“Note the dimensions of our patients’ chests and the way they breathe.”
We traveled by car to other institutions, including the local Veterans Administration hospital on the outskirts of Richmond. This time we saw first-hand the ravages of lifetime smoking, compliments of the countless free cartons of cigarettes given to soldiers during two world wars.
Two men, old before their time, sat in chairs, plastic tubes feeding oxygen from portable tanks into their mouths and noses. I stared at the two—so different and yet so alike. One looked like he had just been rescued from a concentration camp: thin and emaciated with flushed skin, his every attempt to breathe seemed a tiring effort. The other soldier, barrel-chested, wheezed and coughed and spat sputum (phlegm) into a cup by his side.
Seeing them took me back to my childhood, to my world in the tenements, when I was just a kid called Berto. To this day I retain vivid images of The Old Guys, three World War I vets who gathered at the shoe-repair shop of their legless war buddy, Harold Ruddy. That’s where I saw the devastation caused by the Germans’ use of mustard gas. Our neighbor, Tim Brown, lived a life of oxygen deprivation, drowning in a sea of air, because his lungs were almost non-existent.
But the men in that veteran’s hospital hadn’t been gassed—at least not by others.
They had unknowingly damaged themselves with decades of heavy smoking.
“Class, note the typical “blue-bloater” and “pink-puffer” habitus (body shape) of our patients.”
Dr. Marja Gortan was a lung specialist, a former refugee from Eastern Europe. Diminutive, almost doll-sized, she paced back and forth in front of us, her long white professor’s coat fluttering, as she pointed out the skin color and body shape of the thin emphysema patient and the large-chested variation, which we then called chronic bronchitis. Now they are considered varieties of chronic obstructive pulmonary disease.
We walked through the respiratory patient ward wide-eyed. Men—and women—so desperately ill from cancer that holes had to be cut in their necks, had tubes inserted to bypass the tumor-scarred upper parts of their windpipes. Such images burned themselves into my brain: terminal lung and voice-box cancer patients, some with no vocal cords, were forced to speak by burping out words. And what were they doing? Inhaling cigarette smoke through those tubes, their wasted fingers shaking while they held the lit cigarettes up to the openings in their necks called tracheostomies.
When we left the VA hospital to return to our campus, Dave looked toward a nearby doorway and gasped.
“Geez, looka’ that!”
The six of us stared: Gortan was standing in the doorway lighting a cigarette.
Year two saw perverse cosmic jokes played by the fates on the unsuspecting.
That year we lost our class clown.
“I have some tragic news,” the dean announced. “There was a terrible auto accident this morning and … uh … Mr. Andrew Kagill was fatally injured.”
He cringed, when a loud scream erupted from Tanya. Other students quickly surrounded her, and the sobs were not just from the girls.
This is life’s biggest lesson: No one is immune to the Dark Angel.
But the bitter irony lay in what transpired later
The year was coming to a close. We had covered the various internal pathologies of the human body, and now we would be exposed to the accidental.
“Old Gordie’s gonna do the horror show, isn’t he?”
Dave and I sat in the amphitheater next to Bill, June, Peggy and Connie. The pairing was so obvious that no one laughed or made snide comments anymore. Our class had found itself.
This was climactic, Grand Guignol horror show. Given by one of the foremost forensic pathologists in the nation, it was an anticipated event for every second-year class.
Gordon Makland had made a career of studying the effects of external trauma—accidental, malicious, or self-inflicted. Was it chance or murder? Show him a body, and within minutes he could tell you cause of death and whether or not it was by chance. He could wax poetic on the effects of gravity and its impact on falling bodies and why certain teenagers unintentionally killed themselves by hanging.
“Old Gordie’s slide show,” as everyone called it, was the culmination of our sophomore studies.
Makland was not one-dimensional. He was also an avid amateur geologist and rock hound. I was, in later years, privileged accompany him and play mountain goat and spelunker in search of mineral specimens.
That day in late April we sat and fidgeted and nervously joked while Sid Graham the projectionist set up the 35-millimeter slide trays. Yes, young doctors, we actually used primitive stuff like film back then.
Makland stood in typical slumped pose, his gaunt, six-foot-four frame leaning over the podium. He nervously drummed his fingers so close to the microphone that the room resounded with laughter to the elephant-herd sounds. When he caught on and stopped, the dark blue eyes in his rectangular jowly face penetrated the semi-darkness, and he cleared his throat. Then he smoothed graying cowlicks back into place and harrumphed.
“I want to warn you, ladies and gentlemen. What you are about to see is graphic, raw, and not to be taken lightly. These were once living beings like you. If I hear any snide comments or levity I will end the session. I will also have the offending individual expelled. Do you understand?”
We all nodded.
The first slide startled all of us. The vacant-eyed face of a dead, motor-vehicle-accident victim stared back at us in full frontal view. A good part of his brain had been forced down through his nose from the impact of his head against the windshield.
His demise had occurred long before mandatory seat belts and collapsible steering wheels.
“Visualize the force vectors involved as this man’s head hit and penetrated the windshield at sixty miles per hour.”
He didn’t have to remind us—we could feel it.
Slide two: two bushel baskets containing what appeared to be pounds of raw hamburger. What seemed out of place was the foot still encased in a worn work boot poking out the top of one basket.
Makland’s voice seemed overly dry, as he off-handedly remarked, “This farmer got pulled into his own thresher machine.”
One student in the back rose and quickly ran out of the room.
Slides three and four. Front view: a small hole with burn marks in the middle of a young woman’s forehead. Her eyes had popped out of their sockets. Back view: The entire back of her skull was missing.
“This was the result of domestic violence. Love and hate walk side-by-side, ladies and gentlemen. Please note how the shock wave of the bullet caused a massive exit wound.”
Several more students rose and left.
And so it went: bodies turned to mush by falls; burn victims, their muscles so contracted by the heat that they appeared to be in a boxer’s stance; drowning victims, their bodies bloated and their lips, earlobes, noses, and eyelids eaten away by fish and crabs.
“That should do it. You can shut down the projector, Mr. Graham.”
The fates laughed cruelly, as Graham’s finger hit the advance button by mistake.
Along with gasps, we stared at one final picture. Taken through the passenger door, the view showed the auto-accident victim impaled by the steering post, legs pulped by the engine, mouth wide open, tongue protruding, eyes staring at eternity.
You would have become a fine doctor, Andy.
May brought the usual, early, Richmond summer heat and humidity, but we sweated more heavily for another reason. Now we faced the first of a three-part hurdle to achieve the degree of Doctor of Medicine: the first part of the National Board of Medical Examiners’ certification exam. The faculty had lightened up on its academic onslaught by giving us review classes covering all of the information we had been swamped with over the past two years.
Once again we cocooned ourselves in our rooms, hid out in library carrels, or found secret, unused niches in the education building to study like monks. Not even our friend
s could help us through this.
We had been warned that part one was written by Ph.D. types, so we had better know all our basic sciences. It has always been a running battle between the Ph.D.s in science and the M.D.s as to what really matters in a medical education. As students, we were caught in the middle of the academic fracas.
It took two days, and when it ended our fates were sealed. Those who passed would advance to year three. Those who did not either had to retake it or a state-sponsored, equivalent-competency test. Neither was a piece of cake. The prime advantage of passing the National Boards lay in one word: reciprocity. Those who successfully completed all three parts—the first now, the second at the end of year three, and the third during first-year post-graduate—would be granted a license to practice medicine in all but three states: Florida, California, and Hawaii.
The reason? Those three sunshine states did not want to be inundated by geezer physicians when they retired.
“Hey, City Boy, got your whites yet?”
Dave stood in the doorway of our apartment on Church Hill, looking like a thin line of whipped cream. He grinned at me. In one month we would be hitting the wards.
Soon our little black bags would be put to daily use.
I quickly changed into my outfit, and we laughed hysterically at our reflections in the full-length door mirror: tall and short, slim and stocky, Mutt and Jeff.
We changed back into civvies and ran down the stairs to Dave’s car. We were headed to his family’s farm near Lynchburg again for some well-earned rest and relaxation.
We would need it.
Year three would use live ammunition.
Lock and Load
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 f
rom 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.
Dr. Galen's Little Black Bag Page 3
