Читать книгу Dr. Galen's Little Black Bag: Stories - R.A. Comunale M.D. M.D. - Страница 5

“Holy shit!”

Andy Kagill clutched his groin protectively, while the rest of us guys experienced that uniquely male sensation that occurs when we sit in cold water.

The gals looked on with Mona Lisa smiles.

“Yes, ladies and gentlemen, this poor woman definitely had a vaginal overbite.”

Second year medical school had begun on a beautifully balmy August day—definitely not weather conducive to studying. But this was pathology year, the year of the odd, the unusual, and the unexpected. Our previous year had been spent learning the normal, or what was considered normal. Now we got to see in full detail the tricks that Mother Nature could play on her children.

We stood there in the Pathology Museum, staring at a vast array of organ specimens in thick glass jars. Needless to say, the urology and gynecology sections grabbed our attention.

“This is a perfect example of a teratoma,” Professor Madden intoned, pointing at a large jar containing the mortal remains of a woman upon whom nature had bestowed the ultimate indignity: Lining her vulva were two complete rows of teeth.

For you scientifically inclined readers, teratomas are tumors that usually begin when a baby forms inside its mother. Cells that ultimately become different types of organs and tissues locate in the wrong place and develop just as they would in their correct position—hair, eyeballs, limbs, you name it. They can be found anywhere from the base of the tongue to the genitals.

Our class clown, Andy—yes, medical school has them—leered at his girlfriend, Tanya.

“You aren’t going to surprise me, are you?”

The smile on her face could have air-conditioned the room.

“You’ll never know.”

Most of us had survived the first year’s comprehensive exams, that critical testing of mind and body, fighting fatigue and knowledge overload. Ten did not. Three would be repeating freshman year, one had shot himself, and six had decided their best interests lay elsewhere.

Year two meant pairing off, kindred men and women finding each other and beginning the dating/mating ritual full tilt. Dave had fallen head over country-boy heels in love with Connie, whom he called the Teacher. My other friend, Bill, aka Baby Face, had lost his gentleman’s reserve over Peggy, the Southern Belle.

Me? I wasn’t the passionate type.

Right.

Until I met June, aka The Model.

From that time on the six of us became life-long friends. We survived and thrived in school because of one another.

I miss you, my friends.

Sophomore year. We carried our black bags to clinical presentations, ready to jump up and approach a patient staring back at us from a chair, wheelchair, or stretcher when a professor called our name.

“Mr. Galen.”

“Yes, sir?”

“Take a look at our patient. What are your observations?”

Dr. Stemp was known for pulling surprises.

The young man, no more than seventeen, smiled at me when I approached him. He sat in gym shorts and tee-shirt, totally unfazed by the two-hundred-or-so eyes staring at him.

“Hi … uh … Mr.…”

“I’m Terry.”

“Okay, Terry … uh … would you please take your shirt off?”

“Sure.”

He reached over his shoulder and, in that special guy way pulled the back of the white tee up and over his head and then looked right at me.

I don’t know if my classmates in the amphitheater saw it, but I had one of those pit-of-the-stomach reactions when I spied the glistening, red-black, one-inch spot on Terry’s right shoulder. I moved closer to him, palpated it and then felt under his arms and around his neck. The enlarged lymph nodes were unmistakable.

“Terry, would you lie down?”

He stretched himself out on the cart, and I ran my fingers over the place in his abdomen where the liver would be. It wasn’t hard to find. It was twice normal size.

I helped him sit back up and turned to the professor.

“Terry has melanoma, and it’s spread to his lymph nodes and liver.”

The room went silent. Even as sophomores we knew what it meant. We had just completed a section on malignancies of the skin. This young man’s fate was sealed.

It is fairly easy to read a textbook and study photos and descriptions of different medical problems. It’s another story when the subject is alive, alert, and damned nice.

“Didn’t you forget something, Mr. Galen?”

Dr. Stemp raised his right eyebrow.

Terry whispered softly, so I think I was the only one to hear him.

“Listen to my chest, Doc.”

I quickly opened my bag, took out my stethoscope, and self-consciously strained my ears. The classical machine-shop rumble of a hole in the heart wall separating the two main chambers roared back at me.

“Terry has a VSD, Dr. Stemp, a ventricular septal defect.”

Stemp nodded, and I sat down.

In small groups, the rest of the class approached, examined the devil on Terry’s shoulder, and listened to the demon in his chest. After we finished we applauded the young man as an attendant wheeled him out of the room. When they reached the door, Terry sat up, forming the two fingers of his right hand in a V and yelling, “I’m going to lick this, guys!”

Stemp stared at the floor; the rest of us tried our best not to cry.

Other memories of those days march through my mind: more practical exams with microscope slides, unlabeled organs in jars, and fresh specimens delivered straight from the operating room or the morgue. Each bore the cryptic questions designed to tease and distract us. We didn’t just identify, we had to extrapolate: What would you expect this patient’s blood tests to show? What symptoms did he or she experience because this organ was not doing its job? And so on.

We learned something else: vigilance. At conferences we saw doctors called on the carpet and made to look like fools for missing what were obvious diagnoses to the pathologists once they had sliced open a deceased’s body. We witnessed even high and mighty specialists knocked down like bowling pins by the pathology reports. And indirectly we learned that cherished beliefs often have no basis in fact.

“Class, Mrs. Dayten was kind enough to share her problem with you today before her surgery.”

The general surgeon smiled benignly at the middle-aged woman sitting in the wheel chair. We had just studied breast tissue and the various tumors that could occur.

“Miss Sabo, would you do the honors?”

My classmate Judy hesitated then rose from her seat and approached the woman.

“Hello, Mrs. Dayten, I’m Judy. What seems to be your problem?”

She jumped back reflexively when the woman abruptly pulled open the top of her gown. Even from the back row we could see the corrugated surface on her left breast.

Paget’s disease of the breast. Insidious and misleading, it often appears as a skin rash like eczema and lulls the unaware into ignoring it until it becomes untreatable. Today’s health-savvy women are trained not to ignore even the slightest changes. Back then, neither the patient nor the medical professional were as enlightened.

Once more we stood in small groups around our patient and saw and felt the peau d’orange (orange-peel) roughness of the skin over the tumor.

Mrs. Dayten was to undergo a radical mastectomy in several hours. The women in the class held her hand.

We knew what would happen to her. Surgeons would remove not only the entire breast but also the lymph nodes under her arm and even some of the muscle tissue. That side of her chest would become a living skeleton.

Now, decades later, I shake my head in dismay. The procedure maimed those who underwent it and did little to prolong their survival.

What present-day treatments will become anathema under the scrutiny of future knowledge?

The year progressed and we marched through the various disciplines of the human body, studying each organ system with its unique chemistries, physiology, and anatomy, both visible and microscopic. And as we did so, we were introduced to the living personifications of what could go wrong.

“Note the dimensions of our patients’ chests and the way they breathe.”

We traveled by car to other institutions, including the local Veterans Administration hospital on the outskirts of Richmond. This time we saw first-hand the ravages of lifetime smoking, compliments of the countless free cartons of cigarettes given to soldiers during two world wars.

Two men, old before their time, sat in chairs, plastic tubes feeding oxygen from portable tanks into their mouths and noses. I stared at the two—so different and yet so alike. One looked like he had just been rescued from a concentration camp: thin and emaciated with flushed skin, his every attempt to breathe seemed a tiring effort. The other soldier, barrel-chested, wheezed and coughed and spat sputum (phlegm) into a cup by his side.

Seeing them took me back to my childhood, to my world in the tenements, when I was just a kid called Berto. To this day I retain vivid images of The Old Guys, three World War I vets who gathered at the shoe-repair shop of their legless war buddy, Harold Ruddy. That’s where I saw the devastation caused by the Germans’ use of mustard gas. Our neighbor, Tim Brown, lived a life of oxygen deprivation, drowning in a sea of air, because his lungs were almost non-existent.

But the men in that veteran’s hospital hadn’t been gassed—at least not by others.

They had unknowingly damaged themselves with decades of heavy smoking.

“Class, note the typical “blue-bloater” and “pink-puffer” habitus (body shape) of our patients.”

Dr. Marja Gortan was a lung specialist, a former refugee from Eastern Europe. Diminutive, almost doll-sized, she paced back and forth in front of us, her long white professor’s coat fluttering, as she pointed out the skin color and body shape of the thin emphysema patient and the large-chested variation, which we then called chronic bronchitis. Now they are considered varieties of chronic obstructive pulmonary disease.

We walked through the respiratory patient ward wide-eyed. Men—and women—so desperately ill from cancer that holes had to be cut in their necks, had tubes inserted to bypass the tumor-scarred upper parts of their windpipes. Such images burned themselves into my brain: terminal lung and voice-box cancer patients, some with no vocal cords, were forced to speak by burping out words. And what were they doing? Inhaling cigarette smoke through those tubes, their wasted fingers shaking while they held the lit cigarettes up to the openings in their necks called tracheostomies.

When we left the VA hospital to return to our campus, Dave looked toward a nearby doorway and gasped.

“Geez, looka’ that!”

The six of us stared: Gortan was standing in the doorway lighting a cigarette.

Year two saw perverse cosmic jokes played by the fates on the unsuspecting.

That year we lost our class clown.

“I have some tragic news,” the dean announced. “There was a terrible auto accident this morning and … uh … Mr. Andrew Kagill was fatally injured.”

He cringed, when a loud scream erupted from Tanya. Other students quickly surrounded her, and the sobs were not just from the girls.

This is life’s biggest lesson: No one is immune to the Dark Angel.

But the bitter irony lay in what transpired later

The year was coming to a close. We had covered the various internal pathologies of the human body, and now we would be exposed to the accidental.

“Old Gordie’s gonna do the horror show, isn’t he?”

Dave and I sat in the amphitheater next to Bill, June, Peggy and Connie. The pairing was so obvious that no one laughed or made snide comments anymore. Our class had found itself.

This was climactic, Grand Guignol horror show. Given by one of the foremost forensic pathologists in the nation, it was an anticipated event for every second-year class.

Gordon Makland had made a career of studying the effects of external trauma—accidental, malicious, or self-inflicted. Was it chance or murder? Show him a body, and within minutes he could tell you cause of death and whether or not it was by chance. He could wax poetic on the effects of gravity and its impact on falling bodies and why certain teenagers unintentionally killed themselves by hanging.

“Old Gordie’s slide show,” as everyone called it, was the culmination of our sophomore studies.

Makland was not one-dimensional. He was also an avid amateur geologist and rock hound. I was, in later years, privileged accompany him and play mountain goat and spelunker in search of mineral specimens.

That day in late April we sat and fidgeted and nervously joked while Sid Graham the projectionist set up the 35-millimeter slide trays. Yes, young doctors, we actually used primitive stuff like film back then.

Makland stood in typical slumped pose, his gaunt, six-foot-four frame leaning over the podium. He nervously drummed his fingers so close to the microphone that the room resounded with laughter to the elephant-herd sounds. When he caught on and stopped, the dark blue eyes in his rectangular jowly face penetrated the semi-darkness, and he cleared his throat. Then he smoothed graying cowlicks back into place and harrumphed.

“I want to warn you, ladies and gentlemen. What you are about to see is graphic, raw, and not to be taken lightly. These were once living beings like you. If I hear any snide comments or levity I will end the session. I will also have the offending individual expelled. Do you understand?”

We all nodded.

The first slide startled all of us. The vacant-eyed face of a dead, motor-vehicle-accident victim stared back at us in full frontal view. A good part of his brain had been forced down through his nose from the impact of his head against the windshield.

His demise had occurred long before mandatory seat belts and collapsible steering wheels.

“Visualize the force vectors involved as this man’s head hit and penetrated the windshield at sixty miles per hour.”

He didn’t have to remind us—we could feel it.

Slide two: two bushel baskets containing what appeared to be pounds of raw hamburger. What seemed out of place was the foot still encased in a worn work boot poking out the top of one basket.

Makland’s voice seemed overly dry, as he off-handedly remarked, “This farmer got pulled into his own thresher machine.”

One student in the back rose and quickly ran out of the room.

Slides three and four. Front view: a small hole with burn marks in the middle of a young woman’s forehead. Her eyes had popped out of their sockets. Back view: The entire back of her skull was missing.

“This was the result of domestic violence. Love and hate walk side-by-side, ladies and gentlemen. Please note how the shock wave of the bullet caused a massive exit wound.”

Several more students rose and left.

And so it went: bodies turned to mush by falls; burn victims, their muscles so contracted by the heat that they appeared to be in a boxer’s stance; drowning victims, their bodies bloated and their lips, earlobes, noses, and eyelids eaten away by fish and crabs.

“That should do it. You can shut down the projector, Mr. Graham.”

The fates laughed cruelly, as Graham’s finger hit the advance button by mistake.

Along with gasps, we stared at one final picture. Taken through the passenger door, the view showed the auto-accident victim impaled by the steering post, legs pulped by the engine, mouth wide open, tongue protruding, eyes staring at eternity.

You would have become a fine doctor, Andy.

May brought the usual, early, Richmond summer heat and humidity, but we sweated more heavily for another reason. Now we faced the first of a three-part hurdle to achieve the degree of Doctor of Medicine: the first part of the National Board of Medical Examiners’ certification exam. The faculty had lightened up on its academic onslaught by giving us review classes covering all of the information we had been swamped with over the past two years.

Once again we cocooned ourselves in our rooms, hid out in library carrels, or found secret, unused niches in the education building to study like monks. Not even our friends could help us through this.

We had been warned that part one was written by Ph.D. types, so we had better know all our basic sciences. It has always been a running battle between the Ph.D.s in science and the M.D.s as to what really matters in a medical education. As students, we were caught in the middle of the academic fracas.

It took two days, and when it ended our fates were sealed. Those who passed would advance to year three. Those who did not either had to retake it or a state-sponsored, equivalent-competency test. Neither was a piece of cake. The prime advantage of passing the National Boards lay in one word: reciprocity. Those who successfully completed all three parts—the first now, the second at the end of year three, and the third during first-year post-graduate—would be granted a license to practice medicine in all but three states: Florida, California, and Hawaii.

The reason? Those three sunshine states did not want to be inundated by geezer physicians when they retired.

“Hey, City Boy, got your whites yet?”

Dave stood in the doorway of our apartment on Church Hill, looking like a thin line of whipped cream. He grinned at me. In one month we would be hitting the wards.

Soon our little black bags would be put to daily use.

I quickly changed into my outfit, and we laughed hysterically at our reflections in the full-length door mirror: tall and short, slim and stocky, Mutt and Jeff.

We changed back into civvies and ran down the stairs to Dave’s car. We were headed to his family’s farm near Lynchburg again for some well-earned rest and relaxation.

We would need it.

Year three would use live ammunition.