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medical *
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It was a good day until late afternoon on Wednesday. Dr. Palchak recommended that I use Glutamine regularly as a prophylaxis against peripheral neuropathy. I looked at the information online. It appears that the NIH did a study that showed no benefit. However, there appears to be no harmful side-effects and I'm going to give it a try.
At around 5 PM I had another episode of chills, much milder than a few days ago. I took a nap and awoke with a low grade fever and some pain in the right shoulder and neck which responded to a boost in ibuprofen. I'm keeping my fingers crossed that I don't have any problem that will jeopardize receiving chemotherapy on Friday.
Internship Ends
Internship ended on June 30, 1970. Richard Fisher was continuing on at South Baltimore General in Internal Medicine. Tom Shawker, my roommate was off to continue training in radiology. I'm the only one who decided to opt out of further medical training. The advantages of leaving were more money than training wages, an opportunity to reduce my work week to 40 hours from 80 hours with an increase in my opportunities for sleep, and the chance to begin a new career path that was non-standard and for which there were no models. I intended to use my medical training to work a part-time job at relatively high wages while obtaining an advanced degree in Computer Science.
Just as most computer programmers of the time, I was self-taught. I had worked for a brief time at the NASA facility in Greenbelt, MD and had the opportunity to learn a programming language. When I moved on to Android and Jimmie Osborn, I was being tutored by a man who had begun his career punching cards and hard wiring IBM sorting machinery in the Navy at age 18. At the time, I would venture that mathematicians as a class tended to look down on computer programming as a pedestrian, non-creative occupation.
While a junior in medical school, I had done a rotation in psychiatry at the University of Maryland and had run across Malcolm, a genius mathematician with the fixed delusion that he had created the world during an episode of vomiting. There was no doubt that he was extremely bright, almost certainly genius-level IQ. I was assigned to his team of caregivers for 4 weeks and he took a liking to me. Malcolm had entered college at age 12 or 13 and stopped attending any formal classes before his 16th birthday. Now age 26, he taught courses involving the "theory of problem solving" and "heuristics." Naturally, he was someone who fascinated me. Here is the wiki link should you be interested in learning something more about his area of interest.
http://en.wikipedia.org/wiki/Heuristic
Malcolm insisted on playing chess a couple of times a week and I was a very weak opponent. He often said to me: "Sohr, you lack imagination." Once I asked him if he thought there was any hope for me in spite of that and he just laughed.
At the end of internship, I had spent five years of my life in formal medical training. Much of it was interesting, but these years had ground me down. I was 27, married and divorced and about to marry again. Family responsibilities had reduced the amount of time and energy available for medicine. As I think about this, my cancer is draining away my muscle mass much as medical education consumed the decade of my 20's.
Now, at the end of my internship, I was looking forward to a jump in wages and a reduction in work responsibility that would make life more pleasant. In addition, I was about to become a student in a field that excited me intellectually in a way that was different than medicine. I would wake up some parts of my brain that had not exercised much for the previous few years.
On the down side, I would be making enough money such that alcohol was always available in my budget. Also, I had recently been introduced to marijuana and I was fascinated with the notion of altered states of consciousness. Books like "Doors of Perception," "The Island," and Timothy Leary's work on programming LSD experiences, had sparked my interest in the "mystical" possibilities of psychedelic drugs.
I had been introduced to marijuana at the end of my third year of medical school when my wife brought back a couple of joints from her trip to California to meet a nursing school girl-friend. (She also brought back the telephone number of some guy that she had met there and she seemed to reach a new level of verbal criticism directed at this "getting-fat" man who greeted me in the mirror every morning.)
I kept trying marijuana and had actually came to believe that it must be the "emperor's new clothes." For the first 7 or 8 times, I didn't feel a thing. Then in March or April of 1969 I found myself in an IHOP in Baltimore talking to my friend Michael. I was in the middle of a complaint about the lack of effectiveness of the joint when I happened to look at my fork, which was loaded with several tiers of pancakes and dripping with raspberry syrup. I put the fork down and looked again and burst out laughing.
There was more opportunity for experimentation when working as the intern in the emergency room where the schedule was two 12 hours shifts on consecutive days followed by a full day off.
Why, you ask? What did marijuana do for you? At least initially, it seemed to give me "time." The rush of my schedule had abated. I could lie back and listen to music without constantly worrying about the next thing on my schedule of tasks. I could bake bread with Molly and have several laughs while kneading the dough.
As I'm thinking about this now, Rhapsody in Blue comes to mind. An experience with Marijuana seems like the first minute or so of the work. It is slow but alive, like a cat stretching out her muscles. As the music continues, one enters a much busier world, not one that feels chaotic, but is filled with activity--analogous to the every day work world. If you'd care to hear what I mean, you can try:
http://www.youtube.com/watch?v=1U40xBSz6Dc
I particularly liked the time distortion with marijuana. For me it packed an hour of relaxation into a few minutes. Music came alive again. I hadn't really "listened" to music while I was in medical school. It had lost the importance of the shared experience with friends in grade school and with dances in high school. But now with marijuana, it had returned in spades. And there was so much good stuff out there in 1969! Marijuana seemed to help me align my mood with the music. Molly was very much into music. I remember spending a Sunday afternoon with her after I had smoked something and listening to a Donovan album that moved me beyond words with its beauty. It probably helped that I was falling madly in love with this deep, intelligent woman with the incredibly biting sense of humor.
My perception of the spiritual side of the drug experience was probably an attempt to replace the loss that I was experiencing in my continuing attempts to push the Catholic octopus out of my thinking.
A New Job
The city of Cambridge, MD was having difficulty recruiting a physician for its emergency room in the summer of 1970. Barak Obama would say that it was on the wrong side of history in 1960. It acquired notoriety during the Civil Rights struggle when the courthouse was bombed.
http://en.wikipedia.org/wiki/H._Rap_Brown
Maryland was a slave state and the Mason-Dixon line which separated slave-holding states from free states during Lincoln's era ran along the northern border of the state.
For such a geographically small area, Maryland has a variety of topography and shares the Chesapeake Bay which actually has more miles of coast line than California. It was settled by Catholics at St. Mary's City on the Potomac River in 1632. It was the 4th British colony. Shortly thereafter, Protestant dissenters sailed to Smith Island in 1634 and formed the community where I would practice medicine for a few years and where I hope to have some of my ashes scattered.
The religious wars in England were echoed in Maryland with bloodshed on both sides. When we look at the intolerance that appears as doctrine in some version of Islam, we can see corresponding insanity in Christianity, even during our American colonial period.
German migration into Maryland became significant in the 18th century and by the time of the Civil War, a German language newspaper had the 2nd or 3rd most numerous circulation. The Germans were not slave holders and the State became divided over political lines, the eastern and southern most parts of the state being slave holding, while the northern and western parts were not. Some opponents labelled Abraham Lincoln a tyrant based upon the Federal occupation of Baltimore in May 1961 and martial law was declared throughout the state.
Suffice to say that Maryland was deeply divided by the civil war. The villain of the era, John Wilkes Booth, was a Marylander as were most of the conspirators in the Surratt house where the plot was hatched that resulted in Lincoln's assassination.
In the 1950's a bridge was built across the Chesapeake Bay that made it possible for people on the Western Shore (including Washington, D.C. and Baltimore) to drive to the sea at Ocean City, Maryland in about 3 to 4 hours. Prior commutes had required driving around the Bay or using a Ferry service. This opened up tourism to the Eastern Shore, an area that looked more like Selma, Alabama than Baltimore with respect to differential treatment of blacks and whites. Refusal of restaurant seating to blacks was common all along Route 50, the major corridor to the coast. Freedom rides to integrate restaurants were begun.
Here is a selection from http://www.crmvet.org/tim/timhis61.htm that illustrates some of that history.
Cambridge MD — 1962
See Desegregate Route 40 Project for background and previous events.Cambridge MD is a small industrial town on the Easternshore of Chesapeake Bay. Racism and segregation are far more virulent on the Eastshore than in the urban areas around Baltimore or the western portion of the state, a condition of long historical standing — at the time of the Civil War it was said that the Easternshore was slave-holding Dixie, while the area to the west of Baltimore was practically Pennsylvania.
Cambridge is the capitol of Dorchester County. In 1960 one-third of Cambridge residents are Black, all of whom live in the 2nd Ward which has been represented for six decades by the only Black on the five-member City Council. There are three Blacks on the police force, but they are limited to patrolling the Black neighborhood and are not allowed to arrest whites anywhere. The schools are segregated, with Black schools receiving half as much funding as those attended by whites. All lunch counters, cafes, churches, and entertainment venues are segregated. The local hospital does not admit Blacks who have to travel to Baltimore two hours distant by car (longer by bus). Nor do Black doctors have privileges at the segregated Johns Hopkins hospital.
By 1962, Cambridge has fallen on hard times. The city's major manufacturer, a food-processor, has closed its Cambridge plants and the jobs are gone. For whites, unemployment is over 7%, twice the national average, and Black unemployment is a devastating 29%. Two of the remaining factories, both defense contractors, have a tacit agreement with their white workers and the city council — the companies will not hire Blacks in return for the workers rejecting any attempt at unionization. Under Federal poverty regulations, Dorchester County is in the same category as Appalachia.
By the end of 1961, efforts to desegregate public accomodations along the highways between Washington and the north have largely succeeded. Led by Clarence Logan and other Morgan State College students, Baltimore's Civic Interest Group (CIG) — a SNCC affiliate — begins sit-ins and freedom rides in towns on Maryland's Easternshore.
In January of 1962, CIG/SNCC organizers Reggie Robinson and Bill Hansen arrive in Cambridge. Protests commence in Cambridge with 100 activists marching downtown to desegregate various establishments. Half of the protesters are Cambridge high school students, the other half are students mobilized by CIG from Morgan State and Maryland State Colleges, along with a few white supporters from Johns Hopkins. Some of the demonstrators are arrested. Hostile whites jeer, and in some cases, assault them. Bill Hansen is beaten by a mob and then arrested for "Disorderly Conduct." The Cambridge Mayor blames the violence on "outside agitators," and calls Hansen a "professional integrationist."
More than 300 Black residents attend a mass meeting that night at Waugh Church to show support for the protesters, and in the following days they found the Cambridge Nonviolent Action Committee (CNAC) — pronounced "See-Nack" — to support and continue the protests. Frederick St. Clair and Enez Grubb are elected CNAC co-chairs at a mass rally. A week after the first protests, CIG and CNAC organize a second "freedom ride" into Cambridge, this time including supporters from CORE, SNCC, Northern Student Movement (NSM), Black students from Howard University, Morgan, Lincoln, and Maryland State Colleges, and white students from Swarthmore, Haverford, and Bryn Mawr. Again white vigilantes attack some of the protesters, again Bill Hansen and others are beaten, and again Hanson and others are arrested. White students are beaten more than Blacks.
Penny Patch, a white student from Swarthmore, recalls "Everyone sang, the songs bound us together and made us strong. [The white mob] gathered around us, screaming, waving baseball bats. I was scared. But I also drew enormous strength from the songs we sang." She later goes on to become a full-time SNCC field secretary in Albany Georgia and the Mississippi Delta.
CIG expands the freedom rides and sit-ins to other Eastshore towns such as Chestertown, Princess Ann, Salisbury, and Easton, an effort that evolves into the Maryland Easternshore Project" a summer campaign of CIG/CNAC. Meanwhile, CNAC continues demonstrations in Cambridge, relying on local high school students led by Donna Richardson, Lemuel Chester, Dinez White, and Dwight Cromwell. For awhile, Edward Dickerson, a local white student, defies family and community to take part in CNAC protests. His parents kick him out of their home and threaten to commit him to a mental institution.
Maryland Governor Tawes asks the legislature to pass an anti-discrimination bill to end segregation in public accomodations throughout the state. But Easternshore legislators weaken the bill by allowing counties to exempt themselves. In other words, Easternshore counties like Dorchester where segregation is widespread can choose to ignore the law. In Cambridge, the police allow white racists to beat nonviolent protesters, and then arrest the demonstrators. The all-white, volunteer Rescue & Fire Company (RFC) is a major civic institution. It runs the swimming pool and skating rink on a segregated, white-only basis, and those facilities become targets of CNAC protests. In retaliation, the RFC threatens to deny ambulance service to Blacks.
Howard University graduate Gloria Richardson is drawn into CNAC by her daughter Donna, one of the main high school activists. Gloria soon becomes CNAC's most prominant leader. Throughout the Southern Freedom Movement, women play significant leadership roles, but men typically hold the prominant positions. That is not the case with CNAC, which is primarily led by women at all levels. In the spring of 1962, Gloria and Yolanda St. Clair are sent by the community to attend a SNCC conference in Atlanta, and CNAC becomes a SNCC affiliate.
By the end of summer, most Cambridge eating facilities are still segregated as are entertainment venues such as the movie theater and skating rink. Protests taper off when school resumes in the fall, and CNAC begins deep organizing down at the grassroots, developing activists and leaders throughout the 2nd Ward, and broadening its base among poor and working class Blacks.
Said one unemployed Black war veteran: "Here if you are a colored person and go looking for a job, they tell you they only want skilled workers. If you have the particular skill, the vacancy suddenly 'has been filled.'" Said another unemployed Black man, "Things for us can't get any worse. We have nothing to lose and maybe something to gain by backing [CNAC]. I don't have anything but time and my life to give to the Movement. I'm willing to give both if necessary."
To the dismay of the traditional upper-class Black elite — long accustomed to being the community leaders — CNAC adds a factory worker and a welfare recipient to its executive committee rather than additional ministers, a move that signals CNAC's committment to the issues and priorities of those at the bottom of the economic ladder. And CNAC rejects the gradualist, conciliatory, approach favored by the Black elite.
So that was the environment that made recruiting for a job in Cambridge more difficult.
It so happened that my best friend was dating the daughter of Erik Cripps, a British photographer who lived on the remains a plantation on the Miles River. The estate had a number of buildings including an old chapel that had been renovated into a living area that included a loft space for a bedroom. There was a large dock into the River that we were able to use for boating and crabbing. Also, Mr. Cripps was gone for the summer and we had the occasional use of the large estate house with multiple bedrooms.
Molly and I married in August and the estate house was the scene of a party that lasted for more than 24 hours. I only make it through the first 16 and when I awoke I ran into two characters, David and Russ who had been drinking the entire night. When I bumped into them in the kitchen, they clinked their glasses with my coffee cup and gave the toast: "To the loneliness of the long-distance drinker."
It was an idyllic 10 to 12 weeks. Lots of time off living in a beautiful location on water encouraged a constant stream of friends visiting from Baltimore. Kristin, aged 3, at the time joined us and proceeded to run around as a nudist for a few weeks, only dressing up when a red-haired teen-ager would appear one or two mornings a week to ride his motorcycle and cut the grass. I applied for graduate school at the University of Maryland and they accepted me as a "Special Student." They would look at my performance in a few courses before making a decision about admitting me to their computer science department to work toward the doctoral degree.
In addition to the party aspects of my life, I was also starting a new job, the first one outside of a training environment. My one contact there was Dr. James "Jimmy" McCarter who was at least 8 years my senior and was highly recommended by Nurse Evelyn Wade, M.D. as a very bright, excellent physician. To some extent, this colorful physician took me under his wing and gave me the lay of the land and told me of the people I'd best avoid.
He described himself as moving to the community as a new surgeon and deciding to operate on his own wife's appendix rather than having the other surgeon in town do the case. McCarter said that he knew that he was stepping on a political beehive but he said that he felt that his wife's safety was his primary concern and that if the procedure were to be done in Cambridge, then he would have to do it himself.
There was still talk about him locally because of his arrest for performing abortions at a time when the Maryland law was about to change, but still wasn't there. Rumors had it that Nursing Students at Johns Hopkins had managed to find safe abortions in a hospital environment in Baltimore for many years, but I had friends who in 1966 and 1970 had to go the "back alley route." Anyone who remembers those days is unlikely to wish to return to them. It is interesting that there is a book "End of the Road" by John Barth who was raised in Cambridge, Maryland that deals with some of those issues. It was written in 1954 and I think it is among his best work.
Dr. McCarter spoke about his abortion arrest. He was not ashamed of it and looked upon it as a part of his obligation to his patients. He then described, the Internal Revenue Service auditing his practice shortly thereafter. The state wasn't really able to silence him through the medical board and medical practice act. The internal revenue service had been called upon to do the execution.
However, he escaped their clutches. "You know, Eric, I kept a log of each abortion that I did, the amount charged and the amount received. I paid taxes on all of that income." He smiled and said "You can do almost anything that you want in the United States, as long as you give the Government its fair share. Remember that no matter what you do."
Some of the practices that I saw in Cambridge bothered me. One time there was a cardiac arrest in the operating room. The nurses ran to tell me about it. When I got there, the patient was without a heartbeat but no one was doing chest compression. The anesthesiologist was still masked at the patient's head and giving him oxygen by ambu bag ("bagging the patient"). However, the surgeon was still suturing the gall bladder wound incision rather than doing chest compression. I had to say, "Excuse me doctor, in order to get past the surgeon to the patient to do CPR."
Another incident occurred one evening in the emergency room. A young African American came to the emergency room by ambulance. In a motor vehicle accident, a one-car rollover, he had sustained a through and through vertical laceration of his left ear that extended from the top edge, the helix, almost to the tragus. The top of th ear was diced in half.
The surgeon had a faint smell of alcohol on his breath at the time that he arrived but there was no evidence of speech slurring or clumsiness. Many people in the area had a drink with dinner, so alcohol on a physician's breath at 6:30 PM when he was not really "on call" would not have been out of the ordinary. I asked if it would be wiser to send the fellow to plastic surgeon a few miles up the road in Easton. "No...this won't be bad."
I was still on call and was interested. I knew the ear was very tricky and that the cartilage was hard to preserve. If the cartilage dies, the ear rolls up like a cabbage...a boxer's ear. As the surgeon prepared the wound he began a paternalistic conversation about the auto accident itself. The kid had a heavier smell of alcohol on his breath and claimed that a deer had stepped out of the shadows. "A deer!," said the surgeon, "I might have guessed."
The surgeon used no anesthesia. I expected the surgeon to close the wound in three layers--fine sutures to reapproximate the cartilage itself and then separate suturing of the front and back skin. So the three layers would be 1. back skin 2. cartilage 3. front skin. However, the surgeon repaired the ear as a single layer. The needle and suture material passed through all three layers. At the time and as inexperienced as I was, I knew that this was a sadistic man doing a very sloppy repair that was destined to leave severe scarring for life. I felt powerless.
I had a wonderful case that I still reflect upon from time to time. A middle aged couple was travelling back from the beach at Ocean City to the D.C. area on a Monday afternoon. She had chest pain on the highway and her husband drove her to the Cambridge Hospital. She arrested as soon as she was brought into the treatment area. However, she responded quickly to oxygen and defibrillation and resuscitated easily. I had never seen anyone come in from the street and respond so quickly.
Even more interesting and memorable was her husband. This was a time before I had extensive psychiatric training. He seemed to be blase about his wife's condition. He nodded appreciatively at the good news about her improved condition, but he was anxious to tell me about his new invention which promised almost limitless energy. "Of course there is no such thing as a perpetual motion machine--that would violate the second law of Thermodynamics," he said. I nodded in agreement.
http://en.wikipedia.org/wiki/Second_law_of_thermodynamics
He proceeded to tell me that it was possible to begin tapping the rotational energy of the earth. He was so glib and so positive that I sat there not sure if he were delusional or really on to something. Remember, many pioneers in science and engineering had been considered crackpots at the time they expounded upon their thinking. Unfortunately, Crackpot! A delusion.
I had counted on this job in the emergency room to last me through the fall. That was the agreement on July 1--continued employment on weekends after the tourist season. I was promised 2 or 3 weekends of work a month. This would carry us through the basic expenses while Molly and I attended classes.
However, there was an incident around labor day that ended my relationship with the hospital.
It started with an ambulance call about a drowning in a quarry or swimming hole. The rescue crew was on the way to the hospital and stated that the patient had a pulse at one time in the ambulance but that they had lost it. I asked the nursing supervisor to get the crash cart into the treatment room. Then we waited for the ambulance.
At the time of the patient's arrival, the history we had was that the patient had been in the water for around 20 minutes before being found and that he was pulseless at the scene. The ambulance crew reported a pulse in route but there were no observed respiratory attempts. There was no specific history of attempts at CPR. We started CPR immediately but it was not possible to move air by either mouth to mouth or bag. I couldn't feel anything in the mouth that was obstructing airflow. I needed to pass a laryngeal airway.
I turned to get a laryngoscope and the airway from the crash cart. It was still locked. I looked at the nurse. She said, "We can't find the key to the crash cart."
I couldn't believe it. I said "Get a fucking axe and break the lock and open the crash cart." At least a minute went by. A fireman was able to find a crowbar and break the lock on the cart. As soon as the cart was opened, it was like a jack in the box...it seemed as if a hundred 4" x 4" bandages jumped at least 3 feet.
I found the laryngoscope...there was no light. Batteries were dead. There were no extra batteries on the cart. Someone found a flashlight and scavenged the batteries. The laryngoscope bulb did work and I passed the endotracheal tube. There was no visible large obstruction but the airway resistance was incredibly high and I could not ventilate him. The ekg monitor had been a flat line since arrival. The man was dead and probably dead for some time.
I believed it most likely that the "pulse" noted in the ambulance was an error. It is notoriously difficult to detect pulses in moving vehicles traveling at high rates of speed over rough roads.
Nothing attracts crowds like an attempt at CPR. We had loads of hospital staff there plus the volunteer fire department. It was an embarrassing attempt--shameful in 1970. This case would be a source of gossip in the community for next few days. Anyone with any medical knowledge would know that this was abysmal medical practice. I thought that the victim being a black male made the matter that much worse. "Maybe even whitey doctors don't care."
A couple of weeks later, the hospital chose to fire me for the use of the f* word in that incident. They wouldn't acknowledge their own negligence in the debacle. I had used the crash cart on a few occasions and never had problems before. After that incident I have made it a practice to check the crash cart myself before any shift done in an emergency room where I work.
For Molly and me, our expected source of income was suddenly gone. I scrambled around to find other work. For physicians, it's not always so easy. Approval by hospital governing boards can take time and emergency room schedules are often constructed months in advance. There was some intermittent work in a local emergency room where I had a contact, but it wasn't steady enough to pay the bills.
I loved my course work at the University that looked at the foundations of computing, linear programming, operations research, and modern algebra, but it was starting to feel like my first year of medical school where I was too broke to continue to go to classes.
Molly and I took a trip to Burlington, Vermont to visit my friend Allen Leadbetter. He told me that Larry Week, M.D., the father of the problem-oriented medical record, had a large computer project attempting to automate the medical record. I managed to visit with Dr. Weed. The work was impressive with early use of touch screens to make selections for data input. Although he had no available work, he gave me a list of contacts in the Washington, D.C. area--people working on medical computing applications.
I returned home to Baltimore made some calls. I was invited to Rockville, Md. and the Public Health Service for an interview where I met my next mentor, Bruce Waxman, Ph.D. (**), the author of "Computers in Biomedical Research." This turned out to be a love-hate relationship that lasted for a couple of decades. As I write this, I really can't remember why we never spoke after about 1985 (okay, it just came to me!). Anyway, he was one of a kind, a remarkable personality. I'm sure that he received a great deal of the anger that I felt toward my father. He dealt out his own brand of shit in return, the origin of which I'm less sure of.
At any rate, Bruce Waxman was in a position that allowed him personal access to nearly everyone involved in medical computing. Why? Because he exercised a significant amount of control over a stream of funding from the Public Health Service for persons doing technology innovation in medical care delivery.
Bruce had Bucks!
He also combined the thinking of a visionary with Mandarin-class understanding of the NIH bureaucracy. If you wanted to go to California to examine several ongoing projects, Bruce could find a way for you to go and to take your wife as well for the cost of the second plane ticket.
Bruce had bucks and Bruce had balls!
It was an exciting time in my life.
** explanation later
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