Internship

Internship

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medical            *
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Late yesterday afternoon I developed a shaking chill that lasted for 15 or 20 minutes. My biggest fear was that I was developing an infection. It is possible for tumor to obstruct airways and to allow mucous and debris to collect in a closed space and to form a breeding ground for pneumonias.

It is also possible that the tumor itself is producing materials that cause fever. Naturally, I'm hoping that is the source.

I slept for about 8 hours and awoke drenched with sweat, hungry, and no change in pain level. I'm assuming this is a good sign.

My boys and brother Dana left for Oakland and the flight back to the East Coast yesterday a little before noon. My brother Geoff will stay for a while. If he is not careful he may get the moniker of "family undertaker." It's great to have him.

I've had hundreds of laughs and sweet moments in the past few days--I continue to feel lucky.

                     Sunday night at the Thai Restaurant. From Left. Geoff, Brian, me, Jasmine, Dana, Keith

                                 Sunday AM. Dana and Eric Roasting Coffee with a Heat Gun.

               Archie is mystified by the stuffed dogs at the Paso Robles Art Show on Saturday.

    Brian grabbing a beer while Keith makes the deep dish pizza we ate on Friday evening.


Tuesday was a good day. Pain was only moderate. I got a scare from my insurer who called me early this A.M. and told me that Stanford was no longer a participating member of my network and that a significant portion of my care would be out of pocket. However, a few phone calls to Stanford convinced me that things will work out.

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Internship. The first post-graduate year.

The trust that the medical training system places upon young physicians is mind-boggling. Throughout medical school you become increasingly aware of the nature and extent of responsibility that will soon fall upon your shoulders. However, even the most mature 25 year-old can't be expected to have more than a passing knowledge of the human condition. Consequently, the way in which the young physician deals with complexity is likely to be rigid enough to keep him in a zone that is comfortable. This reduces the number of variables and emphasizes the medical data over the social situation.

For Example. At age 33 I was doing family practice, including obstetrics, in Glendive, Montana, a very isolated community 200 miles from the nearest obstetrician. A patient came to me who was a Jehovah's Witness. I was already caring for her children. An essential part of her religious belief was the need to avoid blood products. At the age of 25,  my decision-making would have been simplistic. If she hemorrhaged to the point that I thought her life was at risk, I would transfuse her with or without her permission. I would elect the standard of medical care as the sine qua non and deal with the consequences to her religious beliefs later.

However, by age 33, I was able to take a more nuanced approach to the problem. If she had hemorrhaged during delivery, I would have done my best to manage her condition without blood products unless her husband, also a Jehovah's Witness, had specifically asked me to use blood. I would have placed my patient's conscience and her expressed wishes above my own professional beliefs.

I know that there are a number of physicians  whose solution would be to refuse to take such a patient. I've talked to several. But I've come to believe that medical care is a "negotiation," and that there must be give and take on both sides.  By now you know that I'm not a Jehovah's Witness. When members of that faith come to my door to give me the good news, I tell them politely that I do not appreciate the proselytizing and to please cross my name off of their list.

I think that the Jehovah Witness stance on the use of blood has actually been medically beneficial for them over the past few decades. I believe most physicians would agree that blood transfusions have been used too liberally, frequently "routine," and that the patient would have survived without blood products in a very high percentage of cases where blood was administered. Having refused blood protected Witnesses from HIV, Hepatitis B, and Hepatitis C. There is also actual data on blood use for Jehovah's Witnesses for Coronary Artery Bypass Grafts. The mortality and morbidity is less for those procedures done without using blood products.

Work in the emergency room seemed the most daunting challenge as a young physician. Anything could come through that door at any minute. Some cases would demand immediate decision-making without any opportunity to consult a book or a colleague. There were wonderful satisfactions as well, like making a diagnosis of a ruptured tubal pregnancy, or a leaking abdominal aorta. It was a time for learning techniques, such as suturing children in a way that reduces their terror as much as possible.

Although I had been in clinical training for two years before graduating from medical school, the quality of oversight was mediocre. It wasn't until I began to see children in the emergency room that I began to understand what I had missed. The pediatrics department at South Baltimore General Hospital was run by Robert Irwin and Ernie Maher. At least 10 to 20 children were seen in the emergency room on a daily basis. A critique was done on each and every child's visit and this was thoughtful feedback. What a commitment! You could not help but learn a lot of pediatrics from their notes. Based upon their teaching, I was very well prepared in pediatrics by the time I started my own private practice West Virginia a few years later.

My next favorite rotation was the medical ward. There I met the wonderful nurse, Evelyn Wade. She was probably in her early 60's. There is no doubt that she would have been an excellent physician but she came from an era where women were unlikely to be admitted to medical school.

Evelyn worked the night shift. She would come on duty at about 10 PM and begin reading the charts, not just the nursing notes, but the medical notes as well. She never used the title "doctor" but always "mister." For example, Dr. Bernie Carper was an attending pulmonologist and a conscientious teacher at South Baltimore.  Ms. Wade might grab one of his charts and say, "Let's see what Mr. Carper has been doing today."

Interns had no credibility with Evelyn until she had trained us. "Mr. Sohr...never put an old person on q4h (every 4 hour) vital signs. This means you will be waking them up at night. Old people need their sleep, particularly when they are scheduled for surgery. I went ahead and changed that stupid order of yours. Don't do it again."

Evelyn cursed like a sailor and she carried a hand gun in her purse. There is a story that she had taken out her gun and stuck it in the face of a very nasty, unruly patient and demanded that he return to his room. She had a deep, gravely voice but was all sweetness when she was introduced to our girlfriends. She was very disciplined. Despite her severe arthritis, she always selected at least one of the patients for total nursing care, which she would provide "just to keep my hand in, dearie!"

As interns we were given a room for sleeping and studying. It was similar to a motel room. I recall that I had put a hole in one my walls by throwing my shoe at 3 A.M. when told to come pronounce a patient dead. We were almost always sleep deprived. It was one thing to be called because someone was having a medical problem. It seemed unfair to be called after the death. There was an expectation that for any death, the intern had to examine the body, to pronounce the death, and then to notify the family. We came to understand that people on Evelyn's ward only died at about 6 A.M. We were up anyway, could examine the body, and call the family at a decent hour. The other nurses were not so accommodating.

I made a lifelong friend in my internship, Richard Fisher, who still does internal medicine in the Glen Burnie area. I recall a mandatory meeting of all house staff sometime during that year. I was sitting next to Richard. The chief of medicine began talking about the need to avoid any kind of intimate relationship with patients. He spoke about the ethics of these boundary violations for several minutes.

Finally I turned to Richard, "What's the hell's going on?"

Richard looked at me and said "I don't know either, but somebody here does."

I remember Richard becoming very attached to a patient with a viral hepatitis who died a lingering death from liver failure. They often ate lunch together and Richard visited frequently throughout the day. I don't think that I was brave enough at that time in my life to form such an attachment to a dying patient and I recall my admiration of Richard for being the complete physician and remaining with the patient when all hope was gone.

Medicine is all consuming to those in training. If one were to attend a party of interns, almost all of the conversation will be about medical cases--there is nothing more fascinating at that time of life.

I'm going to tell a story that is easy to misinterpret and to leave the reader thinking that the physicians involved were callous and uncaring, yet nothing could be further from the truth.

George with Barium Impaction

George was a man in his early seventies. He had been given a barium enema and had failed to ingest enough fluid afterward such that the barium had essentially formed a gritty plug that was occluding his rectum. Such plugs with feces are not unusual. I've had one in my lifetime and hope to avoid another. The formal name for this condition is "impaction." The treatment is to remove the impaction manually by lubricating a gloved finger, inserting it in the rectum, breaking up the lump of material there, and hooking a little piece of it and pulling it back out through the anus. You can  see that this is an uncomfortable process for all involved. But those are the essential steps.

Because George's impaction was such a severe one, all of the interns were put on notice. "If you are on the fourth floor for any reason, you are expected to do your part. Go to George's room and 'chip away' at his impaction." And we did for the next several days.

Unfortunately, there is a major nerve, the Vagus, which innervates a number of parts of the gut and the heart. It is possible for distention of the rectum to slow and even stop the heart. This occurred late one evening and George had a cardiac arrest.

George was in a semi-private room and his bed was closest to the door. More and more equipment and people piled into the room during a resuscitation attempt that went on for close to an hour. The crew pulled out all the stops because we knew that there was no known heart disease and that the inciting event was our attempts to relieve his impaction.

Throughout all of our attempts to resuscitate George, the roommate's TV remained on at full blast. Just as George was being pronounced dead, the medical crew heard Ed McMahon say "And here's Johnny!" All of us just broke up laughing in relief from the tension of the previous hour. I've always wondered what George's roommate thought about that incident.

Danny's Easter


I mentioned previously that hospitals were particularly interested in obtaining American Medical Graduates to fill the positions of interns and residents in the 1960s. However, there were many more positions than there were American graduates and there was a large influx of foreign medical graduates into the U.S. In my year at South Baltimore General Hospital only 6 of 16 internship positions were filled by American Medical School Graduates. Most of the internal medicine and surgical residents were foreign born as well. I found it interesting to bump up against other cultures in a working environment and I particularly enjoyed the potluck dinners and parties with such a culinary variety.

The hospital was situated next to a predominantly black housing development known as Cherry Hill. The hospital also serviced white ethnic areas of southern Baltimore City as well as the suburb of Glen Burnie, both of which were blue collar areas. Generally our patients were wary of foreign physicians, especially those that had any difficulty with language.

Sometimes problems with language were extreme. In obstetrics we had a Haitian physician who was just fine technically but with a poor mastery of English. I know that this is hard to believe but I observed him doing a delivery and the woman was screaming at him. "Doctor, you hurt me! God damn it you're hurting me. Stop it! Stop it! You hurt me." The doctor turned to me and asked, "Hurt? What does that mean?" At first I thought, it was a dry sense of humor. But it was real ignorance.

On Easter Sunday 1970 I was working the early shift in the emergency room. At about 7:45 A.M. the ambulance brought us an elderly, Caucasian male who had become exceedingly dizzy while driving through the Baltimore Harbor Tunnel. He was a general practitioner from New Jersey who had been visiting his daughter in Washington D.C. He was on his way home and, according to his wife, had patients scheduled the next morning. His wife said the dizziness was followed by problems with speech that appeared to be improved when she saw him again in the emergency room.  She begged me to find a private physician for her husband.

It has been more than 40 years and I don't recall precisely the sequence of clinical events, signs and symptoms, etc. However, the illness appeared to be a basilar artery stroke and the patient appeared to have a variability in symptoms. I contacted the neurosurgeon who was on call and he said to admit the patient to the hospital and that he would follow sometime later, either in the evening or the following morning. That didn't seem right--the patient was a working physician and had an acute, unstable neurological event. How could the surgeon be comfortable in delaying a visit based upon my assessment?

My next step was to call the Chief of Medicine. I desperately wanted a senior physician to look in on the case and provide comfort even if there were no available medical interventions. There was a time in medicine when "professional courtesy" was the common practice. Generally doctors felt an obligation to other physicians and their families. The Chief was adamant--he was at home with his family and wasn't going to budge. He was unwilling to come and wouldn't accede to my request that he ask someone else to come in his stead.

I had no other options. The emergency room evaluation had been completed and I had attempted to find a physician as the wife requested. I had no choice but to call the intern on the medical service to admit the patient.

Danny was the intern on call for medicine. He was a Sikh with a heavy accent. As Danny began the admitting process for the patient, I couldn't help but notice the wife's look of despair.

I looked in on the patient informally over the next day or two, but he died reasonably quickly.

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By the end of my internship, I was tired of missing sleep and could not envision another year of medical training. So I applied for graduate school in computer science at the University of Maryland in College Park and found an emergency room position at the hospital in Cambridge, Maryland.