Even most so-called accidents could be studied like diseases with various risk factors: teen gun violence required a gun, a grudge, alcohol, and impoverished future prospects. Take away the preconditions and the harm stops. Figure out what goes wrong and fix it. Goodness emanated from Harvard and a few other centers of excellence and spread in a centripetal manner, pushing back the darkness. Good doctors went out and displaced not-quite-so-good doctors. Better medicines and surgical procedures displaced older ones. Medical science and care from World War II till the time when I entered medical school was one success following another, a nonstop steady climb. There was no reason to believe it couldn’t go on forever.
A surgeon in charge of my surgery rotation said that he knew who I was but that he was going to treat me as if I was normal. I sincerely thanked him and told him I would try to act that way.
Like other things we do to protect patients from our germs, hand washing and wearing gloves and masks, scrubs and surgical gowns were adopted originally to protect doctors and nurses from the diseases of the people they were taking care of.
Scrubs were not made to be worn outside of the OR, where they were always covered by sterile gowns, but as soon as the first absentminded surgeon went out of the OR in scrubs, fashion history was made.
Scrubs have no pleats. Except for the patch pocket over the left breast, suitable for holding three-by-five index cards, they are exactly like cutout clothes for paper dolls. When they started using scrubs in the OR they were white, but blood on white looks too much like what it is and bright white under OR lighting was not restful. Now they are slightly rumpled, gray, blue, green, or, more recently, pink. They started using pink in the OR under the mistaken assumption that doctors wouldn’t want to be seen in pink scrubs in the cafeteria or elsewhere. Very shortly after the introduction of “OR only” pink scrubs, pink scrubs were everywhere, including neighborhood basketball courts.
If everyone wore surgical scrubs instead of regular clothing, we could save trillions of dollars. There is no other way to fully clothe a person for less than ten dollars.
Doctors on call or stepping out of the OR are so important they don’t have time to put on a shirt and tie. Exhausted, unshaven, and wearing scrubs, I was more credible than with a freshly shaven face, pressed shirt, and tie. There was an intrinsic seriousness to what we were doing that made wearing scrubs okay.
Back in Hollywood Hospital, there were no scrubs. The doctors were very well dressed, and the patients were in pajamas. The doctor in charge of the whole place wore baby-blue alligator shoes, drove a light blue ’59 Cadillac convertible, and wore what I was sure was the button to end the world as a tie clip.
I wanted to be a good diagnostician. There was a way of touching people that created trust and gave relief from the day-to-day way people treated one another. I was watching and learning from masters. The doctor’s job was to shut up long enough to let the patient be the most important person in the room, because she was. There was an unforced and absolutely real respect for people just because they were people. And we, as doctors, were their servants. For all the things that felt wrong, that felt right.
If you weren’t an idealist, why would you go to medical school?
During my core rotation most of our patients were eighty-five or older with overwhelming, intractable problems, which we ignored while looking for things around the edges to adjust. If there was something that we believed in, that helped us keep our spirits up, it was the salvageable patient.
When one of my fellow students presented a demented ninety-six-year-old patient who went into heart failure because she ate tuna fish, I couldn’t help wondering aloud what exactly the point was. Our junior resident told us that the point was for us to learn physiology from fragile patients so we would be ready and up to the task of saving a salvageable patient when one came along.
Richard was a very polite, fastidious twenty-nine-year-old heroin addict who was nervous about letting anyone except himself draw blood because they might mess up the few good veins he had left. I watched his technique closely. Learning how to draw blood and do other procedures was high on my list of interests. He tapped the needle against the skin and tried to bounce it into the vein. He thought he was better at it than he really was.
Every morning the whole team watched as the resident listened to the heart and lungs of each of our patients. Usually he said nothing because there was nothing to say. One morning while examining Richard he stopped and had each of us listen to a spot he had located on the patient’s back.
“Those are rales and rhonchi,” he stated flatly. “Richard is coming down with pneumonia.”
He had one of us write orders for a chest X-ray and massive doses of IV ampicillin. Four hours later Richard was short of breath, running a 105-degree fever, sick as a dog. The chest X-ray hadn’t been done and the antibiotics hadn’t been given. The one time we had a physical finding that might have made a difference on the closest thing we had to a salvageable patient, the damn orders were written but never taken off. Our resident was closer to tears than mad. Richard did well. If he had been eighty-five, he probably would have died.
My father asked me what I was learning from all this. I told him that needing a doctor was a bad sign.
It continues to amaze me how easily doctors can walk away from their mistakes. A patient would be sent to the ICU with horrendous complications and zero prognosis, and the surgeons who botched the case could be toweling off in the locker room and chatting about how to bill for the various procedures involved and the upcoming Pats game.
The month before I finished medical school one of my sisters had a psychotic break right after she quit drinking. I went down to New York and was a model of tough-minded efficiency, hiring an ambulance and getting her transferred to a better hospital and better care after it was carefully explained to me why such a thing was not possible. That evening I had two Heinekens, a dozen oysters, a big steak, a double of Jack Daniel’s, and called it a day. A job well done. The best proof I had that I didn’t have a problem with alcohol was that I drank at least a little every day for many years and didn’t have any trouble.
By the end of medical school, I could walk through an emergency room or an ICU and feel comfortable and know how to act. I owned a solid Victorian house where my mother and siblings came for holidays. I was the only person in my medical school class graduating with a two-year-old on his lap. Right before the ceremony, my cousin Steve taught Zachary how to say, “Pop’s a doctor.”
“Half of what we’ve told you is untrue. Unfortunately we don’t know which half, and it will be up to you to figure that out,” said the commencement speaker.
It was a clever and wise thing to say, but nowhere near half of what we were taught was true except in a very conditional and relative way. We also lacked the support to make use of what we knew, but besides that.…
Later, when I interviewed applicants for Harvard Medical School, they were all bright and earnest and planning to help people. I hurried them through all that because I couldn’t tell one from the other.
“Yes, yes, yes … but what exactly is being a doctor going to do for you?”
I wanted life and being a doctor to be like getting on a bike, pedaling hard, and generating good. By going into medicine—working against suffering, disease, and disability—I was set for life with good thing to do after good thing to do and I would be able to make a living at it. To put myself even more firmly into positive territory, I went into pediatrics. If you were going to change the world, it was a good idea to start with people. And if you were going to change people, it was a good idea to start early.
“Sorry I’m late, dear. I was snatching babies and children from the jaws of death.”
I thought that as a pediatrician I would be taken care of and protected, that if people knew I was a pediatrician they wouldn’t break into my house or mug me, that I wouldn’t have to stop and chat after minor car accidents, that my way would be smoothed. I wanted
to be someone no one could take exception to.
When I told a professor at Harvard that I wanted to go into primary care, he said that it would be a waste of a Harvard education. He had done primary care. It was easy. With a Harvard education we could cure generations rather than individuals.
So it wasn’t enough that I was in medical school. I was supposed to be lining up to cure generations. And I’d thought I was crazy.
Waiting for something to happen
(Vonnegut family photo)
chapter 8
Man’s Greatest Hospital
Chance favors the prepared mind.
—Louis Pasteur
I had applied to twenty medical schools and gotten into one. I would have been overjoyed to go anywhere that had “Medical School” in its name. Four years later I was an insider, asking questions about how much responsibility interns had, whether they were supervised by fellows or senior staff, and what program graduates ended up doing.
Massachusetts General Hospital—MGH—seemed nice. I had done a couple of rotations there and done well. During my interview it was more or less settled that if I ranked it number one, MGH would be where I did my internship and residency. A happy person with decent self-esteem wouldn’t bother to have credentials as good as mine.
When I was a resident, patients were taken care of quickly, with compassion and respect. They did not have to wait for hours and hours. Their insurance coverage was something we figured out later. There was a sincere, almost naïve belief in science and settling arguments with science and data. Children with life-threatening infections had lifesaving antibiotics in their system as soon as possible after hitting the door. We were fiercely determined to do the right thing for whatever patients came our way.
The beginning of the end was when we were told we couldn’t give out advice on the phone anymore; everyone had to be told to come in and be seen. Someone somewhere thought someone might be wrongly reassured or misinterpret what we said or we might make a mistake that would end up with an injured or dead patient and a lawsuit. We were always incredibly conservative about having anyone with remotely worrisome symptoms come in anyway. There was not a single case of things going badly because of our phone advice or any study about phone advice in general that the powers that be were responding to. It was an administrative answer to an administrative concern. Giving phone advice was good for senior residents’ training and helped more than a few children get appropriate care for minor injuries and illnesses.
Having patients come into the emergency room to be seen rather than get advice over the phone seems like a small thing, but it introduced a wedge between doctors and patients. The job was no longer to do what was right for the patient no matter what. It was hard enough to figure out what was really best for the individual and obey the ancient dictum “First, do no harm.” Now we had to be in accord with risk management, HMO guidelines, managed care, HIPAA, ICD-9 coding, and on and on. Every bright idea that was supposed to improve medical care has made care worse, usually by increasing costs and restricting access. It was a better world when you could call a senior pediatric resident on the phone to help you through a diaper rash or vomiting or diarrhea. Ninety percent of what gets treated in today’s ERs at a cost of billions of dollars, zillions of unnecessary tests, and eons of waiting would go away if people could just talk with a well-trained senior resident. The point is supposed to be getting people appropriate help.
I myself didn’t like asking for help. My first night on as an intern in the ER, I faced an unprecedented barrage of twenty-plus patients, many of whom were seriously ill. The junior resident, who was supposed to be helping me, went to the library and fell asleep. The senior resident, who was backing him up, was busy in the pediatric ICU. When I was asked in the morning why I hadn’t asked for help, I explained that I’d just assumed, being new, that whatever happened was more or less normal and I didn’t want to be a complainer.
When I was a junior resident in the neonatal ICU and a little 800-gram preemie was trying to die by rupturing one lung and then the other and then the first one again and the air from the ruptured part kept filling up the chest and squeezing the good lung tissue and the heart, I put in three chest tubes to drain off the air. The senior who was backing me up mentioned on rounds the next morning that maybe I should have woken him up. If another patient had crashed while I was putting in all those chest tubes, I would have, but it seemed under control at the time.
Attitude is everything. I had more than my share of days where IVs all went in, I got spinal taps on the first pass, and I caught everything before it could hit the ground. It was a blend of will and attitude. When I felt well, things went well. I had a Teflon jacket of positive expectation that got me into and through medical school, internship, and residency. The universe wanted me to succeed.
The stark facts about medical care are that needing a doctor is, in fact, a bad sign, and needing an ICU is a very bad sign. The pediatric intensive care unit (PICU) is a great place to disabuse yourself of notions of fairness. Here, whatever doesn’t kill you doesn’t make you stronger. It makes you weaker and kills you tomorrow or the next day. Things don’t even out.
Christmas Eve ’81 it was snowing. I was the senior resident in charge of the PICU. There were maybe one or two patients in the unit who had any chance of surviving, walking, talking, and going to school. Most were on ventilators. One had drowned in a wading pool and was resuscitated but never woke up. They called it a near drowning because his heart and lungs and kidneys survived. One boy was brain-dead from being beaten by his mother’s boyfriend, but we couldn’t let him go because then the mother’s boyfriend could say it was us who had killed him. The sweetest little boy in the world with the nicest parents in the world was getting weaker and weaker and couldn’t breathe on his own because of some mitochondrial defect. We knew exactly what was wrong but couldn’t do anything about it. A patient with meningococcemia in the isolation room looked like she might do okay. A one-month-old who’d had her heart operated on the day before was not doing well. And so on.
I went out of the unit into the hall on my way to the on-call room to have a cigarette and heard gales of laughter. The families of the patients in the PICU were playing charades, gesticulating, shaking their heads, not talking. Just like anyone else playing charades.
——
For three years, with one week a year off for vacation, I rode my bike four miles to the hospital and back, even in bad weather, every day, sleeping over when I was on call every other or every third or fourth night, depending on the rotation. I was working a one-hundred-plus-hour workweek, but it didn’t seem that bad. Sometimes on call I actually got to sleep a little.
I learned everything I could about taking care of sick children. I was in very good physical shape, as fast as the wind on my ten-speed bike and able to beat most people at squash. I was a good intern and resident. In the beginning of my senior residency I was asked if I would consider being the chief resident. I was honored but too much in debt and not getting any younger. At thirty-four, with a second child on the way, I felt it was time to look for a job.
If the thing you’re best at is being a resident, maybe you’ve peaked too early.
My second son, Eli, was born December 3, 1980, the year of my senior residency, right before the charades game in the PICU family room. I loved my children but often had to stop and think of what a good father would do. I was doing my best imitation of a good parent. I was also doing my best imitation of a good husband.
I had a serious sleeping problem and started taking Xanax for it and feeling much better. I associated not sleeping with going crazy. I didn’t want to leave it up in the air whether or not I would sleep at night. Xanax seemed to make me the person I was meant to be and had no side effects. One miracle after another.
It was ten years since I had been seriously crazy. I had done medical school and was finishing up residency. The year 1981 was a much better one than 1971.
I wo
ndered how it had all come to pass, but it always hurt when I pinched myself.
It was early spring when I arrived for my last night as senior in charge of the ER, and there was one “expect note.” Sometimes there would be half a dozen or more. I checked the crash cart and the laryngoscope batteries. Whenever I was in the ER and had small bits of time with nothing else to do, I’d scan dermatology texts. Sooner or later I’d run into someone with the disease in the pictures and it would click that I’d seen it somewhere, even if I couldn’t remember what it was.
EXPECT: Prince of the River Nile Smith. One-week-old black male with conjunctivitis. Born at home, did not receive silver nitrate or erythromycin prophylaxis.
Care and Protection order. Child must be admitted and treated for presumed GC conjunctivitis.
Gonococceal (GC) conjunctivitis was the number one cause of blindness before there were laws mandating treatment of all newborns. The closest I’d ever come to seeing a case of GC conjunctivitis was a woman who had a positive GC culture one week prior to delivery. There were lots of ideas about what we should do, and in the end we decided to do them all. The mother and baby each received so many different antibiotics via different routes before and after delivery that whatever germs were there were ripped to shreds worse than Bonnie and Clyde in that machine-gun ambush.
Textbooks show massively swollen, very red, weepy eyes with copious pus.
I got a call from the chief resident at Mass Eye and Ear Infirmary. “We have a seven-day-old baby here with eyes that look fine, but there’s a care and protection order on him because the parents wouldn’t comply with treatment at Children’s Hospital. Our pediatric floor is full, so we’re sending him over to you.… I don’t want to make you nervous, but the father has about a dozen very quiet friends dressed in camouflage fatigues and combat boots. Our security people have already talked to your security people.”
Just Like Someone Without Mental Illness Only More So Page 7
