a penchant to dish back as much as she got it from the old guard misogynist Attending Physicians who constantly aspired to punish women physicians.

It reminded me of the egocentric male patriarch who takes it out on his wife and daughters because he is incapable himself of dealing with the emotional vacuum  of having to live without a son as his heir.

  • My glass is half empty. God only gives me only beautiful daughters.

These old farts wasted way too much time attempting to wear down these brilliant medical tomboys until they finally understood clearly; by realizing that women could actually do the job. The women were then accepted; although with more reluctant vitriol than what would have been applied to reinstating a prodigal son. This capitulation was always made however, with the sour after-taste equivalent of turning aside to spit out a piece of bitter fruit.

  • Well, she did fine managing that cardiac arrest. But I still think a woman’s place is in the home.

This Resident was not only very self-assuredly competent but also made it her mission to do her best to put some teeth into my ongoing medical Bar Mitzvah. She assigned me sit in the CCU every third night to watch heart rhythm monitors until I was eventually seeing the little green bleeps on the inside of my eyelids when I was finally allowed to go to sleep.

She said:

  • The only way you will learn arrhythmias is to watch every bloody beat until you see anything that looks abnormal, then correlate it as best you can with a reference book to see how close you can come to the truth. After that you can come and ask me if you are correct.

This was the extent of her advice:

  • Get out your EKG book. Figure them out for yourself. Print anything out that you are not sure of and we’ll go over them later. And try to make any clinical decisions you need without waking me up. The nurses will help you out.
  • So just what kinds of things should I call you for, then?
  • Cardiac arrests. Call me if they die. Absence of spontaneous breathing, no pulse and no blood pressure associated with ventricular tachycardia or ventricular fibrillation is not something you will have to tediously ponder.

When I eventually entered my Internship at St. Luke’s Hospital in New York City there were two female senior residents who were also tough as nails and did not take any gaff or nonsense from anyone.

One in particular was a fairly rugged, unforgiving mentor. An underling had to demonstrate smarts to first get and then to stay on her good side; while flirtatious subterfuge was no substitute for not knowing the answer to any of her questions. She was not even gay, either, as was the failsafe explanation the rumor mills defaulted to when dealing with women who were all business while on the surface, yet seeming to have very little in the way of a social life.

No. She was not gay; not un-loved; not under socialized nor a grown-up wall flower, either, but only hard core dedicated to her work as she kept her personal or social life completely private.

One incident demonstrated her fearless ability to get down and dirty in the trenches. On this evening, a cardiac arrest victim was brought into the ED in a full resuscitative code scenario. He was probably DOA but all stops were being pulled out to save his life.  Regardless of prognosis, everyone gets the maximum benefit of the doubt, and every such scenario has something to offer as a teaching or learning experience.

It is the usually the job of the Resident to supervise and guide the therapy, while letting the nurses and subalterns handle the drudgework.

Doing closed chest CPR compressions happens to be a real drudge and something to be avoided unless circumstances force the doctor to have to do it himself. The chore usually defaults then to the nurses or the respiratory technicians, as the doctor is obviously preoccupied with the other more erudite aspects of running the code.

Most people in these situations do CPR from the side of the bed, which offers little mechanical advantage as the work vector is more laterally oriented than vertical; which makes it incredibly exhausting labor.

As this scene unfolded the female Resident could see that the nurse who was doing the chest compressions was getting exhausted, and so took in upon herself to pitch in as her relief while at the same time barking out all the orders required to keep the code in process.

  • Get outta my way. I’ll do that for a while.

Whereupon she jumped up on the gurney, straddled the patient and started pumping his chest with the added efficiency this position afforded as a mechanical advantage.

I had never seen anyone before or since in a hospital setting, do it this way.

She happened to be wearing a tight white, short mini-skirt and with her legs spread out over each side of the man’s torso, a good part of her crotch was nonchalantly but innocently exposed. Good thing she happened to be wearing underwear or the scenario would have really been quite surreal.

It was good for another reason too.

It happened that simultaneously, the Cardiology Fellow had passed a temporary pacemaker empirically into the subclavian vein without X-ray guidance. Then when he turned it on the patient’s right arm started to flail up and down at the paced rate of 70 flails per minute. And each time it flailed, the man’s fist would pound up and down inside the female Resident’s crotch.

As it turned out, the pacemaker wire had taken a wrong turn by snaking up into the carotid vein which juxtaposed it to the brain center that controls right arm function. The result was that each time it paced, it caused the man’s right forearm and hand to involuntarily contract.

Being completely nonplussed by the situation and immediately recognizing the problem, the Resident, in not so much as missing a beat shouted:

  • Get that goddamned thing out of the brain and put it into the heart.

After which she turned to me and said:

  • I’ve had sex a lot of different or sometimes very strange ways in my life. But this is the first time I ever got it being fisted by a dead guy.

I was sufficiently impressed by her composed demeanor, telling her later this was one sexual foreplay scenario that even the Kama Sutra would be hard pressed to match.

She said:

  • Yeah. Maybe. But from now on if nothing else, I think I’m going to stick to wearing pants.

Too bad, because she did have beautiful legs; which was the one thing for sure that made it a pleasure to go along with her on those mini-skirted medical rounds and guaranteed that we would always be alert and paying attention to whatever she said.

 

Pioneers

Completely surrounded by the Indians

© Photo

Hennepin County Medical Center

Medical School: The VA Hospital

A Few More Humiliations 

One of my first rotations in general medicine was at the VA Hospital in Jamaica Plain, Massachusetts. In the 1970s the VA hospital system was more like an extended care facility or a hotel than an acute care institution. Hospital stays for a simple seizure evaluation could last for weeks or months.

The patients were required to wear green and white striped sear-sucker pajama robes, could smoke on the open wards, despite having emphysema, lung or throat cancer, while the ones who were not bed ridden would even take the elevators down to the cafeteria at mealtime.

One ridiculous scenario of note was the man who still smoked through his tracheotomy after having had his larynx removed for cigarette induced throat cancer; making him a true veteran of the cigarette wars as well as any other he may have fought.

Another one was the typical Irish drunk in alcohol withdrawal DTs, tied to the bed, with a bead sweated forehead, while swatting away at imaginary flies he had named after long lost friends.

  • Get offa me O’Donnell. Go to hell O’Doule. Go fuck yerself in the arse Father Ryan. Give us a little kiss there Mary Rose, ya trollop, ya whore

The place operated like any typical Federally subsidized bureaucratic waste project. Nothing could get done without excess paper work, repetitive requisitions, delays in responses, and the litany of more reasons not to do something that had to eventually be done anyway, than to just go ahead and do it. This was coupled with an endless shortage of even the most rudimentary medical supplies making it a good thing that no one was really that sick or they would have all been dead by the time their tests and consultations were done. 

The Resident I worked with was an exceptionally bright Indian at a time when there was considerable bias in the United States medical system against Foreign Medical Graduates (FMGs), as well as against women.

There was additional bias even against Americans who could not get into U.S. medical schools, who instead went to foreign schools; because these students never had the same credibility as those graduating from the U.S. schools.

FMGs also had to go through extra layers of testing called the Fifth Pathway, to be licensed, which were nothing more than creative barriers set up specifically to discourage these people from emigrating and working in the U.S. The paradox was that because our own schools were not graduating enough doctors to fill the needed residency programs, or because there were shortages in certain disciplines, we still needed FMGs. Usually they gravitated to non-teaching community hospitals, where they essentially functioned as warm bodies, but did not get the same level of vitally important training offered in academic hospitals.

Women were not treated any better. They were deemed as being weak, soft, unable to stand the rigors of training, too emotional and doubtful to ultimately make a career out of it because of their known susceptibility to want children and then to stay  home with their kids. Training female physicians was felt to be a waste of resources, and even after passing the initial hurdles, once entering their training programs, they would be singled out for abuse or treated like second-class citizens.

One particularly nasty physician in the Harvard system, who interviewed medical school candidates or applicants for internship, had a uniquely cruel way of sizing up the candidate.

He would turn up the heat in his office, no matter the season, then first ask the candidate to open a window he had previously nailed shut.

Any candidate who tried but failed, then either asked for a tool or told him he should get a maintenance man, would then qualify for being interviewed a second time. This poor person then of course sweated bullets throughout the ensuing inquisition while not even knowing he had already garnered a preliminary pass by his first response.

Anyone who lost his temper at failing to get the window open would not be interviewed and asked to leave, while anyone who cried, to which the women candidates were particularly prone, would be told they should leave medicine altogether and look for another career.

Anyone who immediately went to another window and opened it was accepted without further interviews.

This technique reminded me of one used by a premarital counselor who would take the affianced couple out to the woods, where she then asked them to cut down a small tree with a band saw. The way they worked together was all she needed to know to predict the long-term success of the marriage; then advise them whether or not to take their vows.

She related one improbable scenario in which the female partner sat down and demanded that the man work the two-person saw by himself. I think that was my ex-wife; being evaluated for her second marriage.

However, this Indian resident was neither soft, nor weak, nor emotional, nor lazy, nor stupid, nor poorly trained, nor any other bigoted epithet one could conger.  He was bright, industrious, a hard taskmaster who took the time to get me through some rudimentary skill sets as well as a jump start on the road to developing sound fundamental work habits.

Even writing orders was an embarrassment when on my first try he read them while scornfully deriding:

  • And so. Vill your patient starve to death? You did not even write an order for his diet. Or do you think he cannot eat and needs some IV fluids instead; and if so what vill that be?
  • Oh. You have to take care of that, too? Patients need food and water?

We were expected to arrive early and to stay late, whereas on other rotations we worked banker’s hours. We also learned in short order that there was no excuse for not knowing our patients in intimate detail and to be immediately up to date on their current test results. In addition, we salon had to do a tremendous amount of scut-work, which included the likes of making, staining, and microscopically looking at blood slides as well as collecting, spinning and analyzing urine samples or other unmentionable body fluids, solids and semi-solids

It was quicker to do it on the floor than in the VA lab, often being information we needed to know on a timely basis to expedite therapies. In today’s modern hospital labs these results are accurately turned around in minutes by a technician.

One day on rounds, when I was not up to speed on some test results or a specialty consult had not been done, my Resident taught me the hard lesson that I was ultimately in charge of the case, that the patient’s life and destiny was in my hands, and that if I did not know something or if something had not been done that I only had myself to blame.

Knowing how inefficiently slow the system operated, he told me from that day on if I needed a result or if I needed a specialist that I should go to the department in question, to make such a pest of myself that anyone involved would hate the very sight of me. After that, my charts were complete and consultants saw my patients as a priority.

Still being a shy, standoffish person, I gradually came to learn that face to face or direct personal contact is the most efficient as well as the most courteous way to communicate, that it not only helped future networking, but after all was also not even the least bit painful.

This Resident also expected me to know anything and everything about the primary or secondary disease entities of all my patients.

On one occasion when I failed to answer a question about cirrhosis he told me I was “refractory to education” and should consider becoming a plumber.

  • You vill fail as a doctor. All your patients vill die. You vill be a curse on the house of medicine and a blight vhich anyvere you may go.

I wanted to cry.

He then told me to read the text section on any disease I was involved in treating, tested me on it the next day and did not stop there by adding the afterthought that texts are out of date the day they go to print; such that the only way to really keep up was to read the journals.

He gave me a pile of that year’s American Journal of Medicine and told me get a subscription after I was done reading them.

  • Only that vay vill you always be on the cutting edge. 

Interestingly, in the hallowed halls of academia there was a permeating bias against Indians. They were never seen in the upscale training programs.

At Columbia Presbyterian, the Cardiology director at one time privately admitted that he made two piles of applications for Fellowship: One pile for the Indians; and one pile for “all the others.” The Indian’s applications were then swept into the trash bin.

Some people also sniggered at the Indian custom of wearing a small Avatar dot in the middle of the forehead by parroting a possible socially acceptable answer to the query:

  • So, what does that little dot in the middle of your forehead mean anyway?
  • Oh, sir. In my religion, it means that every day is Ash Vednesday

I felt otherwise, because it was early in my career as a third-year medical student that the inspirational foundation for my future work ethic was laid down by one of those Indian pariahs, who while making the best of his lot in life, was making mine miserable in his role as the medical Master Sergeant in a second-rate VA hospital in Jamaica Plain.

When I eventually sold my practice, it was to a mixed cultural group, half of whom were Indians that were individuals I had worked with side by side for years and whom I always held in the highest regard.

Subscribing to the Hindu faith, it was somewhat of a shock for me to discover that they did not drink alcohol, they did not go to parties, they shunned bars, usually did not ever dance, were extremely family oriented and were very devoted to their children as well as to their patients. Education of the next generation was a number one priority.

They were also equally if not more knowledgeable than I was and generally worked their butts off with very few, if any, complaints about their workloads.

It was also an insight into my own indifferent bias to not even know anything in general about the Hindu religion, even though I had learned about its history and tenets in college. I thought it was simply a polytheistic concept hinged upon reincarnation, cosmic cycles, and portrayed by strange looking multi-armed gods who looked more like an octopus than a real person.

I did not know, for example that Hindus have a litany of holidays that include the following:

  • A celebration of the triumph of good over evil
  • A festival of lights
  • A celebration of renewing family ties
  • A celebration of exchanging personal gifts
  • A habit of giving excess bounty to the poor
  • A celebration of sweeping out the old and bringing in the new

 

Odd thing is it not, how it sounds vaguely like Christianity or Judaism.

 

Hindu greeting card

 

Source: Hindu Cards for Holidays

 

Bowel Obsession

An Apple a Day 

As a medical student one of the first things I learned with certainty is that a very large sub-segment of the American public is obsessed with bowels and bowel movements. However, it probably should have come as no surprise to me, because my father happened to be one of those people possessed by the mental demon that demands a daily colonic evacuation.

It appears no matter how sick a person on the medical floor happened to be, if he or she could have a regular bowel movement at sunrise, somehow even the worst of days would always become a little bit brighter.

The best etiology I can ascribe to this pervasive obsession is a mythical generic sense that fecal matter is a toxic substance that must be regularly purged from the body. If not it will slowly but surely release some deadly poison or toxin, thus resulting in some ill defined non-scientific irreversible harm. The reality is that feces is simply the residue left after food is digested by both enzymes and bacteria, leaving behind an organic substance containing about 50% of its original potential energy. This means that human digestion is horribly inefficient.

The only possible toxicity of the substance resides in some of the dangerous bacteria or viruses it can sometimes carry, for example, into a water supply, restaurant food, farmed vegetables or onto the family toilet.

If you think about the digestive inefficiency, feces in nothing but a waste of waste; meaning that if a 100% efficient digestive tract successfully utilized all of its fuel it would probably expel nothing but Methane gas perhaps maybe once a month or so.

More likely because as a nation we are so over-consumptively obese, these gas eruptions would occur on an hourly basis like Old Faithful.

At one time or another, I am sure that all of us have probably encountered a few people whose bowels do seem to operate on this principle.

Bowel efficiency also implies that if operating at 100 % capacity, most living organisms could survive by eating about half as much as they currently do, resulting in a tremendous saving of natural resources.

All is not lost however, as feces remains both an organic source for use as a fertilizer as well as a potential source for fuel. Western Indians and pioneer settlers frequently used buffalo chips for heat or cooking, while all societies reprocess manure for use on crops and gardens This means that most human societies indirectly eat what they shit. 

No matter how scientifically sophisticated the argument, however, this will still not deter the bowel obsessed personality from changing his mind about feeling as though he must take a good dump every day or his world will just somehow will not be right and all celestial orbits will be out of synch.

In part, this is a carryover from certain Old-World ideas or old wives’ tales that regular bowel movements are essentially vital to maintaining good health, being fables only rooted in the one simple truth that obstipation can actually cause bowel obstruction.

The overriding paradoxical gap in the logic of feces being labeled as internally toxic is that no matter what a person does to get rid of it, there will always.at all times, be some residual of it in his bowels.

The modern-day advertisement about feces acting like “paste and spackle” on the bowel walls that should be purged as a necessity to lose weight is a shill game that only makes some clever shyster wealthy form the suckers who send him money for the “cure,” otherwise known as the enema. One of the recurring problems with bowel obsession lies in the fact that the term “constipation” has been grossly misinterpreted to mean that one is abnormal if one does not poop every single day. However, it is a scientific fact that only a few bowel movements per week indicate good bowel health, if the stool itself is healthy in its configuration.

What constipation really means is that the stool is scybalous, meaning that it consists of small, hard, nut-like lumps that are difficult to pass because it has an abnormally low water content which then sets up the potential for abnormal, harmful straining to eliminate it or even a risk for fecal impaction.

I have seen plenty of old ladies or men in my practice who have been so diligent about their habits and have strained so hard at stool that they have caused such severe vasovagal pulse or blood pressure drops that they have passed out on their toilets and cracked open their skulls or broken their hips.

There are also plenty of people alive today who can remember a parent forcing them to spoon down cod liver oil or to eat an apple every day or plenty of others whose parents also made them sit on the pot every morning while not being allowed to leave the bathroom until they could prove they had passed some stool; this being a sure if not divine sign of continued excellent health.

My father-in-law can even recall his mother in the late nineteen-thirties chasing him around with an enema bag at the first sign of a sneeze or sniffle in order to purge the brown monster lurking behind the scenes and abetting the impending cold or flu.

My poor father must also have had one of those bowel obsessed mothers, because for his entire adult life he was one of those people who could never leave the house until he took a dump; an event that must occur at or about the same time every morning or his life would come to a dysfunctional grinding halt. For example, on one occasion when my brother was visiting from Denver and we were supposed to play golf, the tee time had to be set back until we could go to the pharmacy to get a laxative suppository for dad. We then still had to wait around even longer for the blessed evacuation; like sitting Shiva in the Labor and Delivery room.

I first discovered he had this problem on a fishing trip to Texas with my Uncle Pete. We were all waiting for my father to exit from the bathroom so we could make the drive from Houston to Matagorda, when the bathroom door burst open and my father started shouting for my mother to come help him. Thinking the worst because of the alarm in his voice I rushed to the scene myself only to see my father standing there in soaking wet clothes and water soaked walls with an enema bag lying on the floor. Apparently, he had lost control of the slippery little devil, whose hose had escaped from his rectum and then blasted him and the entire bathroom with its purgative contents. That was when my mother finally confided this had always been a ritualistic problem and how much of a negative impact it had always had on their lives.

When I took care of him in his final year of life, I also discovered that he inspected each bowel movement with a flashlight; then felt compelled to describe them to me. One day he said:

  • You know. That’s the first normal bowel movement I’ve had in a year.

I refused to ask what his definition of normal was.

However, no amount of argument or explanation that it is not essential to take a daily dump but also that regular purging with enemas or laxatives could paradoxically make things worse by disrupting natural colonic muscle tone or messing up electrolyte balances, could ever undo the psychological imprinting of a domineering Italian mother sitting with a broomstick outside little Sallie’s bathroom door every day and not letting him escape until he proved to her that he had pooped.

Even worse than that, as he got progressively older, my father became increasingly obsessed with being sure that he ate specifically for his dump. He accomplished this by loading up his diet with everything from dates and prunes to tasteless cardboard or paste-like fiber cereals, to flax seeds, combined with stool softeners and polyethylene glycol cocktails in a never-ending quest to find the correct combination of things that would keep his bowels sufficiently greased and ready to go. It wouldn’t even matter if he liked what he ate if the result was perfectly successful.

Bowel Flakes: The new high fiber but tasteless cereal that truly lets you eat for your colon.

Even in this modern era there is a segment of society that fully believes in the toxicity of internal feces and the necessity to regularly empty the internal cesspool or a belief in the fact that when confronted with a negative biorhythm that a good old-fashioned purging high colonic enema will be just the thing to save the day.

My sister, a person devoted to holistic health, is one of those individuals, but then again, she also believes that most of her health-related issues derive from the fact that she is also perpetually infested with parasitic worms and that a regular enema will be just the thing to periodically rout the little critters.

On a vacation trip to Mexico I met a young couple in their twenties who bored me to tears one day on the beach with a two-hour personal treatise on the Yin and Yang of food. They were obsessed by the effects of mixing incompatible food products on bowel health and the absolute necessity to have one or two high colonic enemas every week, which they gave to each other, just in case some of the wrong things inadvertently had gotten mixed together.

  • When we go to a cocktail party, we never eat cheese, crackers and fruit at the same time. And we never drink wine when we eat cheese either. Most people are completely unaware that mixing wine or fruit with cheese and starch is a lethally toxic combination that would require an immediate purge. You see, wine may only be a fermented grape, but they always serve it with real grapes and cheese is fermented milk, which does not at all mix with the starch in crackers, yet every time you go to a cocktail party that is all you ever see. Wine, grapes, cheese, and crackers.
  • No kidding. Maybe they should have four-course cocktail parties instead then.
  • Not a bad idea. But only if they come in thirty-minute intervals so that each course is properly digested first.

After that they asked me if I wanted to come up to their room, see their enema equipment and smoke some pot.

I thought to myself: Only if I get to see you purge each other after we smoke. That would be another thing to paste on my “Interesting Firsts List.”

But I politely declined without even bothering to go into the countervailing argument of asking how they justified polluting their lungs and brains with unfiltered cannabinoid smoke, while still keeping their bowels clean and free from harm. It would have only been a waste of time, so I went to the bar instead; ordered a pitcher of Sangria and just to be safe, asked the waiter to put the fruit on a side plate.

One of the first things a third-year medical student learns is how to write routine orders, and one of those orders he soon learns never to forget is the one for an evening laxative because of the multi purpose benefits to everyone involved.

First, it helps prevent fecal impaction so that the student or a nurse does not then have to go and dig the scybalous out of his patient’s rectums with his fingers.Secondly, it makes the patients much more pleasant during morning rounds because they usually feel as though their day has gotten off to a very fine start. Third, it prevents being awakened at 2 a.m. by the night nurse who is harangued by the patient to get a laxative order.Then finally because the laxative usually takes effect at about 6 a.m. the ward has then had a chance to be successfully defumigated before the regular business of medical rounds takes place about two hours later.

That way the only people who really suffer are the poor dedicated day nurses whom after years of exposure become inured to the smell of offal in the morning and then learn to completely ignore it.

 

 

An apple a day…… keeps the doctor away

 

Medical School: “Obstetrics and Gynecology.” But Not Misogyny

Why Not Obstetrics? 

For an elective rotation in Obstetrics and Gynecology I signed up for a thirty-day stint at The Providence Lying-In Hospital. What better way to get exposure than to be in a place dedicated entirely to the biology of the human female and her reproductive system?

Sleeping quarters were provided in a building that also housed female nursing students on the floor above us.

Imagine fifty horny nursing students locked up in the same building as three or four male medical students as being almost as good as a seminary student getting to live in a nunnery. At first, I could not imagine what stupid logic went into that demographic, but as time went on I came to understand the point to be moot and irrelevant.

Things got off to a bad start, when on the first day I was assigned to an Obstetrical surgery case; a hysterectomy. The problem being that as no one had taken the time to teach us how to do a sterile scrub and don, the attending surgeon went berserk at our awkward fumbling. This delayed the case while exposing his own paranoia that the operative field would be contaminated. He threw us out of the operating suite.

That illustrates one glaring fault about medical training, especially in a nonacademic satellite facility: Not knowing how much the student does or does not know and usually assuming that he knows more than he actually does; without really asking first; or sometimes not seeming to really care. In this case, the seasoned nurses came to our rescue by kindly showed us how to scrub in and put on a surgical gown.

There is also another glaring deficiency in the tritely overused expression that in procedural medicine all you need to do is to: “See one, do one, then teach one.” I doubt that anyone would agree this axiom should apply to cardiac valve surgery.

Nor did it apply to the situation I found myself in when I had only assisted at several post delivery episiotomies, a procedure whereby the lacerated vagina and perineum is sewn back together after the baby rips it apart while coming through.

The vagina happens to be a very accommodating organ; as both birthing baby heads and “fisting “perverts have empirically discovered; but like everything in life there are always certain limits.

The OB Resident, having been completely exhausted by his duties, delivered a baby, then turned to me and announced as he took off his gloves:

  • Hey, I’m really tired. I’m going to bed. You sew her up.

This was the same resident who had previously taught me to carefully suture so as not to hook the bladder or the bowel and to pay extra special attention to the final purse string cinching by making sure that the vaginal opening at the perineum was nice and tight.

  • That’s what I call ‘the husband stitch’ and there are probably a lot of grateful men out there who don’t even know why their sexual satis-friction is all because of me.

Yes, unless the husband happens to be thirteen-inch-Long John Holmes and it won’t ever fit in there again. Or if so, maybe it just gets stuck.

So, there I was, expected on my own limited experience, to sew up a lacerated vagina as well as to correctly place the husband stitch and make this mother neo-virginal again. I had a serious crisis of confidence and whimpered softly to the vacating Resident:

  • Please come back. I’ll do anything for you. I’ll even send a copy of your personally autographed photo to all the happy husbands so you won’t have to live in un-adored anonymity anymore.

No such luck. Yet once again the senior nurses talked me through it, although to this day I have no clue as to where the stitches really went, or how tight the final cinching turned out.

I had nightmares for weeks about a crooked vagina, a loose vagina, an ultra-tight vagina or a nasty vaginal-rectal fistula which would be followed by having to deal with a vendetta from a very ungrateful husband; not to mention litigation.

To back up a bit, this OB rotation was organized into weekly segments that included:

  1. Prenatal clinic
  2. Postnatal clinic
  3. Routine check up clinic
  4. One of many potential routine problems clinic
  5. VD clinic
  6. Labor and Delivery
  7. Obstetrical night call

Also, no matter what weekly clinic we were assigned to, we had to be on standby call every third night for labor and delivery. So, although there are probably some perverts out there who might think that unlimited access to peering at female gonads could be fun, better think again.

This activity is cold, indifferently clinical and involves handling women who would rather be doing anything else than have a frigid slime covered speculum pushed up their crotches, or an equally slimy finger stuck up their rectum; and sometimes simultaneously. They do not like it and they do not like you for doing it.

Next, not everyone looks like a Playboy model, as well as the fact that one is required to examine ages that range from nine to ninety, including all builds, shapes, sizes or body types with levels of hygiene that range from the immaculate to the totally neglected.

There is nothing worse than examining a three-hundred-pound woman who does not believe in soap and water, or who may have a yet unidentified species of fungus growing within the folds of her breasts or her labia.

Then, although the “Routine Check Up” clinic was relatively innocuous, there was always the dread of discovering the unknown surprising disease entities lurking in the cracks at the “I Think I Have a Problem” clinic: Yeast, gonorrhea, herpes, chlamydia, syphilis, vaginitis, urethritis, cystitis, trichinosis, and chondyloma. It was a great day indeed if the symptoms were only related to a benign ovarian cyst.

Women of all ages, from all walks of life; from rich to poor; ugly to beautiful, anorectic to obese, hygienic to unbathed with a wide assortment of troubles; with the best part of it all sometimes having to tell the parent of a minor that her good little supposedly virginal daughter had recently been up to quite a bit less than good and wasn’t really virginal anymore. Or worse: knocked up.

Of course, this was the era before HIV and because condoms were not necessarily all the rage, VD and STDs were more a nuisance than a death sentence. But it was still at a time when teen-age sex was quite verboten or severely stigmatized; especially so in Providence, Rhode Island which being a suburb of Vatican City, had no nightlife at all and in 1972 had little to offer a date but a front seat six pack followed by a back seat boogey.

It all became a female genital blur. Pretty pussy, ugly pussy, hairy pussy, shaved pussy, clean pussy, dirty pussy, messy pussy, sweet pussy, sour pussy, pregnant pussy, laboring pussy, lacerated pussy; and then various combinations or permutations of adding to that: big lips, small lips, large clits, little clits, and crotch zits.

After the daily assembly line of “pussy galore” I would fall off to sleep at night with visions of pussy-plums dancing in my head.

Now top that off with taking care of women in every stage of pregnancy, finally culminating in the counter-joy of having to listen for hours on end to a large open labor ward housing a dozen or so women who all raise their voices in completely non-syncopated timing as they scream out the raucous chorus of the opera known as the: “The Throes of Parturition.”

And although a baby’s birth can never be timed for perfect convenience, some of the attending Obstetricians would add an alcohol drip to the usual regimen to time the delivery by more propitiously delaying its occurrence from the middle of the night toward a reasonable hour the next day.

This made the operatic chorus all the more interesting for the added feature of having a room full of inebriated laboring women and the interesting quirky things the booze did to their personalities. Some of them became quite psychotic and had to be restrained. It was atavistically primeval.

Then on to the delivery room, where although a rapturous joy for the parents, I found nothing joyful at all about the gush of pee, blood, baby, baby shit, mommy shit, amniotic fluid, placenta; and then secondarily the effect that gallons of all of these body fluids did to the only pair of shoes I owned.

It got so bad that I cancelled a weekend tryst with the woman I was dating at the time by making up some lame excuse, and then told her I would call her back in a few days.

She did not take it well, then made oblique references to the fact that I was probably cheating on her with some nurse or nursing student in Providence, while she was alone, lonely, and horny back in Boston. I could not at all get through to her that worse than that; I simply had no desire whatsoever to see her naked, much less do anything else with her body parts or any woman’s body parts for that matter. Like writer’s block, I had developed a serious case of libido block that could be best characterized as nothing more than a bad case of female genitalia burnout.

She said:

  • Sure. I’d believe that just as much as I’d believe you didn’t want me anymore because you and that stupid roommate of yours were gay. I knew that anyway. Goodbye and Good luck.

No chance of cheating anyway, as even the female nursing students had also evoked as much negative libidinous attraction as alien body snatchers that came out of vegetable pods. Add to that the fact that their recreational drug of choice at the time was Quaaludes (“Sopors”), which did not exactly make them a boat-load of fun at social gatherings. There is nothing like going to a party where everyone passes out, and truthfully speaking, date rape with a limp dish rag was not my cup of tea.

Yes, lets all get to the point where not only do we not know what we did, or who we did it with, but also do not remember if we even liked it. My preference for pussy was to have it alert, awake and even faking interest if necessary; but not semi-comatose and diffidently snoring.

Despite my girlfriend’s innuendos, it was not even a case of latent homosexuality because I knew I did not harbor the slightest hint of homosexual tendencies. I honestly and truly liked pussy! It was just a simple case of overexposure resulting in a negative feedback loop. Too much of what otherwise might have been a good thing, so to speak because it just wasn’t the Hugh Heffner presentation.

After the OB experience in Providence, I also knew that I would never look at sex and the human reproductive cycle in the same way; and that if I ever chose the OB-GYN discipline as my medical vocation, I would probably want to eventually go ahead and just have myself neutered.

 

 

 

Pussy Galore: No problem for Agent 007

 

Photo: clothing.cafepress.com

 

 

 

 

Medical School Third and Fourth Years: Clinical Rotations

Clinical Rotations

The third and fourth years of Medical School are entirely clinical involving monthly rotations through various subspecialties. The exposures focus on medicine and surgery, including certain required subjects as well as some leeway for choosing electives.

This is designed to expose the student, especially in the third year to a wide variety of basic elements, while forcing him/her in the fourth year to begin thinking about making a final decision on choosing an Internship. Although there are several choices, the critical choice boils down to whether someone wants to be a thinker or a cutter.

It also exposes the student to certain disciplines he will then automatically weed out potential future careers.

For example, when I had to spend thirty days on an in-patient psychiatric ward, I knew I would never be able to make a career out of the abstract qualitative issues associated with the mysteries of the scrambled brain. These were hard core cases, such a as incurable Schizophrenia and sometimes it was difficult to tell the inmates from the screwy attendants taking care of them. In this case, I chose to fly over the Cuckoo’s nest. 

On the Neurology Service, I knew that spending a career dealing with irreversible neurologic damage or chronic demyelinating diseases would make me suicidally depressed and that I would end up in the psychiatric ward anyway; without a real stroke, but equally incapacitated.

Hematology seemed too abstruse, and because it paired with Oncology was even more depressing than Neurology. I had a great deal of difficulty dealing with the depressing diagnosis of “cancer” knowing instinctively I would never be able to tell anyone they had it. The: “C” word. Or worse yet: the “Big C.” A bad one. Already spread everywhere. Metastatic and incurable.

Endocrinology seemed the most logical as it dealt with clearly defined human positive or negative feedback loops; but I found its scope too limiting. All glands. Not much fun. It would be like spending a lifetime adjusting a thermostat.

Pathology was a turn off after seeing only one autopsy. Bodies smell horrible because they have a sickeningly sweet odor when refrigerated. They also have a spooky color: Clay blue-grey.

Then when not cutting little specimens into pieces after extracting them from a corpse, the rest of it is spent squinting through a microscope to define well after it was too late to be of real assistance, what really happened to the person in question.

There is little satisfaction in telling the corpses’ doctor:

  • Hey, nice going. You were right about what he had but he died anyway.

Or

  • Hey, nice try but you royally fucked this one up. You had absolutely no clue whatsoever as to what it was that finally killed him.

Nephrology was too wrapped up in acid-base metabolism because I was never very good with ions and pHs. Beside that, if you look at the kidneys sideways, they curl up and die. This introduced the added negative feature of having to take care of dialysis patients; which for some reason offered no appeal. I think it was the machines, the constant smell of uremia, and the fact that all the patients are puffed up on enough steroids to make them look like pumpkins.

Pulmonary was boring. The lung. Oxygen: in. Carbon Dioxide: out. That’s what green plants do, only the opposite. Or maybe get a tumor or a blood clot. Maybe stiffen up. Mostly get infected or destroyed by chronic nicotine use.

Gastroenterology raised the exciting specter of spending a lifetime looking up peoples’ butt holes, and scoping other dirty orifices, or as necessary in Urology, if dealing with diseases of the penis, urethra, and bladder, offering the great opportunity to delve into some other equally enthralling orifices.

  • Yes. The bad news is that your prostate is larger than a grapefruit. But the good news is that it is still smaller than a watermelon. And the indifferent news is that none of that has anything at all to do with your erectile dysfunction.

Or

  • Oh, kidney stones. Take this little plastic cup home with you; filter every drop of your piss through a kitchen strainer, then save anything that looks remotely like a small meteorite, put it in the cup, and bring it back to me. That is, if the excruciating pain even allows you to get off the floor to go and pee in the first place.

Or

  • Sorry madam. But after six vaginal deliveries, bladder prolapse is an anticipated end game.

Pediatrics was out of the question simply because it broke my heart to see sick children; especially in the academic environment of seeing them referred for the worst childhood diseases; some of which were hopeless or incurable. There is nothing worse than having to deal with a child on chemotherapy or having handle those who suffer the world’s worst congenital deformities or inborn errors of metabolism.

Surgery was an extremely attractive option to the point I became enamored of going into plastic surgery. But after standing on my feet for long complicated general surgery or vascular cases and after seeing the gross disfigurations or severe burns that the plastic surgeons dealt with, I soon abandoned that plan.

Who knew at that time what lay ahead for the lucrative side of plastic surgery or that that soon a physician could make millions by adding or modifying lips, tits, cheeks, chins, noses and buns or by sucking out the unwanted fat pads and dough wads from the cadres of obese overeating Americans who were too lazy to want anything other than an instant cosmetic fix.

Then, there is the issue of being dissatisfied with your genetics. The only thing I ever really wanted to know about certain cosmetic repairs, is how much obligatory disclosure there might be on the part of the prospective spouse to tell his or her fiancé about whatever anatomical part was fixed before the prospective child was born with the same deficiency.

  • Honey. This baby has no chin. Are you sure it’s really mine?

Michael had a hand in talking me out of surgery because he said it was less than cerebral. He said if a monkey could be trained to be an astronaut, then given enough time any Simian could even learn to operate.

Being too smart to be a surgeon, he suggested I should stick with something in the domain of Internal Medicine.

Fate may have intervened, as when I became older my eyes got worse, I needed bifocals and developed a cervical disc related neuropathy that reduced my fine hand-finger coordination.

Nobody can put a lot of faith or trust in a surgeon who can’t see, feel, or properly tie and cut knots. Or worse, one who develops tremors.

Not wanting to be bogged down in generalities, and with diminishing choices, I gradually became enamored of Cardiology. The heart is not only complicated in that functioning primarily as a pump; it also has numerous other highly technical and interacting components to deal with: muscle function, chambers, pipes, valves, as well as an electrical system.It was a veritable gold mine for the intellect as well as having antiquity’s mystical aura as being the organ which is the repository of the soul. Most of the body’s other organs also think highly of the heart’s central importance, come to terms with having to depend upon it; and if possible avoid getting it too upset.

Later on in my career, however, I never ceased to marvel as to how many people could care less about their hearts or souls and more about what was in their wallets, or as equally superficial, who were especially fixated on how they looked.

Over the several decades after the great depression America became a society obsessed with youth and a quest for materialistic wealth.It was a quest that left a spiritual vacuum in the souls of many of the seekers and the perpetual impossible dream of turning back the clock on the natural aging process.

This obsession has progressively manifested itself in the worship of empty headed, uneducated teenaged Hollywood icons, their wastrel lifestyles and the materialistic trappings that goes with their territory or Hubris.

In this eternal quest for youth and prestige small fortunes are spent on plastic surgery, fraudulent cosmetic products, ineffective diet and weight loss plans, spas, automobiles, houses, clothes, and jewelry while at the same time having no attention paid to physical and/or spiritual health.

I have had patients who are driving Bentley or Mercedes Benz automobiles, then complain about the co-pay on an office visit dedicated to the ideal management of their cholesterol, or bitch about the cost of a diagnostic exercise test designed to see if their arteries are seriously plugged. Yet these are the same people who will think nothing of spending fourteen hundred dollars to tune up the carbureting heart of their fancy car.

One of the more extreme absurdities was the three-hundred-pound cigarette smoking diabetic who came in for a medical preoperative clearance to get his droopy eyelids cosmetically repaired. My diagnostic assessment was: What’s the point?

I have also seen people who have had breast implants, face lifts, nips, tucks, putty fills, hair transplants and wrinkles botoxed to oblivion, who also never once in their lives paid any attention to their blood lipids, only to then present to an emergency room in the throes of a massive heart attack.

In the Cardiology trade, we label this diagnosis: Drop Dead Gorgeous.

What a very different philosophy from that of the Native American who venerated: age over youth, the counsel, advice, and historical perspectives afforded by the village sage, as well as the desire to live in harmony with his environment; taking only what he needed while leaving the rest for someone else.

At a time when almost no one lived past forty, wrinkles were a sign of prestige. The old wizened shaman became a societal asset as well as a valuable cultural resource for helping the tribe to avoid potentially fatal pitfalls or for guiding young people to productively safe futures.

In our society, the tail of naïve youth wags the dog of lifetime experience as we discard our surfeit of wrinkled up old people like they were second hand clothes earmarked for the Goodwill Industry recycle bin.

 

 

Make be beautiful,

Make me thin,

Make me look like her or him.

Make me young,

Make me hot,

Make me something I am not.

 

 

   Photo source  www.impawards.com/1999/drop_dead_gorgeous.html

 

Medical School: Physical Diagnosis

Humility

The teaching system is structured in such a way that it eases a medical student into the process of doing a patient’s history and physical examination. The student then, although not expected to be brilliant in deducing diagnoses, is at least expected to begin to think about at least one diagnosis that can be isolated to a single major organ system.

We were first required to start with blindfolded examinations of each other; then write down what we felt to be significant findings, only then to suffer the double humiliation of the proctor not only pointing out everything we had missed, but also pointing out all our own personal physical flaws.

The first humiliation, for example, was that we all made gross assumptions that skipped important details.

For example, most of the medical students did not even first state the gender of the person. This was followed by our omissions of simple facts such as the fellow student we had just examined might be wearing glasses, had a beard, or wore earrings.

All of this underscored a basic tenet in medicine that one should never overlook the obvious and also that one should never assume anything.

When I began my first presentation of an examination of a fellow student, I was stopped after the first sentence.

  • So, first of all, was the person a male or a female? Even blindfolded you can tell if a person has breasts, or buttocks, or a penis or not.
  • Well, yes but….
  • Then why didn’t you first say that the person you were examining was a female? There are many important medical issues that depend entirely upon gender you know.
  • Uh, yes but…I didn’t think I should…I mean she’s a fellow student. Wouldn’t she object to being groped?
  • But nothing and grope nothing. This is an objective clinical exercise, not a course in sexual harassment. So just because you might be embarrassed about this means you can sit there and tell me that someday you might miss a breast cancer? The medical examination of the breast is entirely clinical and is not the equivalent of fondling. At least it had better not be.

When I told my mother about this experience she shrugged it off as being nothing that should bother me too much. She trivialized it as she reminded me that her near-sighted brother Bobby had also learned his physical anatomy by the Braille method, albeit at night in the back seat of a car, yet never once seemed to have any problems with gender identification.She said:

  • Forget the tits. That’s how your Uncle Bobby discovered that women have three holes.

The second humiliation came with the fact that all of us then had our own physical imperfections glaringly pointed out to us; dermal scars, a murmur, a curved spine, acne, a sloped shoulder, a missing pulse, an old fracture, crooked teeth, glasses, or braces; you name it. The worst part about it was that we were all only about 21 years old. By the time the proctor was through with me I thought I was should just cash it in and apply for the job of being a cadaver for the class of 1974.

It was the beginning of a lifetime dedicated to thinking morbidly of even the slightest personal ailment, a thought that unfortunately played back into my mother’s perverse tendency to always look for the worst in people.

Noticing all the things wrong with someone or painting worst-case scenarios for diagnostic outcomes does not make for an optimistic outlook on life. By the same token, it does also constantly remind one that life is indeed very short. This thinking can either work beneficially by making one always try to live in the moment or it can backfire by incubating a ridiculous urge to live life to extremes.

In my case, it did not take more than a few clinical deathbeds prompts to instill a desire do everything I wanted to do while I was still young.

I did, in fact, try too many risky things at least once and stupidly tried some of them twice; like scuba diving the 130-foot-deep Maracaibo reef in Cozumel with no real experience, scuba diving an ocean inlet on an outgoing tide, sailing and tipping over a Hobie Cat in a full October gale without a wet suit in 60-degree water, taking psychedelic drugs; smoking hashish, trying cocaine or more than once, when I became a House Office, attempting to screw every nurse in sight, without condoms. Damn the V.D. Full speed ahead and fire all the torpedoes.

The second phase of Physical Diagnosis comes in learning to logically format and to then scribe all the elements of a comprehensive approach to diagnosis; Age, Gender identification, Vocation (or not), Chief complaint, Past Significant Medical History, History of Present Illness, List of Medications, Social History, Family History, Surgical History, Allergies, Review of Systems, Physical Examination, Differential Diagnosis, Plan for Diagnostic Testing, and Therapy.

Then one must write a set of Orders to be carried out the actual implementation of the Diagnostic preposition and Care Plan.

At the end of this process I realized I had watched too many doctor shows on television because this was nothing at all like the relatively easy, carefree approach to medicine enjoyed by the likes of Dr. Kildare. It was also not even close to the equally irrelevant focus the actors had on each other, but not on their patients, in the complicated soap opera lives enjoyed by the likes of the cast on General Hospital.

These people spent all their time perusing sex when they weren’t screwing over all their other friends or relatives physically, emotionally or financially; but somehow never seemed to get down to the real business at hand: like taking vital signs and emptying bedpans.

  • Doctor. Your patient in Room 3 has a fever.
  • What was the exact temperature, nurse?
  • I don’t know doctor. But not as high as the hots I have for you.

Nothing at all like that, this new aspect of Medical School, being very difficult, was the first time I doubted my vocation. Unfortunately, it would only be the first of many self-doubting or soul-searching episodes as little did I know how bad things could ultimately be or how humiliating things were about to become.

First, when doing any clinical rotations, the student is expected to wear a shirt and tie, put on a short white jacket that designates the inferior rank of neophyte, as opposed to the long white coat that comes only when rising to the rank of an Attending Physician. One also then must carry around about twenty pounds of ancillary tools in a little black bag, or in the coat pockets of the white jacket, including a stethoscope, ophthalmoscope, reflex hammers, tuning forks, note pads, pens, calipers, EKG rulers and of course the Little Red Book.

I felt like a G.I. going off to battle or as uncomfortable as I was at any time I ever had to put on a tuxedo.

If I had ever thought a Cub Scout uniform was bad, having to dress like a cross between a Bus Boy and a Good Humor Man was nauseatingly stilted and made me feel as though I would be infinitely better off instead standing stiff legged still in front of a drill Sergeant. with a little round wooden dowel shoved up my rear end. Cinch tied like a wild bucking bronco under his first heavy saddle; and saddened by the reality of having to ditch my soft comfortable hippie togs for a suit that made me look like a fumigator, off I trudged to the hallowed halls of the hospital wards.

My first real test in clinical medicine was being rotated to a hospital to examine a patient with liver failure, after which I wrote up the findings per protocol and then presented the case to a proctor in front of a group of five other students.

I thought I had done a pretty good job. The proctor however, did not.

My paper was a monument to how much red ink can actually be held in a ballpoint cartridge and how close a graded paper can come to being a Jackson Pollock masterpiece. I had missed just about everything pertinent: spider angiomas, everted navel, ascitic fluid, liver size in centimeters, rhinophyma, etc.

Then to make matters worse, when I attempted a verbal defense in front of my fellow students, the proctor jumped down my throat like that drill Sergeant would have done anyway, as he proceeded to rip me a brand-new asshole.

If I ever did have that little plug up my butt, this was when it would have hit the ground with a hollow empty thud as my knees turned to jelly and sphincter tone suddenly failed.

He said:

  • Do you know who I am? Do you know who I am? You don’t even know who I am, do you? Well let me tell you, then. I am Dr. Frank Iber, and I am a full Professor of Medicine at Tufts University Medical School. So, when I speak or when I critique; you will remain silent and do nothing but listen and learn. Your examination of that patient was a disgraceful example of incompetence. As such, we shall now proceed to go back to show both you and your fellow students how superficially incompetent your evaluation really was. And when we are all done with that, you will take your paper back home, then you will re-write it, after which you will also memorize the section in DeGowan on all the signs of liver disease for a verbal quiz, which I will administer at my personal discretion.

And so, we did. And so, I did. And so, he did.

Bad enough I got the proctor with the bad temper and the inflated ego, but he also happened to be a national expert in Gastrointestinal Diseases who also wrote the textbook section on “The Liver.” I guess then this rotation was both the bait and the trap, eh?

It was stupid of me to have been mollified into assuming everyone was like the jocular, philosophical proctor who taught us all to be HIPPAYs. In retrospect, I guess that professor, with his pleasant affect and his all- forgiving non-offensive mentoring personality must have been a Psychiatrist.

To make matters worse, I really did not know who Dr. Iber was until I looked him up in the school directory, and thus learned a painful lesson about the mysterious hierarchies of the world of Medicine. Some people are, in fact, more important than others and obviously not ashamed to let you know it. Doing background research ahead of time, if nothing else, could have at least ensured me a few ingratiating brownie points.

I was hurt, humiliated, embarrassed, demoralized, angry, and ready to quit school. However, Michael propped up my badly bruised ego, having encouraged me by the reassurance that everyone goes through it, and that after the first time it can only get better.

It was just another game that had its own set of rules, with a peculiar set of standards that had to be learned; such as the correct timing for self effacing groveling or the tossing of dust on and over ones bowed, scraping head. Once you know the rules, it becomes infinitely easier to play the game.

I was not so sure, but then again, the alternative would have been meeting a real U.S. Army Drill Sergeant and having to trade in my Little Red Book for a Big Brown Duffle Bag along with a one-way ticket to Southeast Asia.

It did take a while, but I got over it and I did improve.

My roommate Michael said it was just like learning to drive. Scary at first, and you might hopefully have only a few minor accidents, or get a few tickets, but after you get the hang of it and learn to play the game, it’s just as easy as learning anything else.

But to me the length and breadth of medical knowledge seemed as insurmountable as a successful climb to the peak of Mount Everest; even with the added benefit of having some extra oxygen canisters on board.

Michael also helped with the proactive part of things by proceeding thereafter to point out the best clinical rotations to take in the third year of school as well as the pitfalls of each one, the peculiarities of the proctors, the nice ones, the mean-spirited ones along with all the important signs, symptoms, facts, or trick questions to anticipate as each one came along.

When you come to think of it, the scary thing is that in just over twenty-two months of clinical training, the Medical student goes from the floundering, blubbering naïve state I found myself under the hawkish scrutiny of Dr. Iber, to becoming an Intern in a hospital where he or she has the responsibility of making decisions that can mean the difference between life or death.

Because Internships begin in the summer, there is an insider’s facetious mantra in all the academic medical training programs that is unknown and secreted from the general public:             “Just don’t ever get sick in July”

The failsafe here is that the rigid pecking order ensures constant supervision at every level. The Attending supervises the Fellows and the Residents; then the Fellows and the Residents supervise the Interns.

But Interns will always at times find themselves in situations in which the decision to be made must be expeditious and solely his own responsibility. That is when the “Yell for help” becomes the credo of not only the real neophyte; but also of everyone else in the teaching hierarchy.

Then the more he is exposed to disease, dilemmas and disasters, the better trained the physician becomes as he slowly rises to the top of the medical food chain and finally gets to wear that long white coat: Full Attending Physician or Professor of Medicine.

One thing I came to learn for sure was that there is no shame in admitting “I just don’t know” because in Medicine when pride supersedes humility the unintended consequences might be permanent harm or even death. No one in medicine knows everything. But everyone does know something.

And just as is it at the highest levels of any professional performance, there is always someone who is better at something than anyone else is.

Even Tiger Woods could lose and eventually every icon becomes old, tarnished or simply out of date. Just ask Jack Nicklaus what he thinks about that.

At least I got the drift that when finally getting to the top of this academic world, I could still reserve the right to be somewhat nice or pleasant about it; and also learned that compassionate constructive criticism was probably a better way to teach a subordinate than abject self-promoting narcissism.

 

Ask and it shall be given unto you

Seek and you shall find

There is assurance of salvation

And blessings when you knock

(The Bible. Hebrews 11:6)

 

 

     Jesus:  http://www.carmelwagga.org.au

 

 

 

 

Matricide and Patricide

Murdering Dad and Mom 

 

Mamma Cass

Be cold and blue

Janis Joplin

She got screwed

Jimi Hendrix

He dead too

Sing about it

Too ra loo 

 

One professional boundary that should never be crossed is to medically treat first-degree relatives. By definition, there can be no objectivity in this adventure.

If it is true that the shoemaker’s children often go barefoot, then it also axiomatic that a physician’s children should avoid the care that any other lay person would intuitively believe to be easily accessible.

I learned this lesson the hard way when I attempted to treat my mother for an episode of prolonged incapacitating inner ear vertigo; then also my father for severe back pain. After all, what do I know about the ear or the spine; I’m just a Cardiologist. But when filial guilt set in, I capitulated to the pleas that forced me to do my best.

In my mother’s case, she would usually have to be dragged behind the car on a leash to get her to a doctor’s office. This behavior was in part justifiable because of her ordeal with breast cancer, which had been diagnosed when she was in her thirties.

Her surgeon was so aggressive that besides doing a radical mastectomy with lymph node resections, he also put her on quasi-experimental chemotherapy. In subscribing to his personal theory about estrogen receptors in the breast being a future potential hazard for recurrence, a few weeks later he performed a total hysterectomy. At the time, none of this was scientific protocol, but the surgeon was operating with the best interest of his patient as his first and final intention. To some degree he was eventually proven right, while in others, he was not.

Weighing ninety pounds, bald, and looking like death warmed over when she finally left the hospital, my mother then did everything in her power after that to avoid medical care. The irony was that she survived the cancer only to live long enough to become demented; dying of Alzheimer’s’ Disease when she was eighty-four.

So, in my attempt to help her out with the decade’s post-cancer episode of vertigo, after several failed trials of empirically or otherwise recommended drugs, I gave her Dilantin. a drug used to control seizures, as a last resort; having read one case report on it’s efficacy for refractory vertigo. This anecdotal medical trial, was for me the equivalent of one of my patients getting all their Cardiology therapies on Med M.D. and nearly culminated in being her last resort as well. As a drug mediated reaction, she developed a spiking fever to 106 degrees that nearly cooked her to death.

Ironically enough, the fever also cooked away the vertigo, and although being cured by serendipity, she then believed by inverse logic that I was a fantastic doctor.

She said:

  • See. All that money we spent on Medical School was worth it after all.
  • Yes. Brink of death therapy should be my new mantra.

In my father’s case, well after my mother had been placed in a nursing home for Alzheimer’s disease, he drove to my house one day in agonizing back pain. His regular doctor was off for the day and he begged me to refill the Valium previously prescribed to relieve the back spasms. Not wanting him to suffer, at first I balked but then complied with his request.

Later that night I decided check on how he was doing, only to find him in bed, nearly comatose, barely rousable, and so stoned he was beyond the ability to even slur his words.

The intensity of the back pain had caused him to misread the label on the prescription bottle, so he not only overdosed by taking 20 mg instead of 5mg but had also mixed the drug with the wine that he customarily drank at dinner. He thought the label said to take four at once, then four more four times a day, instead of reading it correctly as not to take more than a total of four in one day.

I did a bedside coma vigil, periodically rousing him, and hoping he would not pull a John Belushi or a Momma Cass. But he did make it through; waking up the next day feeling tired, amnesic for the episode but also feeling somewhat better.

He said:

  • Wow. That was great. I don’t know how you did it, but my back feels terrific.

That was a good thing too, because if had not awakened, there is no doubt that various eyebrows and certain suspicions would have been raised in the ensuing police investigation.

  • So, you gave your own father a lethal dose of Valium, eh? I also understand that you are the Executer of his Trust. Is that true?
  • No sir, I really loved my daddy. And yes sir, I am.

 

The road to hell is paved with good intentions

 

 

© Pfizer www.drugrehab.net/img/valium.jpg

 

 

 

Medical School: Year Two

Clinical Exposure

Physical Diagnosis is a medical school course that overlaps the conclusion of basic sciences and is given at the end of the second year.

Students are required to buy the “Bible of Physical Signs” other wise aptly known as: Physical Diagnosis, a little red leather covered book by DeGowan and DeGowan, which they are then told to memorize and carry with them in their little black leather bags for the rest of their lives. Memorizing it is easier said than done. After all, it is a Bible and if the Bible itself is all you must memorize, then perhaps over a lifetime you might become successful at regurgitating it.

Just ask Billy Graham, or any other Bible toting evangelist. Pose a question. Receive a parable in return. No real thought required. Problem solved. Or problem only temporarily shelved:

  • Go in peace my son; I know that your life really sucks, but keep praying to God for eternal salvation. Things might seem to be bad right now, but ultimately, they can only get better.
  • But that’s the same thing my stockbroker told me when I lost all my money. Twice.
  • My son. Do not ever confuse the secular world of monetary greed with the promise of joyous everlasting life in the next world.

Unfortunately for physicians, we must memorize a few dozen Bibles, as the solutions to our problems can often be so obscure that even invoking the name of God does not always result in a comforting resolution.

  • After this terminally ill patient finally does rest in peace, we’ll say perpetual Novenas to the Gods of Malpractice that we never get sued.

There is a rigorous approach to the Physical Diagnosis course stressing the basic elements of abnormal physical findings that my instructor boiled down to what he thought would be a jocular contemporary mnemonic to assist us getting through it: HIPPAY; which stands for History, Inspection, Percussion, Palpation, And…. Yell for help!

He thought he was being funny. We thought he was being idiotically insulting. After all, we were the nuclear radiated mutant hippie class, were we not, so why keep rubbing it in?

Medicine is replete with mnemonics that are designed to prompt memory and remain useful cues if they are appropriately applied; but not like the singsong one traditionally used to teach children the alphabet. It took my mother quite some time to force my understanding that LMNOP (ele-mena-pee) does not stand for one single letter or a single-minded desire to evacuate the bladder.

This point illustrates that in learning anything, Rote is not necessarily equivalent to Right, unless logical thought processes use the Rote in the Right way.

For example, using MOST DAMP as the mnemonic cue used to treat the internal drowning of congestive heart failure has a rational application, if it is used with a certain clinical panache. If not overzealousness automatic use of all of these elements may sometimes do more harm than good. Sometimes you only need M&Ms to treat heart failure: a little Merck (Lasix) and a few drams of Morphine.

This was only one of the reasons God invented narcotics and why a leading research Cardiologist at the Columbia–Presbyterian Hospital orientation program gives his first-year Fellows a button to wear on their white coats that reads: Lasix kills. This teaching point being not to treat every patient with a cook-book recipe as opposed to an analytical thought process with subsequent careful medical titration.

P: for Phlebotomy did not even work out very well; when in the Middle Ages leaches were used to bleed patients half to death, having subsequently been abandoned as an ancillary therapy for heart failure.

  • Yes. Once we leach out all his malodorous phlegmons, your husband will hardly be able to speak, much less ever be able to stand up or possibly even walk again. But he will be better.
  • Thank you doctor. I’ve been trying to get him to shut up, sit still and stop chasing after my ass for the last thirty years. I’ll be sure to remember you in his Will.

Mnemonic learning is also helpful in medical training because the body of medical knowledge is so overwhelming. But this method eventually becomes abandoned as clinical experience adds a base of reality testing to rote learning.

Yelling for help is always sound advice for the same reason. One cannot possibly remember everything and so asking a colleague for a consultation or advice or personally consulting text and literature can often be vital. Unfortunately, some egocentric doctors seem to forget this tenet; or worse they sometimes forget that they forgot.

It was amazing as my career in medicine moved along, as to how many colleagues seem to have forgotten that the story a patient tells is about seventy-five percent of the diagnostic battle, the physical exam adds another fifteen percent; and with a good synthesis of both, a seasoned clinician can then direct a limited number of lab tests that should hopefully finish off the job.

That is unless the disease entity is so obscure as to baffle even the best minds, which is why we have places like the Mayo Clinic or other Meccas of academic excellence. When in real doubt: Punt.

It is also unfortunate that many physicians do not care to take the time to listen or do not know how to peel back the onion-skin of the patient’s story to get to the core of the problem. This is a skill that takes years of practice to develop and even more years of practice to ensure that it can be done in a short framework of time.

For the most part, physicians do not have the luxury of the infinite amount of time that Marcus Welby seemed to have when as week after week, not only did he have only one patient to attend, but also found himself purposefully inserting himself into that patient’s personal life and then becoming the family’s best friend.

Better than having a family dog, just go out and get your own personal M.D. and although in real life it simply does not go down like that, some of my patients still think nothing of having me entertain their queries while I am shopping for food or practicing putting.

  • Doctah, doctah. I know you’re relaxing on your day off, but do you think you can take just one tiny little minute to take one eensy little peek at my teensy little new skin rash?
  • Oy vey. As you know, I am not a Dermatologist. But if I were going to guess, it looks to me like it might be case of genital herpes. So, you can put your clothes back on now, then go ahead and pay for your groceries.

Shortcutting the non-essentials is also critical to saving time. For example, when seeing a patient and asking when the chest pain problem first started, one is not interested in retorts that catalogue every action the patient did from birth or tedious monotonous histories such as:

  • I woke up today at 5 a.m. I usually wake up at 4:50 a.m. I knew right then I was in for trouble. Then I had a bagel for breakfast. That’s not what I normally eat. Normally I eat granola and yogurt. Then my coffee pot broke and I need my coffee and my normal food so that I can have my normal bowel movement. If I don’t get my normal bowel movement I know my entire day will be off and I will just be logy and tired and miserable all afternoon or maybe even have to take a nap even though I really don’t want to. So, against my better judgment I gave in and had a Sanka. Then when I finally had my bowel movement, later than I usually like to have it, it wasn’t like the normal one. Usually it is short, fat, tubular, dark and brown, then breaks into pieces and sinks to the bottom of the bowl. This one was long, thin, light and yellowish; about 18 inches total, stayed all in one piece and floated. That was when I knew I was really going to be in for a bad day. So, then I had to get dressed when I normally don’t get dressed and….

Prattling on and on and having nothing to do with the fact that this person is being evaluated for the new onset of chest pain; it took me years of experience to learn how to re-direct a patient’s thought process and expedite getting quickly to the point without being undiplomatic or making the patient feel as though I was rushing them.

  • Why don’t you just think about what’s happening in your case as being bad constipation in your coronary arteries. Now tell me about your chest pain.

Unlike the legal system, in which time, like a running taxi meter is endless, where time also then equates to  money, and additionally where the truth can be hopelessly perverted, ignored or purposefully obfuscated, in Medicine time is of the essence, money is discounted and the truth is the vitally important element that can mean the difference between life or death. I came to believe that the universally appropriate gift for a Law School graduate should be a tie tack shaped as the Infinity Sign.

After all: Time is infinite. And legal time means infinite money.

 

(Reminds me a little bit of the 3-Cs (prior post: Cornflakes, Coffee, and Cunnilingus). Except that now everyone is getting fucked, but no one is getting laid)

As a countervailing issue, in the modern era of medicine there is often too much reliance on the shotgun approach to lab or procedural testing, while too little emphasis is placed on basic logical thinking. Accessibility and availability of advanced technology as well as excessive malpractice litigation has sent the cost of medical care through the roof.

With the fear of the Medical Malpractice legal vultures always circling overhead; on wisps of doubt, as well as the fact that it does not cost a physician anything to order a test, we are now living in the era of medical errors of commission. Lawyers have taught us that if one can think of a test to do, one should simply do it. Meanwhile as always viewing issues from the perspective of Monday morning quarterbacking and self-righteous hindsight they constantly feed off the carrion of imperfect outcomes.

When asked to see some patients in consultation, where the requesting physician has omitted many elements of basic training, including a good history and physical examination as well as a dearth of logic or common sense having been applied to a morass of useless information, I rely on an axiomatic statement taught me by an attending physician who supervised us during those first years of training in physical diagnosis:

  • Ladies and Gentlemen, when all else fails, why don’t we just begin by examining the patient?

However, there is a certain degree of psychic trauma that accompanies the beginning clinical training as the second-year medical student leaves basic book learning behind.

This is a Right of Passage in which rote memorization does not help unless facts can be synthesized, in which introverted, socially isolated intellects actually have to meet, touch and talk to real people disadvantaged by illness and where quantitative analysis breaks down at the level of qualitative evaluation.

It is a time when multiple choice test questions become replaced by a differential diagnosis and when a patient may face the additional problem of dealing with multiple concurrent illnesses. Guessing wrong on this test runs a gamut of far different potentially negative results than only receiving a poor numerical grade.

  • Oops, sorry, it was a really a heart attack and not just a bad case of indigestion.

It is a time when deductive reasoning reigns supreme; but also, when a naïve student begins to develop a personal inventory of logic that only comes with continued experience and clinical exposure. The patient becomes a book that has a limitless number of pages, but a book that also does not have an index or chapter headings.

Every patient becomes a new black box. The student then must logically deduce what is potentially wrong with a person who cannot necessarily explain it well and who may also be covered with dirt, crust, scales, rashes, odors or sometimes even with insects. One also must be able to do it expeditiously; without regard to race, color, creed, personality, sexual identity or personal bias, and preconceptions; not even withstanding the deeper layers of the physical exam than can include a rectal or vaginal probe, or both.

It is a time when the art and science of medicine is a blank palette in a student’s hand and is also a time where the cornerstone of the Hippocratic oath is placed in the foundation of the medical student’s career. But as  with any potential building, some cornerstones and some foundations turn out to be more solid than others.

Being shyly xenophobic to begin with and since I had never even wanted to speak to strangers; much less then even having to touch them, I struggled to overcome the barriers I needed to expeditiously become superficially intimate with perfect strangers in a short period of time.

Medical training requires the ability to become intimate while at the same time maintaining a certain professional barrier that should preclude becoming friends. Because once a doctor truly befriends his patient, he tends to lose the ability to think objectively and thus the serious potential pitfall to provide a disservice.

One of the great failures of medical training programs and a disservice to humanity in general is to guide or to allow the student, Intern, or Resident to enter medical disciplines that do not suit any or all of his individual talents, his personality, or his individual skill sets; as well as failing to inform some of these individuals that they should seek career choices in another discipline altogether.

  • Son. Surgery is not your forte. But you are good with a knife, so you might want to consider a career as a butcher.

It is very hard to do this after a student has come so far and for so very long. But similarly, the mustard of medicine is often very difficult to cut and not every student really gets truly seasoned by the time he graduates.

Some physicians I know who did make it all the way through, unfortunately should have never even been allowed to lay a hand or a scalpel on a cadaver; much less to later lay either of these two tools upon the body or flesh of a live human being.

 

 

Swedish Aphorism

Vhere iss Yorgay?

Yorgay is in da bootcher shop practicin’ to be a doctor.

Vhere den iss Svengay?

Svengay is in da medical school practicin’ to be a bootcher.

Und vhere might den be Ingrid?

Ingrid is in da haystack practicin’ to be  a nurse

(Swedish Aphorism/courtesy of Michael)

 

 

The Battle of the Sexes: Part 2

Physically Speaking

One of the few things a man can truly hold over a woman’s head is the fact that in general, men because of their biology are physically stronger than women. Unfortunately for some abused women, their men like to occasionally give a live demonstration of this physical prowess in ways that result in bruises, broken bones or black and blues.

This fact of biology is why at the professional level in sports, women cannot compete in the same league with men and why there are clear-cut distinctive separations in their organizations: for example, the LPGA, the WNBA and the Women’s Professional Tennis Tour.

There are also some esthetically plain and simple “lack-of-interest” lines that will probably never be crossed, accounting for why we will not likely ever see a woman’s NFL or a female professional baseball league. Even the WNBA basketball is only marginally interesting and close to being a financial bust for its team owners.

People just have an innate penchant to preferring brute male gladiatorial strength.

The only thing that might really fly then would be a Woman’s Professional Mud Wrestling Organization (WPMWO). This is only because of the perversely innate titillation that men seem to relish when seeing half-naked dirt covered women with heaving breasts and visible camel toes duking it out in an ersatz good old-fashioned catfight.

The contrived tennis match between Billy Jean King and Bobby Riggs was a pathetic attempt to show sexual parity in sports; an event just about as interesting as watching water boil. All it revealed was that no matter the gender, given enough disparity in age anyone can beat anyone else at anything.

On that subject, Patrick McEnroe but it bluntly when he said that the number 150th ranked male tennis player could hands-down beat the number one ranked woman’s player, adding that no one would want to watch a match like that anyway, because it would only be boring. 6-love/6-love/6-love, if there even is such a thing as “Love” in tennis matches to begin with.

But promoters will try anything; so much so that the hype surrounding Michelle Wie, dubbing her the ‘Female Tiger Woods,’ and then trying to push her onto the men’s golf tour not only ended in a catastrophic non-event because she could never even make a cut; but one must also wonder how much damage this failed fiasco did to the poor 16-year-old teenager’s psyche. It took years for her to recover.

Even the so-called Champions Senior Golf Tour is barely yawn inspiring because it lacks the cache of youthful vigor; and only highlights a bunch of gray haired stars of yester-year hobbling around on shortened courses.

This is just about as exciting as it would be to watch retired baseball players come back to establish an old-timers league: 70 foot base paths, 200 yard fences and underhand pitching.

But nevertheless, there are still five great equalizers women can always fall back on in the event they are ever assaulted or beaten up by some physically stronger, abusive spouse or lover:

  1. A concussive swat with a good old-fashioned cast iron skillet.
  2. A pot of boiling water poured on the head or crotch.
  3. A head shot with a full swing 9 -iron.
  4. A Lorena Bobbitt circumcision.
  5. A blue-steel .44 magnum bullet between the eyeballs

Tennis anyone?