Dr. Galen's Little Black Bag

by R. A. Comunale M. D.

I turned to see The Three.

  Even now, decades after they had retired and gone the way of all mortal flesh, the mention of the trio of doctors still evokes nods and smiles from those old enough to remember.

  Nelson Bolganich, George Maitland, and Joe Grasso.

  White-haired, with piercing blue eyes that seemed out of place on that pudgy little body, Nelson had served in the Navy during World War II before joining the Public Health Service. Afterward he had opened a general medical practice in what was then a rural Virginia suburb of Washington. Roly-poly friendly, he could pin you to the wall if you said something medically stupid.

  George, husky big with basketball-player hands and a former member of the Army Air Corps, had that lilting voice that always made you feel welcome—but God help the med student or resident who treated his patients in a blasé manner. George had no tolerance for sloppy or indifferent patient care. He also could verbally dissect a colleague who performed beneath his high standards.

  Joe, “the Godfather,” was balding and plump. He played the “Larry” to the other two stooges. A quiet, retired Army colonel and deep thinker, he could become an angry Vesuvius when hospital staff members and ancillary personnel mistreated their patients. But he would open his wallet at the drop of a hat if a nurse, medical student, or colleague fell upon hard times.

  The three men had gravitated toward one another as kindred spirits.

  “Come on, Galen, move it. Damn, even with my bad leg I can take the stairs quicker than you!”

  Nelson had received a Purple Heart for war injuries, and by golly he could still take the stairs two at a time. He was approaching sixty then.

  George, a young fifty-five, deliberately held back. His long legs would have left the other two—and me—in the dust.

  Joe, the oldest at sixty-six, talked a mile a minute about the students, interns, and residents. Education was his life. Then he surprised me by asking for my opinion about the training programs and the quality of the new staff coming on board.

  I hesitated, reminding him that I was almost as green as they were. Then his face erupted in a—to clean up the expression—pie-eating grin.

  “That’s why I’m asking you, Galen. The three of us are too old to remember how young flesh thinks.”

  Nelson and George countered with a “speak for yourself, geezer,” just as we entered the cafeteria.

  We grabbed our trays and moved down the counter, picking out entrees for the wait staff to place on them. I was hungry, but the stew of the day seemed to warn me away, so I snatched up two Jell-o cups, a banana, and what my city-kid sensibilities could barely accept as a roll.

  Nelson laughed, as he asked for a double helping of what was euphemistically labeled pastrami.

  “That’s a biscuit, boy. Didn’t they have biscuits where you grew up?”

  Nelson, I never told you then, but no, we didn’t have biscuits in my old neighborhood. What we had we were thankful for having.

  George went for the fried chicken, and Joe selected a salted-pork dish.

  I wonder even now: Nelson and George ultimately died from heart attacks; Joe tragically had multiple strokes, which whittled away at that wonderful mind of his.

  Genetics or diet? Nature or nurture?

  We sat at a round table—three knights and a squire—and once more I felt the scrutiny that only medical students and residents experience when in the presence of senior physicians. They bombarded me with questions about different medical conditions and how I would handle them. I knew I was being tested. And then it stopped.

  The three lit into their food, while I managed to spoon Jell-o into my dry mouth and suck out the contents of an overripe banana from its skin. As I munched on the biscuit, Nelson looked up at me from the gray goo on his plate.

  “Anyone croak in your charge, Galen?”

  “Not yet. But give me a chance. I’m sure I’ll do something right soon enough.”

  The other two laughed, and Nelson almost choked on his food.

  “Come to think of it, guys, I had an interesting case a coupla weeks ago,” George interjected.

  “Yeah, this fella comes in complaining that the tip of his nose and chin hurt every time he made love to his wife.”

  “You sure he knew what he was doing?”

  Joe’s face had split into a grin, and even I had to smile at that one.

  “Hold on, guys, we don’t want to upset the kid here. Remember, he’s still wet behind the ears.”

  Nelson looked at me intently, spooned more of the pastrami slop into his mouth, and asked the sixty-four-dollar question.

  “Okay, Galen, what’s wrong with Maitland’s patient?”

  I wondered why they were goading me like this, but I put the biscuit down and stared at each of them.

  “You want a differential diagnosis?”

  Now all three were staring back at me, and I felt the mist of sweat forming in my scalp.

  The diff, as we called it, is a list, in order of likelihood, of what a doctor thinks is wrong with a patient. Usually the physician has a few bits of data and observation at his or her fingertips. Then they get swirled around in the little gray cells, eliminating some possibilities and raising others. But George had only provided that one, small, tantalizing bit of information.

  Why are they testing me?

  “Okay,” I began, “your man is exercising rather vigorously, I assume, so two possibilities arise. One, he has a neurologic problem affecting the nerve endings that give sensation to his nose and chin. But that doesn’t quite fit a defined nerve pathway, and if his brain had a problem in the area that recognizes faces there would be other signs and symptoms.”

  The Three didn’t take their eyes off me.

  “Gentlemen, I’ve never seen a case like this, but I do remember reading about unusual signs of angina.”

  They all smiled!

  Yes, to all of you would-be medical detectives, sometimes the only symptom of a potential heart attack is pain at the tip of the nose or chin—or even the tip of one finger on the left hand.

  “How am I doing?” I asked George.

  He clapped his hands.

  “What happened to your patient?”

  He frowned.

  “I called Pat Boland and asked him to test the guy.”

  Boland was the best cardiologist in the area at the time.

  “And…?”

  “The guy leaves my office to go over to Pat’s place … and then he drops dead in the parking lot!”

  Speaking of dropping, that’s what my jaw did. I could barely get out a “what did you do?”

  Joe took the cue without missing a beat.

  “He probably went outside, took the guy’s wallet and turned him around to make it look like he was coming in.”

  I noticed that Shepland seemed riveted to what I was saying. I think my story had scared him.

  “Dr. Galen, why would those three doctors pull a joke like that on you?”

  “It was their way of testing the new kid. They wanted to see what I could do and how I handled stress.”

  “But that doesn’t seem fair, Doc.”

  “No one said that life was fair, Rick. And it did one very important thing for me. They asked me to join their on-call group. That was a great privilege and honor.”

  The young man exhaled. Then his face lit up.

  “Did you ever actually have someone die like that here?”

  “That’s another story, Rick, and I probably don’t have the time to tell it today.”

  “He’s got the time,” Virginia piped up, and Barbara nodded agreement.

  Danged secretaries!

  But then the office phone rang.

  “You’ve got a busload of nuns with venereal disease coming in,” Virginia said with a wink.

  “Okay, Rick, I’ve gotta get back to work. Any more questions?.”

  ”Yeah, Doc. Do you think I can do it … I mean … become a doctor like you and Gramps?”

  “Rick, your grandfath
er asked me the same question forty years ago. Now, scoot, boy!”

  “See ya, Doc.”

  What Goes Around

  “Is this Robert Galen?”

  When my phone rang that early May evening, I answered it in the usual, pleasant manner that has endeared me to so many of my patients.

  “Dr. Galen. Who the hell is this?”

  “Uh … is … is this Robert Galen?”

  Once more my charming personality responded.

  “Yeah, whaddya want?”

  “Dr. Galen, this is J.G. Traywick. Remember me?”

  How could I forget? It was only ten years—ten years to the month, that last month of medical school.

  Berto, follow your heart. Let no one—teacher, friend, even your parents—destroy your dream.

  Corrado Agnelli’s words helped carry me through four hard years of study. And a few weeks before those years drew to a close, the Powers That Be, representing none other than Dean J.G. Traywick, called us from our various ward duties to gather in the central amphitheater used for hospital lectures. They told us to expect something special.

  By then our student black bags had become a bit worn. Sometimes the zippers stuck. On some the leather cracked. They had been scarred by use and abuse—as had we.

  They told us to line up alphabetically. Those at the front had sneaked peeks through the doorway of the convocation room and passed the word back: “They’re here!”

  Our graduation gifts—full-sized, textured-leather black bags with hinge flaps and our own names in gold lettering! When I received mine, I just kept staring at those thirteen gold letters: ROBERT GALEN M.D.

  Ever since I was eight years old, when I discovered the dead lady in the river and first met Corrado, I had dreamt of this moment.

  But I wasn’t there just yet.

  “Okay, Cinderellas, back to work!”

  Traywick liked to think he had a sense of humor.

  No matter. On our way back to Ward 3, Dave and I clutched our new bags, now rewrapped. Three more weeks and those two last letters would become fact.

  I had night call. Every doctor dreads the middle-of-the-night, emergency-room admissions no one else wants: elderly nursing home patients, alcoholics in terminal liver failure, and others fitting no specific description.

  It was 4 a.m. and, wonder of wonders, the place had remained quiet. I was checking on the patients unlucky enough to be there, but we had escaped the hassle of a new arrival—or, at least, that’s what I thought.

  “Mr. Galen, you’ve got one.”

  I cringed, as I heard the floor nurse called my name.

  Soon I was standing over Eulah Jackson, eighty-six years old, African-American female, limbs contracted by stroke and poor nursing-home care, buttocks burrowed with pressure ulcers. Her head turned in the direction of my voice, as I introduced myself.

  Eulah was blind.

  “Let me go!”

  It was barely a whisper but I heard it.

  I looked at her input record: strokes, heart attacks, infected ulcers, kidney failure, and blindness. Then, at the bottom of the page:

  Lab shows probable acute multiple myeloma with secondary hypercalcemia.

  She had fulminant, bone-marrow cancer with lethal levels of calcium, causing shutdown of bowel function and severe abdominal pain. If the poor woman had sneezed too hard her bones would have broken.

  I worked her up, started some of the therapy required to lower her calcium to relieve the pain, and waited for the attending physician to arrive.

  That event occurred at six o’clock, when I presented my patient. The attending doctor elaborated an extensive treatment protocol, as the other students and house staff—and I—grew more and more incredulous. He was demanding treatment that was futile and absurd. The woman was ready to meet her Maker.

  The intern and resident stared at their shoes. Even the nurses shook their heads but kept their mouths shut.

  “Doctor Tinsley … uh … how will this help Mrs. Jackson?”

  Yes, I opened my big mouth. Why would that surprise you? But I was confused. On the one hand I wanted to save the world. On the other my own life experience in the tenements told me such an ambition was futile. I had really just hoped Tinsley would aim me in the right direction, as had my mentor Corrado.

  What I got instead was a piercing stare.

  End of discussion.

  Later, as I was getting ready to go for a quick lunch, the intern gave me a two-finger summons.

  “The dean wants to see you.”

  Minutes later I sat in his secretary’s anteroom waiting for an audience with the Great One. Normally friendly and talkative, she would not look me in the eye. Her intercom buzzed, and she directed me to enter the inner sanctum.

  John Gilbert Traywick IV, dean, sat behind his double-size, dark-cherry desk. There was no doubt he was a scion of one of the school’s royal families. There also was no doubt he fully intended to remind me of my own lowly status.

  “Sit down, Galen.”

  I was sweating in my starched student whites. He looked me over with his sky-blue eyes hooded by bushy-white brows. The jowls he proudly displayed in wide-faced smiles for publicity photos were now double-folded and scowling.

  “Mr. Galen, do you know why I called you here?”

  “No, sir.”

  “Don’t you understand what you did?”

  “No, sir.”

  “Are you stupid, Mr. Galen?”

  “No, sir.”

  “But you just don’t get it, do you?”

  “Sir?”

  His famous exasperated look splayed across his face. He shook his head, but not one white hair moved.

  “Mr. Galen, you showed great disrespect for your attending.”

  That thoroughly confused me. My grades were exemplary and my clinical work was never faulted.

  For some reason a quote from the great Mexican general Zapata crossed my mind.

  Es mejor morir de pie que vivir de rodillas!

  It’s better to die on your feet than live on your knees.

  I stood up, approached his desk, looked him straight in the eye, and said quietly, “Dean Traywick, I truly don’t understand. What did I do wrong?”

  I think I startled him, because he involuntarily pushed his chair back from his desk.

  A few seconds passed. Then he resumed his position. I retreated and sat back down.

  “Mr. Galen, why did you question Dr. Tinsley’s treatment plan for your patient?”

  Ah, so that was it! I cleared my throat.

  “Sir, my patient is dying. She wants to die. What Dr. Tinsley ordered us to do was not in her best interest.”

  I knew it—I had crossed the Rubicon—but I was in it now, so I quickly continued.

  “I appreciate Dr. Tinsley’s expertise and skills, and I know I’m still just a student. But he must know—and have—reasons that I do not understand, so I asked him why.”

  Traywick stood up and faced me.

  “Mr. Galen, if you were any other student I would have expelled you. Do you understand that?”

  “No, sir, I don’t.”

  “Galen, you are living proof that education does not always convey common sense.”

  I had nothing to lose.

  “Dr. Traywick, maybe you could…”

  “God help us, you just don’t get it. Get out of my office!”

  I left and went back to the ward.

  Eulah was lucky. She died before the testing could begin.

  So was I, because I managed to graduate.

  Yes, Traywick, I remember you.

  “Uh … Dr. Galen, are you still there?”

  “Sure.”

  “As you may know, I’ve retired as dean, and the alumni association has appointed me head of their fundraising committee. That’s why I’m calling. As a graduate I’m sure you can understand the expenses of running the medical school and the need for support from our distinguished alumni. How much can we count on you to contribute?”r />
  “Nothing.”

  “I’m sorry I didn’t hear that. Guess I’m getting old. How much did you say?”

  “Zero. Nothing.”

  “I don’t understand.”

  “Mr. Traywick, are you that stupid?”

  “Uh … I…”

  “Well, J.G., I guess you just don’t get it, do you?”

  I hung up the phone. Dare I say that I slept very well that night?

  Little Orphan Annie had it right: Tomorrow is only a day away.

  I was nearing the end of another fun-filled, full schedule of patients: colicky babies, dyspeptic politicians, and a few chest and belly pains thrown in for good measure. I was beginning to run out of steam.

  “Who’s left, Virginia?”

  I could sense my secretary characteristically raising an eyebrow.

  “New patients, the Delauncys. She’s coming in for a prenatal checkup.”

  I closed my eyes and rubbed my temples. Not my most favorite thing, seeing new patients at the end of the day.

  I watched them out the window, walking up the sidewalk to the door, a couple in their mid-thirties, well-dressed with a confident stride.

  Husband and wife sat together in the examining room, while I went through my routine questioning. Eric Delauncy was a professor of electrical engineering, and his wife Natalie was a graduate education professor. She explained that she was about four months pregnant—with her first child—and she wanted a mini-checkup before proceeding to an obstetrician. She noted that her cycles had stopped a little more than four months before.

  She had no complaints and took no medication, but she did take vitamins and extra folic acid. She said she had read about their importance during pregnancy.

  Her husband remained in the room at my request. I have always found it wise to do so, because a spouse’s presence eases some of the nervousness for a new patient during an initial visit.

  The examination was exceptionally unexceptional. Mrs. Delauncy was in excellent condition.

  There was only one problem: She wasn’t pregnant.

  As I examined her, I became more and more convinced that what the young woman considered a pregnancy was actually an enlargement of the muscular lining of the uterus—a fibroid tumor.