Because I Come from a Crazy Family

by Edward M. Hallowell

  “You can imagine,” he said, “how totally embarrassed I feel when I feel I have to pick up an ashtray and lick it, even with someone looking right at me when I do it. Some of them say right out, ‘That’s disgusting!’ and I say, ‘I agree,’ as I put the ashtray down and walk on. Thankfully, with the underwear, no one is looking, but I feel totally ashamed and disgusted anyway. Why do I do this, Doc? I’m really sick, aren’t I? Can you help me?”

  Other experienced psychiatrists had tried and failed to help Hank. He could no longer afford insurance or a private fee, which is why he was seeking help through Tulane and Charity. To top it all off, now he was stuck with me, a second-year med student who didn’t have a clue.

  But I did have backup, thank God. In addition to a resident who supervised me, I could also turn to a senior member of the faculty, Dr. David Melke. When I presented the case to Dr. M., he asked me what I wanted to do. “What I want to do is tell him to stop it,” I said. “But I know that’s stupid. No one wants to stop these habits more than he does.”

  Dr. M. responded, “In years gone by, this man would have been put into psychotherapy, maybe even psychoanalysis, because that’s all there was. It wouldn’t have worked. In really bad cases like this one, people sometimes committed suicide.”

  “Why does he do this?” I asked. “Is there any way we can help him?”

  “Why he does it we can’t really say, except that it is part of a well-established diagnostic entity called obsessive compulsive disorder. You should read about the difference between the obsessive compulsive style, which MacKinnon and Michels write about in the book you’re reading, and obsessive compulsive disorder, which is what’s crippling this man.”

  “Insight won’t help much, will it?” I asked, knowing that it wouldn’t.

  “Probably not very much, but your support definitely will. He needs to be able to talk with you and know you are not going to laugh at him. Everyone else, his friends, his family, the world, they all ridicule him. He ridicules himself in all likelihood and finds himself disgusting. You need to help him understand that what he’s got is caused by biology, not lack of willpower or hidden unconscious drives. You can help him a lot by explaining to him that what he suffers from is more like a seizure disorder than anything else. He simply can’t control the compulsions any more than a person can control a seizure.”

  “OK,” I said, “I can do that. I can offer him support, which I am actually doing, even though my first reaction was to laugh at him inside.”

  “You can learn from that reaction,” Dr. M. said. “It’s the reaction he brings out in most people, so knowing that, you can understand him and support him even better.”

  “But is there anything I can do beyond that? Other experienced doctors have tried. I feel kind of out of my depth here.”

  “Welcome to psychiatry,” Dr. M. said. “We all feel that way often, because we don’t have the cures we need for lots of the problems we help people deal with. But in this case, I think there is something you could try that hasn’t been tried yet.”

  “Really?” I said, feeling a surge of hope and excitement. “What?”

  “The MAO inhibitors have been found to be useful in treating OCD, and I don’t believe he’s ever had a trial of an MAOI, has he? If that doesn’t work, we might consider psychosurgery.”

  “Surgery? Really? Well, in any case, he hasn’t had an MAOI yet,” I said. “Let’s give that a try first.” Dr. M. agreed. So began my first excursion into the world of prescribing. I couldn’t sign the prescriptions of course, the resident did that, but I could do everything else. Like worry about side effects.

  Monoamine oxidase inhibitors, or MAOIs, can help OCD, but they have an unusual, and to me totally nerve-racking, side effect profile. If the patient taking an MAOI eats any food with the amino acid derivative tyramine in it, his blood pressure can shoot through the roof and he could have a stroke and even die. It’s called a hypertensive crisis, and it’s potentially lethal.

  So I had to go over in great detail the list of foods Hank had to avoid, lest he possibly die. This was a tough conversation for me, but Hank was so eager to get some relief, he didn’t mind it one bit. No fava beans, OK. No aged cheeses, OK. No red wine, OK. No smoked meats or fish, OK. No food restriction would cramp Hank’s style anywhere near as much as the OCD.

  Hank and I made a plan that he would be very careful with what he ate and he would check in with me on the phone every day to report on his progress.

  At first I spent each day and night expecting to get paged that Hank was in the ER, his blood pressure through the roof! But that page never came. Instead, Hank phoned in or sometimes came in for our brief daily check-ins and started to report progress. If I was overjoyed, which I was, imagine how Hank felt. He cried. He hugged me. He reported making forays into the outside world and actually walking past ashtrays without even touching them, let alone licking them.

  The MAOI didn’t cure Hank completely, any more than our daily chats did, but they did free him up enough to go outside and begin learning how to control his compulsions.

  People who disparage medications in psychiatry ought to meet the Hanks of this world, before and after.

  I’ll never forget him, my first patient-teacher in psychiatry. It also makes me smile, all these years later, how anxious I was having just one patient under my care (and with backup, no less) on a medication with one potentially dire, i.e., lethal, side effect. We do begin with baby steps.

  It’s every pre-med student’s fear and every med student’s fear, and on some days, every experienced doctor’s fear: How do you handle all that responsibility? If you’re a car mechanic and mess up, or if you’re an attorney and mess up, it’s unlikely someone will die. But if you’re a doctor? We all play it out in our minds until, at some point, we get used to it. It becomes ambient noise; we become skilled in living with the possibility of bad outcomes.

  What I learned—starting with Hank, and then from the thousands of patients since—is that if you hang in there, you’re handling it. Lyn’s husband, Tom Bliss, the orthopedic surgeon and my earliest doctor role model, told me, “Patients are better off having you than not having you. Just don’t walk away. And always ask for help when you need it. The more cases you handle, the more skilled and confident you become.”

  But even as a raw med student or intern, with so little experience, I never felt terrified by the life-or-death decisions on my shoulders because I knew I was never alone. I never had more responsibility than I was able to take on. If something came up that I couldn’t handle, there was always somewhere to turn, someone to ask. If I’d been alone in the middle of nowhere it might have been different, but I never was, thank God. A few years later, one of my best teachers in psychiatry, Dr. Tom Gutheil, summed it up in one of the most valuable maxims I’ve ever learned: “Never worry alone,” he’d tell us, “never worry alone.”

  44.

  When the third year finally came, I started to love med school. My first rotation was Surgery. As a third-year med student, I was paired with a senior resident named McCormick. He could not have been more different from the pompous surgeon who’d been my Anatomy instructor. He was earthy, blunt, and interested in helping people. No one called him anything but McCormick. He had a first name, but no one ever used it. I followed McCormick around for the three-month rotation and was at his beck and call for just about anything.

  Although I was essentially his slave, I loved McCormick. I don’t know why, because he routinely abused me. He always called me “dink” or “fuckin’ dink,” never Ned. He chain-smoked Marlboros, barked orders constantly, and asked questions I couldn’t answer. But he also taught me a ton and I loved his out-there, no-holds-barred, take-me-or-leave-me honesty. While other residents were kissing up to faculty and angling for jobs, McCormick didn’t appear to give a damn what other people thought. I loved that. It reminded me of many people in my family.

  And, boy, did McCormick ever love being a surgeon. “I’
d rather cut than fuck,” he said to me more than a few times. “Surgery is so off-the-wall hard-ass and definitely gonna mess up your life. I mean, there is no such thing as a surgeon who has a happy normal life, you really gotta love it to do it. How many surgeons have happy marriages? I don’t know any, do you, dink?” He was really asking me.

  “I know one,” I said. “My cousin. But he’s an orthopedic surgeon.”

  “They don’t count. It’s easy to be happy if everyone you operate on gets better and no one dies. But how many general surgeons have happy marriages? Damn few, I can tell you that. And how many surgeons are obnoxious? Most of us. How many surgeons end up alcoholics, divorced a hundred times, alienated from their children, drowning in debt because they can’t handle money, and have people everywhere they go pissed off at them? Most of us. But, lemme tell ya, we love what we do. We love to cut. Oh, shit, do we ever love to cut. We love to fix people. And most of all we love that we are better than all the other docs. All those wimps who don’t dare do what we do. We try not to let it show, but I can guarantee you, deep within the heart of any surgeon worth his salt is a voice saying, we rule.” Then McCormick would light a cigarette. “You get it, dink? We rule. Now go get Mrs. Lafitte’s labs.”

  I had only three months with McCormick, but he left his mark on me forever. My best friend in medical school, Steve Bishop, who went on to become a psychiatrist as well, used to make fun of my love of McCormick. “Surgery is all sublimated sadomasochism,” he’d say. “What you’ve got going with McCormick is a sadomasochistic relationship, pure and simple.”

  “Hey, dink,” McCormick asked, smoking the ubiquitous cigarette while we were having a coffee outside Charity at the aluminum truck on Tulane Avenue, “have I turned you on to surgery yet?”

  “You have done that, Dr. McCormick,” I said. “You’ve definitely turned me on to surgery. Although the stench of that anaerobic abscess will follow me forever.”

  Another drag on the butt, another sip of coffee, then the butt drops to the sidewalk and McCormick steps on it with his penny loafer (no socks). “What I told you about how surgery fucks up your life? Guess what—all of medicine fucks up your life. Beats the hell out of me why so many people wanna be docs. They go in thinking they can save the world, or make a lot of money, or get respect, I dunno, but I can tell you one thing for sure, they have no idea what they are getting into. Most of ’em end up burned out, drugged out, divorced, alone, miserable, it’s a shitty story what life has in store for most of us. So you damn well better love what you go into if you want to stand a fuckin’ chance of beating the odds. That’s for damn sure.”

  I wanted to give McCormick a hug, but I thought he’d probably knee me in the groin if I did that, so I just said “Thanks a lot.” I don’t know where he is today, forty plus years later, but I’d like him to know he did OK by this dink.

  Like the world of McCormick, medicine at Charity was a unique world. Studying there afforded opportunities not only to meet gifted, gritty teachers like McCormick, but to work with patients in a much more responsible role than most medical students at other schools got to.

  For example, on one steamy August night during my OB/GYN rotation (I did OB after Surgery with McCormick), the air conditioning in Charity shut down. New Orleans in August is like a tropical rain forest. Without AC, the hospital air was all but liquid. As the night wore on, I had to change my scrubs over and over because they were sopping wet from my sweating.

  If I was hot and dripping, just imagine what the women in labor were going through. We all worked together to keep them as comfortable as possible, but the words “comfortable” and “labor” don’t usually appear in the same sentence.

  Around three in the morning, a woman in her thirties came in to deliver her fourteenth baby. She was assigned to me. I brought a cold washcloth to her bedside as I introduced myself. She gave me a big smile as she gladly wiped her face with the cool cloth. “Sweet Jesus, did the AC go out in this place? Oh, Lordy, I don’t know what I’m gonna do, did it really go out?” she wailed.

  “I’m afraid so,” I said, and then, after looking down at the chart, added, “Harmony.”

  “Well, this baby ain’t gonna wait, I can tell you that. I don’t need you to do much, though. I’ve done this a few times before.” With a loud grunt, she shifted her large frame around on the cramped gurney, trying to find the least awkward position. “There ain’t no easy way, you just want it quick. And I don’t want no drugs, and no ’pisiotomy. They just love ’pisiotomies here at Charity, and I’m telling you, I don’t want one! You hear me?”

  “Yes, ma’am, I do,” I said as forcefully as I could. She was correct. The Tulane department of OB at the time mandated that all vaginal births include an incision diagonally and downward from the vagina, a procedure called an episiotomy. It was supposed to reduce the risk of vaginal tearing, which, if it does occur, can create a big mess. And with medical students doing most of the routine deliveries, the policy was intended to prevent complications that medical students like me couldn’t handle.

  But I believed this woman had had enough experience giving birth that I could obey her command and simply let the process go its natural way. If I got into trouble with the resident or the attending, I’d just tell the truth. The patient does have the right to refuse a procedure, after all.

  All of a sudden, Harmony let out a whoop. “Honey, it’s coming!” At that moment my hand was inside of her, using my fingers to measure how dilated her cervix was. “I’m plenty dilated up, if that’s what you’re checking, or maybe you just having a good time down there!” She let out a hoot/scream of laughter/pain and then gave my free hand a titanic squeeze.

  Next thing I knew she was crowning and the baby shot out into my waiting hands.

  “It’s a boy!” I announced, trying to add something useful to the procedure.

  “My twelfth boy. I’m a regular dingaling factory. Clean him up good now and let me hold him, you hear me?”

  With the help of the nurse, we suctioned and patted and dried. Based on skin color, reflexes, muscle tone, heart rate, and quality of respiration, the Apgar score is assigned after one minute and then again after five. This baby scored 10 and 10. A healthy baby and a healthy mom, especially for someone who’d just delivered her fourteenth baby.

  He was adorable. Actually, I found all the babies adorable. OB was by far my favorite rotation in medical school, even more than my months with McCormick. In that one month of August, I delivered thirty-five babies.

  When I handed this squinchy-faced infant to his mom, Harmony looked down at him and heaved a sigh. Something was bothering her. As her eyes flooded with love—unmistakable, even with number fourteen—she looked up at me with a troubled look. “Doc, you could help me with one thing.”

  “Anything, just ask.”

  “Honey, I am fresh out of names. I come here expecting a girl, don’t you see, and then I get another boy. He’s beautiful for sure, but I just don’t have a name for him. If he’d been a girl, she was gonna be Georgina, after my best girlfriend, by the name of Georgina, of course, but seeing as he’s a boy, well, Georgina won’t do, and I just plain do not like the name George. So I was thinking as I been laying here, maybe that nice doctor’s got a name for my baby?”

  In the middle of the night, in the sweltering heat and humidity of Charity Hospital in August with no AC, my brain was on tilt. Without a second thought, without even pausing for a millisecond (years later, I would learn this is what we people who have ADD are prone to do), I proposed, “How about Fenway Park?”

  “Ho!” Harmony crowed. “How about that! That’s a right classy name. I love that. How you say, again, Fenway Park?”

  “No, no,” I sputtered, “I was just joking, you can’t name him Fenway Park. That’s the name of the baseball field in Boston, the city I come from up north.”

  “I know where Boston is, child, one of my sisters lives there with her fat, no good husband. Oh no, I take that back. Lord, fo
rgive me. He is a good man. He treats her fine. Just some days I wish he could work harder instead of laying on his fat, no ’count butt. Shut your mouth, Harmony! Lord, forgive me. Anyways, Doc, I’m glad to name this boy after a place in Boston in honor of my mighty fine sister.”

  “Really, I don’t think you want to do that. Fenway Park is the name of a baseball field. He’s gonna be stuck with this name and he may get made fun of because of it and he may not thank you for giving it to him. In fact, he may be very angry with you, not to mention me! Please, I can come up with some normal names for you. Bob, Joe, Frank—”

  “Too late, Doc. He can change his name if he wants to when he gets old enough. But for now, I am in charge and my new son’s name is Fenway Park. It’s a gift you’ve given me, Doc, it’s a right classy name, and I am grateful to you and to the Good Lord for sending me this beautiful name for my beautiful son number twelve.”

  45.

  Like my own family, Tulane Medical School, Charity Hospital, and the city of New Orleans teemed with wildflowers: colorful characters not traditionally cultivated. Not many days passed without a funeral procession dancing down one of the streets in the Quarter, mourners dressed in motley array, men in black top hats, women sporting parasols of many colors that they twirled and swung around as they sashayed along, accompanied by the brass instruments playing slow hymns like “Nearer My God to Thee,” followed by upbeat tunes like “When the Saints Go Marching In.”

  I loved watching these processions from my dorm window, or even better, while sipping a beverage in one of the many raucous but welcoming bars scattered throughout the Quarter. My God, I thought to myself, this is the way I want to go. Why on earth don’t we white folk do it like this? I could see people with tears streaming down their faces even while they were pirouetting and dancing. And isn’t that exactly what a funeral should be? Tears over the loss, weeping that you will not see the person again, at least in this world, coupled with a celebration of the life the person lived, and jubilation over how much love all the people gathered felt and feel for each other and for the person who’s passed away? At Exeter, the English Department had a blanket policy against using euphemisms for “die” like “pass,” yet these New Orleans funerals seemed to defy the idea of dying and celebrate the idea of passing on.