Читать книгу Dr. Galen's Little Black Bag: Stories - R.A. Comunale M.D. M.D. - Страница 6

Berto, do you really want to be like me?

I lay in the four-poster, twin-size bed, the overstuffed mattress probably not much younger than the handmade chestnut wood frame passed down through six generations in Dave’s family. The rustic sounds and scents easily penetrated the thin bedroom walls: crickets chirping, small nocturnal creatures rustling through piles of decaying leaves; the ch-hoot of the wood owl and the groaning yips of raccoons competing for food scraps tossed atop a nearby compost pile.

Even the early summer couldn’t ward off the natural night chill permeating the little farmhouse in the middle of nowhere. I settled the patchwork down quilt around my neck, turned on my side, and closed my eyes. It was so easy to fall asleep.

I dreamed that night.

I was once more a young boy named Berto. I strode through the alleys of my memory, seeing once more the friends who had shared my life: Angie, Tomas, Salvatore, and others. I ran through the tenement streets, legs pumping, short gasps of breath in anticipation of what I would see, what I would learn next at the storefront clinic run by my mentor, Dr. Corrado Agnelli.

Doors seemed to melt away. I entered the examining room. A man lay on a table. He was gaunt, wasted, the sheet covering his body missing the outline of one leg. I saw my friend, the one who had opened the door to my life’s work, lying there.

“Corrado, it’s me, Berto. What’s wrong?” I heard myself cry out.

The face staring up at me smiled wanly, and then tears flowed from the man I sought to emulate.

“I’m dying, Berto. I will die alone.”

He paused to catch a breath then stared into my soul.

“Berto, do you really want to be like me?”

I awoke screaming with Dave standing over me and shaking me.

Those three weeks between the end of sophomore year and the beginning of our clinical rotations as third-year students were painfully short.

Dave’s parents had accepted me as a second son, a brother to their only child.

They instructed me in the ways of farming and how plants and animals really lived.

Dave and his father, Big Dave, laughed at my awkward attempts to cut and split firewood. I nearly amputated my left foot and smashed my toe from clumsy swings of axe and hammer. His mother, Mary, showed me what fresh vegetables looked like and how to prepare them. To my amazement they were actually edible, not the gray mucilage I was accustomed to from my mother’s ethnic, iron-cauldron-cooked “everything soup.”

Dave and I walked and walked over rutted dirt roads, gazing at gentle-sloping hills dotted with tobacco patches and pastures of grazing cows. My skin easily burned in the full Virginia summer sun.

“Why do you want to leave here, Dave?”

We sat on mounds of hay grass, with large, dried tobacco leaves our only fans and protection against the midday gnats and blue-tail flies that populated the cow pastures.

A nearby black snake sunned itself, as Dave turned to me.

“Sometimes even paradise can be boring, City Boy.”

He looked down for a second then faced me once more.

“’Sides, I got Connie waitin’ fer me, and I betcha you ain’t stopped thinkin’ ’bout June.”

We walked past the now-abandoned tin shack where Aunt Hattie, the local conjer lady, had lived and died, and I felt once more the chill of my first and last encounter with the burnished ebony woman, when she had warned me about the Bone Man. We walked through cow-patty-filled fields and over rock-strewn woods. Dave easily stepped over the moss-hidden stones, while I tried my best to avoid tripping and breaking my neck.

I laugh now, as I remember how unsuccessful I was at avoiding cow pies.

Suddenly we came upon a clearing in the midst of Jackson oaks, persimmon trees, and scrub vegetation. The ground rose and fell in short mounds and depressions unlike anything I had seen before.

Dave stood there, head bowed, eyes closed, and I suddenly understood: It was a cemetery, his family’s final resting place. Six generations of pioneer farmers, each striving to earn a better life, had lived and died on that property. Someday Big Dave and Mary would lie there, too. Dave was the first in his family to achieve his level of education. He was also the last of his line—unless Connie would change that.

We walked and walked, and we shared each other’s demons. And then it was time to go.

Strange, as we left the little farmhouse to return to Richmond, Dave’s parents hugged me as they did their natural son. They were proud of us both.

The first morning back we dressed in our starched white pants and shirts. They felt stiff and rough, not like the synthetic-blend fabrics used today. We had received our list of clinical rotations in the campus mail. For the most part Dave and I shared the same, six-to-eight-week turns in the various medical and surgical services. Connie, Peggy, June, and Bill had also been matched with us.

It was only a short walk across the Marshall Street Viaduct from our apartment on Church Hill. It was 6:30 a.m., but the heat was already scorching by the time we neared the hospital. Cars honked at us and drivers waved. The locals knew we were the new medical kids, little black bags clutched in our hands, striding into our first day of ward duty.

“Galen, Nash, you’re with me.”

Our first boss was Joe Tremayne. As a first-year, post-graduate—we called them interns then—he was directly in charge of us newbies. It was not considered a fun job. Not only did he have to do his own work, he also had to diaper and change us during our first, critical rotation. Of course the resident over him felt the same way about interns. Tremayne himself was fresh out of school, full of book knowledge and undergraduate ward experience. But this was also his first day as a real doctor. And so it went up the pecking order, from first- to second- to third- and fourth-year students all the way to chief resident and attending physician.

Pity the poor nurses who had to deal with all those large but fragile egos!

We learned quickly who the real bosses were: the floor nurses and nurse supervisors—and justifiably so. They were the patient’s first line of defense against the incipient young Dr. Frankensteins, who wanted to diagnose and cure everything while creating unimaginable mayhem.

We started in learning about early morning rounds, the ritual procession of students, interns, residents, and professor doctors going from patient to patient, reviewing each one’s status, test results, and anything else the attending could throw at us to catch us off guard.

“Dr. Tremayne, what’s Mr. Jacobs’ renal status?”

Our intern flinched. He began to reach for the patient’s chart, but his hand was slapped away by Dr. Godfrey.

“Tremayne, I asked you a question. I don’t want you to read. Do you or do you not know your patient’s lab numbers?”

It wasn’t a fair question. Tremayne had just arrived that day. The resident tried to explain that but was stared down. Godfrey’s smile was not friendly. He had snared a victim. He would have fun playing with this mouse.

Then the floor nurse saved the day.

“Dr. Godfrey, Mr. Jacobs’ test results aren’t back yet.”

She stared at the pompous ass. She had been the floor nurse when his own ears were still wet.

“Uh … thank you, nurse,” Godfrey mumbled then turned toward another bed. This time he directed his questions at the resident who had actually dealt with the patient.

After rounds, our crew, minus Dr. Godfrey, sat in the doctor’s lounge in back of the nursing station. The first-year resident glanced at Tremayne then directed his words toward us and the senior medical students.

“Learn to expect the unexpected. Know who and what you’re dealing with, and then be prepared. Need I say more?”

We shook our heads.

The rest of the morning we introduced ourselves to our assigned patients and then familiarized ourselves with their charts. But that time was not uninterrupted. Patients could be sent to our floor at any time, usually admitted from the emergency room after they had been evaluated for their complaints. Those determined to have major problems were admitted to a general medical floor.

Dave got the first one.

“Mr. Nash, you’ve got Mrs. Cassidy. She’s a lol (little old lady) with dyspnea (shortness of breath) and leg pain. Work her up for CHF (congestive heart failure).”

Tremayne was a nice guy and, as it turned out, a good intern and resident who later specialized in gastroenterology. We kept in touch for decades until his sudden and unexpected death at age fifty-five.

He had always believed in being physically fit. Ironic, but he died in his home exercise room.

Dave was perspiring, as he grabbed his bag from the shelf and headed down the hall to room 315. I could see the orderly pushing a now-empty gurney from the room. His patient had arrived and was in bed. The nurse assigned to her would be checking her information and taking her vital signs. It was his first patient.

I have always maintained the greatest respect for nurses and, after witnessing how one had gone out of her way to save Tremayne’s ass, I vowed never to interrupt them when they were doing their job. It earned me valuable brownie points.

Bag in hand I likewise headed down the hall. I wanted to get to know my patients, get a feel for their physical and mental condition. There’s a difference between assessing medical information and developing empathy and understanding. Good doctors are well-versed in their technical skills; great doctors understand people.

Thank you, Corrado, for showing me what makes a great physician.

I walked into room 312. My first patient, Leroy Simpson, had been admitted three days ago. From the scuttlebutt, he was something of a scalawag with the ladies and was now suffering the consequences of severe prostate infection. His condition warranted IV antibiotics.

Yes, young doctors, today you whip out your electronic pads and send an e-prescription order for a quinolone (very potent) antibiotic after determining the particular type of germ causing the problem. And, yes, if your patient doesn’t have prescription insurance, he or she will bellyache until the cows came home about the cost—often up to $10 per pill.

Your patient would be better in a day or two but still hate your guts.

Back in my day those drugs didn’t exist. We were stuck with pills that could not handle those infections, so we were forced to pump very toxic medications into patients’ veins—or their butts if it could be given intramuscularly.

Sometimes it took two weeks in the hospital, assuming the patient didn’t suffer complications such as inflamed veins, massive skin rashes, blood clots, kidney or liver failure, or even sudden death.

And if they got better, they hated your guts.

Plus ça change, plus c’est le même chose.

The more things change, the more they stay the same.

I stuck my head in the door and saw a nurse taking Simpson’s blood pressure and temperature. She saw me, smiled, and then resumed what she was doing.

Never interrupt a nurse.

She finished and, barely avoiding Leroy’s attempt to pat her rump, passed me in the doorway.

“Thanks for waiting, Galen.”

She was younger than I was, just out of nursing school and, I have to admit, if I hadn’t been totally smitten with June, I would have been tempted. I watched her an extra second or two, as she left the room.

Simpson leered at me then growled, “You can’t have her, Doc, she’s all mine.”

I forgot to mention: Leroy Simpson was eighty-six.

And so it went, awkwardly at first, then with a bit of chutzpah and luck, I got to know my six patients. Leroy was the oldest; Barry Jackson, nineteen, was the youngest—and sickest. The boy had swallowed ethylene glycol (antifreeze) on a dare, and now his kidneys were shot. Our job was to attempt to stabilize him before transferring him to the renal unit, where he would undergo dialysis.

This was in the early days of treating kidney failure, several years before two brilliant surgeons—David Hume and Richard Lower—pioneered a kidney-transplant program at my school.

Barry didn’t make it.

Medical conferences at lunch were next. That was good. You could eat all the sandwiches you could steal from the faculty table. The afternoon brought scut work, such as taking blood, checking test reports, and wrapping up with the intern and resident. My friends had all gotten new patients and had done their first workup. They congratulated me for not having to work too hard that day.

Tremayne heard it and snickered.

“Don’t feel bad, Galen. In case you haven’t heard you’re on duty tonight.”

Yes, I had drawn the short straw. I would work the night shift and not return home until the following evening. I turned to Dave, who understood.

“Yeah, I’ll drop by with some fresh clothes and your shaving kit.”

It was after midnight when I got my first patient workup: Johnny Mangan. Johnny was the friendly young boy with only half a skull because of tumor surgery. I got to know Johnny’s hopes and dreams in that brief time between my examining him and his death several hours later.

The nurses brought me his untouched breakfast tray.

My friends and I made our bones on that first rotation in general medicine. We saw life snuffed out despite our efforts. And we carried those memories forward into our personal lives and careers.

Next stop: surgery.

Bill, Dave, and I felt like we had joined the big boys’ club when we entered the surgeons’ locker room and got to see the Kings of the Hospital in the altogether.

Not impressive.

They showed us how to change into scrub pants and shirts and put coverings on our shoes and heads.

It was not an enlightened time for women, so Connie, Peggy, and June were required to change in the nurses’ locker room.

We learned that surgical rotations required an inhuman schedule. The surgeons started rounds at 5 a.m. before working long hours in the operating room and then doing post-surgery follow-ups on their patients in the clinics.

In recent times, various regulatory boards have declared that students and residents should only work an eighty-hour week. But back then you went on duty at dawn and went home the following day at 7 p.m.—if you were lucky—and then it started all over again.

“Thirty six on, twelve off” was the rule.

“Are you snoring, Mr. Galen?”

I felt the rap of a bloody forceps on my gloved hand, as I stood for hours holding a retractor while trying to control my bladder.

But we did learn. We helped yank out diseased gall bladders and perforated appendixes. We heard and felt the snap, as the orthopedic surgeon would rebreak an improperly healing bone and pin the ends back together. We observed the chest surgeon use giant snippers to cut through ribs to get at a lung or heart.

“Mr. Packard, a thirty-six-year-old carpenter, is here today for pericardiectomy. Mr. Galen, what were his presenting symptoms?”

We stood around the bed of the African-American male just before he was to be prepped for surgery that would remove the sack that covered his heart. He had suffered an unusual complication from an infection called rheumatic fever as a child. As a result the case around his heart had become stiff and hard, preventing it from fully contracting and expanding. He couldn’t walk or do the activities that most of us took for granted without rapidly tiring.

That’s what we all thought.

And then…

“Holy Jesus, look at that!”

The chief surgical resident had completed the initial cutting and removal of two portions of ribs to expose the heart. The heavy chest retractors had spread the ribs even farther, and we crowded and craned our necks to see what we could see from our back-row vantage point.

“Isolation precautions, stat!” the surgeon yelled, as we six, lowly, third-year students wondered what the hell was going on.

The operating room nurse quickly herded us aside.

“It’s tuberculosis. I’ve never seen anything like this!”

Today’s CT and ultrasound scans would have forewarned the surgeon. But we had only simple chest X-rays, and they could not detect the problem.

Ezekiel Packard had had rheumatic fever. What no one realized was that he also had tuberculosis and, unlike most TB that affected the lungs and kidneys, his infection had settled in the heart sack, the pericardium. The cheesy, thick-white, tuberculosis infection caused the scarring.

Tuberculosis is very contagious and, like syphilis, was a big concern among healthcare personnel who had to deal with a patient’s unknown condition.

They shooed us out of the operating room and told us to shower and change into fresh clothes—a fitting last day for surgical rotation.

We were happy to be back in whites again. Now we would be on call only every third night, with kids and little babies the beneficiaries of our developing skills.

“Children are not small adults. Remember that, ladies and gentlemen.”

That bit of wisdom emanated from the pediatric resident just before the professor of the day strode onto the ward. We had heard about Herr Professor Doctor Guetlich, aka the Nazi.

I have never been certain if the nickname fit. What I do remember are two things:

1. A previous, third-year class member had suddenly stood up one day, clicked his heels together, and shouted, “Sieg Heil!” As the story was told, Guetlich snapped to attention and returned the salute. Apocrypha?

2. The professor’s favorite expression was, “Die Kinder sind germ bags.”

Children are germ bags.

We had been warned: Expect to get sick at least once during pediatric rotation. I was lucky. Growing up in the tenements and hanging out at Dr. Agnelli’s clinic had exposed me to an array of bugs my friends had never dreamed of. I was the only one who didn’t develop some kind of viral infection.

These were the days before multiple vaccinations turned kids into pincushions by their second birthday. We were expected to have received all the UCHD (usual childhood diseases) before entering medical school. Oh, we still had to be vaccinated against smallpox, typhoid, tetanus, diphtheria, and polio. God bless him, Corrado Agnelli had administered those fun-filled shots to me using the thick stainless steel needles so common then.

The effect was profound. I wanted to crawl under my bed for a week, especially from the old-style typhoid shot. But a number of my classmates were not so lucky. Two of the guys came down with mumps and became sterile. In adult males the swelling is in the genitals, not the face, and the disease destroys the reproductive cells. One girl barely missed developing encephalitis (a brain infection) from chickenpox, even though her parents had told her she had had the disease in childhood.

My friends suffered several viral respiratory infections before their immune systems could get up to speed.

I also learned that, in pediatrics, book smarts do not always go hand-in-hand with common sense.

We were paired off in the infant unit the first week. This time my partner was Chuck, a classmate I knew only in passing. He was smart, had done well in the classroom and on written exams. But there was something not quite right about Chuck.

“My God, go stop him! Go stop your partner!”

The nurse came running down the hall and almost yanked me off my feet. She was gibbering.

“He won’t listen, he won’t listen.”

Chuck had been assigned the job of obtaining a blood sample from a month-old baby who had been admitted to the infant unit with an unspecified infection.

Simple task.

It is fairly easy to obtain blood from older children and adults. Put a tourniquet around the arm, watch carefully as a vein pops up in the elbow crease and, voila! You get your blood sample.

Babies are different. They are like very old people, whose veins in their arms and forearms are deeply buried and inaccessible. Instead, babies have nice, juicy scalp veins on either side of their heads.

Chuck was very good at taking tests and reasoning from point A to point B. If you needed blood from an arm, you put a tourniquet around the arm above the vein.

And if the patient is an infant? Chuck’s reasoning was very logical: for a scalp vein, well, you place a tourniquet around—you guessed it—the baby’s neck!

I stopped him just in time.

Chuck was advised to switch to a Ph.D. program, and he did well at it. Years later I heard that he taught comparative anatomy at a university and was made the faculty adviser for students who sought to enter the healthcare field.

Sometimes I saw miracles.

“Galen, she needs an exchange transfusion.”

The pediatric chief resident possessed the Wisdom of Solomon. Stuart Zelany was an older man, an engineer who had finally found meaning in life by returning to school, obtaining his M.D. then specializing in what he loved best: children. He, like Agnelli, was a doctor’s role model, a resident who made you want to stay late and observe even when you weren’t on call.

“Here’s the scoop, guys,” his deep voice rumbled.

He was, to us kids, the Old Man—he was over forty!

“This baby has ABO incompatibility, and its red blood cells are being chewed up by maternal antibody reaction.”

It was one of those genetic, toss-of-the-dice situations. The blood type of the mother and her baby did not match. Enough of the non-matching cells had managed to cross over into the baby’s circulation before birth, so a destructive process had begun that caused the baby’s red blood cells to break apart.

Little Tyra, who was not quite one day old, wouldn’t survive another twenty-four hours, unless…

Zelany, mesmerizing us with his calm, steady voice, pointed out the increasing jaundice (yellow skin) and swelling in little Tyra’s face and abdomen. He had us obtain special blood samples for blood typing and cross-matching. Then he demonstrated the technique of putting a catheter—a plastic tube—in the large vein in her belly button.

Slowly he removed some of the baby’s damaged blood into a large, special syringe and then, oh-so-carefully, gave Tyra the new blood. For each small amount of bad blood removed, an equal amount of good blood replaced it. The biggest danger was trying to remove and replace too quickly. That would overload the baby’s heart and cause it to fail.

To this day I can see Zelany’s ham-hock-sized hands gently holding that little baby and crooning over and over, “It’s okay, little one. It’s going to be okay.”

It took several hours. We stood, watched, helped when we could, and even prayed silently. We exhaled only when Zelany smiled and said “done.”

Tyra became a grandmother forty years later.

Amazingly soon third year was coming to a close with our last rotation in obstetrics and gynecology.

June immediately demonstrated her uncanny ability with the young, pregnant women in the prenatal clinic. There was a light in her eyes whenever she had the opportunity to assist a resident or attending physician in the birth of a baby or the surgical correction of a woman’s pelvic problem. It was obvious to the rest of us that The Model had found her calling.

Dave had no such interest.

“City Boy, I’ve helped birthing in too many horses and cows to want to do it all my life.”

Bill’s skill and empathy made him stand out, but, he, too, did not have the fever for OB/GYN work, and Peggy and Connie preferred general medicine and pediatrics.

Me? I also found great satisfaction in catching babies. June and I were the only students whom the residents allowed to perform simple deliveries on our own. It almost became a contest to see who could deliver the most vaginal (normal) births.

I would like to say that I let June win, but she beat me fair and square.

I probably would have followed June into an OB/GYN residency except for one incident.

“Mr. Galen, would you like to assist me?”

It was a singular honor. Dr. Tully, the department chairman, was dealing with what he called an unusual situation, and all the other residents were involved in other cases. June also had a full schedule.

By then I was an old hand at suiting up and performing the pre-op, surgical-scrub ritual of cleaning one’s hands and forearms before being assisted by the scrub nurse into sterile gown, latex gloves, and face mask.

I entered the OR and was startled to see that the patient lying on the table was a child. According to her chart, Saranda was only eleven years old. But she had been raped by her older brother, and Mother Nature had played the cruelest trick by allowing this girl to physically mature earlier than normal.

This child was going to have a baby.

I looked at the department chairman, a distinguished OB/GYN, and he saw my look.

“Saranda has a problem, Galen. Her pelvis is too small to deliver naturally. We’re going to have to do a C-section.”

Caesarian section: a procedure involving opening the abdomen, lifting the uterus up, and opening it to extract the baby, which couldn’t escape any other way without hurting itself or its mother.

As the young girl was being anesthetized, Tully whispered to me through his mask.

“There’s a problem with the baby, Mr. Galen.”

I held the retractors and helped mobilize the uterus. The surgeon’s scalpel quickly made an opening.

There was an audible gasp from the entire operating team, as we stared at what came out.

Nature is not nice. It doesn’t care what we want or expect. I saw a misshapen creature with very small head. Everything was wrong.

“Mr. Galen, God help us, it’s a fetal monster.”

No, this was not some horror or science-fiction movie. When the genetic dice are tossed, sometimes they come up craps.

The term fetal monster is used to describe a malformed, genetic mistake. It can take many forms and appearances. The one kind thing about such a situation is that the baby is either born dead or does not live more than a few moments.

Such was the case with Saranda’s baby.

I decided then and there that obstetrics was not my field. Maybe June would have felt the same. I’ll never know—and I never told her.

I can still hear Saranda’s groggy voice as she awoke out of the anesthesia.

“Can I hold my baby?”

We ended third year with a fun-filled review before taking part two of the National Boards. It was more clinical in nature this time, and our ward duty had really helped us prepare.

Bill and Peggy were off to visit her relatives—always an ominous sign for a single guy.

Connie and Dave spent a lot of time at her apartment while Peggy was away.

About June and me, let’s just say that old Berto was no slouch.

But that’s another story.

Year four would be starting soon.