That was my welcome to the unpredictable world of medicine.
The clinic had two “hard site” facilities, and we also provided services to a battered women’s shelter and to a locked-down drug rehabilitation center. Once a month, our mobile van would pull up to a street corner, and we would offer services to whomever walked in the door. I never figured out how patients found that mobile van, since it seldom parked twice on the same corner—but they did, in hordes. We’d pull up, and the waiting room would instantly fill with people suffering from a dizzying array of maladies and displaying an equivalent variety of personalities and needs.
Of all the types of patients who made an impression, the most unusual to me were the prostitutes. After all, even though I was married and had fathered a child, I was still a somewhat sheltered Jewish boy from Brooklyn. You can imagine how flustered I was when my medical assistant told me that one of the prostitutes, a regular at the van, had a crush on me. I was teased unmercifully because this patient must have weighed three hundred pounds. Still, she was a very successful prostitute—at least, to hear her tell about it. Once, during a pelvic examination on this patient, I found a large green grape deep inside her vaginal vault. I couldn’t resist asking her how it got there. She sighed and said, “I tole ’im, if he puts ’em in there, he better gets ’em all out.” I declined to ask the follow-up question.
Practicing medicine alongside dedicated physicians and other staffers, I learned a great deal about providing care for the most indigent members of our community—for the shattered families and malnourished infants of the battered women’s shelter, and for the unfortunates of the drug rehabilitation facility. Such places and patient populations gave me a glimpse into a world that served to wipe away some of the naiveté of this yeshiva boy.
Despite the array of experiences that the clinic afforded me, I decided to leave after only a year. Physician assistant salaries were absolutely exploding, and I had received offers that would almost double my current salary. The clinic really could not afford to pay me much more than it was doing, so I left, reluctantly but firmly, knowing of my growing family’s needs. It had been a trying first year, but one that had seen me move from being a newly minted PA to becoming a blooded PA veteran.
From the Lower East Side, I went to Brooklyn to work for the Interfaith Medical Center, a facility run jointly by Brooklyn Jewish Hospital and St. John’s Hospital. The Center was located in a pretty tough neighborhood and served a population similar to that of the clinic I had just left. I felt right at home.
My job was in the neonatal intensive care unit (NICU), which treated premature babies, some as small as 700 grams; we called them micro-preemies. The job was another eye opener. Once, I was doing a workup on a newborn for possible sepsis, or blood infection. The baby needed a spinal tap, a common enough occurrence in the NICU and something the PAs there did regularly. So I went upstairs to the maternity ward to find the baby’s mom, to obtain her signature on the consent form for the procedure. Walking into the room, I saw a little girl laying on one of the beds, sucking her thumb. I asked where her mom was—and only then noticed her plastic armband. This thumb-sucking twelve-year-old girl was actually the preemie’s mother.
At the NICU I saw firsthand the elements of one of the great debates raging in medicine and medical ethics today: the debate over the distribution of this country’s precious medical resources. During my time at Interfaith, I watched a micro-preemie struggle to live for about seven months, during which time he had to undergo eleven surgeries, hundreds of cribside procedures, and countless sepsis workups—and then, tragically, die. His suffering was unimaginable, and his total health care costs, all borne by Medicaid, easily exceeded a million dollars. Yet even at the outset his chances of living had been less then one in ten, and, in the remote chance that he survived, he would most likely have been blind and profoundly retarded. Witnessing such circumstances raised crucial questions about whether the sheer expense of such an undertaking had been justified, and if it had not been, where we were supposed to draw the line in our efforts. These questions continue to haunt medical professionals around the country today.
Heartbreaking as the NICU sometimes was, there were plenty of happy moments that kept me going, and I would likely have stayed at Interfaith for quite a while, but eight months or so after I arrived, the hospital slipped into financial trouble and one of my paychecks bounced. I had to look for other work and soon found it at Beth Israel Medical Center in Manhattan. The man who hired me for the neurosurgery department at Beth Israel was the departmental chairman, a brilliant and somewhat wacky neurosurgeon. He was also the president of a private company that held a contract with a major group insurer, Health Insurance Plan of New York (HIP), to provide neurosurgery services (cranial, neck, and spinal) for the group’s subscribers. I was paid a salary by the hospital and another by the surgeon for working at his HIP office. To this day, I’m not sure that the hospital ever learned about that second salary, but I certainly earned it by working more than eighty hours a week.
Neurosurgery was a large division of the hospital; the usual census on the neurosurgery ward was thirty-five to forty patients, and to care for them, the hospital had assigned four PA positions to the department. There were private patients and there were HIP patients; in those early years of managed care in America, the distinction between the two sets of patients on the neurosurgery floor was always obvious. Clinicians contracted with HIP for a flat fee per year, no matter how many patients they saw or operated on, giving them little financial incentive to perform surgery on the HIP patients (an essential idea of cost control in managed care). Not surprisingly I noticed that we tended not to do surgery on HIP patients if there was any doubt that they would benefit from the surgery. However, because private patients were paying individually for their services (usually through other insurers, of course), they tended to end up in the operating room regardless of any lingering doubts.
Our department didn’t have house staff or residents (postdoctoral MDs), so the PAs did everything. I admitted patients, scheduled and prepped them for surgery, completed administrative paperwork, assisted in the operating room in the mornings, and then saw postoperative patients. All afternoon I changed dressings, administered tests, filled out discharge summaries, and wrote orders for patients who were going home. After grabbing a bite to eat for dinner, I’d spend the evenings reviewing the outpatient CT (computerized tomography) scans, myelograms, and MRI (magnetic resonance imaging) scans, determining who would be admitted next.
Drawing on my NICU experience, I quickly became one of the only PAs in the hospital who performed spinal taps, called on frequently when other hospital staffers had a patient who was a “difficult stick.” After doing a spinal tap on a 700-gram micro-preemie, performing an adult spinal tap was as easy as steering a Mini Cooper into the Lincoln Tunnel.
Urged by my supervising physician to push my practice to the limit allowed PAs by law, I performed other procedures usually done by physicians themselves—procedures that, when I did them, often raised eyebrows. Once, in the surgical intensive care unit (SICU), I stuck a 60cc syringe into a patient’s brain through a surgical incision we had made that morning. As my boss coached me over the telephone, I drew off some cerebral spinal fluid, thus relieving the pressure that had been building in the patient’s brain. The procedure worked and the patient was fine, but a few hours later the SICU director found out what I had done and had a colossal fit. He complained to the hospital administration, and the subsequent brouhaha caused quite a flap. Everyone began weighing in and taking sides. Such a bedside procedure would normally have been done by a skilled neurosurgeon—but instead I had done it while being instructed by my supervising doctor, and the procedure had indeed been successful. After a few days, things cooled down, and I continued to practice as directed—on the edge.
My days at Beth Israel began at 5:30 A.M. and did not end until 8:30 P.M. Since I lived only a few blocks from the hospital, I was called
at all hours to return to the hospital and do something that couldn’t wait until the morning or until Monday. The amount of work I did and the variety of that work and its importance within the medical system demonstrated that PAs could be better used in our medical system, to take some of the burden from physicians, possibly bringing down the overall cost of health care. It doesn’t really require a licensed MD—a person who has had four years of college, four years of medical school, maybe five more years of residency—to give an injection, perform a basic test, or do much of the other basic work of medicine. There is an adage in medicine that 90 percent of the time you draw from 10 percent of your knowledge; the other 10 percent of the time, you need to draw from the other 90 percent of your knowledge. Practically speaking, this means that 90 percent of the time the presenting problems of patients are routine, the sort of problems that PAs are well trained to cope with. If PAs did more of the 90 percent, routine sort of work, it would leave the MDs to concentrate on the 10 percent, the more complex and difficult matters.
At Beth Israel, my crazy schedule and relentless workload affected and exhausted me; I was further depleted because in addition to my paid work, I was attending law school at night. Relatives of mine had convinced me that if I added legal training and knowledge to my PA degree and expertise, I could clean up monetarily, perhaps specializing in medical malpractice.
The first year of night law school cured me of that idea. I hated what I was learning. There wasn’t a branch of law that appealed to me in the slightest. The study of law was boring and, well, legalistic, rather than dealing with lofty principles and great ideas. Or perhaps I was being too harsh; I hadn’t really wanted to go to law school, but I had attended because I thought it might indeed be interesting to merge medicine and law. I stayed long enough to understand that law wasn’t for me. In particular, I was revolted by the notion of engaging in medical malpractice law.
Attending law school wasn’t a complete waste of time because it enabled me to discover within myself a latent interest in all things forensic. I noticed an Office of the Chief Medical Examiner (OCME) advertisement in the New York Times, for PAs to work as MLIs. Intrigued, I considered applying, but was initially discouraged by the relatively low salary being offered. Then, on a rare free Sunday evening, I attended an opera recital at Carnegie Hall—and over the course of the concert, my beeper went off fifteen times (on vibrate). Fifteen times I had to go out into the lobby and use the pay phone to call the hospital. After the tenth such call, coming back to my seat, I thought to myself, “If your patients were dead, Shiya, you could probably sit through a concert without interruption.”
That night clinched it for me. I applied for the chance to become an MLI for the OCME, and during my interview there, I was accepted for the position.
It was love at first sight. After learning what it was I would be doing, and why, I concluded that PAs were born for such a job. During my interviews for the position, I learned that the new chief medical examiner was staking his reputation on an innovative program in which PAs would comprise the entire investigative staff—and that therefore we would have all the support in the world. Moreover, even though I would be taking a serious cut in base salary, I was assured that I’d make out okay because there were too few investigators to handle all the work, so there would be a lot of overtime. I did the math: time-and-a-half meant that I could make in sixty hours what I’d previously had to work eighty to obtain—and sixty felt like a breeze to me after what I’d been through at Beth Israel. That was important to me, because now my wife and I had two children. I was twenty-five years old, thoroughly disenchanted with the Orthodox Jewish lifestyle, and with a marriage that was showing signs of crumbling. In that scenario, a new job carried the potential to turn my entire life around.
Quickly accepted for the MLI training program, I reported for work at OCME. In September 1990, I received my identification and my shield, emblazoned with the number 110 and the crest of the city. I was the tenth person employed in the program. But only seven MLIs, including me, were still working; the rest had already dropped out.
TWO
ONE DAY YOUR colleague Fred is in the office and he’s okay. The next day he’s absent, and you hear that he’s ill; on the third, you receive an e-mail saying that he has passed away; on the fourth, you go to his funeral. At the wake, you gaze at Fred, laid out in a very comfortable-seeming casket. He actually looks pretty good, lying there in his nice suit and embalmer’s makeup.
You may suspect that it’s all set design and special effects, but you don’t know the half of it. That casket has no real cushions; Fred’s suit probably doesn’t have a back. There is wadding stuffed up his nose and in his throat to keep fluids from leaking out, a plug in his backside for the same reason, and if he weren’t wearing so much makeup he would look, well, dead.
Fred’s travels as a corpse, and what happens to him along the path from the hospital to the funeral home, then on to the cemetery or crematorium, are unknowns to you—and you don’t mind these matters being unknowns because dead bodies are taboo things, somebody else’s problem. This isn’t that different from the way we treat many other matters. We eat bread, but we don’t grow wheat or know much about how it’s grown; we wear shirts, but we don’t grow, harvest, or spin cotton or sew the shirts ourselves. We just don’t think about what goes into the process of getting bread to our plate or shirts on our backs. In much the same way, we may go to funerals, wakes, and cemeteries, but we don’t deal with dead bodies. Instead we simply accept the sight of our friend, cousin, or spouse lying there in the casket, but give no thought to what went on behind the curtain so he or she could end up there. Many people who work in the industry, including MEs, funeral directors, and embalmers, do so because they wanted a peek behind the curtain. And they desired that peek because they are fascinated with death.
Death is still, cold, quiet, and gray. Life is moving, warm, noisy, and full of color. The opposite of life is not only death, it is also the absence of joy—which is why, sociologically speaking, the opposite of a funeral is a wedding. Though it was this fascination with death that led many of us to the industry, in reality our days are filled not with death itself or the struggle to know death, but with cleaning up after it. By the time we get involved with a body, death has come and gone, leaving us with only the empty shell, the abandoned luggage of what was once a human being. This is a key concept for those of us who deal with death’s remnants on a daily basis; it’s an understanding that we must have if we are going to do our work properly. Death merely heralds the beginning of our work.
Trainee medicolegal investigators (MLI-Is) definitely have to reach this understanding, and they do so not through gentle coaxing but through a rigorous sink-or-swim training program implemented by the more seasoned investigators at OCME. In my case, it began with my training officer telling me, during my first week on the job, that I would do the honors on the first body I ever saw at a death scene.
I didn’t want to touch that first body. It was in awful condition and in exceedingly awful surroundings: a man of about sixty years of age in a single-room occupancy hotel on the Bowery, his emaciated body lying half-on and half-off a narrow bed in a filthy, roach-infested room barely large enough to contain the bed, a small dresser, and a chair. For the last twenty years of his life, this man had been a dedicated alcoholic, and the small sad room had been his home for most of those years. Some time before death he had defecated in his pants, and from the looks of his clothing, he had also regularly urinated on himself.
It was a sweltering September day in Manhattan, and the stench in that little room was so thick you tasted it. The foul miasma was compounded by contributions from the fifty or so other rooms on the floor, each housing another sad sack, none of whom seemed to bathe any more regularly than my guy.
I didn’t want to go near him, let alone touch him, but I had to. My training officer stood just outside the door—there was no room for both of us in that room anyway—grinn
ing from ear to ear as he watched me prepare my gear. I pulled out my camera and my clipboard, and as I put on my gloves, I said, aloud, “I can’t believe this is my job.” My words were uttered not in anticipatory glee or in regret, just in astonishment that this was something I could do—and was going to do.
Society needed me, or someone like me, to touch him. You needed someone to touch him, to find out what had happened to him, to verify who he was, whether he had any communicable diseases, and if his death in any other way might impinge on public health. And he needed someone to touch him because every dead person has a right to be examined, to learn whether foul play or bad treatment has brought an end to his or her life.
This man’s body was particularly disgusting. There was a maggot infestation at his crotch that, I could tell, had begun even before death, birthed by professional-grade bad hygiene. I held my breath and got to it. Hesitant and awkward, I tugged tentatively at the body, glancing repeatedly at my training officer for guidance. My skin started to crawl because a cloud of body lice appeared when I disturbed the body. The maggots writhing under the decedent’s skin made me slightly queasy. But I got through the task of investigating the body, which, of course, was just what my supervisor had hoped for—and with that one inspection I officially moved behind the curtain, becoming a participant in the elaborate play that would eventually deliver Fred into the scene in the funeral home which you attended as a mourner.
Dead Center Page 3
