Consultant US Public Health Service 1971
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medical *
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Today I'm sitting in a chemotherapy infusion room at Stanford. Jasmine is a very private person and I don't really have permission to talk about her in these blogs but she is too sick today to comfortably make the trip. My brother Geoff is here and I insisted that she stay home.
We left Morro Bay at about 3:40 A.M. I drove and we got here a little after 8. The set-up in the clinic is great...the electronic medical record system lets the lab know what is needed. Ms. Villalobos (not the cab driver in Pulp Fiction) drew my blood and started my IV for infusion...very professional, a slick needle insertion..beautiful eyes as well.
I met with the fellow, Rodeep Brar, M.D., a "California boy." He was very sharp, picked up a problem in medications and solved it immediately. We then had a very frank conversation about my future. He gave me an even chance of surviving a year. He pointed out that my treatment is more designed for quality than length of life.
I was very curious about my various possible pathways to death. He advised me to watch carefully for leg swelling--even low platelet counts can be associated with deep venous thromboses and pulmonary emboli. Other acute problems could be dehydration and pneumonia secondary to lowered white counts and immune suppression
He said that they would be happy to life-flight me to Stanford if called by my local hospital. I told him that I would want to avoid that and receive treatment near my home. He asked about my advanced directives and we were able to speak frankly about forgoing resuscitation attempts should I have a cardiac arrest.
As physicians we are both aware that death eventually comes. As an oncologist, he has certainly seen his share. He related that the most common pathway is gradual loss of energy and difficulty breathing as the tumor progresses. Because I will be scanned so frequently, he thinks that I will know about the progression from the imaging before I am aware of it physically.
We talked about my greatly reduced muscle mass, a reflection of the humoral influence of the muscle and the use of steroids which reduces muscle mass as well. ((No matter how hard I try, Schwarzeneggers Encyclopedia of Body Building will not work for me at this stage of my life ((or any stage I suspect.))) Gee, I wrote this sentence that reminds me of computer code.)
Denise is my infusion nurse. Again... consumate professional...this whole place reeks of it. Denise has reviewed my orders and gives me several medications, pre-infusion. There is a large dose of Dexamethasone, a steroid, Diphenydramine which blocks the Histamine 1 receptor and Pepcid which blocks Histamine 2. The histamine receptors are implicated in allergic reactions, so the drugs are used to mitigate the risk. Dexamethasone will also reduce the risk of allergic reactions through another mechanism.
The Diphenydramine (benadryl) is a downer. These tend to affect me very quickly and profoundly. I warn her and tell her not to let me tell her any dirty jokes. She promises that she will see that I behave appropriately at all times.
The preops take a while. The first infusion, Taxol, takes about three hours and ends about 4 PM. There are no significant side effects, a little cold sensation at injection site for 20 minutes, warmness of fingertips and toes that lasts less than 30 minutes although my feet continue to feel a little warmer than usual.
http://en.wikipedia.org/wiki/Paclitaxel
Next they hang Carboplatin. It slides in within 40 minutes. There is a little burn above the injection site that lasts for a few seconds and doesn't recur.
http://en.wikipedia.org/wiki/Carboplatin
Avastin is the last drug. Generic name Bevacizumab. It will take 90 minutes to run in. I try to persuade her to increase the rate knowing that she can't.
http://en.wikipedia.org/wiki/Bevacizumab
I am very curious about the origin of the generic name and did a cursory search and did not find it. If someone out there knows, will you please post a comment? As I am receiving this I have a sudden urge to defecate that passes in a few seconds. I've brought a couple of changes of underpants and some workout shorts just in case I have an accident on the way home. It could be a long 200 miles. I'll let you know. It's also making me cough, which has not been an issue for a few days. I wonder if these drugs are throwing spears into the sleeping dragon. I sure hope so.
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Winter 1970 - 1971
I've been thinking about that winter more than 40 years ago and I think it was the happiest time in my life up until that point. I missed Kristin. Her mother had decided to take her to Europe for an extended period of time. She had sole custody and there were little in father parental rights in Maryland at that time. I had no say and there was minimum communication. She never told me when she expected to be back and I only found out about her return and her whereabouts by accident. She told me where to send the support checks.
Although I had lost my expected job and our money prospects had dwindled, Molly and I weren't destitute and we could go out and eat roast beef sandwiches and drink beer once a week after classes often meeting friends at a place called Pappy's on Rt 40.
After Christmas we really were broke and we survived pretty much with tuna fish sandwiches on home-made bread. But, Molly makes great tuna fish with olives.
The Interview
I met with Bruce Waxman in December 1970. He was the chief of the Technology Branch of the National Center for Health Services Research and Development (NCHSRD) which was in turn a part of the Health Services and Mental Health Administration (HSMHA), etc. The Acronyms Increased from bottom to top of the chain.
The NCHSRD's mission was to address issues of access, cost, and quality of medical care. After its creation, a hodgepodge of existing, funded grants and contracts from across the Public Health Service were dropped into this agency for funding and management. The agency never managed to carve out a strong foundation and was subject to the political forces of the day, leading to several attempts to reorganize it into more meaningful definitions of priorities and divisions of labor.
Bruce Waxman was about 44 when I met him. His hair was heavily greyed. He was short, cared little about his dress, had an enormous belly that created problems for his pants and belts--he was always tugging them up--a boisterous, charming voice that was completely under the control of the master, except when he lost his temper, a not uncommon event. He had come from the NIH where he was instrumental in seeing the value of the Mini-computer.
The following wikipedia article describes the PDP-8.
http://en.wikipedia.org/wiki/PDP-8
Notice that the LINC computer built by Clark and Molnar is cited as a principal inspiration for the PDP-8. Bruce Waxman had worked with Wes Clark to make affordable computers available to bench scientists (computers in biomedical research, the phrase used in Waxman's book). This had occurred the NIH. The two remained life-long friends.
Waxman moved from the NIH to the Chief of Technology at the National Center for Health Services Research. He apparently brought several projects with him in the move and maintained his network at NIH through proteges there. Waxman was a masterful bureaucrat. He had years of experience in the so-called NIH study sections, the means by which NIH made funding decisions for scientific projects. The study section model was carried over throughout the NCHSRD.
The basic division between NIH and NCHSRD was supposed to be pure medical science versus delivery of advances in medical science and services to the people. NIH would be the ivory tower. NCHSRD was designed to become active in the way in which the provision of medical services occurred. This meant that NCHSRD had to get into bed with service organizations and physicians who delivered the medical care--a challenging, messy task.
The Interview
I needed a job, badly.
When I met Bruce, he was very friendly--a booming voice called out to his secretary, "Winnie, can you please get Dr. Sohr a cup of coffee." He had a spacious office with a conference table in the front, his personal desk in the back of the room and a couple of armchairs in front of his desk.
He walked out from behind his desk and sat in one armchair and I sat in the other. He lit his pipe. He quizzed me--
what was my background?
what had I done recently?
why didn't I want to practice medicine?
did I want to join the Public Health Service as an enlisted officer because he could arrange a commission that would solve any of my draft issues?
It's hard to fully describe the liveliness of the man or his fluency. He should have been named Bruce WaxPoeticMan. His vitality, magnetism, and self-echoing voice could take control of most rooms, even when he was uttering pure bullshit, which he sometimes did, generally for effect.
I didn't want a commission in the Public Health Service. To me it meant using the military to avoid the draft, like National Guard. He said he didn't have any current Civil Service positions open although he expected several in the summer and would like me to return later in the spring.
As we spoke, he was called away from his office. While he was out, I looked at all of the objects in his office, his coffee cups, badly done cartoon portraits, his tea pot, copies of his book, and personal photos. I kept coming back to what appeared to be a family photo, but there was something odd about it. The youngest person in the picture was an African American boy who appeared to be about Kristin's age. Maybe he had an African American child.
Well, here was my race card and the opportunity to do one of the slimiest things in my life. I decided to use the story of the young black drowning victim in Cambridge based upon my belief that he would be more likely to see me as a kindred soul if he had that knowledge.
When he returned I told him I was very grateful for his offer of a commission, but that I could not morally accept working in any branch of military service during the current war, even a branch that had been formed to meet the needs of US merchant mariners.
I don't think Dr. Waxman was wedded to morality although I think he was honorable (and dishonorable in some of the same areas of life as I was). He loved his country. He desperately wanted to make a difference. He had a large streak of narcissism that motivated him to work harder in identifying "stars," medical people who were doing important things who needed funding and who would be ever grateful to him for managing to get it to them. He worked very hard for them, but made sure that they knew how hard he was working. I don't think he understood a moral decision to turn down military service, but he was a tolerant man in many ways, able to accept what he saw as the foibles of people around him.
I then went on to tell him I really liked graduate school and was still looking for part time medical work. I informed him that my financial situation appeared set when I matriculated but I had been scrounging around for work sources after a hospital and I parted ways suddenly in September. (This was the bait. Prospective employers are always interested in this kind of information. Was I drunk on the job? Did I get caught having sex with a female employee? He would have to follow this up. When he did the information would not appear to be easily offered.).
I explained that my preference was still to remain in school, that finals were coming in the next three weeks, and that I could borrow if necessary until the pieces of a medical income came together. I told him there were house call opportunities available, that I did have a few ER shifts lined up, that there were locums possibilities in practices, and other chances for work here and there.
I told him that I had come for this interview because Larry Weed had recommend I call him. I told Bruce that I saw his shop as the place I would like to come with a degree in computer science--a few years down the road. I explained that by summer, my financial situation would be resolved, I would be hooked into a department at Maryland and I might find it difficult to leave an academic situation. I reiterated that I was incredibly excited by what I saw his office doing, but I was worried that I did not have sufficient knowledge of several areas, including computer hardware, communications theory, operations research, and mathematics.
He brushed that aside. He said there were very few people in the country with my credentials, a practicing physician with a solid background in programming with knowledge of a couple of higher level languages and the assembler language for the Univac computer at the University of Maryland.
Then he asked me about the problem at the hospital. I told him I was fired. He asked for all the details. I didn't embellish. The story stood on its own. My intention was for him to get the information in a manner that would not seem the gratuitous ploy that it was.
Then he revealed to me that he and his wife had mostly raised their four children and wanted more but couldn't have them. They decided to adopt and believed that it was important to adopt children that others were less likely to want. He described his difficulty in obtaining a black child and dealing with the bureaucracy of the time and the emnity of black organizations that totally disapproved of chldren of African heritage being raised by Caucasian, "much less Jews," he laughed.
Then he said, master Mandarin that he was, "Dr. Sohr, I don't have any positions, but I think I know how to work around it. Perhaps it would be possible for me to bring you aboard as a consultant. It would be a straight fee per day, no holidays, leave, retirement...straight up pay. $50 dollars a day. Talk with Dr. Cohen.
Bruce left and Dr. Cohen appeared. He laughed and said, I heard Bruce say $50 a day. We can't do that for someone with your qualifications. It'll be $75 a day. How will that work out?
"I'm very happy to accept your offer!"
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