A: Training days
Bar Mitzvah: 1973
Saint Luke’s Hospital in New York City is a private voluntary not for profit institution located on the upper west side of Manhattan. It is also one of several satellite teaching hospitals belonging to the Columbia University Medical School, whose mother ship; The Presbyterian Hospital of Physicians and Surgeons (P & S) is located further uptown near the George Washington Bridge. Being nearly adjacent to the undergraduate campus of Columbia University to the northwest and separated from Harlem to the east by Morningside Park, the immediate surrounding neighborhoods consisted of a mixture of university students and faculty, hospital workers, the earliest vanguard of upwardly mobile yuppies as well as the dregs of slum dwelling humanity. The more impoverished elements consisted of Hispanics, mostly emigrated from Puerto Rico, and Blacks that had emigrated from the Southern plantations at the end of the Civil War. At this point in time neither Harlem nor Spanish Harlem were holding out any bright rays of hope or promise for these denizens of New York City’s populous infrastructure. The result was that the local indigent population marginally used the medical clinics for long term health care issues or more likely than not, only used the hospital when they were forced to because of emergencies, crises, critical illnesses or when they were in extremis. These crash-landing presentations usually fall into the vernacular medical designation known as “The Train Wreck,” often requiring an enormous dedication of resources and clinical acumen to reverse them and then get their victims properly back on track.
The hospital owned two rental apartment buildings that availed subsidized affordable housing to the Medical and Nursing staffs. Because both buildings were located directly across the street from the main building this made commuting to work or taking night call relatively easy. The commute was also safe, because before Rudi Giuliani took the handcuffs off the police and let them actually do their work; the city, under Mayors Beame, Dinkins and Koch was a denizen of thieves, muggers, pushers, pimps, prostitutes, junkies, drug dealers, professional street beggars and homeless people who squatted in and took over public areas such as sections of Pennsylvania Station, bus terminals or parks. Certain highly profitable street corners were actually for sale on the beggar’s underground commodities market, sometimes fetching prices as high as five thousand dollars. Conversely, any beggar who attempted to encroach on someone else’s established territory might risk a knife or a gunshot wound. Even an ordinary public citizen taking a casual or accidental stroll either through the Pennsylvania Station Homeless Homestead or the notorious Needle Park could risk buying a one-way ticket to the morgue or an admission to the St. Luke’s Hospital Intensive Care Unit.
This was when my brother’s advice rang true about how to survive on the streets of N.Y City―wear old clothes so you look poor, put on sneakers in case you have to run, keep your cash in the toe of your shoes and above all else do not ever make eye contact with anyone. I did learn to navigate the streets as well as how to anticipate and to avoid potential trouble. But after five years of street survival it took another five years of living in peaceful suburbs to stop continuously looking over my shoulder or jumping out of my skin if I heard someone running, jogging or walking briskly on the street behind me.
The teaching hierarchy of the hospital consisted of University appointed Attending Physicians who directly supervised everyone else who was in training as distributed in the following pecking order: Fellows, Chief Residents, Senior Residents, Junior Residents, Interns, and finally P & S Medical Students. The hospital’s forte was Internal Medicine and Surgery, in particular, vascular and cardiac surgery; with the open-heart program being headed up by one of the finest surgeons of the day, John Hutchinson, a light skinned black man who could easily have passed for white. In fact, everyone did think he was white; including the red neck Afro-American hating bigot from Easthampton who subsequently shit his pants when he found out that it was a black man who had literally held his heart in his hands when reattaching all the vascular plumbing necessary to keep his own dark soul alive.
For the most part the medical staff was required to take care of general ward patients, meaning those indigents admitted without private insurance that comprised the bulk of the hospital census. Required rotations consisted of general medicine, emergency medicine, intensive care, cardiac care and private ward medicine. Private patients, mostly from the white upper class, were segregated to another wing of the facility and taken care of by their own physicians, only some of whom had academic appointments, and others of whom did not seem to have read anything current in medical advances since the day they left residency. Although this might at first glance seem to mean that indigent care was second rate, in fact the opposite was closer to the truth, as by default these people were being exposed to the latest and most current thinking that medicine had to offer; along with daily supervision of care by faculty appointed physicians. In counterpoint, for the few mandatory months we were required to rotate through the private wards, most of the house officers eschewed this responsibility because of having no control over case management, coupled with being looked upon by both the doctors and their patients as being lackeys and/or marginally competent nuisances.
- Who are you?
- I’m your intern.
- I want a real doctor. Where’s my real doctor?
- Probably sitting home watching TV and into his fourth Martini by now. Want me to call him in?
However as just alluded to, some of the private physician’s lack of skill and judgment was typified the day that my Junior Resident found the patient of a doddering old Internist to be in severe congestive heart failure and on the brink of death. He amended the Internist’s tersely inadequate handwritten chart note of an hour before from: “Patient is short of breath. Let him rest” to: “Patient is short of breath. Let him arrest” by scratching in the “ar” in front of the “rest.” What the patient really needed was an urgent transfer to the CCU while the sarcastic forgery was motivated only by the fact that the Resident had become completely fed up trying to salvage and then cover up other people’s less than handy work. In fact, the only thing this aging monument to cavalier medicine was good for, and the only time I ever heard him speak up was usually during some clinical conference. Without fail he would correct anyone who ever used the phrase mitigate against” by suddenly piping up to say “militate. The word is militating.” That solitary fact he had down pat.
His terse interruptions reminded me of one of my private patients, an author and retired English professor who proverbially corrected my mispronounced use of the term ”angina,” every time I used it in reviewing his symptoms. The same brief monologue was reiterated. He said:
- The word is Latin, ergo the “i” is a hard “i” and not like the soft “i” in the alcohol ‘gin’ but rather like the letter itself; and ergo―an-geye-na. When referring to the female genitalia, you do not say va-gin-a, do you?
- Only if I am shit faced drunk, sir. Then I call it pussy. Derived from the Old German puse vulva; meaning a pouch, a sack, a scabbard or to stuff something.
- What you really mean to say is when you are irrevocably inebriated, yes? And pussy is not German. It is derived from the Old English meaning: warm, soft and furry. Ergo pussy cat. Referring to it otherwise is vulgar.
- OK then. When I am irrevocably inebriated, I like to stuff the warm, soft, furry, pouch of a female Homo sapiens with my pendulous penis. Now let’s get back to talking about the immediate problem with your dolorous cor viscus.
Of course, since every other doctor on the planet mispronounces the word, whenever I subsequently said ‘an-geye-na’ my colleagues skeptically raised their eyebrows, sniggered and shunned me like a pariah. This type of vulgarity, in heralding the end of the classical Latin period in medicine was only the beginning of many more vulgarities to come occurring somewhat in parallel to the same demystification in the Roman Catholic Church.
- Per omnia secula, secula, seculorum. Amen.
- Huh? What does that mean?
- Forever and ever, Amen.
- Then why didn’t you just say so? And by the way, what does “Amen” really mean?
- Incontestable truth. No arguments.
Upon this backdrop, the arrival of my Medical Intern group in July of 1973 was as inauspicious as would be a personification of T.S. Eliot’s poetic line “not with a bang but a whimper.” It was like throwing a new cog onto a finely tuned gear that momentarily groaned and tried to reset itself without stopping to wait for the appropriate mechanical adjustment, but then went on relentlessly grinding, remolding and incorporating the offensive little kink. We were mutually introduced, given a cursory orientation, told what was expected of us, given our schedules, handed keys to our call rooms and then told to “go to work.” As joyous a day this was for the Interns ahead of us who were just now being promoted to Junior Residents, it was equally a sad anxiety provoking day for us neophytes. And even though the medical students who would be assigned to work under us were theoretically at the bottom of the totem pole, it was a false bottom because the real responsibilities resided with us. These duties would now include: admitting new patients, writing their orders, rounding on existing ones, coordinating care, ensuring complete and neat charts, collecting data, knowing all the pertinent data, drawing blood, starting IVs, staining slides, and worst of all, every third night having to be on call.
Being on call required staying on premises, sleeping in the building, carrying a pager; and for either twenty-four hours or, worse, for seventy-two hours straight through on weekends to be available for new admissions―while at night being responsible for problems on the entire ward. The Junior or Senior Residents provided backup, but it was conveyed rather sternly on day one that these individuals were only to be called for legitimate questions of management or if a person was too overwhelmed with work to be able to function. It was stated in no uncertain terms that all house officers prided themselves in being able to “suck it up” and that being “overwhelmed” was a relative term one should rarely if ever invoke; or if so, it had better be really and truly overwhelming; like a tsunami of critical illness. This was suddenly the real deal and very serious business. School was finally out for good but now it was going to be a litany of far more pencils, infinitely more books or journals and significantly more teacher’s dirty looks.
I never felt as inadequate as I did on that first day when the full realization hit home that I now had to be a real doctor with real responsibilities for other people’s lives. The closest second to that would come later when I finished training and went into private practice with the full realization that even though I had a bit more experience, I now had no one to back up any of my reasonably solid or sometimes meekly tenuous clinical decisions. I reported as required to one of the general medical wards as my first rotation and was met by a gleeful newly promoted Junior Resident who would be my immediate supervisor. He gave me a patient list that was headed up by an elderly black male who had already been admitted with pneumonia. Then in turning over the pager said:
- I don’t know if you are Jewish or not―but think of me handing off this pager as being your real Bar Mitzvah―because today, my boy is the day that you truly do become a man. And by the way, it’s very bad form to let your first patient die. So, good luck, and welcome aboard.
As it so happened my veritable bad luck was to draw the lot of being on call the first night I worked. In being paired with another Intern in charge of another floor, we found ourselves assigned as roommates to one of the call rooms. At about midnight when we had finished enough work to attempt sleep, we opened the call room door only to be met with a spate of truculent curses from the two new first day residents we had rudely awakened. Apparently, they had not been informed of being assigned to other rooms. Nicer rooms. Nicer and better Junior Resident’s rooms. But because actual physical possession of the bed is 10/10ths of the law, we were greeted not with a soft mattress and pillows but rather with hard and harsh castigations.
- Get the fuck out of here.
- But this is supposed to be our on-call room; and we have a key.
- Get the fuck out of here. Sleep on the floor, anywhere. We don’t care. Just get the fuck out of here.
We did find a place to sleep. Not on the floor, but as a close second, in the hardback plastic chairs located in the patient lounge on my ward, leaning back and using a small table for a footrest hassock. That was after cleaning up the filthy ashtrays and food remnants that were pocketed in various spots about the room, then snarling a territorial warning at any wayward wandering patient who happened to come in to satisfy his nicotine fit. Needless to say, we did not get much sleep, or even if we did nod off, one of the two beepers would go off periodically either beckoning us to: retrieve a new admission from the ED, or to answer some nurse’s call for an IV insertion, or an order for a sleeping pill or a laxative. Or worse; for someone whose status had deteriorated and needed us to make a personal appearance, an appraisal, or medical stabilization that could easily take the rest of the night.
That was not bad enough, as by the next day the black man with pneumonia had died suddenly in his sleep, leaving me to wonder why I had ever chosen this profession at all and second-guessing what I had possibly done to cause this person to die. I had no self-esteem, had gotten no sleep, while now having to face another workday, starting it off totally exhausted and fully believing I was an inadequate involuntary murderer. But the Junior Resident was compassionate when I told him how I felt. He said it was just a joke about letting my first patient die, that the man had such an advanced illness he had very little chance of survival anyway and that all physicians lose patients throughout their career. He said that the best you can do in retrospect is to believe in yourself. He added that in always second guessing everything you do for someone you will always find peace or solace if you can honestly say you did absolutely everything you possibly could. He also said you must at all costs retain a sense of humor, because this was the kind of business that above all required a person to have to able to laugh, just to keep from crying.
- That’s why we are training you and that is how we will train you. I can also tell you for sure; there was nothing else you could have done for that man. It was entirely up to God and the antibiotics we used; so in the end it was obvious that for him, neither one of them worked out too favorably.
About eight months later when I was assigned to the ICU and got a patient with multiple interacting; terminal co-morbidities, this same Resident ripped me a new asshole when I suggested we should just go ahead and let him die.
- You don’t know enough yet to decide about life and death. You have no right to think like that at this stage of your career. Yes, this man has very little hope, but any hope is enough to give him every benefit of the doubt. And since he is in renal failure, tomorrow I want you to give the group a small dissertation on treating the medical complications of uremia as well as an explanation for the mechanism of renal tubular acidosis. We are going to use this patient as an example of pulling out all the stops in treating every medical complication he might have. This is a major teaching center, for God’s sake. Now in the future, I’ll inform you Mr. “Let Him Go” when I think you are experienced and smart enough to be able to make those judgments. So, while you’re studying tonight for your uremia presentation, think about whether or not you would say the same thing if that man happened to be your own father.
Even though the man did die several days later, the episode did serve to be humbling as well as educational, and from that day forward, every terminal illness served to teach me not only the natural history of numerous disease states, but also afforded me the opportunity to do everything in my power to abort or to favorably modify the end-game; Meet the Reaper.
Secondarily, it taught me better judgment and widened my perspectives. Taking care of someone in the downward irreversible spiral staircase leading to death is sometimes like holding back a flood by sticking your finger into a cracked dyke. These situations serve to occasionally allow for the earlier interception of a reversible clinical problem in someone else who might die the same way; if not for the physician’s personal experience, anticipation and diligence. As physicians, we never “let people go” unless they are terminally ill, or brain dead. As a rule, we exhaust all resources to save people. Then again, sometimes people simply die no matter what you do.
One exception to not letting someone go occurred during my training when I was a Senior Resident and finally let a twenty-eight-year-old man bleed to death. He was a hard-core alcoholic with cirrhotic liver failure that caused the portal hypertension resulting in massive recurrent bleeding from esophageal varices. His liver was dead, and the rest of his body was trying to catch up. It was also before technology advanced to the point of liver transplantation. My heart went out to him initially because had no family or friends and I fully believed his environment had conspired to provide such little hope in life that finding solace in booze was his only means of escape. The real problem was, as it is with most dangerous addictions, that the escape eventually does become permanent. But in taking a protracted course, as the ship slowly sinks; the addict also sucks too many other people or other valuable resources into the vortex along with it. That is of course unless the addict does everyone a big favor by inadvertently taking a lethal overdose. Being naively enthusiastic, I spent time with him, counseled him, got him briefly to go to AA, and arranged for social service support; but to no avail. He always coupled the vacant eyes of a lost hollow soul with the inadequate personality that had already put him beyond reasonable reach. There was simply no humanity left inside the thin remnant of his human shell. As with any addiction, I eventually came to recognize his look as the same predictive look of recidivism I would encounter repeatedly in clinical practice, especially when counseling against tobacco use. When you tell someone they must stop smoking, their eyes immediately glass over vacantly then either roll up or glance to side. Their facial expression suddenly becomes a blank mask. This lets you know immediately, simply because they do not want to, that there is no hope for that person to break the habit.
This man then, had multiple admissions due to relapses of the drinking habit that caused repeated massive bleeds. It finally culminated in a hospitalization that required 28 units of blood and depleted our blood bank. With every possible treatment option exhausted, the case went beyond even the gastroenterologist’s or surgeon’s ability to stop the crimson flood, such that even the best minds on the subspecialty medical staff capitulated and gave up. They unanimously pronounced that there was nothing else to do. If he kept bleeding; he would eventually die. His intern called me one night to tell me the patient was going into shock and should we “just let him go?” After I gave him the same lecture that I had received two years earlier, then telling him I would handle the rest, sent the Intern to bed. After he left, I pulled the curtain around the young man’s bed, sat holding his hand for the rest of the night, and let him peacefully die. He could not be saved, either in body or in soul, and we desperately needed the bed and the blood for people we could help. It was a judgment made in the context of reasonable experience as well as one sanctioned by the academic staff. It also let my intern entirely off the hook, in a situation where any plea I might have made for help had a pre-ordained denial by the powers that be. Don’t call us; we’ll call you.
Ironic, I thought, that this man with nothing at all going for himself had understandably fallen under the spell of evil spirits, but that the likes of the Grateful Dead’s Pigpen Mc Kernan, who had the world by the balls, died exactly the same way at the age of twenty-six. He chronically poisoned his own liver with a mixture of Strawberry Kool-Aid and Ripple wine. Believe me. At that young age this is very hard to do and, requires an enormous quantity of fermented grapes mixed with sugar water to accomplish the task. It was said by some eyewitnesses that Pigpen started drinking at breakfast; and that breakfast lasted pretty much all day. One of the most difficult problems to deal with as a physician is the addicted patient. The cure rate is only about thirty percent and after you do all that you can do, there is still only so much that you can really do. The rest is up to the patient. The only thing understandable about it all is the fact that each addiction is the indifferent demon that does not care at all: whom, what, where, when, how or why. Hollywood, the music industry and Mount Everest are littered with the corpses of dead addicts.
In the lobby of St. Luke’s hospital in Manhattan, there is a large statue of the hospital’s namesake, standing in front of his mascot, an ox. Saint Luke, a healer himself, is the patron Saint of physicians and surgeons, who was also a famed iconographer who specialized in portraits of The Virgin Mary. His own iconic mascot is usually considered to be imagery representing sacrifice, and possibly the ultimate sacrifice made by Jesus. But don’t ever tell that to a Hindu. They believe the cow is sacred, but not necessarily its owner.
The first and last time I saw this statue was when presenting myself for duty. But for some strange reason, I never went in or out the front door after that day. This somehow created an inadvertent disconnect between my call to a supposedly high vocation and its necessary guiding light. From that point forward the hospital only became a generic base for my practical clinical education, as I never again thought of any associated spiritual implications or ramifications.
There were too many situations to come along in the future in which there was nothing fair about who lived or who died, about what age it happened, about who got what terrible disease and who did not, or about who really deserved to die and who did not. There was no logic to it, no discernable divine plan, and no last minute intercessions from some divine being or Saint for the many hapless people I saw who had fervently prayed but who then had their prayers go up with the same smoke of their cremated remains.
By the time I had survived my first day at St. Luke’s Hospital not only did I never believe I was going to make it as a physician, and in taking little solace from the good saint’s inspiring statuary and legacy, simply concluded by muttering to myself:
- Holy Mary Mother of God, why did I do such a ridiculously insane to myself?
As expected, no one answered. And then my beeper went off again.
I then spent the next thirty years of my life sacrificing myself to night call; to the point that not only did it literally nearly kill me, but it also to eroded or destroyed most of my intimate interpersonal relationships. It then secondarily caused me to change my religious orientation as I began to direct all my subsequent prayers from Jesus, instead to Hypnos, the Greek god and patron saint of sleep. Keep the cow. I would rather take a Valium and a get a few extra REMs.
To sleep: perchance to dream; ay there’s the rub.