Postgraduate Year One: Lessons in Caring

POSTGRADUATE YEAR ONE

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POSTGRADUATE YEAR ONE: Lessons in Caring

KENNETH M. HEILMAN, MD

1 2009

1 Oxford University Press, Inc., publishes works that further Oxford University’s objective of excellence in research, scholarship, and education. Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam

Copyright © 2009 by Oxford University Press, Inc. Published by Oxford University Press, Inc. 198 Madison Avenue, New York, New York 10016 www.oup.com Oxford is a registered trademark of Oxford University Press All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Oxford University Press. Library of Congress Cataloging-in-Publication Data Heilman, Kenneth M., 1938Postgraduate year one : lessons in caring / Kenneth M. Heilman. p. ; cm. ISBN: 978-0-19-532126-5 1. Heilman, Kenneth M., 1938- 2. Physicians—United States—Biography. 3. Residents (Medicine)—United States--Biography. [DNLM: 1. Heilman, Kenneth M., 1938- 2. Education, Medical—Personal Narratives. 3. Physician-Patient Relations—Personal Narratives. 4. Students, Medical—Personal Narratives. W 18 H466p 2008] I. Title. R154.H45A3 2008 610.92—dc22 2008010989

1 3 5 7 9 8 6 4 2 Printed in the United States of America on acid-free paper

This book is dedicated to my patients, who trusted me, taught me so much, and helped to make my life meaningful.

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Preface

I

am an academic physician who cares for patients, teaches, and performs research. As an educator, I have thought often about when it was that I learned the most about being a doctor. Time and again, it is the lessons learned during my internship that have had the greatest influence on me and helped guide my career. Over the years of teaching, I have learned what biblical scholars have known for centuries, namely, that people often learn best through stories. For several decades, I have shared stories from my internship not only with students and trainees but also with patients and their families. These people often encouraged me to write them down so that they would be available for others. Kept busy by professional commitments, I put these stories on hold. About a year ago, I learned that Patty O’Keefe had died. She was one of the nurses with whom I worked as an intern and who had taught me much. Her death gave me the push I needed. Many of the events in this book happened more than 40 years ago, during my internship at the Cornell program at Bellevue and Memorial Hospitals. Since then, medicine has undergone tremendous changes with the development of powerful new drugs, new diagnostic procedures, new forms of surgery, and even new preventive measures. At the same time, neither people, diseases, nor doctors have changed and, despite the efforts of government, insurance companies, lawyers, and businesspeople, the relationship between a doctor and a patient has not changed either.

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The idea of writing this book first came to me during my internship. However, as an intern and then a resident, I never had enough time for sleep, much less writing. The most I could do was to jot down occasional notes, which I have kept all these years. After two years’ training, first as an intern and then as a resident, I was unsure that I wanted to continue in internal medicine. I had always been fascinated by neurology. Because back then there were virtually no treatments available for neurological diseases, everyone warned me that, however interesting, neurology did not offer much of a future for a young physician. During my second year of training, the conflict in Vietnam intensified and the armed services developed a terrible shortage of physicians. Because I could not decide upon a direction but could still practice medicine and be of service, I decided to forgo the rest of my deferment and joined the Air Force. Though the Air Force kept me busy, I had a little more time to write about my internship. The more I wrote, though, the more I felt that my stories would be more meaningful if I had more experience as a doctor and, hopefully, some wisdom. I put them aside. Now, years later, I continue to feel that I never learned as much as I did as an intern. The stories reflect a few things I learned about medicine, but they focus on something of greater importance—what I learned about people, the relationship between patients and health professionals, and my views of health care. No other year of my life has had such a profound influence on me. I went to medical school at the University of Virginia (UVA) in Charlottesville. At that time, Charlottesville was a small city of about 30,000. Besides the UVA Hospital, there was Martha Jefferson Hospital. Because people who developed an acute illness generally went to Martha Jefferson, medical students had few opportunities to observe acute or emergency medicine. During my fourth year in medical school, a woman in pulmonary edema from heart failure was admitted to UVA Hospital. Although pulmonary edema is a common disorder, neither I nor most of my classmates had ever seen a person

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with this condition. Upon learning about the woman from a fellow student, we raced down to the emergency room to see how the patient presented and how she was being treated. The emergency room was so jammed with residents, interns, and students who were equally excited to see the patient that by the time we arrived people were standing on chairs to see over the heads of those in front of them. After this, I felt confident about my decision to pursue an internship in a big city hospital where I would see a lot of emergency medicine. I applied to programs at Boston City Hospital, Bellevue Hospital in Manhattan, and Montefiore Hospital in the Bronx. Montefiore sent me a letter with the date and time of my interview. In the early 1960s, the drive from Charlottesville to the Bronx took about 12 hours. Except for the New Jersey Turnpike, there were no interstate highways; and to reach New York from Virginia, you had to drive through downtown Washington and Baltimore. The letter from Montefiore Hospital told me to be there at 8:00 AM. I drove most of the night, arrived about 7:00 AM, and shaved and changed in the car. At the auditorium at Montefiore, I joined about 100 other medical students waiting to be interviewed. As I entered, a secretary gave me a number. She explained that when it was my turn, she would call out the number along with the number of the room in which I would be interviewed. After two hours, she called my number. I walked into the interview room and found two doctors sitting in it. Both were wearing long starched white coats with stethoscopes in the side pockets. We introduced ourselves. After asking me to sit across from them, the doctors explained that they were going to administer a small oral examination. Most of the questions were straightforward and easy to answer. Finally, they said, “One last hard question. With TB meningitis, the spinal fluid can have white blood cells, an elevated protein, and a low glucose. Are there any other abnormalities that can be found?” “I think the chloride might be low.” They both looked surprised. “Wow! Very good!”

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They then wrote a few notes and sent me to another room, where a physician in a suit asked me if I had any questions. “No, not right now.” “Mr. Heilman, the physicians who met with you liked the way you answered their questions. You went to an excellent medical school and have a good medical school record. I feel confident that if you rank us at the top of your list on the matching form, you’ll be able to come here as a straight medical intern and then become a medical resident. We’re not permitted to ask you where you’ll rank us, but what do you think of our hospital?” “I’ve heard good things about your hospital, but I was very disappointed by the interview process and am concerned that the process might reflect how house staff are treated.” “I’m not sure I understand.” “Giving people numbers, rather than appointment times, is very impersonal. In addition, you have all my college and medical school records, letters of recommendation from my attending physicians at UVA, a letter from the dean, and my board scores. Why give us an oral examination rather than speak with us about the type of training we’ll get and what our interests are?” “Then you won’t be ranking us highly?” “This was my first interview. I have to finish all my interviews before I can make my rankings.” He thanked me for visiting, and I thanked for him for his time, left the hospital, and went to visit my mother in Brooklyn. My next interview was with the Cornell program at Bellevue Hospital in Manhattan. Their interview process was the exact opposite of Montefiore’s. They gave me a time for my interview, and when I arrived, I was greeted warmly by a secretary, who led me directly into the office of Dr. Thomas P. Almy, chief of the Department of Medicine. Here waiting for me were Dr. T. P. Almy and Dr. Donald Luria, professor of medicine and chief of the Department of Infectious Diseases. They introduced themselves to me and

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engaged me in conversation. They discussed the strengths and weaknesses of their program, explored my interests, and set up a tour of the hospital for me. When they finished, they said, “We can’t ask where you’ll rank us, but we can tell you that we’ll list you very high. If you decide you want to come here, you’ll match with us.” I thanked them and told them that their program was very appealing to me. The next place I visited was Boston City Hospital, where I had applied to several divisions. My first interview was with Dr. Melman, chief of the Department of Renal Medicine at Boston University School of Medicine. Like Bellevue, Boston City gave me an appointment; but when the secretary led me into Dr. Melman’s office, his nose was buried in a journal. I stood there for five minutes before he looked up and said, “Sit down.” In a sarcastic tone, he asked, “What makes you think that you’re good enough to be an intern and BU?” I was already unhappy about the way he treated me when I entered his office. Although I knew that some people used “stress interviews” to test an applicant, I knew that I was already accepted at Cornell and that I really liked the program at Bellevue. Thus, I felt somewhat brazen and replied, “Dr. Melman, you have all my records, scores, and letters. Perhaps you could tell me why you think BU is good enough to attract me as an intern.” He must not have liked my response because he said, “If you don’t already know that, perhaps you shouldn’t be applying here.” I replied, “I didn’t know applying here was a mistake until today. I’m crossing out this program.” I left his office. I later learned that Melman’s idiosyncratic way of dealing with people was not directed at me specifically. While in Boston, I interviewed with other medical school divisions at Boston City Hospital, such as Tufts. All these people were very nice, but I listed Cornell-Bellevue first on my priority list. I matched for Cornell-Bellevue and took my internship and first year of residency there.

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My experience at Bellevue was everything I had hoped it would be. Even in the first week, I took care of several patients with acute pulmonary edema. I learned a lot more than medicine, however; and it is the nonmedical lessons that I describe in this book. To protect people’s privacy, I have changed the names of patients and the circumstances that brought them under my care. I have also changed the names of a number of the professionals about whom I write. While I have some notes from my internship to which I have referred in writing this book, much of what you will read is based on long-term recall. I would like to think that my recall is flawless, but there are multiple studies that demonstrate that experience alters long-term recall. Perhaps the best example of the influence of time on recall is a study by Professor Ulric Neisser. Professor Neisser was teaching psychology at Emory University when President Kennedy was assassinated. The next day he asked his students to write down exactly what they were doing when they heard the news and to assess how certain they were of their recall. He collected these papers and carefully stored them. Several years later, he wrote to these former students and again asked them to describe in writing exactly what they were doing when they heard that President Kennedy had been assassinated and to state how confident they were about their recall. A very high percentage of the former students responded to his request. Professor Neisser and his coworkers then matched the students’ delayed recall with their early recall. There was a very poor correlation between the two. Most of the former students, however, felt confident that their recall was accurate. After reading this study, I feel confident that parts of this book are fictional. In addition, although I put the stories in chronological order, I am uncertain of the chronology and suspect that some of the stories took place during my first year of residency and not my internship. My youngest daughter, Eden, who recently graduated from law school, told me how fiercely competitive law school is. When I asked

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if that was just her view or was idiosyncratic to her law school, she suggested that I read a book entitled 1L. Written by a Harvard law student, it describes his experiences in law school. The book taught me that my daughter’s experiences were not unique to her law school. It also made me aware of how different my medical training was from the training received by most law students. Our attending physicians taught us much, but as an intern, I learned the most from other interns, residents, nurses, and patients. As well, the atmosphere at Cornell-Bellevue was one of cooperation. Like law students, we were busy learning our profession, but unlike many law students, most of us became aware that cooperation rather than competition would do more to help us achieve our goals of caring for sick and dying people. As an intern, I worked very hard and was often sleepdeprived, forced to eat terrible hospital food, paid a miserable wage ($75 a month), and almost always under stress. Still, my internship year was one of the most special of my life. This was the first time that my work was meaningful. I was finally helping people. Learning was, and is, always a joy; and the novel experiences to which I was continually exposed kept me in awe. There was such a strong esprit de corps among the house officers, and we enjoyed each other’s company so much that even on those rare occasions that we did not work, we would often spend time together. I am indebted to them for making my internship one of my happiest and most fruitful years.

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Acknowledgments

I

want to thank my daughter Eden Brooke Heilman JD, son-in-law James (Chip) Bradley Wilson Jr. DO, Lynda Crawford, and Shelley Reinhardt for their help editing this book.

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Contents

1. Naiveté: Patty O’Keefe 2. Clinical Judgment

3

8

3. Responsibility: Night Sweats

12

4. Chutzpah: Distant Sounds

26

5. Credentialing: The Imposter

30

6. All Animals Are Equal, but Some . . . : Administrators

35

7. Fabrication: Gum Guaiac

40

8. Priorities: Do Not Admit Her

48

9. Disbelief: Someone Is Chasing Me

54

10. Confidence: Listening to the Voice Within 11. Mortality: No One Dies

64

12. Experience: It Was Just a Gesture

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13. Cynicism: Cough It Up Again

79

14. Purity: Freedom from the Body 15. Altruism

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88

16. Ethical Boundaries: Iatrogenic Melanoma 17. Suffering: Phantom Pain

110

18. Gratitude: Thank You, Doctor 19. Intimidation or Invitation

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122

131

20. Decisiveness: Don’t Confuse Me with the Facts 21. An Afternoon Off

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22. Know Thyself: Not Cut Out To Be a Physician 23. The “Disposition Problem” 24. Nirvana: The Last Day

162 170

151

1 Naiveté: Patty O’Keefe July 1, 1963

B

etween graduation from medical school and the start of my internship, I had three weeks off. Beginning on July 1, I would be spending most of my time in the Medical Building at Bellevue Hospital, which was on 23rd Street and First Avenue, and I needed to find a place to live that was nearby. I slept on my brother Fred’s couch while looking for an apartment and finally found something that I could afford on 14th Street and Avenue A. I needn’t have looked for my own apartment. I only slept there for a few nights during my entire internship. Several days before our internship began, all newcomers were given a day of orientation. We received new uniforms that included short, heavily starched white linen jackets, the sleeves of which bore a red caduceus. We also received heavily starched white linen pants.

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4

The chief resident showed us the Cornell Medical Wards, which included the men’s wards (A1 and B1), the women’s ward (Ground B), and the Emergency Ward (EW). In the 1960s, most hospitals did not have intensive care units (ICUs), and the EW served as both emergency room and medical and surgical ICU. This is where the sickest patients from all three medical and surgical services (Columbia, Cornell, and New York Universities) were cared for. The chief resident at Cornell, who would be leaving in a few days, handed out our schedules. I saw that during the first month I would be assigned to one of the men’s wards (B1) and would be on call my first day. We were told to report to our wards at 7:30 AM. The night before the first day of my internship, I slept very poorly. It was a warm evening, the apartment had no air conditioning, and with the window open, all the sounds of the city came floating in. Still, it was my excitement that kept me up most of the night. The alarm was set for 6:00 AM, but at 5:30 AM, I got out of bed, showered, and dressed in my new white uniform. After filling my new little black bag with all my doctor tools, I walked from my apartment to the main entrance of Bellevue and arrived a little before 7:00 AM. Just as I walked in, I heard a page: “Dr. Hellman. Dr. Hellman. To EW. Stat.” Only family, friends, and people from western Pennsylvania knew how to pronounce “Heilman” correctly, so I knew it was me that they were paging. I grabbed my bag tightly and ran to the EW, thinking “It’s started, but this is what you wanted!” At the EW, the orderlies were wheeling in a young man. His eyes were closed, and he didn’t move. After the orderlies moved him to one of the EW beds, I checked his blood pressure and pulse, both of which were normal, then noticed that he was deeply comatose. Knowing that head trauma is not uncommon among young men and is one of the major causes of coma, I carefully examined his head. There was no evidence of trauma, and his pupils were small and equal in size. There was no reason to call the neurosurgeon.

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Many patients who came to Bellevue were alcoholic. Often, they also suffered from Wernicke encephalopathy, which results from the malnourishment that is typical of alcoholism. In medical school we learned that when we saw a comatose patient, we should treat him or her empirically for low blood sugar, even before the results of the blood sugar test were available. Thus, after drawing blood for tests, I started an IV and give the patient 100 mg of vitamin B1 (thiamine) plus glucose. Despite this, he remained comatose. To make certain that some other metabolic disorder was not causing his coma, I asked one of the orderlies to take his blood to the laboratory for immediate testing. “That’s your job, not mine,” he responded and walked away. One of the nurses came over and said that she would get someone to bring the tubes of blood to the lab after I had labeled them. I quickly put on the labels, filled out the lab request forms, and handed the tubes to the nurse. Next, I took out my stethoscope to listen to the patient’s heart, not because I thought that heart disease was causing his coma but because I didn’t know what else to do while I waited for the test results. As I listened to his heart, I noticed that his breathing was becoming increasingly shallow. If this continued, the lack of oxygen would damage his brain. In medical school several of us had been particularly concerned about learning how to treat someone who had stopped breathing. While we could give the person mouth-to-mouth respiration, we might also need to insert a tube into the major breathing pipe, the trachea. The endotracheal tube was then attached to a respirator that pushed air into the lungs. Because it is not possible for a person to breathe while the tube is being inserted, the procedure must be done very quickly. As a result, the tube often goes down the “wrong pipe” into the esophagus. Needless to say, whenever we had the opportunity, we practiced intubating cadavers.

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A catwalk was suspended above the patients’ beds. It allowed the few nurses working in the EW to see if patients or doctors needed their help. When I noticed that my patient’s breathing was becoming shallow, I looked up at the catwalk. That’s when I first saw Patty O’Keefe. Like all nurses then, she wore a starched white uniform and her Bellevue Nursing School cap. She was very attractive—and formidable. A large scar from what looked like a knife wound ran down one side of her face. When she saw me looking up for help, she came down and asked in a raspy smoker’s voice, “Can I help you?” “This patient’s respirations are getting shallow. I’d like a laryngoscope and an endotracheal tube. Could you also get a positive pressure breathing bag to use after we get the tube in place?” She looked at me. “Have you used these before?” I nodded yes. She then looked at my patient. “I’d be happy to get these for you, but would you also like me to bring some Nalline?” As soon as she mentioned Nalline (brand name for nalorphine), I recalled that it is used to block the action of opiates on the brain and realized that she was trying to let me know the cause of the patient’s coma without being confrontational. I looked at my patient’s arms again, but there was no evidence of needle tracks. I remembered that many addicts hide their habit by injecting the heroin into the femoral vein in their groin. “Sure, bring some Nalline in a syringe.” “How much do you want?” I had never used the drug before. “The usual dose.” “He looks like he weighs about 150 pounds. I think 2 or 3 mg might do.” “Sounds fine to me.” After she rushed off to get the Nalline, I opened my patient’s eyes and noticed that his pupils were tiny pinpoints. Looking at his femoral region, I saw multiple needle tracks. I thought to myself, “Heilman,

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you jerk. This is so obvious. How could you miss it?” In less than a minute Ms. O’Keefe came back with the Nalline, which I injected into the patient’s vein. A few seconds later, he woke up. By then, Ms. O’Keefe was off to help a doctor stop a gunshot victim with damage to a major pulmonary artery from bleeding out. My patient looked around and realized what had happened. He looked at me. “Thanks, Doc.” “Don’t thank me; it was that nurse over there who saved your life.” The following day I saw Ms. O’Keefe in the Bellevue cafeteria. I walked over to thank her for helping me. I apologized for having missed the patient’s heroin overdose. “Have you ever seen one before?” “No. I don’t think there were many cases like that where I went to school.” “You won’t miss it next time.” She was right. More than 40 years have passed since I completed my internship. I’m still learning. Recently, I heard someone on the radio discussing the activities that bring people joy—family, friends, food, success, and entertainment. Learning was not included. Ever since I was a young child, I have loved to learn. Another gift from Ms. O’Keefe that day was the insight that I had chosen work that would engage me in a lifetime of learning.

2 Clinical Judgment July 3, 1963

T

here is an old puzzle about three young men walking down Third Avenue in the Bowery section of Manhattan. The goal is to determine which of them is an intern at Bellevue. A panhandler, who is obviously a chronic alcoholic, asks them for money. The first man tells him that he will give him money but only if he promises to get a good meal. The second explains that if he gives him money, he will just use it to buy more alcohol, so he is not going to give him any money. The third gives him money but asks him to promise to use some of it to buy an alcoholic drink. The answer is that it’s the third man. The intern did not want the panhandler to have a big meal. He knew that the man had probably not eaten in a long time and that a big, fatty meal would increase his chance of developing acute pancreatitis. Instead, he wanted him to

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have some drinks so that he did not experience delirium tremens (DTs) or seizures, both of which can be induced by alcohol withdrawal. Around 3:00 AM my second night on call, I admitted a 57-year-old man, Mr. Pico. He had a history of alcohol abuse, and after eating a large, rich meal, he suddenly developed severe abdominal pain together with nausea and vomiting. He explained that he had thrown up at least 10 times. When I examined him, I found that he had a rapid pulse, but other than some abdominal tenderness and dehydration, the results of his examination were normal. His symptoms were those of acute pancreatitis. After collecting some of his blood for tests, I started an IV to help replace the fluids he had lost. Because people who have severe vomiting often lose a lot of potassium, I added potassium to his IV. Mr. Pico’s bed was on one of our two men’s wards, which were located on the first floor of the Medical Building. The building was close to 23rd Street, and the chemistry lab was close to 30th Street. On my first day, an orderly taught me that it was the interns who brought the blood tubes to the laboratory. Walter Degnan, one of the first-year residents, showed me a shortcut to the lab. It entailed walking up to the roof, crossing the roof until reaching a hospital building on 30th Street, then walking down to the lab. The night Mr. Pico was admitted, I took this shortcut, which was not very short. The roof did not have any lights, but the light from the city allowed me to make my way to 30th Street. In the lab I found a middle-aged lab technician asleep with his feet resting on top of an empty desk. After clearing my throat several times, he did not awaken, so I gently said, “Excuse me, sir. I need some help.” He still did not awaken, so I said I a little louder, “Sir, could you help me?” He awoke and looked at me holding the tubes of blood. “There’s no reason to yell at me.” I had not yelled but still apologized, handed him the blood, and gave him a piece of paper with my test requests. “When do you need these?”

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“As soon as possible.” We had no cellular phones and not even pagers back then, so I wrote the ward phone number on the same slip of paper that listed the requested tests and asked him to call when he had the results. “We can’t do the enzymes until tomorrow, but we can do the lytes.” “Having the electrolyte levels would be very helpful.” Tommy, our chief resident, usually made rounds at 7:00 AM with the interns and residents who were on call the night before so that he could learn all about the previous evening’s admissions. When I saw that it was 6:30 AM but I had still had not heard from the lab technician, I called the lab. The man I had met earlier answered the phone “Yes. I was just about to call you when the phone rang. All his lytes are normal.” I asked for the actual values because I wanted to record them in the patient’s chart. “You really need these, doc?” “Yes, I do.” “Okay. The sodium is 143, the potassium 4.9, the bicarbonate 27, and the chloride 103.” I asked him about the calcium. “The calcium and enzymes will be done this afternoon.” I thanked him and hung up the phone. The value of Mr. Pico’s serum potassium worried me. If before being treated with potassium he was normal, which is what the value indicated, then giving him potassium might make him hyperkalemic. When a patient’s potassium gets too high, the patient can develop abnormal heart rhythms and even die. I quickly grabbed an IV bottle that contained glucose but no potassium and replaced Mr. Pico’s with it. Fortunately, his pulse was regular and his electrocardiogram looked normal. I was very relieved that the potassium I gave him did not cause a heart problem or even kill him.

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Tommy appeared at 7:00 AM, and we started making rounds. The first bed we came to was Mr. Pico’s. While I summarized Mr. Pico’s medical history and physical findings, Tommy looked at his IV bottle. After I mentioned the patient’s vomiting and my diagnosis, Tommy said, “Ken, you need to label your IV and write down that you have potassium in there.” “It’s not labeled because there’s no potassium in the bottle.” “With that history, why not?” I handed him the piece of paper on which I had first written down the values. He looked at it and laughed. “Were these done by the Bellevue chemistry lab?” “Yes.” Tommy ripped up this paper. “Put potassium in that bottle, and from now on, Ken, please trust your clinical judgment.” After we completed rounds, Tommy asked, “Ken, did you save some of Mr. Pico’s blood from last night?” I told him I had. “We have our own flame photometer so that we can perform our own analyses.” He took me to the lab with the flame photometer, and we analyzed the blood. We found that his potassium was dangerously low when he was first admitted. The potassium I gave him might have helped him or even saved his life. Immediately after we saw this result, Tommy smiled, pointed his finger at me, and winked. I smiled. “Okay. I’ve learned. I’ll try to learn to trust my clinical judgment.” While no one was able to prove that the lab technician had confabulated results, all the residents knew that his results were unreliable, and that is why we performed almost all tests in our own labs. For the remainder of my two years at Bellevue, I never walked across the roof again. Since then, I have also tried to trust my clinical judgment—but I still like to have it confirmed by laboratory tests.

3 Responsibility: Night Sweats August 1963

E

ach Friday at noon the interns presented the week’s more difficult cases to a group of attending physicians. Tommy, our chief resident, would select two cases, and the interns who had cared for the patients would present them. Afterward, an attending who was expert in the primary disease that led to the person’s admission to Bellevue would analyze the case. Food—never far from an intern’s mind—was brought in from a nearby restaurant. Almost always, it was pizza, but on rare and happy occasions we enjoyed excellent corned beef and pastrami sandwiches. During the second month of internship, I was late to the conference because my patient’s IV needle had come out of the vein and

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Responsibility: Night Sweats

the IV fluid was collecting in the tissue under his skin. I inserted the IV needle into a new vein in his other arm and taped it securely. As I was leaving, I noticed a man in his late forties lying strapped to a gurney. I did not recall seeing him during morning rounds, which probably meant he had just been admitted. Charlie Adams was the intern on call but had to present a case at the conference, which is probably why he had not yet moved the man to a stationary bed. The man was having difficulty breathing and appeared to be in coma. I looked around for someone to pull Charlie out of the conference while I tried to take care of the patient, but no one else was on the ward. When I got closer to the man, I noticed that he was blue but still breathing. I ran to the closet where we stored oxygen tanks, grabbed a green tank and a mask, rolled the tank back to the patient, and gave him oxygen. This helped his color only a little. He was still having trouble breathing and was trying to cough up mucus. I got a portable suction with a sterile tube, but when I returned to the patient’s side, he was no longer breathing. At age 16 I was a good swimmer and loved the mountains, so I decided to spend the summer working as a junior counselor and lifeguard at an overnight camp. In preparation, I took a Red Cross course in water safety at the local YMCA. They taught us the backpress method of artificial respiration, which at the time was the most modern means of reviving someone who had stopped breathing. The victim lies on his or her stomach, and the rescuer rhythmically presses on the victim’s back at the lower margin of the ribs. Two summers later, I wanted to work as a waterfront instructor and took the appropriate Red Cross course to prepare. We learned what was then the newest method of pulmonary resuscitation. Instead of facing in the same direction as the victim, the rescuer kneels by the victim’s shoulders, facing the feet. The rescuer also places the victim’s hands under his or her face so that the elbows are pointing outward. After each press of the rib cage, the rescuer lifts the victim’s arms at the elbows. To obtain the correct rhythm, with each back press the rescuer

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would chant “Out goes the bad air” and, with each lift of the arms, “In goes the good.” Later, in medical school, we learned that this method was no longer considered effective and were taught mouth-to-mouth resuscitation. This method is still used today. The people who developed mouth-to-mouth resuscitation provided evidence that it not only was more effective than the back-press/ arm-lift method but provided the advantage of making it possible to deliver both artificial respiration and, if needed, cardiac massage through the chest wall without having to repeatedly turn the victim over. When necessary, one person could even do both. Unlike the back-press or back-press/arm-lift method, the rescuer is in close contact with the victim during mouth-to-mouth respiration. “Could this be dangerous for the rescuer?” asked a classmate. “Why do you ask?” the instructor asked. “If the victim has a lung infection like TB, it seems to me that the rescuer could catch it.” “You fill the patient’s lungs with air from your lungs—you don’t breathe in the air that the patient exhales. Theoretically, you could get cold sores by touching your lips to the patient’s, but almost all of you have already been exposed to that. This is a very safe procedure. To my knowledge, there’ve been no reports of the rescuer becoming infected by the patient.” Unlike the Emergency Ward at Bellevue, the open wards had no endotracheal tubes, respirators, or even manual respirator bags. If this man’s life was to be saved, I would need to perform mouthto-mouth resuscitation. While trying to resuscitate him, I felt the carotid artery in his neck to see if his heart was beating normally. He had no pulse, and thus, I started to give him closed cardiac message. After five minutes, I again checked for a pulse and still could not feel one. I considered the possibility that his heart was beating but that his blood pressure was so low that I could not feel a pulse; if

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that were true, as soon as someone came back on the ward, we could start him on an IV with a medication that would raise his blood pressure. It took me a second or two to put my stethoscope in my ears and the bell over his heart—no heartbeats. After dropping the stethoscope to the floor, I resumed mouth-to-mouth respirations and cardiac message for another 10 minutes. There was still no change in his status, and I began to think my efforts might be futile. I reached into another pocket, found my little flashlight, and opened the patient’s eyes. His pupils were widely dilated and did not respond to the bright light. I checked his blink reflex by putting a cotton swab on his cornea—still, no response. There was no evidence that any part of his brain was working. I stopped my efforts to revive him. Just as I stopped, Charlie Adams and his resident returned to the ward. “Charlie, is this man your patient?” “Yes, I’m sorry to leave him like that, but I had to present at our conference.” “Your patient had an arrest. I tried to resuscitate him but couldn’t. On my way to the conference I noticed that he wasn’t breathing. I don’t know how long he had stopped breathing before I saw him. Anyway, I was unsuccessful.” “You didn’t do mouth-to-mouth on him, did you?” “I did, but it didn’t work. I’m sorry.” “No, Ken. I’m sorry. That patient had terminal TB.” I was incredulous. “What the hell is he doing on an open ward? He should be in isolation!” “I took care of him while I was on the chest service. When he came to the ER today, the nurse realized he needed admission. Because he mentioned my name, they had an orderly bring him up here. I left him in the gurney so that I could bring him to the chest service when I came back from the conference. With his TB, that’s where he belonged. They could isolate him, put him on a respirator if he needed it, and get him to take his medicines, which he always stopped.”

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“Charlie, what the hell were you thinking? He should have been moved off this ward the minute he got here. You put everyone here at risk. There’s no damn reason for such stupidity!” I had more to say to Charlie, but by this time our chief resident, Tommy, had heard what happened and took hold of my arm. “Ken, please come with me to my office. I need to speak with you privately.” I was not finished with Charlie, who subsequently blessed the world by going into pathology, but because I had such high regard for Tommy, I followed him to his office. “Ken, please sit down. First and foremost, we need to be concerned about your health. I want to call Julia Janes on the Columbia Chest-Pulmonary Service to get her advice. Charlie was really in error today, and I’ll speak with him. But you almost looked ready to punch him, and if you did that, you’d be the one to suffer. You’re a wonderful intern, and I don’t want to lose you.” “Thanks, Tommy. I’m finished with Charlie. I don’t want to be on service with him for the rest of the year. You can call Dr. Janes if you think it’s necessary, but I recall being told that you can’t get TB through mouth-to-mouth.” Tommy started dialing the phone. “I just want to make sure we do everything right.” Tommy reached Dr. Janes in her office. She listened to the story. Although she thought there was probably nothing to worry about, she wanted me to come to her office so that she could speak with me, “face-to-face. At Dr. Janes’s office I recounted what happened. She asked if I had had a TB skin test. Before I could start at Bellevue, I had to have a skin test, and the results were negative. She assured me that there was virtually no risk that I would develop TB but thought I should repeat the skin test in six weeks. She gave me the date and told me that she would personally perform the skin test. I thanked her and went back to work.

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Several weeks later, while making rounds with our team, Tommy looked at me. “Aren’t you supposed to get that skin test today?” “Yes, but I’m feeling well. Besides, Dr. Janes said there was little risk of me catching TB.” Tommy smiled. “For your safety, your patients’ safety, as well as our welfare, get that skin test.” I did, and by the next day there was a large swollen, red area where Dr. Janes had injected me. Up until then, every skin test I had had was unremarkable; a tiny scab where the needle had gone in was the only result. This was a real change and suggested that my immune system had been exposed to TB. Two days after I had the test, Tommy asked to see it. “That’s huge. Let me give Dr. Janes a call now. I want you to see her as soon as possible.” When I saw her, Dr. Janes asked if I had a cough, fever, shortness of breath, night sweats, or any other symptoms of an infection. I told her no. She listened to my lungs and said they were very clear. She wanted me to get a chest X-ray and to bring back a copy so that she could review it. “When?” “Right now!” Walking back to Dr. Janes’s office with the X-rays, I looked at the films. My lungs looked perfectly clear. Dr. Janes put them on her view box. “There’s no evidence of TB.” At the time, the medical literature recommended that physicians with a positive skin test be treated with isoniazid, a very effective antituberculosis drug with few side effects. “Do you want to start me on isoniazid?” “No. Most people who convert their skin test don’t come down with TB, so I really see no reason for you to take the drug. But we should check your chest X-ray in several months. Of course, if you

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develop any new signs or symptoms, let me know right away, and we can start you on isoniazid.” Several weeks later I awoke in the middle of the night soaked in sweat. I didn’t think anything of it because I had experienced night sweats about once a month for my entire life. I attributed them to the dream stage of sleep. This particular night sweat was more intense than usual, but because I did not also have a cough, I decided not to mention it to Dr. Janes. A couple of months later, I did a rotation at Memorial SloanKettering Hospital. Many of the patients there had leukemia or lymphoma, such as Hodgkin’s disease. Hodgkin’s disease used to be fatal until a physician at Memorial, Dr. David Karnofsky, discovered that the combination of nitrogen mustard, a poison used in World War I, and extensive radiation helped patients in the first stage of Hodgkin’s to fight the disease. Indeed, many of them went on to live for years afterward. Being at Memorial was a good break from Bellevue because it was rare for the on-call intern to be summoned during the middle of the night. One night, while on call, I fell asleep and did not awaken until the operator called me at 6:30 AM. Half-asleep, I took a very hot shower that fogged up the bathroom mirror. Afterward, I decided to shave, but because I could not see myself in the mirror, I shaved by feel. Under my chin, I felt a big lump. It was probably the size of a cherry, but to me it felt as big as a grapefruit. I cleaned off the mirror with my towel. There was no question about it. It was a swollen lymph node. Because patients with Hodgkin’s also have night sweats, I was convinced that I had developed Hodgkin’s disease. As I thought about which of the attending physicians at Memorial to see, I remembered about medical student’s disease. At UVA it had been caused one time by a lecture the surgeons gave us about moles and melanoma. Following the lecture, one-fifth of my classmates had their moles removed—but not one had a melanoma. On another

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occasion we learned that muscle twitching is a sign of Lou Gehrig’s disease. Certain that they had the disease, several students immediately made an appointment with a neurologist because of their twitching muscles. I decided that I might be jumping to conclusions. This thought was ratified in the next moment: While brushing my teeth, I noticed that my gums felt sore and bled. I was ecstatic! As an intern, my dental hygiene was terrible, and I decided that the swollen node was caused by gingivitis. I scrubbed my teeth and gums furiously, then flossed my teeth. Later, on the way to rounds, I saw Tommy off in the distance. I didn’t know why he was at Memorial Hospital and caught up with him. “Hi, Tommy. What are you doing up here?” “We’re having a meeting to put together the call schedule for the next few months.” Tommy looked at my neck and pointed. “What’s that?” “I don’t know. I woke up with it this morning. My gums are also sore, so it’s probably a reactive node from my gingivitis.” “Can I feel it?” “Sure.” “It does feel like a node, and it’s freely movable which is good. Is it tender when I’m touching it?” “A little.” “You’re probably right—the swollen node is probably from your gums, but let’s go up to the Medicine office. There’s a great ENT physician, John Holman, right across the street at New York Hospital. I’d like him to examine you and decide whether to treat you with an antibiotic or to biopsy that node. I want him to see you this morning.” Tommy did not want to alarm me, but I knew what he was thinking and was frightened. “I have to make rounds. I’ll brush three times a day, floss, and if it’s not gone by next week, I’ll go to see him.” “Ken, I want you to go today. I’ll ask one of the residents who’s on an elective to cover for you.”

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We went up to the Department of Medicine’s administrative office, where Tommy called Dr. Holman and got him to squeeze me in during his morning clinic. I walked across York Avenue to New York Hospital feeling very anxious. The minute I arrived at the clinic, a nurse greeted me and took me to a room. When she took my vital signs, my systolic blood pressure was 160 and my resting pulse, which is usually pretty slow, was 96. As soon as the nurse finished taking my temperature, which was normal, Dr. Holman came into the room. He was in his early fifties and had a full head of gray hair held down by the leather headband of a headlamp. Kindly and gently, he prompted me to provide a brief medical history. He was not happy when I told him that I had smoked for five or six years. He told me to stop smoking and noted that if everyone quit cigarettes, he would be out of business. He asked permission to examine the lump. He felt it, checked to see if he could move it, and asked me if it was tender. He then felt my neck for other lumps. “That’s the only one.” With his bright light, gloved hand, and a tongue depressor, he examined the inside of my mouth and my tongue. Using his bright headlight and mirrors, he looked down my throat at my larynx and vocal cords and up my nose at my nasopharynx. He took off his gloves, washed his hands, turned off his light, and sat on a rolling stool next to me. “Everything looks good. You even still have your tonsils. I don’t see any signs of malignancy.” I never told Dr. Holman that I was exposed to TB because I was unaware that TB could give this type of swollen node. “Do you think the node is swollen because of my teeth?” “I know you think so. I’m not a dentist, but if you have gingivitis, it’s very mild. I didn’t see any signs of swelling or inflammation.” “I guess that means that you want to biopsy the node and rule out a lymphoma?” “No, I don’t. Here, look in this mirror. Do you see those two pimples near your left nasolabial fold? I think you cut yourself shaving a few

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days ago, and those are two little staphylococcus abscesses. I think they’re the reason the node is swollen.” I was relieved to hear that he did not think I had Hodgkin’s but still asked, “Do you think it would be worthwhile taking a systemic antibiotic?” “No. I’d treat them with a local antibiotic ointment. The nurse will give you some sample tubes outside.” I shook his hand. “Dr. Holman, thank you so much for seeing me so soon. This is great news because I was sure I had Hodgkin’s.” He smiled. “My pleasure. If anything new comes up, please come back to see me and remember: Stop smoking.” I walked back to Memorial feeling much better than I had earlier during my walk to New York Hospital. I stopped by the medicine office to see if Tommy was still there; he was and was relieved to hear the good news. As Dr. Holman suggested, I used the antibiotic ointment. After a few weeks, the inflammation subsided and the node got a little smaller, but neither went away. Several months later I had another rotation at Memorial. As I was walking down the hall, one of the plastic surgeons, Jim Wilson, who had a house in the Hamptons near my brother’s, greeted me, then stared at my face. “Heilman, what is that you have going on the left side of your face?” “It’s some type of chronic staph infection.” “Baloney!” he said. “That looks like a basal cell carcinoma.” “Dr. Wilson, I thought basal cells only happened to Celts like you! Besides, when does an intern ever get out in the sun?” “Heilman, I saw you last weekend at the Hamptons with your brother. Look, come back to my office. Let me get a little punch biopsy. I’ll give you some Novocain so you won’t feel it. We’ll find out in about a week which one of us is correct.” Before doing the biopsy, he took a picture of the sores on my face. After the biopsy, he put the little piece of skin into a bottle filled with liquid and sent it off to pathology.

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About a week later, Dr. Wilson paged me. “Ken, can you come over to my office now? I just got the results of the biopsy.” “Can’t you tell me over the phone?” “No. I want you to see the slides I got from pathology.” At his office he beckoned me over to a microscope he had set up with a slide already in place. “What do you see?” I moved the slide around. “Oh, my gosh—it looks like a TB granuloma! Can you get TB of the skin?” “Yes, very, very rare. I never saw one before, but you got it. I’d like to have Carl Muschenheim see you. He has more experience with TB than anyone I know.” I told him about the mouth-to-mouth respirations, the positive skin test, and Dr. Janes’s assessment; but he still wanted me to see Dr. Muschenheim. I agreed. He made an appointment for me to see Dr. Muschenheim that same afternoon. At Dr. Muschenheim’s private office on East 65th Street, the nurse brought me into the examining room, and the doctor came in. He was an elderly and very distinguished gentleman. He asked me how I thought I got cutaneous TB. I told him the story of the mouth-to-mouth resuscitation. He asked me if I had had a skin test and a chest X-ray. I told him that the X-ray was negative but that the skin test was positive. I also told him about the night sweats. He asked whether I had started on isoniazid after the skin test, and I explained that Dr. Janes did not think it was a good idea. He examined my face, felt the node, and listened to my lungs. “Well, you have what is called primary cutaneous tuberculosis. I haven’t seen or heard of a case in decades. Years ago, we occasionally saw it on pathologists’ fingers. Many of them wouldn’t wear gloves, so if they examined the lung of a TB patient with a cut on their finger, they’d develop a TB granuloma similar to the one you

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have on your face. When you did the mouth-to-mouth resuscitation, you must have had a cut on your face, maybe from shaving. Almost all of the people who had primary cutaneous TB did well—and that was before we had TB antibiotics. To be safe, though, I’d like you to take isoniazid for at least 6 months.” “My night sweats have gone, and the node is getting smaller. Plus, my skin’s starting to look a little better. If it’s just cutaneous TB and is getting better by itself, why take the medicine?” “The swollen node’s not reacting just to staph skin infection. You probably had or have TB bacteria in that node. Before we had antiTB drugs, we’d see these swollen nodes turn into scrofula. The TB bacteria turn parts of the lymph node into a cheesy material, and because it’s inflamed, it adheres to the skin. Eventually, the cheesy material becomes a liquid and breaks through the skin, leaving a chronically draining hole. Scrofula is ugly and hard to treat. Although there’s only a small chance this could happen to you, it’s really not worth taking the chance.” I took the isoniazid regularly for six months. I never developed scrofula, and I never had any other problems with TB. The story about my cutaneous TB must have spread through the three Cornell teaching hospitals of Bellevue, Memorial Sloan-Kettering, and New York Hospital because everywhere I went, people asked how I was doing. A couple of months after I started treatment, Tommy asked what I thought about presenting myself at Grand Rounds. It seemed like a good idea, but I was worried that it would seem self-aggrandizing. “I asked you—you didn’t ask me. And although I know you’ve read everything you can get your hands on about the disease, I’d like to invite Carl Muschenheim as the discussant.” “Of course! He’s the world’s expert—and my doctor!” Tommy knew of my keen interest in preventing this type of infection and suggested I talk about prevention following Dr. Muschenheim’s presentation; I readily agreed.

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The Grand Rounds was well attended by the medicine interns and residents from the three Cornell hospitals. I presented myself modestly: “This charming, brilliant, hard-working, and kind 25-yearold intern was walking to a conference when. . . .” I told the story up to when Dr. Wilson took the biopsy and then introduced him. As Dr. Wilson walked up to the podium, I stepped outside the room. “Now, I’ll bring in the patient,” began Dr. Wilson. He exited the room. We reentered together, and at the podium, he introduced me as the patient. “This is Ken Heilman, the patient whom we’ll be discussing today.” To prepare for Grand Rounds, Dr. Wilson had taken another photograph of my face a few days before the conference. Describing the lesion, he showed the “before” and “after” pictures, then showed slides of the skin biopsy under the microscope. After the slide show, one of my friends asked, “Are you sure this isn’t consistent with the skin lesion associated with syphilis?” “You’re forgetting one thing—syphilis is a social disease. Since when do Bellevue interns have time to socialize?” Next, Dr. Muschenheim discussed the history of the disease and its treatment. Finally, Tommy and I described what was being done at Bellevue to prevent something like this from happening again. Our strategy was to have readily available pulmonary resuscitation apparatus in all areas in which it might be needed. After the conference, Dr. Almy, the chief of Medicine, thanked me for organizing the Grand Rounds and for my efforts to save the patient with TB. He mentioned that there were probably many hospitals that had not instituted the preventive measures now practiced by Bellevue and suggested I write about my experience as a case report for a journal. I asked where I should submit the article, and he suggested the New England Journal of Medicine (NEJM). I was taken aback—the NEJM is one of the world’s most prestigious medical journals. I asked Dr. Almy if he really thought my article had a chance of being accepted. He explained that one of the

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editors, Max Finland, chief of the Harvard Division of Medicine at Boston City Hospital, was an infectious disease specialist. “Knowing Max’s interest, I’d be amazed if it were not accepted.” I wrote the article and submitted it along with the clinical photos and micrograph. A few weeks later, I received a letter from the NEJM accepting the article, pending a few minor alterations. When the article was published it was accompanied by an editorial entitled “Risk in Mouth-to-Mouth Respiration.” I was absolutely thrilled. Following publication, both the NEJM and I received all kinds of letters, some thanking me for my heroism and others claiming that only an idiot would give mouth-to-mouth respiration to an unknown person. I didn’t think of myself as a hero. When I gave the patient mouthto-mouth respiration, I was just doing my job and was not aware of any personal danger. What’s more, my efforts failed. Had I known that the man had TB, I am not sure what I would have done. However, during the 40 years since then, I have always carried a protective mouthpiece in my briefcase. Years later, I heard a story about an intern at Children’s Hospital in Boston who gave mouth-to-mouth to a patient in cardiac and respiratory arrest. The intern was the son of a famous Boston neurologist. As he breathed into the child’s mouth, the child, who had AIDS, spit up bloody sputum. This was at the beginning of the AIDS epidemic. Because there were no treatments, the disease was a death sentence and an AIDS diagnosis was greatly feared. The intern became infected with HIV, developed AIDS, and died after months of suffering. The intern’s death saddened me. He was young. He had conscientiously performed his professional responsibilities. But for the lack of basic prevention, he might still be alive. I realized how lucky I had been and how important is the need to protect health-care workers.

4 Chutzpah: Distant Sounds August 1963

A

bout once a month, Dr. Robert Dawson, chief of the Department of Medicine at the Memorial Sloan-Kettering Cancer Center, would come down to Bellevue and make rounds with one of the teams of interns and residents who were responsible for the care of the patients on one of the three Cornell medical wards. Many patients at Bellevue had enlarged hearts from hypertension (cardiomegaly), leaky heart valves that had been damaged by rheumatic fever, and atherosclerotic heart disease. Thus, estimating the size of the heart by percussion was a very important part of our examination. The percussive technique is not used as frequently now as it was several decades ago. If you were right-handed, you performed the technique by placing the middle or index finger of your left hand on different regions on the patient’s chest, then hitting it with the middle or index finger of your right hand. This produced a drumming-like

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sound. When the examiner’s finger is over the patient’s heart, the percussion sound is less resonant than when the finger is over the lungs. In this way, by moving the left hand around the patient’s chest, a physician can outline the shape of the heart. Dr. Dawson had a very unorthodox means of percussing the borders of a patient’s heart. He started at the right side of the patient’s chest and, with his open hand, he gently hit the patient’s chest. After each hit, he would move his hand a little to the left. When I took the physical examination course in medical school, one of the best clinicians on the faculty taught us that it is more important to feel the vibrations induced by the percussion than it is to hear them. He even suggested that we wear earplugs when practicing percussion. Thus, my fellow house officers and I were puzzled when we saw Dr. Dawson percussing the chest in this manner. On the night prior to Dr. Dawson’s visit, an intern, Tom Foley, admitted a Mr. Siller, who appeared to have bacterial pneumonia. The patient had a history of chronic lung disease, primarily from a chronic infection of his breathing tubes called “bronchiectasis,” and he also had a history of chronic or recurrent sinusitis. Because Mr. Siller had an unusual syndrome, Tom and his resident wanted to present him to Dr. Dawson. During Tom’s presentation, Dr. Dawson repeatedly looked at his watch. When Tom finished, Dr. Dawson did not ask him any questions. This was surprising, but we were beginning to suspect that Dr. Dawson was anxious to be prompt for an appointment following rounds. “Let’s go over to the bed and examine this man,” Dr. Dawson directed. At the bedside, Dr. Dawson asked Mr. Siller why he had come to the hospital. Mr. Siller responded that he had shortness of breath, a terrible cough, and often coughed up green sputum mixed with blood. Mr. Siller also said that he felt feverish. Dr. Dawson did not ask him any other questions but asked him to remove the top part of his hospital gown so that he could examine his chest.

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Dr. Dawson proceeded to percuss Mr. Siller’s chest in his usual unorthodox manner. Though their faces were deadpan, Tom’s and his resident’s eyes were smiling as they stood behind Dr. Dawson. After identifying what he thought were the borders of the heart, Dr. Dawson looked and felt for the point of maximal impact, the position on the chest where a physician can best feel or see the heart beating. Dr. Dawson, however, only looked at and felt the left side of the chest. “I can’t find the point of maximal impact, but by percussion, it appears that the patient’s heart is of a normal size.” He took out his stethoscope and placed it on the left side of Mr. Siller’s chest to listen to his heart. He next listened to the patient’s lungs and mentioned that he heard abnormal sounds, including rales and rhonchi. He palpated the patient’s abdomen, felt for pulses in his feet, and checked his feet for edema. Dr. Dawson thanked the patient for allowing him to examine him and asked us to go back to the little conference room at the end of the ward. We sat in a semicircle facing the chair in which Dr. Dawson was sitting. Behind him was an X-ray view box on which he asked Tom to put the X-rays of Mr. Siller’s chest. Dr. Dawson looked up at the X-rays, got up and walked over to the X-ray box. He then looked at Tom and shook his head disapprovingly. “Please put these in the view box correctly,” Dr. Dawson said as he removed the X-ray image, turned it 180 degrees, such that the structures on the left were now on the right and vice versa, and put these images back up on the view box. Mr. Siller’s heart now appeared on the left side of the X-ray. As Dr. Dawson pointed to evidence of Mr. Siller’s pneumonia, Jeb, a resident who worked closely with Tom, got up, walked over to the view box, removed the X-rays, rotated them 180 degrees, and put them back on the view box in the same position in which Tom had originally placed them so that the heart was again on the right side. “Dr. Dawson, I believe the X-ray goes this way,” said Jeb.

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By now, everyone’s eyes were laughing, but Dr. Dawson’s were not. “Dr. Dawson, I think Tom and Jeb are trying to tell you that this patient’s heart is on the right side of his chest,” said Tom’s resident. “Given his dextrocardia and his history of bronchiectasis and sinusitis, we think he might have Kartagener syndrome.” At first Dr. Dawson said nothing. Then he said, “Gosh, I thought the heart sounds were distant.” At this point, many of the house officers could not suppress their laughter. My resident whispered into my ear, “He would have been much better off just admitting his error.” Six months later, my resident and I were walking down one of the hallways at Memorial Hospital and noticed Dr. Dawson examining a patient in the course of making rounds. He was percussing the patient’s chest using the same open-handed technique he had used earlier with Mr. Siller. We shrugged our shoulders and walked on. Everyone makes mistakes, from the critical to the trivial. Mistakes can propel us to come to a new understanding on our own, or we may need help from others to see that there is a lesson and where it lies. In the end, it is what we do with the experience that matters. Admitting to a mistake is the beginning of learning. It was shocking that Dr. Dawson continued to use a technique whose dangerous flaws had been illustrated so strikingly by his examination of Mr. Siller. The picture of him percussing yet another patient with his poor technique was a disturbing reminder of what happens when we close ourselves to learning.

5 Credentialing: The Imposter September 1963

J

ohn Zegel, a fellow intern, had a patient in the ER who was complaining of headaches. As medical interns, we did not know a lot about headaches. We knew that someone with a headache who also had fever and a stiff neck might have meningitis and needed a spinal tap and treatment with antibiotics. We also knew that people who developed a sudden severe headache and had a stiff neck might have a cerebral hemorrhage and needed a spinal tap and an angiogram. Finally, we knew that people with headaches who also had evidence of optic nerve swelling probably had a brain tumor and that arteriography was the correct imaging test to order. Only the patients with meningitis were admitted to Medicine Service; the others were cared for by the neurologists or the neurosurgeons.

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This patient’s complaint was very strange: He only got headaches when lying down; when he was sitting or standing, the headaches would go away. The patient had somewhat elevated blood pressure, for which he was receiving no treatment, but the rest of his general medical and neurological examinations were normal. John and I did not know what to make of this and speculated that lying down might exacerbate the patient’s high blood pressure, which in turn caused his headache. Nonetheless, John thought this patient’s condition was so unusual that he should call the neurology resident. The resident turned out to be Walter, a medical resident from our program who was covering the Neurology Service that evening. Walter arrived, did a detailed neurological examination, and like us, found no abnormalities. John mentioned the patient’s high blood pressure, and Walter agreed that it probably played a role in his headaches. After some more discussion, we decided to treat the high blood pressure with hydrochlorothiazide, a diuretic. Right next to us one of the residents from New York University was examining another patient. He heard our discussion and walked over to introduce himself. “My name is Steve Schwartz. I’m a neurology resident. Can I make a suggestion?” The NYU Neurology Service was covered by residents specializing in neurology, while ours did not have a neurology resident on call, so we all immediately responded, “Yes, please!” “I’ve never seen it before, but there’s a rare condition I’ve read about called a colloid cyst of the third ventricle. These people have a little benign cyst in their third ventricle in the middle of their brain. When they are upright, the cyst just floats around in the spinal fluid, but when they lie down, the cyst floats up and blocks the spinal fluid from exiting from the lateral ventricles. The buildup of spinal fluid causes a severe headache. I also read that if these patients don’t get upright in time, the pressure can increase so much that they can actually herniate their brain and die.”

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“I guess you think we should admit him,” said Walter. “Yes, but let him sleep in a chair, and tomorrow I’d ask the radiologist to perform a pneumoencephalogram.” During the 1960s, computer tomography (CT) and magnetic resonance imaging (MRI) did not yet exist. “To determine if this patient has a cyst,” he continued, “they’ll perform a lumbar puncture while he’s sitting, remove some spinal fluid, and replace it with air. The air will go up to the brain and fill the ventricles including the third ventricle. On the X-rays, the ventricles will appear black, because they are filled with air, but the air will not be able to get into the cyst and the cyst will remain light gray. This contrast will allow them to see the cyst, if it is present.” “OK, we’ll admit him, and if our attending agrees, we’ll do the pneumoencephalogram. Thanks so much for the advice,” said Walter. We saw the patient on a Monday evening. When I saw Walter in the cafeteria that Friday during lunch, I asked him how the patient was doing. “That NYU neurology resident was right on target. The patient did have a colloid cyst, and he’s on his way to surgery as we speak,” Walter replied. A month or two later I received a letter from the chief administrator of Bellevue Hospital asking me to bring my medical school diploma to his office. It seemed like a bizarre request, but other interns and residents had received the same letter. I called the administrator’s office to explain that the diplomas from my school, the University of Virginia, were famously huge. My diploma hung in my mother’s house in Brooklyn, and without a parking spot at the hospital, I would have to wrestle it onto the subway. I asked if the dean’s office at UVA could instead send a letter confirming that I had graduated in June. “No—letters are easy to forge. We have to see the diploma in the next three days, or you’ll be terminated.”

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I retrieved my diploma from Brooklyn that evening and brought it to the administrator’s office the next day. One of the secretaries inspected it to verify that the signatures were identical to those in a letter from the UVA dean, then crossed me off their list. “What’s this all about?” I asked. “We learned that one of our residents was an imposter. Now we want to make sure that all the interns and residents are real doctors.” “Who was the imposter?” “You wouldn’t know him. He was on the NYU Neurology Service. I think his name was Steve Schwartz, but who knows if that’s his real name.” “I’ve met him, and he appeared to be a brilliant neurologist.” “Yes, he even had people on his own service fooled, but he never went to medical school. We don’t know where he learned all that stuff, but he was a fraud. I guess all this information will come up in his trial.” The next night that I was not too busy, I went to the library to read about imposters. I learned that many are brilliant and often very knowledgeable about the field in which they represent themselves as experts. Two years after I finished my neurology training, I took a special examination administered by the American Board of Psychiatry and Neurology in order to become a certified neurologist. I knew that about half the neurologists taking the exam do not pass it the first time they take it, so I studied very hard for several months. Most American neurologists belong to the American Academy of Neurology (AAN). The AAN has different classes of membership for those who pass the board exam (active or fellow member) and for those who did not pass or who never took the exam (associate member). Looking at the AAN directory, I was amazed to see that a large percentage of neurologists were listed as associates—that is, they had never passed, or had never taken, the board exam. I thought about Steve Schwartz—or whatever his real name might be. I thought that

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he probably could have passed the board. If he did pass but had never graduated from or even attended medical school, would he still be a fraud? And if so, what do we call people who graduate from medical school, complete an internship then a neurology residency, and now practice neurology but never had sufficient knowledge to pass their boards? Over the years I have consulted on patients whose physicians were certified by a specialty board but did not provide high-quality care. I have also consulted on patients whose physicians were not board-certified but who provided excellent care. I believe strongly that high-quality health care is as dependent on physicians knowing what they do not know as it is on their having in-depth knowledge of medicine. Perhaps part of our mission as educators should be to teach physicians how to recognize the limits of their knowledge— and to help patients recognize when their physician has reached that limit.

6 All Animals Are Equal, but Some …: Administrators September 1963

T

he year before I took my internship, the interns and residents who worked in New York City Hospitals like Bellevue, King’s County, Harlem, and Bronx Municipal were not paid a salary because it was considered a learning experience. There is no question that interns and residents learned much during their training, but they also took care of many people who otherwise would have received no care. The interns and residents who worked in these hospitals worked very long hours. Many interns were on call every other night, and during the nights they were on call, it was unusual to get any sleep at all. With this 36 hours on and 12 hours off schedule,

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most interns worked more than 100 hours per week, for no pay. Many of them were married, and some had children. Medical education has always been expensive, and most interns and residents were heavily in debt. The residents and interns, or house officers, decided to form an association to lobby the city to pay them. The idea of calling a strike was floated, with the suggestion that they continue to take care of people requiring emergency medical services but not perform routine medical care. When that motion came up, the only person who voted for it was the resident who had proposed it. Everyone else hated the idea of a strike because it was not the politicians and administrators who would suffer but the patients who needed care. Another resident suggested that house officers demonstrate in front of their hospitals carrying signs that protested their lack of pay. This idea was not very popular because the protest could go on for months, and almost all of us were already time-poor. Finally, a medicine resident from the Columbia Division of Bellevue came up with a great idea. The House Officers Association (HOA) selected three residents who were married and had several children. The residents, their wives, and their children went down to the Welfare Board to wait in line to apply for welfare. The residents wore their uniforms, which had a red caduceus on the sleeve and the name of the hospital for which they worked. At the same time, the HOA called the major New York newspapers, such as the Times, Herald Tribune, Daily News, Mirror, and Post, and told them that something interesting was happening at the welfare offices and that they might want to send a reporter and photographer to cover it. The next day almost all the major dailies ran pictures of the residents in their uniforms with their families, with stories about the economic hardships they had to endure. One week later, the mayor got more than 1,000 letters asking him to pay the house officers. Thus, when I started my internship, I was paid $75 per month. The

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administration also reminded me that I could have all my laundry done at the hospital and eat all my meals there. They even said we could sleep in the on-call room when we were not on call. With a little help from my brother and parents, I was able to get a very small studio on the Lower East Side at 14th Street and Avenue A. I also had my eight-year-old Ford sedan that I used to get out of the city on the rare weekend I had off. In New York, parking is always a big problem, even in 1963. However, if I searched, I could usually find a spot within a few blocks of my apartment. Bellevue was only nine or 10 blocks away, and most mornings I could walk to work. If the weather was bad, I would drive my car but had to park illegally because I could not afford paid parking, which was the only option in the Bellevue neighborhood. On those occasions, I usually found a ticket on my car when I got off the next evening. The tickets were expensive but not as expensive as the parking lot. In the early 1960s, New York City instituted alternate side of the street parking so that the street cleaners would have full access to one side of the street on certain days and to the other side on the alternate days. That meant that even if I parked my car in my neighborhood legally before walking to work, when I returned the next day, the spot would be illegal and my car would be ticketed. (The police were much better at their job than the sanitation department.) At the beginning of my internship, I noticed that a parking structure was being built directly in front of the Bellevue Administration Building and, after inquiring, was told that interns would be able to use it. I was delighted because at the rate I was collecting parking tickets, I was going to end up in debtor’s prison. Toward the end of the summer, the Bellevue Parking Garage was completed. In late summer, about two weeks before the Bellevue Parking Garage was completed, I received a parking sticker that I needed to display on my car. At the dedication of the new garage, city administrators and politicians gathered to take credit for the garage and the new general

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medical building that would soon be built nearby. The next day I drove joyfully from my apartment to the garage only to find the entrance chained off and a sign that read, “Closed. Building Condemned.” I was back to having to find an illegal parking spot somewhere near Bellevue. After finding a spot (perhaps the only legal one I ever found near Bellevue), I walked to the hospital and asked the first intern I saw about the parking garage. Apparently, the city building inspectors condemned it because the concrete used to make the support columns had been mixed incorrectly and might not be able to support a building filled with cars. The construction company was going to reinforce the columns, and the garage would be ready in two months. Reinforcing the columns made them thicker, and thus the number of parking spaces shrank. Several days before the garage reopened, I received a letter from the Bellevue administration. “Dear Dr. Heilman,” it read. “We were planning to provide our interns, who are so important to the mission of this hospital, parking places in our new garage. Unfortunately, we had to make some modifications and lost some parking places. As a result, you will not be able to park in our garage. Please return your parking sticker in the next three days or your hospital privileges will be revoked.” The day after I received this letter I walked through the new parking building and found that each of the thickened columns took up an extra parking spot and that all the administrators’ spots were marked with their names along with a warning that unauthorized cars would be towed. Although I did not know the administrators’ salaries, I knew that they made a lot more money than I did and yet they, not the debt-strapped and barely paid house officers, were given free parking. What is more, they all left the hospital by 4:30 PM and never worked on weekends. New York summers can be very hot and humid. None of the wards, clinics, or emergency rooms at Bellevue had air conditioning; but when I returned my parking sticker, I noticed that the administration

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building did. As I walked over to the director’s secretary, I remembered the end of George Orwell’s Animal Farm. After the animals overthrew the tyrant farmer, the pigs who became the leaders wrote in their new constitution that “All animals are equal, but some animals are more equal than others.” Though today air conditioning is a given and the situation of house officers has improved, the allocation of health care seems more than ever to be governed by the pigs’ constitution.

7 Fabrication: Gum Guaiac September 1963

J

im Lin was a first-generation American. His parents had emigrated from Taiwan while he was in his mother’s womb. His grandparents had moved to Taiwan from mainland China when the Nationalists lost to Chairman Mao and the Communists. His parents came to New York and lived in Chinatown near Canal Street because their cousins, who were the only people they knew in America, lived there. Although well educated as an engineer, his father spoke little English and was happy to find work as a cook for one of the restaurants in Chinatown. Eventually, however, he became the owner of this restaurant. Jim went to public schools in New York and was always an outstanding student. After attending elementary and junior high school in downtown Manhattan, he took a test and was admitted to one of

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the best high schools in New York, the Bronx High School of Science. Each morning he walked to Canal Street to catch the subway that took him to the Bronx. Although he played no sports and had little social life, he did very well academically and was class valedictorian. He got almost a perfect score on his SATs and was admitted to Harvard with a scholarship, where he majored in chemistry and from which he graduated cum laude. He was then admitted to Harvard Medical School and again graduated near the top of his class. Jim wanted to go into ophthalmology and had already been accepted as an ophthalmology resident at Cornell-New York Hospital. First, though, he needed to take an internship; and at that time, during the 1960s, most people who went into ophthalmology took a straight medical internship. Jim was on call Tuesday night and had Wednesday night off, when he was going to have dinner with his parents. Because I would be looking after his patients while he was off, I asked Jim to fill me in so that I was prepared to care for them. His sickest patient was a Mr. Tom McDonald, who was suffering with alcoholic liver cirrhosis. Mr. McDonald was lethargic and confused because he had a mild hepatic encephalopathy, a condition in which the liver cannot clear the toxins out of the blood. Patients with this disorder very often bleed into their gastrointestinal (GI) tract because the veins in their esophagus become engorged and their liver is no longer able to make an important clotting factor that would prevent them from bleeding. Should these people bleed into their GI tract, it would make their level of consciousness decrease even further. I asked Jim if Mr. McDonald had any evidence of GI bleeding. If he did, I would have to watch him closely so that he did not hemorrhage and go into shock. When a patient bleeds into the upper part of the GI tract, there is no tell-tale bright red blood in the bowel movements; by the time the blood has traveled the length of the intestine, it is deoxygenated and makes the stool look like black tar. To learn if there is blood in the stool, we smeared a patient’s feces on a piece of filter paper and

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took it to the laboratory, where we put a substance called “gum guaiac” on the stool. If blood is present, the filter paper turns blue. Jim told me that he was so concerned about Mr. McDonald having a GI bleed that in the past 24 hours he had performed three stool guaiac tests, all of which were negative. Still, as a precaution, he had given a sample of Mr. McDonald’s blood to the blood bank so that the technicians could type and cross-match it with blood they were storing. Learning all this made me feel more secure. About 10:00 that evening I made rounds on my patients and Jim’s. When I checked on Mr. McDonald, I noticed that black, foul-smelling stool covered his bed. I was immediately concerned that he was having GI bleeding and took a sample of the stool to the lab—where I could not find any gum guaiac. While I was looking, another intern came in to perform blood tests, and I asked him where I could find the gum guaiac. “We have not had any for two days,” he replied. “Why?” “It comes from Vietnam, and with the war going on there, it’s no longer being exported.” “How are you checking for fecal blood?” “We’re using benzidine. It’s right over there on the shelf, and next to it are the instructions. Basically, you fill a test tube with some water, put in some of the patient’s stool, then shake it. Then, you put several drops of benzidine into the water. If it turns blue, there’s blood.” I thanked him, then performed the test on Mr. McDonald’s stool. According to the scale posted on the wall, his test was unambiguously positive. Back at the ward, I checked Mr. McDonald’s blood pressure and pulse, both of which were normal, and drew some blood to check for blood loss anemia. The result indicated that he was very anemic. I then smeared his blood on a slide and examined it under a microscope. His red blood cells were very small and much paler than the normal full, deep red of healthy red blood cells. These are the

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classic signs of iron deficiency anemia. In men, the most common means of losing blood is through the GI tract. This meant that Mr. McDonald’s bleeding was not new. I ran to the blood bank and got two units of blood. Although we would still need to evaluate Mr. McDonald to find where in his GI tract he was bleeding, right now he needed blood to replace the blood he had lost so that he would not go into shock. Fortunately, the two units of blood were adequate to prevent Mr. McDonald from going into shock. Although the transfusion did not entirely reverse his anemia, it helped, and he remained stable into the morning. The entire episode troubled me because Jim had told me that he had checked the stool guaiac three times in one day, and each time the results were negative. How could he have done this when there was no gum guaiac in the lab? I was hoping that he had performed the benzidine test but did not provide this detail because it was equivalent to the guaiac test. The problem I had with this explanation was that Mr. McDonald was in a hepatic stupor and severely anemic, suggesting that his blood loss was not new. I thought the best thing to do was to ask Jim again, during morning rounds which test he had used on Mr. McDonald’s stools. Early the next day, Jim and I, together with Walter, our resident, made rounds. When we got to Mr. McDonald’s bed, I described what had happened last night and said that we would have to learn the source of the bleeding to determine if we could stop it. I turned to Jim. “Mr. McDonald was really anemic when I checked him last night. Are you sure that you performed several guaiac tests on his stools?” “Yes, I did three stool guaiac tests yesterday, and they were all negative.” “Could you have confused tests?” “No, Ken. As I told you, I performed three stool guaiac tests on Mr. McDonald’s stools.”

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I wanted to say something then but decided it would be best to confront Jim about there being no gum guaiac in the lab when we were alone. After rounds, Jim was by Mr. McDonald’s bed checking his intravenous line. I walked over. “Jim, I’m really troubled by something. Yesterday you told me that you performed stool guaiac tests on Mr. McDonald’s stool, but I learned that the lab ran out of gum guaiac a couple of days ago.” “Kenneth, without gum guaiac, how could you test his stool for blood?” “I used the benzidine test.” “Well, when I was in the lab, there was gum guaiac, and I used it to test McDonald’s stool for blood. Maybe somebody from another service ran out of gum guaiac and borrowed ours.” I was getting irritated with Jim’s defensive stories. “Jim, listen—I don’t believe you. Mr. McDonald’s anemia suggests that he had been bleeding for some time. I’m confident that if you really tested his stool yesterday, you would have found blood. Jim, you can’t fabricate lab results. You could end up killing someone.” “Are you going to report me?” “I don’t know what to do. I wish I could be sure that you’d never do something like this again because then I could let it go . . . but if I don’t report you and someone gets hurt or dies, I’d feel that it was partly my fault.” Jim took a deep sigh and looked at the floor as he spoke. “Ken, I hope you know that I’m very careful about my patients, but the day I told you about McDonald’s guaiac, I was so busy that I forgot about doing the test, until you asked me. Later, I was embarrassed to tell you and Walter because I knew how important they were. When you just asked me again, I was embarrassed that I had not done the test. I did not want to lose face, and I lied. I promise you, I’ll never do anything like this again.” “For your patients’ sake and for yours, I hope you don’t lie again to cover yourself. I don’t know if reporting you is the right thing to do. I need to think.”

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That night I had plenty of time to think about whether I should tell our chief resident, Tommy, or the chief of our service, Dr. T. P. Almy, about this incident. The thought of reporting Jim, however, really troubled me. I remembered my first year at New Utrecht High School in Bensonhurst, Brooklyn. My older brother had told me that it was very important to join service organizations because it would help when I applied to college. I joined the Service Squad, whose members helped the school administration with a variety of tasks that they performed during their free periods in lieu of sitting in study hall. I had no classes during third period and was sent to the assistant principal’s office to provide clerical help. The assistant principal, Mr. Liebowitz, met me and brought me to a hallway with several doors leading outside. He explained that although students were supposed to go to study hall or the cafeteria during free periods, many violated school policy and left the building through these doors to smoke a cigarette or to buy a Coke at Chookies, the corner candy store. He told me to sit on the steps. I was not to interfere with students who wanted to leave, but if students tried to get back in, I should report them to the assistant principal. A few minutes after Mr. Liebowitz left, I heard someone knocking on the doors and yelling, “One, two, three, four . . . open up the fucking door.” I ran to Mr. Liebowitz and told him that someone was trying to get in. He came back with me to the door and opened it. Standing there was Tony Gino, the toughest gang leader at Utrecht, with two of his friends who were members of his gang. “Come to my office, I need to speak with all three of you,” Mr. Liebowitz said to the boys. As they were leaving, Tony turned to me and silently said, “See you after school.” Most school days could never go fast enough, but this one went too fast. I knew Tony would be waiting for me after school. I considered my options: I could tell Mr. Liebowitz, I could call home so that someone in my family could meet me at the school, or I could ask my friends to join me as I walked out of the school. I decided

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none of these actions would work. They would only increase Tony’s anger, postpone his effort to get even, and possibly result in injury to people I cared about. By the time school ended, I decided to walk out by myself and to face the music. The coast was clear until I reached the stairs to the subway station. Suddenly, Tony and two of friends appeared. I felt panic but walked over to Tony anyway. “I’m sorry about what happened today. I made a mistake. I understand why you are ticked, but if we’re going to have it out, it should be just between you and me . . . and no knives.” Tony was very mature-looking, and I was just entering puberty. He was several inches taller than I and much better developed. I rolled up my long shirt sleeves and, standing about 10 feet in front of Tony, I took the position of a boxer. “Let’s get this over,” I said. Tony’s face broke out into a big grin. “You’re pretty tough, kid.” “I’m scared shitless, but I don’t know what else to do.” “I know what we can do. I’ll let you treat me to an egg cream at Chookies.” “I can’t do that. It would be like paying you off.” “OK, kid,” Tony said, “then I’ll treat you.” I put my arms down. Tony walked over and put his arm around me. “I like you, kid. You got balls.” We had egg creams at Chookies, but I did not let Tony pay for me. The next day I went to Mr. Liebowitz and told him I did not want the job anymore. He asked if Mr. Gino had threatened me. No, I told him, but I did not think that getting other students in trouble was what I wanted to do. From that time on, I never reported anything to anyone. The University of Virginia, where I attended medical school, had an honor system. If you saw someone cheating and did not report them, you could be removed from school. I was so concerned about having to report someone whom I saw cheating that during examinations I hardly ever looked up and, when I did, it was to stare at

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the ceiling. Still, I went back and forth and back and forth. I knew I would have trouble reporting Jim to Dr. Almy or to Tommy. I also knew that if Jim continued this type of behavior and was not closely watched, he could hurt a patient, just as he had almost hurt Mr. McDonald. But just as I had told Tony that I would never do it again, Jim told me that he had learned his lesson and would never lie again. I believed him. In the end, I did not report him. However, Walter, our resident, knew what had happened, and I think that he alerted the other residents to watch Jim closely and make certain that, as a Harvard graduate, he practiced veritas. Jim went on to become an outstanding ophthalmologist. I know that there are psychopaths who do not learn from their mistakes, but fortunately, it is rare for psychopaths to end up as physicians. Thus, after many years of teaching medical students, residents, and postdoctoral associates, I always let them know from the start that physicians and scientists value honesty over everything else. I also continue to believe that educational investment and an invitation to excellence are more effective than punishment. Patients, however, must always be protected.

8 Priorities: Do Not Admit Her October 1963

I

t was midmorning when over the loudspeakers I was paged. I was near the Emergency Room and walked in to use their phone to call the Bellevue operator. “Dr. Heilman, there’s a lawyer on the phone who wants to speak with you. What number are you at?” I gave the operator my number, hung up, and in about 30 seconds, the phone rang. “Dr. Heilman, my name is Jonathan Segal. I work for the law firm of Jacobs, Stern, and Segal. We have a client who is often in the limelight. He has an 18-year-old daughter, Emily, who has been under psychiatric care. Her psychiatrist is Dr. Roger Wynn. It appears that she has had problems with drug addiction and depression.

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Dr. Wynn is planning to admit her to a private institute up in Westchester, and I’m calling to let you know we’ll be sending an ambulance to pick her up. We do not want you to admit her to Bellevue.” “Mr. Segal, I have no idea what you’re talking about. I don’t know who Emily is or why you’re telling me all this.” “I learned that you’re next up for an admission, and in a few minutes, you’ll meet Emily. An ambulance is bringing her to Bellevue right now.” “Why?” “When the maid came this morning to clean their apartment, she found Emily sleeping and had trouble waking her up. This maid knows that Emily has had problems with drugs and depression so she called the police, who called an ambulance.” “Mr. Segal, the patient comes first. If Emily needs to be admitted, she’ll be admitted, but if she doesn’t need to be admitted, we can hold her until she’s transported to the other hospital.” “Dr. Heilman, for some reason, reporters can find out who’s been admitted to the city hospitals. My client doesn’t need the bad publicity that would surround his daughter’s admission to your hospital for a drug overdose.” “If she needs admission, she’ll be admitted. If she doesn’t, you can pick her up here and transport her to your special hospital.” “Perhaps you don’t understand, Dr. Heilman, the legal and financial implications of not . . .” “Mr. Segal, I’m busy, and I don’t have time to listen to you threaten me. Good-bye.” About 10 minutes later, just as Mr. Segal predicted, in came an ambulance. The driver wheeled out a young woman who looked comatose. It was Emily. Seeing that she was comatose, I became angry with myself for not asking the lawyer what type of drugs she abused, but he may not have told me because he did not want anyone at Bellevue to take care of her.

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The minute I realized she was comatose, I decided not only to admit her but also to bring her immediately to the Emergency Ward (EW) in case we had to intubate her. As we wheeled her stretcher to the EW, one of the drivers handed me an empty pill bottle. “Doc, we found this by her bed.” The empty bottle was labeled “Librium” (brand name for chlordiazepoxide). Back then, we had no medication to reverse the actions of this drug and would have to wait until her body cleared it. Soon after we arrived at the EW, her respirations became shallow, and I put her on a respirator. Next, I put in an IV line, drew some blood for routine tests, and examined Emily. Except for her drug-induced coma, she seemed to be pretty healthy. I carefully looked for evidence that she might be shooting up with an opiate, such as heroin, but found none. She did, however, smell of cigarettes and pot. About a half-hour after I stabilized Emily, I was paged and asked to come to the information desk. I walked over to find two men in their middle fifties waiting for me. Judging by their suits, ties, and diamond pinky rings, they looked extremely successful. As I approached, one of the men walked over to me. “Are you Dr. Heilman?” “Yes.” “Dr. Heilman, did you see Emily?” “Yes, I did.” “Where is she?” “I admitted her. She is in our Emergency Ward.” “Dr. Heilman, what did I say over the phone about admitting her?” “I’m sorry, Mr. Segal, but I had no choice.” The man next to Mr. Segal approached. “Dr. Heilman, I’m Emily’s father. Emily’s mother could not be with us; I think she’s probably in LA now. Can you bring me to see Emily?”

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I nodded. “Follow me.” When we got to the EW, both men started through the door. “Only one at a time,” I said. I brought Emily’s father to her bedside. She was lying with her eyes closed with a respirator periodically filling her lungs with air through the endotracheal tube that I had inserted through her mouth. She had an IV with glucose going into her arm and electrocardiogram (EKG) leads running from her chest through her gown sleeve to a monitor by her bedside. She looked very pale and very vulnerable. Very softly, her father called her. “Emily, Emily. It’s Dad. Please wake up.” Emily did not respond, so he repeated himself but this time a little louder. “Emily . . . please . . . please wake up. Talk to me.” She still did not respond and when his eyes started to fill with tears, I said, “She’s not ignoring you. She’s in a coma because of the overdose of Librium she took.” “I understand. I just feel bad that my only child has suffered so much that she took an overdose. I haven’t been a very good father. I’ve never spent a lot of time with her. When she had problems, I always got someone else to take care of her. Her mother has been even worse. She cares only about her acting career. The worst part is that when I found out that Emily took an overdose, I was more concerned about how this would reflect on my image than about her welfare. That’s why I had my lawyer call and threaten you. I’m so sorry I did that to you. I’d like to step outside for a moment to tell Jon Segal that I won’t be requiring his services. Then I’d like to come back in again. Would that be OK?” I said that would be fine but explained that he would need to limit his visits to 15 minutes every two hours. He understood. Emily’s father went outside the EW to speak with his lawyer. When he returned, he kissed his daughter on her cheek and told her he was sorry and that he loved her. He turned to me.

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“I’m going to stay here until she wakes up. I’ll wait in reception and come back every two hours until she’s awake. Please, doctor, if she wakes up or there’s a problem, please let me know.” “Your daughter is basically very healthy, and I think she’ll do well.” Emily’s father visited her every two hours throughout the day. When she awoke, I was at her bed and her father was waiting in reception. I told her how concerned her father was and that he had basically lived in the hospital waiting for her to awaken. Just as I finished speaking, he appeared by the bedside. When she saw him, she smiled, and tears came to his eyes. Because she was no longer in a coma, we removed all the breathing and monitoring equipment. Her father asked if it was now safe to move her to the private psychiatric hospital. I told him yes, she could be transferred and that she needed psychiatric treatment. Again, he thanked me and apologized. No reporters showed interest in Emily’s problems. I do not know how she did at the private psychiatric hospital, but I hoped that now that her plea for help had been heard, her prognosis might be better. During my career, I have had several subsequent episodes where one or more members of a patient’s family wanted me to do something that I did not think was in the best interest of the patient. Most often, it has to do with withdrawing life support from a person who does not have a terminal disease. After sitting down with these families and explaining our thoughts and actions, they will often agree to let us continue caring for their relative, but not always. Now some insurance companies, health-care maintenance organizations, and even some hospital administrators attempt to influence physicians’ decisions about the intensity and type of health care they provide to their patients. Most of these organizations are businesses, and thus, their major interest is often economic rather than the quality of health care. The practice of medicine is also, in part, a business,

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but during graduation from medical school, physicians take the Hippocratic oath, which states “I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone. To please no one will I prescribe a deadly drug nor give advice which may cause his death.”

9 Disbelief: Someone Is Chasing Me October 1963

D

uring one of the weekends I had off, something terrible happened in the ER. Late Saturday afternoon, a young woman who was pregnant ran into the ER. The clerk asked her if she was having problems with her pregnancy. “No, but there’s a man with a gun who’s following me. I think he wants to kill me.” “Why did you come to the hospital?” the clerk asked. “He chased me up First Avenue and was catching up, so I decided to run in here. I thought there’d be a policeman here.” “Is this man your husband or your boyfriend?” “No. I’ve never seen him before. I was walking down the street to visit my sister and noticed that he started following me. When I

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walked faster, he walked faster. One time I turned around to see how close he was getting and thought I saw a gun in his hand. Then I looked down the street, saw Bellevue, and thought I’d run in here.” “Please sit down. We’ll get someone to see you.” “Is there a policeman here?” “Just sit down.” Appearing very anxious, the woman sat down. She kept looking at the entryway, worried that the man would appear. It was a slow day in the ER, and one of the residents noticed that she was anxious and even shaking in fear. He walked over to the clerk’s desk, picked up and read the woman’s paperwork, then walked over to the woman and sat beside her. He introduced himself and asked if this had ever happened to her before. “No, never.” He asked if she had any history of mental illness. “No.” He then asked if she was taking any type of medicine for her nerves or if she had ever seen a psychiatrist. “No. This is not my imagination. For some reason, this man is following me. I think he wants to kill me.” The resident asked if she would mind if he called another doctor. She told him that she thought it would be best if he called the police so that if the man appeared, they could arrest him. The resident thought she was paranoid and called the Psychiatry Service to ask if one of their people could come to see the woman. Just as he was about to hang up, a disheveled man walked into the ER. He walked past the clerk’s desk directly over to the pregnant woman, who was frozen in terror, took a revolver out of his pocket, and fired all six shots into her. He then turned and fled. The woman fell to the floor and died before the resident could reach her. Several shots had been fired into her belly, and while they did an emergency C section, the baby was also dead. The clerk finally called the police unit that was stationed in the hospital, and they apprehended the man just as he was running out of the hospital.

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After the police took the man to jail, they asked him why he killed the woman and her baby. He explained that she was “carrying the devil incarnate and that god had spoken to him, asking him to kill her.” When checking his records, they found that he had previously stalked another woman but had been arrested before he could do anything to her. During his incarceration, his bizarre behavior led to his being evaluated by the Psychiatric Unit at Bellevue. He was diagnosed with paranoid schizophrenia and treated with chlorpromazine (Thorazine), an antipsychotic neuroleptic. With this medication, he went into remission and was discharged from the hospital with a supply of medicine and weekly clinic appointments. He never returned to clinic, however, and stopped taking his medicine three weeks before this tragedy. He could not understand why he had been put in jail for following God’s word. We still do not know how to stop this type of tragedy. Most patients with psychiatric disorders are dangerous only to themselves, but there are some who are dangerous to others. It is very difficult to predict violent behavior. We still hear and read stories about psychotic mothers who kill their children, paranoid schizophrenics who stalk famous or ordinary people, and addicts who steal to support their addiction. Our prisons have become our mental hospitals, but while temporarily protecting the people outside, they offer no permanent cures. After hearing this story, almost every physician and nurse at Bellevue realized that delusions and fabrications are diagnoses of exclusion. No matter how preposterous a patient’s story may sound, unless we can prove a falsehood, we need always to take our patients at their word.

10 Confidence: Listening to the Voice Within November 1963

W

hile I was an intern at Bellevue Hospital, the Cornell Neurology Service was fairly small. Only a few house officers from the Medicine Service were assigned to the program, and since there were no neurology residents, care of the patients with neurological diseases fell to the medical interns and residents. As interns, we were responsible for taking and performing neurological consultations, even though no specialized training in neurology was offered to us. During the day, at least, our patients were routinely presented to neurology attending physicians, so we were confident that they received excellent care. As every medical professional knows, however, emergencies don’t always occur at convenient times, and during the night, only medical interns and residents were available for consultation. Although I had

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spent a month on the Neurology Service in medical school, I was insecure about acting as an expert in neurology and was often worried that I would be called in for a consultation with only my medical peers for support. I suspect now that if was truly necessary, we could have called an attending at home, but calling physicians at home was not a practice at this time at Bellevue. During the evenings there were only two interns on-call: one to look after the inpatients, and the other to evaluate consultations. One evening, we admitted a patient who was experiencing continuous seizures (status epilepticus), and shortly after we admitted a patient who had had a stroke. While my colleague and I were seeing these patients, I got a call from the ER, which was run like a clinic; although there were rooms where doctors could examine patients and perform some simple surgical procedures such as suturing a simple wound or lancing a boil, the administrators would not allow us to perform any diagnostic procedures. We were told that if a patient was sufficiently ill to require an emergency diagnostic procedure, he or she should be admitted to the hospital. We gave the patient who was having continuous seizures a large dose of phenytoin (Dilantin) through an intravenous line. Although the phenytoin reduced the frequency and severity of the patient’s seizures, he was still having one about every five minutes and we needed to give him phenobarbital. While administering this barbiturate through his IV line, we knew we had to closely monitor the patient because at high doses phenobarbital could potentially cause him to stop breathing. When I walked into the ER, a man and woman were sitting on a bench. The woman was holding her head and repeating, “dolor . . . dolor . . . dolor . . .” (meaning “pain” in Spanish). I picked up her chart and read that her name was Isabella Lopez. I was not at all fluent in Spanish, but since we cared for so many Puerto Rican patients who spoke little or no English, I had been trying to learn a few words. I asked Ms. Lopez, “Senora, donde es dolor?” (“Ma’am, where is the pain?”).

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She pointed to her head. The nurse had already taken her vital signs, and they were all normal. She did not have a fever, so it was unlikely she had meningitis. I motioned for the patient and her husband to follow me, and when we arrived at the examining room, I had the patient lay down on the bed. I checked her neck for stiffness, but there was none. Because she was overweight, I was worried that her headache might be a symptom of primary intracerebral hypertension, a swelling of the brain seen in obese young women. Part of the treatment for primary intracerebral hypertension would have called for lumbar punctures, which would have required me to admit her. When I looked into her eyes and saw that her optic disks were not swollen, as is seen in this disease, I was relieved. I performed a very careful general and neurological examination, and everything appeared normal—except for the fact that she just looked sick. I wrote a very detailed note about the situation, and just as I was finishing my note, the clerk found her chart. Reading through the chart, I noticed that she had been seen in the clinic several times for headaches, shoulder aches, and neck aches, a group of symptoms physicians these days would call “fibromyalgia.” Since Ms. Lopez had such a documented history, I felt my burden as diagnostician lighten: My preliminary decision not to admit her for observation was supported by the observations and diagnoses of my predecessors. As an isolated physician, my judgment could be flawed, but collectively, there was a consensus which should have made me feel more confident that there was no medical emergency. Nonetheless, I was still concerned that Ms. Lopez’s headache had resulted from a burst blood vessel and a subarachnoid hemorrhage, even though she hadn’t developed the characteristic stiff neck. Without a lumbar puncture I couldn’t be certain. In the absence of the imaging techniques that we have now—computed tomography (CT) and magnetic resonance imaging (MRI)—checking the spinal fluid for blood was the only way to make a diagnosis of intracranial

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hemorrhage. Watching over Ms. Lopez and her obvious pain, I wished that hospital rules didn’t bar me from performing a diagnostic lumbar puncture in the ER. I wanted to admit her to our Neurology Service, but I thought, “We are already very busy, and this woman does have a history of repeated headaches. Without any clinical evidence of a subarachnoid hemorrhage such as a stiff neck, it would be unfair to further burden the other house officers.” With a nagging feeling that this case wasn’t closed, I told Ms. Lopez that I would admit her to the hospital immediately should she have any more problems, and particularly if she had a stiff neck. I tried to tell her this in Spanish, but I was doing so poorly that Mr. Lopez said to me, “Please, Doctor, speak in English. I will understand.” I told him in English. I also wrote a prescription for a mild painkiller. Mr. Lopez helped his wife off the bed and said, “Thank you, Doctor, for taking such good care of my wife.” After they left the ER, I completed a detailed note about the patient’s history, my examination findings, and my concerns. At the end of the note I indicated that if the patient returned, I should be called immediately. Four days after my initial evaluation of Ms. Lopez, I was heading to the ER to see a patient with chronic obstructive pulmonary disease, when I saw Mr. Lopez standing beside his wife, who was lying on a gurney. I greeted him and asked, “How is she doing?” He looked very sad and said, “Not good, Doctor.” “Does she have the same headache?” He shook his head. “No. She is not complaining of headache. . . . But I could not wake her up and she does not seem to be breathing normally.” I walked over to where she was lying and said, “Ms. Lopez, can you open your eyes?” She did not respond, so I repeated myself, rubbing her chest with my knuckles because pain is a very arousing stimulus. She still did not open her eyes, so I opened them for her and found

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that her right eye was turned outward and down and the pupil in this eye was also very large. These eye signs suggested that some of the nerves that connected to her eye and moved it inward had been damaged, causing a right third or oculomotor cranial nerve paralysis. Either Ms. Lopez had herniated her brain’s right cerebral hemisphere and as it had herniated downward it pressed on this oculomotor nerve or she had a dilation of one of the major arteries in her head caused by weakness of the wall, or aneurysm. This dilated vessel could have pressed on the oculomotor nerve, burst, and sent blood all over the surface of her brain. I checked her neck and found it had stiffened. I also understood what Mr. Lopez had been trying to say about his wife’s breathing. After a period where she wouldn’t breathe at all, Ms. Lopez would begin to breathe, taking progressively larger breaths. This type of periodic respiration is seen with people who have severe brain disease. In view of all these signs, I realized what a terrible error I had made in not initially pursuing all the possible reasons for Ms. Lopez’s headache. At first examination I had thought that she might have had a subarachnoid hemorrhage from an aneurysm that had burst, but because she hadn’t developed a stiff neck or any eye signs, I didn’t admit her to the hospital. If I had admitted her and performed a lumbar puncture, I could have made the correct diagnosis. Perhaps, I thought, the neurosurgeons could have operated on her and saved her life. Now she was almost certain to die. I walked over to her husband and said, “Mr. Lopez, I do not know for sure, but it looks like your wife burst a vessel in her head and spilled blood all over her brain. The way she looks now, there is a good chance that she won’t recover. It’s my fault. I should have admitted her when I first saw her.” Mr. Lopez had understood the gravity of his wife’s condition, but when I told him how sick she was, his eyes filled with tears. “I am so sorry,” I said. “I should have followed my instincts.”

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After Mr. Lopez wiped his eyes, he looked up at me. “Please, Doctor, do not be angry at yourself. You took good care of her. When she got a stiff neck next day, I brought her back here just as you suggested, but the doctor who saw her never examined her. I asked them to call you and they told me that you were too busy. They told me to take her home. The next day she was seeing two of everything and I brought her back again, but they told me the same thing. I asked them to look at your note, and they did. They then told me that you did a very complete workup—but none of them examined her. It is not your fault.” I told Mr. Lopez that she would be admitted today to the Neurosurgery Service but that I was not sure how much they could do for her unless she woke up. The next day, when I went to visit Ms. Lopez, I learned that she had died. I wanted to again tell Mr. Lopez how sorry I was for his loss, but he had already left the hospital to prepare for her funeral. Later that day, I saw our neurology attending, Dr. Fletcher McDowell. Even though my patient had died, I thought he should know about her so that he could tell me where I went wrong and so that he would be informed in case there were any legal ramifications. I related the story to Dr. McDowell. He told me that even had I admitted her, performed a lumbar puncture, and found blood, the surgeons would not have operated on this woman for six weeks because at the time operating immediately after a hemorrhage was associated with poor outcome. (Now neurosurgeons will operate almost immediately.) I knew that Dr. McDowell’s reasoning was accurate for the time, but I also had the feeling that he was trying to make me feel better. Since the first time I had seen Ms. Lopez, I had sensed that she was seriously ill. Ultimately, I did—and still do—regret the decisions I had made after Ms. Lopez’s first examination. I did not follow my clinical instinct. One of the hardest parts of being a clinician is bearing the responsibility of deciding whether a patient is sick or well, and after more

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than 40 years, the death of Ms. Lopez still troubles me. Did I make the decision not to admit her because I was still in training, not sufficiently secure in my instincts? Or was I looking for an excuse to protect our service from another admission? Despite the 40 years, I still have not determined the answer to this troubling question. It’s important to think beyond standard diagnostic algorithms, past administrative hurdles and the satisfactory examination. While we are wise to consider the wider systems to which we contribute— our departments, hospitals, and larger health-care organizations— when we’re caring for a patient, we have to put that patient’s needs first. If we are unsure of what to do, we should insist on becoming sure. During my brief encounter with Ms. Lopez, I had ignored my own instincts, but in the future I would try to let these instincts guide my behavior.

11 Mortality: No One Dies November 1963

M

r. James Jones came to see us in our General Medical Clinic because he had no energy and noticed that his urine was very dark and the whites of his eyes were turning yellow. He also said that at times he felt confused. Mr. Jones looked familiar to me. I noticed that his lips appeared calloused. “Are you the famous jazz trumpeter?” “Famous, no. Jazz trumpeter and jazz composer, yes.” “How come you came here rather than seeing one of the famous doctors on Park Avenue?” “First, you don’t make a lot of money playing jazz at the Five Spot Café. Second, only a few of my friends buy my albums. Third, I heard you got the best docs here.” “I have two of your albums.”

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“See, I told you. You got the best docs here . . . and by the way please, call me J.J.” I led J.J. to the examining room and asked him to take everything off but his shorts so that I could examine him. I noticed that his eyes were jaundiced, which suggests that his liver or gallbladder was not properly working. I felt his abdomen and noticed that his liver was enlarged. He also appeared to have some fluid in his abdominal cavity (ascites), and his legs were swollen with fluid. I asked him to put his hands straight out in front of him, then to bend them back at the wrist and to close his eyes while he kept his hands bent. Every few seconds his hands and arms would flop down, a phenomenon called “asterexis.” All these signs suggested that his liver was failing and, as a result, could not clean his blood. When food is broken down and absorbed by the intestines, chemicals that could interfere with the normal functioning of nerve cells in the brain are released. The healthy liver removes the chemicals, but when it is not working correctly, these toxins get to the brain. The condition is called hepatic (liver) encephalopathy (sick brain). Because he was awake, able to communicate, and oriented, J.J.’s hepatic encephalopathy was not yet severe. I was concerned about him, however, and explained why I thought that he should be admitted to the hospital. At the time, there were no tests to differentiate between the various types of hepatitis. Instead, we classified viral liver infections as either infectious hepatitis or serum (blood-borne) hepatitis. We made the diagnosis by attempting to find out how the patient caught the infection. Heroin addiction and needle sharing among jazz artists were not unusual, and when I examined J.J., I looked at his arms and neck. I saw neither new injection sites nor evidence of multiple old injection scars (“tattoos”). I used this as an excuse to not ask him about needle sharing because I did not want to appear prejudiced. Instead, I asked him a series of other questions: Had he received a transfusion in the last year? Did he drink heavily? Did he have any type of cancer? He answered no to all these questions.

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He asked what I thought was wrong, and I said I thought he had some form of liver disease. He asked me what type, and I explained that I would not know for sure until I did some tests but thought that he probably had some type of infectious hepatitis. He asked where he could have caught it, and I said it was probably something that he ate, like raw clams. He told me that he loved to eat raw clams. After J.J. was admitted, I requested a broad range of tests to help rule out or to confirm the diseases that could have caused his signs and symptoms. Jaundice is caused by a buildup a chemical called “bilirubin.” This chemical is made when red blood cells break down. In their rapid destruction of blood, both sickle cell anemia and hemolytic anemia can give a similar clinical picture; but these tests were negative. His liver function tests, however, were very abnormal and showed elevated liver enzymes. These chemicals normally reside inside the liver cells, but when they are found in the blood serum at high levels, it suggests that the liver cells are dying. J.J.’s bilirubin (bile) was also elevated, but this came as no surprise because jaundice is most often caused by an elevation of bilirubin. The liver is the organ that clears the circulating blood of bilirubin, and with liver failure this chemical builds up in the blood. The liver makes albumin, a protein that is found in the blood serum and helps to keep the serum inside the blood vessels. J.J.’s low level of albumin probably explained why his abdomen and legs were swollen with fluid. With no way to manage hepatitis, the best we could do during the 1960s was to treat some of the complications. When we admitted J.J. to the hospital that night, I prescribed a diuretic to see if we could get rid of some of the fluid that had accumulated in his legs and abdomen along with a low-protein diet so that fewer toxins would accumulate in his blood. I prescribed still other medicines that would prevent him from absorbing protein and reduce the accumulation of blood toxins going to the brain. The next morning on rounds, our chief resident, Tommy, who was an amateur jazz musician, recognized J.J. immediately. I presented

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my findings, and he asked what I thought was going on. I suggested that J.J. had a severe case of infectious hepatitis from something he ate and now had ascites, edema, and even encephalopathy that resulted from liver failure. Tommy walked over to the side of J.J.’s bed. “I love your music. I’m sorry to have to meet you this way, but I need to ask an important question.” “Go ahead. Fire away.” “Do you ever shoot up smack?” “Yes, doc. I do. I don’t have a bad habit . . . more social.” “Where do you inject?” “Different places, but I avoid my arms so that when people see my arms, they don’t immediately treat me like a junkie.” “Do you share?” “Sure do . . . it’s a social thing.” “We need to get you well so you can keep on making wonderful music, but it will mean no more smack.” “You got it. Just make me well. ‘Cause beside the music, I got a little girl at home. Can her mama and my girl visit me?” “Just her mama.” J.J. grew worse every day. So much fluid accumulated in his abdomen that it pushed up his diaphragm, which interfered with his breathing. To help J.J.’s breathing, I inserted a long needle into his abdominal cavity and removed much of the fluid. This gave him some temporary relief, and he was able to breath more easily. Despite our efforts to manage his complications, each day he grew more lethargic and finally lapsed into a coma. We continued to hope that his immune system would start killing the virus but instead his liver functions went steadily downhill. Three days after J.J. went into coma, he stopped breathing. This happened while we were making rounds on the other side of the ward. Tommy was the first to see him. “J.J.’s arrested!” he yelled. “Get the crash cart.”

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Tommy started to run to J.J.’s bed. I ran after him and caught his arm. “Ken, we need to resuscitate him before he dies.” “Tommy, he died already. Giving him mouth-to-mouth and cardiac message won’t bring his liver back and it could give you the same infection.” “Please let me go. We have to try. No one dies on my service. No one.” As I was holding him, I flashed back to a time that I visited Atlantic City. My brother was going to the University of Pennsylvania and dating a girl named Renee, whose family had a house in Atlantic City. She invited him to stay at her house and, although I am certain that this was not part of her plan, he brought along his kid brother— me. That weekend, there was a tropical storm off Atlantic City. The waves were huge and almost reached the boardwalk. No one was on the beach, but many people were on the boardwalk watching the waves. I noticed someone on a surfboard out in the giant waves. A side-tow was carrying the surfer toward a concrete pier. Between the waves, there was room for him to slip under the pier, but if a wave caught him, it would smash him into the pier. He was furiously paddling to avoid being carried to the pier but was unsuccessful. Standing near me was a lifeguard. A teenage girl who was watching started to cry as the surfer approached the pier. She turned to the lifeguard. “Aren’t you going to get him?” The lifeguard shook his head and said, “No. I’m sorry. I hate to see anyone die out there, but one death is better than two.” I repeated this phrase to Tommy. “Let him go. One death is better than two.” Eventually, Tommy stopped trying to escape from my hold, and I let him go. He slowly walked over to the bed, looked down at J.J., and said in a voice cracking with remorse, “I’m sorry. I wish we could have done more.”

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I have always hated death. I thought that I hated death because I was raised as a nonobservant Jew and, thus, without the promise of an afterlife. To me, death was not the beginning of a journey to paradise but the end of everything. I never asked Tommy about his spiritual beliefs but knew that he was raised as a Catholic and that Cornell Medical School was the first non-Catholic school he had ever attended. When J.J. died, however, it was apparent that Tommy also hated death. I held him to stop him from catching hepatitis, but I really wanted to embrace him. We were on the same crusade.

12 Experience: It Was Just a Gesture December 1963

T

he state of New York required that a physician certify a person’s death. To do this, the physician had to fill out the death certificate. When someone died outside the hospital and it was really clear to the police or firefighters that the person was dead, rather than transport the person to the hospital, one of the interns or residents working in the emergency room would travel to where the body was located and certify the person as dead. The authorities on site could then transport the body directly to a morgue or the medical examiner. One day the police called us from a YWCA in midtown Manhattan and explained that they were with a young woman, a Doreen Stewart, who had been found dead in bed. Next to her bed they

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found an empty bottle of sleeping pills. Except for her name and that she had lived in Iowa before coming to New York, they knew little about Ms. Stewart. They asked if we could send up a doctor to pronounce her dead and to fill out the paperwork for the death certificate. Because we were not very busy, I had one of the Bellevue ambulances drive me up to the Y. The ambulances were converted small trucks. By today’s standards, they were poorly equipped—the interior consisted of old Army canvas stretchers strapped to the sides of the truck and some oxygen tanks with tubing and a mask. The Y was an old, unattractive building and had probably been built sometime during the Great Depression. As I approached the building, I noticed many young, attractive women milling around. I asked the driver why all these young women were here, and he explained that many young women who moved to New York to become actresses or dancers lived here until they found a job, an apartment, and a roommate. The rooms were very cheap, the neighborhood was safe, and it was the Y closest to the “Great White Way.” A police officer was waiting for us as we entered the lobby through the revolving door. “Are you the doc from Bellevue?” I nodded my head. “Okay. She’s on the fifth floor. Let’s take the elevator, and I’ll show you her room.” When the elevator door opened on the fifth floor, we got out, and the ambulance driver and I followed the police officer down the hallway. The hallway was narrow and had ugly exposed tubular fluorescent lighting. Although the lights made the hallway bright, the carpets were dark and stained. At the end of the hallway, the police officer knocked on a door, and a voice inside yelled, “Is that you, Tim?” The police officer yelled back, “Yes, Shawn. It’s me. Open the door. I have the doc with me.” The door opened to reveal a small room, about 8 feet wide by 12 feet long. There was no bathroom, and I remembered that when we’d walked down the hall, I had seen a door marked “Women’s

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Toilet” and another marked “Women’s Showers.” The small bedroom contained a brown metal dresser with a mirror attached to its top and a twin bed, placed against the opposite wall, with head- and footboards consisting of vertical iron bars that had been painted brown, perhaps to match the metal dresser. The only lighting was an overhead circular fluorescent light. There were no pictures on the walls, which were painted a light tan, and though the room had a small window, it looked out on another building that was directly behind the Y. On the bed there appeared to be a body that was covered with a sheet from head to toe. Shawn, the policeman who let us into the room, showed me the pill bottle, which was labeled “Doriden” (brand name for glutethimide) and included these directions: “Take one tablet one half-hour before sleep, as needed. Do not use this medicine with alcohol. Dispense 60 tablets.” The bottle was empty, and we, of course, did not know how many pills she’d taken before she killed herself. Shawn handed me a clipboard with a death certificate. He had already obtained her name and home address, probably from the front desk or from looking at her driver’s license, and had filled out much of the certificate, including her name, the approximate time of death, and the cause of death, which he had described as “Respiratory arrest secondary to overdose of sleeping pills.” He handed me the clipboard. “Doc, please sign right next to the X. Then we can call the mortuary to pick up the body and bring it to the Medical Examiner’s so that we all can get out of this depressing place.” After reading the death certificate, I told Shawn that since I had traveled all the way up here, I might as well examine the woman to make certain she was dead. “Doc, suit yourself.” I pulled down the sheets, and as I lifted her cotton nightgown to listen to her heart, my hand brushed her skin. It still felt warm. Perhaps she’d only recently died, I thought. To my surprise, however, I heard a very faint, slow heartbeat when I listened to her chest.

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I also heard some shallow respirations . . . and saw that her belly was a little swollen, as if she were four or five months pregnant. I told the ambulance driver that Ms. Stewart was alive. Her breathing was so shallow that I decided to give her mouth-to-mouth respirations. Fortunately, the ambulance driver had brought in a medical bag that included a breathing mask attached to a squeeze bag, and I used it to supplement her respirations. In 1963 there were no emergency medical technicians or paramedics, but some of the ambulance drivers had a lot of experience with emergencies. After we got Ms. Stewart’s skin pink again, the driver took her blood pressure and found it to be a little low (90/55). “I have some Levophed in the bag. Should we start an IV and give her some Levophed to raise her blood pressure and some Nalline to reverse the medication she took?” “No, I think her blood pressure is high enough. I don’t think her kidneys will shut down, and I think she’s getting adequate blood to her brain,” I replied. “I wish Nalline would work for the medicine she took, but it only works for opiates such as morphine and heroin. Please take out an IV needle, tubing, and a bottle of normal saline so that we can start an IV. The fluids and salt should raise her blood pressure.” I turned to the policemen who had prematurely pronounced Ms. Stewart dead. “Please do me a favor. Can you go down to the ambulance and get one of the stretchers so that we can carry her down and drive her to Bellevue?” He seemed relieved that he could do something to help. He brought up the stretcher and helped the ambulance driver carry her down while I continued to support her respirations with the air bag. By the time we got to the ambulance, carried her inside, and secured the stretcher to the ambulance, it was 5:00 PM and the streets of Manhattan were packed with traffic. I remained in the back with her, squeezing the breathing bag while holding the mask against her face. The driver got into the front of the ambulance and started the

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engine. I asked the two policemen who were standing by the back door of the ambulance if they could run interference to help get us through all the traffic. One of them said, “We’d be happy to try, but I’m not sure it would do much good even with our sirens and flashing lights.” The police closed the back door of the ambulance, and the ambulance driver turned on the siren and lights. He then pulled out into traffic. Although the police accompanied us with their siren and flashing lights, they were correct when they told us they would be of little use. What should have been about a 20-minute ride took us about 90 minutes. By the time we arrived at Bellevue, my forearms and hands were cramping from squeezing the bag. We unloaded Ms. Stewart on to a gurney and then ran with it to the EW. The EW nurses were waiting with an endotracheal tube, a laryngoscope, and a positive pressure (Bird) respirator ready to attach to the endotracheal tube. I had inserted the tube, checked to make certain it was in her trachea rather than her esophagus, then put her on the respirator. Doriden was infamous for having a very long half-life, and thus, Ms. Stewart remained on the respirator for several days. However, she was able to maintain her blood pressure, she had good urine output, and except for her drug-induced respiratory suppression and coma, medically she did very well. On the third day, she started making meaningful movements to painful stimuli. By the next day she had opened her eyes and gestured to the endotracheal tube. We removed the tube so that she could speak. I asked why she tried to commit suicide, and she responded that she did not want to live. “When you’re released from the hospital, will you try again?” Without even hesitating, she said, “Yes, definitely, but next time I won’t fail.” The nurses wanted her transferred out of the EW because she was stable and no longer needed intensive care, but I did not want her on our large ward, Ground B, because it did not have sufficient staff to closely watch a suicidal person. I asked the nurses if she

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could stay until she was seen by a psychiatrist and transferred to a secure psychiatry unit. They understood my concern. While we waited for a psychiatrist, I was able to get an obstetrician to see Ms. Stewart. With no sonograms at that time, all he could do was listen and feel. He thought that the mother was doing fine physically, and as far he could tell, the baby appeared not to have been injured by the Doriden overdose. He gave her an appointment to his clinic and suggested she take vitamins. Before he left, he asked if she had any questions. I thought she would ask if the overdose would harm the baby, but she simply thanked him for seeing her. Finally, the psychiatry consult saw her and arranged for her to be transferred to the psychiatric unit so that she could be treated for depression. At this time tricyclic antidepressants such as amitriptyline (Elavil) were the only available drug treatment for depression; it would be some time before the excellent selective serotonin reuptake inhibitors such as fluoxetine (Prozac) and sertraline (Zoloft) would be developed. Although the tricyclic antidepressants had side effects, such as dry mouth and weight gain, they were one of the greatest advances in the treatment of depression, especially in combination with psychotherapy. Unfortunately, both psychotherapy and the tricyclic antidepressants took several weeks to work, and for some people, they did not work at all. Those with severe depression who did not respond to these therapies could be treated with electroconvulsive therapy, which also had side effects, such as temporary memory loss, but was very effective. Two days after Ms. Stewart was transferred to the psychiatric unit, I visited her to see how she was doing. When I asked the nurse, Ms. Dugan, what room she was in, I was told she was discharged. I was appalled, and my face must have showed it because the nurse asked, “Why are you looking so angry?” “This young pregnant woman tried to commit suicide. Some of us in the medical building worked very hard to save her life. She couldn’t receive enough psychotherapy to alter her depression in just two days, and it takes more than two days for the drug to start working.”

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“The psychiatry residents who evaluated her when she was transferred here presented her to the attending physician. It was the attending’s opinion that she was just trying to get the boy who got her pregnant to marry her. She was hoping that her attempted suicide would make him feel guilty.” As I listened, I became more angry. “Who was the attending?” “Why do you want to know?” “Ms. Dugan, I was the intern who brought Ms. Stewart in from the Y. She had such a heavy dose of Doriden that the police thought she was dead. We had to give her artificial respiration and she was deeply comatose in the EW for several days. She was so deeply comatose that we had to put in an endotracheal tube and put her on a respirator. Does that sound like just a gesture? Did the attending know about this?” Ms. Dugan looked at the floor. “Doctor, please don’t get angry with me. I didn’t make the decision; Dr. Green did. I heard the resident present the case to him, and after Dr. Green spoke with Ms. Stewart, he decided the attempt was only a gesture. He insisted that she wanted only to alarm people, especially her boyfriend, but not to die. She didn’t know how much medicine to take without killing herself and took too much.” I paused and tried to count to ten but only got to two. “How does Dr. Green know she will not do it again?” “Dr. Heilman, please lower your voice. Dr. Green made a contract with her. She promised not to do anything unless she first spoke with him. We’ve had a lot of experience with these types of problems, and you do not. Dr. Green is an excellent psychiatrist.” “Is Dr. Green in the hospital? I really would like to speak with him.” “He’s not available now. I think it might be best to let matters rest or to write him a note.” I wrote a note explaining that I believed Ms. Stewart was at high risk of attempting suicide again and that I would feel much better if

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he could readmit her. Nurse Dugan promised that she would give him the note. As I walked back to the wards, two ambulance attendants were wheeling in a patient to whom they were giving artificial respirations. I immediately recognized her. It was Doreen Stewart. I ran over to her. Despite the artificial respirations, she looked terrible. I thought that maybe she had already died, but I felt a weak pulse. When we got to the EW, I intubated her and put her on a respirator. I checked her blood gases, which revealed that she was now getting enough oxygen. A few weeks before I saw Ms. Stewart, I had read Plum and Posner’s book Diagnosis of Stupor and Coma, which describes how to examine a comatose patient. During my examination of Ms. Stewart, her pupils did not respond to light and she did not move her eyes even when I injected cold water into her ears. She had no corneal reflex, and even after painful stimuli, she made no movements. Although these signs suggested that Ms. Stewart might be brain-dead, I was hoping that they were being induced by whatever medicine she’d taken this time. After we moved her into an EW bed, I asked the ambulance attendants if they’d found any medicine bottles in her room. “No, Doc. We looked all around but couldn’t find anything.” I thanked them for all their hard work. The older of the two men said, “She’s only a kid. I hope you can save her.” We could not save her because her brain had been deprived of oxygen for too long. Her brain cells were dead, and her brain was swollen and herniated. After we declared her dead, we removed her from the respirator. The nurses had covered her head with sheets and pulled a curtain around her bed. After filling out Ms. Stewart’s death certificate, I asked them if Ms. Stewart could remain there until I brought someone to see her. Since they were not busy, they agreed. I went to the phone and had Dr. Green paged to the EW. In about 15 minutes a man in a neatly pressed long white coat appeared. He looked about

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40 years old and had a neatly trimmed goatee that was just beginning to turn gray. I knew most of the doctors who worked in the EW, but because I had never seen him before, I assumed it was Dr. Green. I walked over to him and said, “Dr. Green, my name is Ken Heilman, and I was the person who paged you.” He looked at me with a puzzled expression. “There’s no reason to drag me down here. I got your note, and the nurse told me about your conversation.” I walked over to the bed where Ms. Stewart’s dead body laid and beckoned him to join me. “Come here, I want to show you something.” I pulled the sheets from her face to see if he recognized her. He did, but he did not say anything. “Just a gesture?” I asked. I then walked away to see my next patient.

13 Cynicism: Cough It Up Again January 14, 1964

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s a medical intern, I had to work in the Emergency Room (ER) for one month. The ER was very much like emergency departments in contemporary hospitals. Most of the patients were walk-ins, and many of the acutely ill patients were admitted directly to the Emergency Ward (EW). Although New York City does not get as cold as Boston or Minneapolis during the winter, it gets cold enough and everything is gray: The sky stays gray, the snow turns gray a few hours after falling, and when it warms up, the gray snow turns to gray slush. The salt used to melt the snow and ice on the streets and sidewalks turns the cars gray. Every building seemed gray, and everyone seemed to wear gray winter suits—except for the homeless, who wore anything warm they could find. Most of the homeless were

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addicted to drugs, alcohol probably being the most common. Because of their addictions and poor health habits, older homeless people often have chronic diseases but rarely see physicians or take the medicines that are prescribed for them. It sometimes seemed that the homeless alcoholics were trying to commit slow suicide. The alcohol and other drugs made the suicide less painful, but when it became cold and gray, with sleet and slush, being homeless was unbearable. What better place to go than Bellevue? If you were poor, the care was free, and the hospital was warm, clean, and served decent food. One of the first walk-ins I saw during my month in the ER was a man about 60 years old. He was coughing violently and holding a cup into which he would spit after each cough. When it was his turn to speak with me, it was apparent from his dirty clothing, matted hair, and body odor that he was living on the streets. I asked how I could help. He told me that he had a terrible cough and was coughing up blood. He showed me the cup with bloody sputum in it. I asked how long he had been spitting up blood, and he said a few days. From his yellow-stained hands, it was apparent that he smoked. I asked if he had any chills or fever: no. I asked if he had chest pains, and he took a deep breath: no. I asked if he had lost any weight; he did not know. I asked him to take off his jacket and shirts. After he took off his four shirts, I listened to his lungs, and for the most part, they sounded clear. I wanted to see an X-ray of his chest, but the hospital had a rule that lab tests could not be ordered in the ER; the decision whether to admit the patient was to be based on clinical impressions alone. In some ways, this policy made sense. With or without an X-ray and whether or not it was normal, I was going to have to admit him because he was coughing up blood. All decisions by interns to admit a patient had to be approved by the senior resident who supervised the EW. I told the senior resident that I would need to admit my patient and showed him the sputum. He dumped it out in the sink. While my mother told me never to end sentences with prepositions,

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I asked him, “What did you do that for? I was going to culture it for bacteria and stain it for TB.” “It’s probably not his sputum. He probably got it from one of his friends because he wants to stay warm and get some good food.” The senior resident tossed the empty cup in the garbage, got a new cup, and walked over to the patient. “Sir, I’m not sure where that spit came from, and besides, we’d like some fresh spit. Please sit in the waiting room. If you continue to have blood in your spit, we’ll admit you.” The patient took the new cup, got dressed, walked out to the waiting room, and tried to fill the cup with bloody sputum. When I visited him several hours later, I asked to see the cup. It contained clear liquid that looked like saliva. The man looked up at me. “How did he know it wasn’t mine?” “He’s been here for several years and knows a lot more than I do.” I told him where there was a men’s shelter that would give him a clean bed and some good food. I gave him a dollar for bus fare. He thanked me and left the hospital. When we were completing our shift, I approached the senior resident. “How did you know that the bloody sputum wasn’t that man’s?” “Did you ever read the short stories of O’Henry?” “Only ‘The Gift of the Magi.’ ” “O’Henry’s real name was William S. Porter. He was often a patient here. He was a New York bum who wrote stories for the New York Herald and magazines so that he could make some money to support his alcohol habit. During the winter, he didn’t have enough money for both his alcohol and an apartment, so he tried to get in here. He used all kinds of ploys and was often successful. If he was not successful in getting into Bellevue, he would try to get arrested because the jails were also warm. I think he even wrote a story about this. I’m not sure he used the bloody sputum ploy, but many others have. It would be nice if we could admit them all, but that would leave no beds for the people who we can really help.”

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During this year I learned that there were many people who sought medical care but who did not need the type of help we offered. They did it to avoid imprisonment, to increase claims of damage for litigation, to get paid while not working, and just to receive some attention. These people also need help, but I still find it difficult to help them.

14 Purity: Freedom from the Body January 1964

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oah Block was one of my co-interns. Before entering a general surgery residency, he wanted to take a mixed medical–surgical internship because he felt the six months of internal medicine would better prepare him to take care of his patients’ medical problems. He spent his first six months on our medical service and was now on the surgical service. This particular month we were both assigned to the emergency room. One evening an ambulance pulled up to the emergency room, and a pretty but unkempt woman in her late teens or early twenties stepped out of the ambulance. She had long, brown, wavy hair and, although thin, a nice figure. Her arm was in a sling. One of the ambulance attendants walked inside with her and showed her where to

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sit until a doctor could see her. Noah walked out of one of the examining rooms over to this woman. “I guess you’re next. Follow me.” The young woman followed him into the examining room, where he asked her to take a seat on the examining table. “My name is Dr. Block. What’s your problem?” The woman looked down at her arm in the sling. Noah gently removed the sling to reveal a bone sticking out of her skin. He was surprised because there wasn’t much blood on the sling and she appeared so calm. This fracture is usually very painful, but she did not seem to be in pain. “How did this happen?” he asked. “I jumped out of a window.” “Were you trying to commit suicide?” The woman was silent for a few moments while Noah prepared to irrigate her wound, then answered, “No, I was trying to fly. I found out that I couldn’t fly, at least with my body.” Noah tried not to laugh or smile but could not fully restrain himself. “Do you always try to fly?” The woman stared back at him and, with an insincere smile, replied, “No, doctor, I’m not always crazy. . . . Before I tried to fly, I took some acid.” “Okay, let’s get your arm fixed. The nurse will take you upstairs to one of our operating rooms. An anesthesiologist will put you under general anesthesia. Do you have any health problems or take any drugs?” “Sure, I told you I took LSD. Sometimes I smoke pot, shoot up smack, and sniff cocaine, but I’m not a drinker.” “Thanks for all the information. I just mean medications.” “No, in spite of using drugs and making money by selling my body, I’m pretty healthy.” Noah then performed a rapid examination of her heart, lungs, and abdomen, after which the nurse took her up to the operating room. They put her under general anesthesia, reduced the fractured

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humerus, and stabilized it with a metal plate and screws. They closed the wounds, and after a short stay in the recovery room, she was sent back to the ward. When she was fully alert, Noah came to her bedside. “How do you feel?” “Okay. Can I go home now?” “No, I want you to stay here for a day or two, to make certain there’s no infection. Because you had a compound fracture, we needed to use steel to fix your arm, and we’re worried about infection. We put you on an antibiotic, but we still want to watch you for a few days.” “You’re the doctor.” Her wound looked good, and she never developed any signs of infection. One day after rounds, Noah came back to her bed. “Do you mind if I speak with you? It’s not about the wound.” “No, go ahead. Do your duty.” He sat down in the chair by her bed. “I might as well come right out with it. The drugs you’re using and the way you’re living are destroying your life.” “Why do you think that?” “Look at what happened to you—and the drugs you’re taking are poison. They’re poisoning your body, your mind, and your morals.” The young woman laughed at Noah. “Look, doctor, I might be an addict and a whore, but it’s the closest I can get to purity.” Noah angrily stood up from the chair. “Purity? What’s pure about being a whore? I came here to talk with you sincerely. I’m concerned about you, but I guess it’s impossible to talk with you people.” “If you want to have a dialog with me, take off your preacher’s garb, put away your hemlock, sit down, and listen.” As he sat down again, he said, “I’ll try, but I don’t know what makes people like you do the things they do.” “I can’t speak for other people. I suspect there are many reasons why people use drugs, but for me, it’s a desire for purity. The body . . .” Noah started to get up again. “Please sit down,” she said, “and let me finish. The body is an endless source of trouble. It needs food

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and water, gets diseases, and fills us with lusts, hates, and fears. Where do factions, fighting, and wars come from? The lusts of the body. If we’re going to have true knowledge, we must quit the body. In the old days, that was hard. Gautama Buddha tried to quit the body by fasting and meditating, but he failed. Now we have drugs. You might call my way of living ‘chemical asceticism.’ I’ll submit my body to anything, just to quit it. Purity is not an intact hymen. Purity is freedom from slavery to the body.” After she finished, Noah silently got up and walked to the doctor’s room to make a call. “Hello, Jim, this is Noah. I have a psychotic addict here. I’d like to transfer her to psychiatry. Can you come to see her?” Jim met with the woman shortly after Noah called him. After speaking with her for about a half-hour, Jim reported back to Noah that, although she did use drugs, there was no evidence that she was psychotic and, thus, he could not involuntarily hospitalize her in the psychiatric unit. Although he informed her of several means by which use of drugs could be treated, she showed no interest and walked out of the hospital against medical advice. Noah, like me, had trouble understanding why this woman performed acts that appeared so self-destructive. At that time, neither of us knew much about Eastern religions. Several religions have as their goal “other-worldliness,” and many use asceticism as a means to achieve it. People who practice asceticism abstain from worldly pleasures because they arise from experiences of the body rather than of the mind. In many ways, the drug culture that people like Timothy Leary were promoting in the 1960s was a form of Eastern religious asceticism that relied on drugs, rather than meditation or prayer, for achieving other-worldliness. Several decades after we saw this woman, academic physicians became interested in their profession’s difficulties in dealing with psychosocial problems and began to research the reasons why. The articles they published suggest that physicians and surgeons, such as

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Jim and myself, were trained primarily to deal with “organic” problems and diseases and not with psychosocial problems. Noah’s patient’s beliefs were religious in nature, and there are many religions that espouse behaviors that are not always in the best medical interest to the individuals who practice them. The problem we had in understanding the woman appears to persist. In a recent article, Astin and colleagues1 studied this issue and concluded, Despite evidence that psychosocial issues play an important role in health outcomes, students, residents, and practicing physicians reported that methods to deal with these issues are frequently given inadequate attention in medical training, and many physicians feel ill-equipped to deal with these issues. In addition, environmental factors, including lack of time, insufficient monetary incentives, and a larger cultural ethos that favors the “quick-fix” over the more difficult task of examining the role of psychosocial factors, appear to serve as significant barriers to medicine’s more fully embracing the biopsychosocial model.

1. Astin JA, Goddard T, Forys K. Barriers to the integration of mind–body medicine: perceptions of physicians, residents and medical students. Explore J Sci Healing 2005;1:278–83.

15 Altruism February 1964

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r. Julius Cohen was a 67-year-old attorney who was being admitted to Memorial Sloan-Kettering Hospital for experimental chemotherapy. His diagnosis was non-Hodgkin’s lymphoma. Whenever doctors hear that they will be caring for an attorney, a little chill runs down their spine as they wonder how many of the good physicians they know might have been sued by their patient. Once I saw this man, however, I had no worry. He emitted an aura of kindness, and shortly after I shook his hand, I wondered if he had the ability to read my mind because he said, “Dr. Heilman, please don’t be concerned about me being an attorney. My practice was limited to tax and corporate law.” His medical history was similar to that of many of the people I had admitted with this disease: loss of energy, night sweats, and

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detection of a lump. After his local physicians biopsied the lump, they gave him the bad news. At the time, a diagnosis of lymphoma was a death sentence. The only treatments available were surgical removal of the enlarged node, followed by radiation. Although these treatments prolonged life for a few weeks or months, it was rare for patients to live for five years. The attorney had been admitted to Memorial Sloan-Kettering because he agreed to be a subject for a new investigational drug that Dr. David Karnofsky was testing. Except for his lymphoma, which was treated with removal of the cancerous lymph node and radiation, his history was negative. He had no history of other diseases and had no allergies. He was neither a smoker nor a heavy drinker. But for some skin redness in the area where he had received the radiation, his examination was entirely normal. After I finished the examination, he asked me to tell him about the new medicine. I explained that, as an intern, my job was to look after his general health and that Dr. Karnofsky’s oncology fellow would speak with him about the experimental medicine. Institutional review boards did not yet exist during the 1960s, and it was up to individual researchers to insure that their research did not endanger the health or welfare of patients, to inform patients of possible risk, and to obtain their consent. Not all the clinical research at Memorial followed these rules, but Dr. Karnofsky and his team of chemotherapy investigators did. Thus, I really wanted the oncology fellow to speak with Mr. Cohen. Mr. Cohen, however, wanted to find out how I felt about the experimental therapy. “The fellow has a vested interest in having me participate, but you do not.” “The fellow has access to the research data, but I only have my personal experiences and what I’ve heard from the other residents and interns.” “I’ll speak with the oncology fellow, but please share your experiences with me.” “Mr. Cohen, I’m not sure you want to hear about them.”

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“Why not?” “Because you know that the radiation alone won’t cure you, you hope that taking the experimental medicine will offer you a cure. I’m not sure that I want to be the one who dashes those hopes. My job should be inviting you to health.” “Dr. Heilman, it’s too late now.” “What do you mean too late now? If you decide that you don’t want the treatment, they won’t give it to you.” “No, I didn’t mean that. I mean that it’s clear to me that you have negative feelings about the treatment, and I’d really like for you to share them with me. But I promise that I’ll listen to the fellow when he comes to visit.” “You really want to hear?” “Yes, I do.” “Well, first I should tell you that this medication is derived from nitrogen mustard. That was the gas used during World War I to kill soldiers in the trenches. To give you an idea of how toxic it is, when I inject it into your vein, I’ll have to wear a heavy plastic apron and gloves. The medicine is so strong that it would burn my skin if I got any on me, yet I’ll be injecting it into your vein.” “Does it hurt when you inject it?” “No, the injection doesn’t seem to hurt much, but some of the side effects trouble me.” “What do you mean?” “Almost all the patients who’ve received the medicine have lost their hair and . . .” Mr. Cohen stroked his hand over his bald head. “I don’t think I have much to lose there.” “Many patients develop sores in their mouth. But the most troubling problem is what the medicine does to your bone marrow. It often causes your bone marrow to stop making white blood cells, red blood cells, and the blood platelets that prevent people from bleeding.”

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“Is there anything that can be done about that?” “We’ll monitor your blood closely while we give you the medicine and, of course, if it gets too bad, we’ll stop the medicine.” “So what’s the problem?” “In some people the bone marrow doesn’t recover, and when the white blood cell count gets too low, as it does in nearly everyone we’ve treated, you can get terrible infections. And if the platelets get too low, you can hemorrhage.” “What do you do then?” “We try to treat the infections with antibiotics, and if there’s a hemorrhage, we try to stop it by giving the patient transfusions of platelets. Depending where the hemorrhage is located, we might also try to remove the blood from this area, but this often means surgery after the platelet transfusions.” “Is that all?” “No, but the oncology fellow will go over even more complications. It might be worth taking all these risks if there was a chance of cure, but so far none of the patients with your disease has been cured with this medicine.” “Has the treatment prolonged any of these patient’s lives?” “They haven’t performed the final analyses, so we really don’t know, but from what I’ve heard and seen, I doubt there will be a major effect.” “Are you trying to tell me not to participate in this study?” “Mr. Cohen, based on my experience, the side effects of the medicine seem to outweigh the potential positive treatment effects. I suspect that the experimental oncology service wouldn’t be happy with the advice I’m giving you, but you’re my patient, you wanted to know my opinion, and my first obligation is to you. Mr. Cohen, you have some good time left. Why not spend this good time with your family?” “I really appreciate your honesty and concern. Although I have very high regard for you, I’m not going to follow your advice. I want

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you to understand that I’m volunteering for this research not because I expect a cure but because it might help make this disease meaningful to me.” “I’m afraid I don’t understand. How can any disease be meaningful? As a doctor I study diseases, their mechanisms, and their treatments. We understand the causes and mechanisms of some diseases, but none have any meaning.” “Do you believe disease is the work of the devil?” “No, Mr. Cohen, I don’t believe in the devil, and I’m not sure I should be talking to you about this. . . . I’m not a rabbi, minister, or priest . . . just a doctor in training.” “But Dr. Heilman, this is important for me to talk about, and I really like talking with you.” “We have several clergymen on call who are trained to speak with patients. Do you want me to call one of them?” “No.” “We also have counselors. Would you rather speak with one of them?” “No, I’d like to speak with you. You take care of all kinds of sick people, and I want you to share some of your thoughts. For example, if you don’t believe in the devil, why do bad things, like lymphoma, happen to people like me?” “I’m not sure I know, but I think history has told us that if we just blame diseases on a supranatural power, like the devil, then we might not attempt to learn why bad things happen and how we might prevent or treat them.” “Can you give me an example?” “Sure. During the Middle Ages there were large epidemics of bubonic plague. People thought it was the work of the devil, and they thought the devil had gained power because they were sinners. Thus, thousands of them flagellated themselves and each other for penance when they should have been trying to learn what was causing the plague. Instead of beating themselves, they should have been killing the rats that carried the infected fleas.”

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“So evil is a lack of knowledge.” “Yes, when you understand why something is happening and have the tools to correct it, there’s no evil, and if there’s no evil, there can be no devil.” “Dr. Heilman, you got it.” “Got what?” “Now you understand why I want to participate in this research. So far, I haven’t felt any physical pain with this disease; but knowing that I’m going to die brings mental pain, and altruism reduces this mental suffering. I want to help people learn about this disease. Even if this treatment isn’t a cure and even if this path only leads to a dead end, it’s progress.” “Mr. Cohen, you’re a special man.” “Not really. I believe it was Freud who said that there’s no true altruistic act. Knowing that your suffering has no meaning only enhances your agony, but knowing that something good can come from something bad brings relief. I want relief.” I excused myself because I had other patients who needed attention. The following day the oncology fellow spoke with Mr. Cohen and formally got his consent. A few minutes later, he asked me to give Mr. Cohen his first treatment. I put on my gloves and apron. I got a syringe, filled it with the experimental medicine, and went into Mr. Cohen’s room. He smiled and said, “I am ready.” I put a tourniquet around his arm so that his veins would swell, and when I found a good, large vein, I inserted the large needle into it. When I saw the blood flow back into the syringe, I knew I was in the vein. I released the tourniquet and slowly injected the experimental medicine into Mr. Cohen. Mr. Cohen smiled at me, and after I finished, he thanked me both for the injection and for speaking with him yesterday evening. “My explaining to you why I’m doing this helped me make things clear in my own mind.” While Mr. Cohen lost some of his hair and had a drop in his white blood cell count, he never got into serious trouble. When he finished treatment, he went home. I never saw him again, and several

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months later, when I asked the oncology fellow how he was doing, I was sad to learn that Mr. Cohen had died. I thought a lot about him that day and hoped that if I had been in his position, I would have done the same thing. I thanked Mr. Cohen. In the 35 years I’ve conducted medical research with patients, I’ve learned that Mr. Cohen is not unusual. While he was unusually articulate about his reasons for undergoing the experimental treatment, his motivation was no different from that of many other patients who volunteer despite knowing that this research will not help them, but who often tell me: “It’s still comforting to know that this might help someone else.”

16 Ethical Boundaries: Iatrogenic Melanoma February 1964

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n the 40 years since I completed my internship there have been wonderful advances in the treatment of some forms of cancer, such as Hodgkin’s disease. In addition, we have learned much about reducing risk factors and developed means of early detection. Still, many forms of cancer remain against which we have made little progress in prevention or treatment. We do know, however, that if we can discover the cause of a cancer, we will have a greater chance of finding the means to prevent and treat it. When I was in training, one of the most popular theories about the pathogenesis of cancer was that it arose from a defect in the immune system. A major proponent of the theory was Dr. Alfred Northland, one of the attending physicians at Memorial Sloan-Kettering.

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According to Dr. Northland, cells are being born all the time. Sometimes, when a cell divides, an error occurs that affects the new cell’s genetic makeup. As a result, instead of performing the same function as the parent cell, the new cell reproduces itself very rapidly. Because the new cell’s genetic makeup has changed, the proteins that it manufactures are altered. Normally, the person’s immune system would detect the aberrant protein and destroy this cell. This immune response might prevent our bodies from ever developing cancer, but if the immune system is not working properly, the abnormal cells continue to produce more abnormal cells, which in turn might develop into cancer. Memorial Hospital and the Sloan-Kettering Institute were and are private, voluntary institutions. Thus, patients either paid “out of pocket” or with health insurance. To help care for indigent patients with cancer, New York City built a public hospital named James Ewing that connected to Memorial Hospital. The medical interns and residents at Memorial were also responsible for the patients admitted to this city hospital. One afternoon, Maria Rodriguez was admitted to James Ewing. She was an attractive 38-year-old woman who was jaundiced. Her ovaries had been removed a little over a year ago after she was diagnosed with ovarian cancer. Her oncologist, Dr. Northland, was worried that the jaundice signaled the spread of the cancer to her liver. Therefore, he admitted her for a needle biopsy of her liver. I examined Ms. Rodriguez, and in addition to being jaundiced, her liver was enlarged and tender; everything else appeared normal. Dr. Northland planned to do the liver biopsy just with local anesthesia and had scheduled it for the day after her admission. However, Ms. Rodriguez appeared so nervous that Dr. Northland became concerned that she would move during the biopsy and so decided instead to sedate her heavily. The biopsy itself was uneventful. The pathology report revealed that the ovarian cancer had metastasized to Ms. Rodriguez’s liver. I was in the room when Dr. Northland told her this terrible news.

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She asked what he planned to do. He explained that there was not much that could be done—there was no successful chemotherapy, and although in some trials the pituitary gland was removed so that it would not release the hormones that stimulate ovarian tissue, the procedure had no effect on survival. Dr. Northland promised that he would always give her enough pain medication so that she would not suffer, then asked her to come to his office in a week. By now her eyes were full of tears, but she was trying to control her emotions because she wanted to ask him more questions. “How long do I have?” He thought for a few moments and said, “I’m not sure. Everyone is different.” His gentle and caring demeanor impressed me. “Who is going to take care of my two boys? They’re so young.” “Ms. Rodriguez, you’re not going to die tomorrow. Also, I’ve met your husband. He seems very nice and very caring.” “He is, and he’s a wonderful father, but he has to work.” “What about your parents?” “They still live in Puerto Rico.” “Maybe they can come here.” “No, Doctor. They’re very old.” “I’ll ask the social worker to come up and speak with you. I’m sure something can be worked out. I want you to stay here tonight so that we can watch you and make certain there’s no bleeding at the biopsy sight. But if everything goes well, you can go home tomorrow. Please tell your husband to pick you up at about ten in the morning.” She was able to muster a little smile and said, “Thank you. Dr. Northland. You’ve been wonderful.” The next day before rounds, I checked Ms. Rodriguez’s dressing. It looked like it was ready to fall off, so I removed it. I saw something that I did not expect. Her wound from the liver biopsy looked fine, but a few centimeters to the right was a little black circle with dried blood around it. The black circle looked like a dark mole, but I did not understand why there was blood around it. I worried that it was

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a melanoma. I remembered that I had examined the area and could not understand why I had not seen it before. I felt awful that I had missed this. I considered getting a dermatology consultation, but because Dr. Northland wanted Ms. Rodriguez discharged today, I thought I would first mention it to him during rounds. As we approached Ms. Rodriguez’s room, Dr. Northland asked how she did after he told her the results of the biopsy. I related that she’d wept most of the evening and I’d given her chloral hydrate to help her sleep. “Ken, maybe you should order some Miltown for her.” “I’ll write her a prescription before she leaves, but I wanted to tell you what I found when I changed her dressing this morning.” “Why did you change her dressing? The same dressing is supposed to stay on for two days.” “It was ready to fall off, and I wanted her to have a good dressing before she went home. Anyway, a few centimeters to the right of the biopsy, she has about a half-centimeter black circle that has blood all around it and looks to me like a melanoma. Before she goes home, I’d like to have dermatology look at it to see if it needs to be removed.” Dr. Northland thought for a few moments, then sighed deeply. “Ken, you know it won’t make a difference. She’s going to die from her ovarian cancer.” “I know, but how we do know that the cancer in her liver is ovarian and not melanoma?” “Because the tissue we removed from the liver did not look like melanoma.” Ms. Rodriguez was discharged that day. She went home and spent several months with her family before dying. Her husband had the funeral home bring the body back to Memorial for an autopsy. Several days later the results were put in my mailbox. The report stated that she had ovarian cancer that had spread to many areas of her body including her liver. At the end of the report there was a section called “Other Conditions.” Here, it was mentioned that

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there was a small melanoma in the same area where I had seen that black circle. The next month we had a new attending physician, Dr. Phillip Epstein. He asked how we enjoyed working with Dr. Northland. We told him that he seemed to be an excellent physician and was very kind to his patients, always taking time to speak with them. Dr. Epstein asked if Dr. Northland told us about his research. My co-intern and I shook our heads no. Epstein described it. “He’s shown in rats that if an animal does not have cancer and receives a transplant that contains cancer cells from another animal, the rat’s immune system kills the cancer cells. In contrast, if the rat does have cancer, the transplanted cancer cells will live and reproduce. The reason these new cancer cells remain alive and reproduce is because the rat with cancer has an impaired immune system.” As Dr. Epstein was explaining the importance of this research, I started to think about Ms. Rodriguez. Could it be that the melanoma I found when changing her dressing was inserted into her skin by Dr. Northland when he performed the liver biopsy? Could he now be testing humans to learn if they responded like his rats? Had he wanted to learn if the melanoma cells from another person would live in Ms. Rodriguez because she had an impaired immune system? These ideas seemed too far-fetched, and I tried to put them out of my mind. About two weeks later, the interns and residents attended a conference on Dr. Northland’s theories about the role of the immune system in cancer. Afterward, several us went to the cafeteria and over lunch talked about Dr. Northland. A resident, Jim Sergeant, asked, “I wonder if he’s also doing this research on our patients?” Jim’s comment brought back thoughts about Ms. Rodriguez. “Jim, why do you ask?” “Several months ago,” Jim replied, “I had a patient who went for a biopsy. I found what looked like a melanoma on her skin near the biopsy sight.”

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My jaw dropped. “I had a patient with an almost identical story. I thought about the possibility that Dr. Northland was experimenting on patients but tried to put it out of my head—until now. Your story is almost exactly like mine. I bet he is transplanting melanoma. Do you think we should speak with Dr. Northland about this?” “No, we should speak to the chief of medicine, Dr. Dawson. Let’s go upstairs now and see if we can speak with him.” “Jim, we should give Northland a chance to explain.” “No. I’m going up now. If you feel bad about this, let me do the talking.” Dr. Dawson was not in his office, so we made an appointment with his secretary. When we finally spoke with him, he showed some concern but also explained that patients with one form of cancer often develop a second one and what we observed was probably a coincidence. Jim and I were not entirely convinced by the coincidence argument and recommended that Dr. Dawson investigate. About two weeks later Dr. Dawson called us into his office. He had spoken with Dr. Northland, who had admitted that he was transplanting melanoma cells into people with terminal cancer as well as into normal people to see if those with cancer would develop melanoma and those without would reject the transplant. Although we suspected that he was performing these transplants, we were still amazed when our suspicions were confirmed. As a result of legislation during the 1970s, every hospital now has an institutional review board. Before anyone in the hospital can do research, they have to submit the research protocol to this board. Included in the protocol is an example of the informed consent form that will be given to potential experimental subjects. It describes the possible benefits and risks of the experiment and states that by signing the form, the subject indicates that he or she understands the experiment, its rewards, and its risks and is participating voluntarily. When Dr. Northland was conducting his research, however, there were no institutional review boards. Although some hospitals attempted

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to monitor research on human subjects, not all hospitals did. Instead, they assumed that their physicians were following the Hippocratic oath, which states, “I will follow that system or regimen which, according to my ability and judgment, I consider for the benefit of my patients and abstain from whatever is deleterious and mischievous. I will give no deadly medicine to any one if asked, nor suggest any such counsel. . . .” Transplanting melanoma cells was certainly a violation of this standard. In response to our complaint, Dr. Dawson asked Dr. Northland to stop the research and planned to bring the matter before the hospital board so that it could consider revoking his privileges. He told us that Dr. Northland’s unethical research was not limited to Memorial but included Long Island Jewish Hospital, where he also had privileges. Hospital officials there discovered that Dr. Northland was secretly intravenously injecting malignant melanoma cells into both his patients with cancer and those without it. The hospital instructed him to stop the research immediately, withdrew his practice privileges, and informed the New York State Board of Medical Examiners, which withdrew his license to practice medicine. This news relieved us. At the same time, some of the ethical dilemmas raised by Dr. Northland’s research remained a source of conversation that we pursued during lunch and dinner. For example, Walter, one of the residents, asked whether we thought it was ethical to run a controlled study using a placebo. Another resident, Tom, responded that although patients are informed they might receive a placebo, most people with serious disease participate in studies in the hope that they will receive the active medicine and become better. He felt that controlled studies are unethical because while there is explicit honesty, there is also an implicit seduction. Several of us, including myself, were very influenced by Arrowsmith, a novel by Sinclair Lewis. The novel relates the story of young Dr. Martin Arrowsmith, who is testing a new medicine to treat a disease that is causing an epidemic. Although his mentor, Dr. Max Gottlieb,

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explains how important it is to do a controlled study, after the epidemic claims Arrowsmith’s wife, he feels compelled to treat everyone at risk for this disease with the active medicine. All medicines have side effects, and some can make a disease worse or cause another disease. The only way to learn whether a medicine works is to do a controlled study. Thus, as Gottlieb expressed it, Arrowsmith’s compassion and empathy might have caused unnecessary suffering and death. Two years after these discussions with my fellow house officers at Memorial Sloan-Kettering, I joined the Air Force and was sent to Izmir, Turkey, to be chief of medicine of a 75-bed NATO Hospital. Rabies was endemic in Turkey, and many children developed it following bites from stray dogs or scratches from stray cats. Rabies was feared by the community and health-care workers alike because it is almost universally a fatal disease. When evaluating children who might have been exposed to rabies, I tried to follow the guidelines of the World Health Organization; but when I attempted to learn how these guidelines were developed, it brought back memories of Arrowsmith and Gottlieb. Louis Pasteur was the French investigator who was primarily responsible for the germ theory. He also developed a vaccine to prevent rabies. Pasteur infected rabbits with saliva from rabid dogs. He killed the rabbits so that he could cut out and crush their spinal cords. To weaken the virulent rabies virus, Pasteur allowed the infected spinal cords to age. On July 6, 1885, shortly after Pasteur developed the rabies vaccine but before its efficacy in humans had been tested, a distressed mother brought her nine-year old son, Joseph Meister, to see Pasteur. The child had been bitten severely in the face by a rabid animal. If untreated, he would likely develop rabies. Because rabies is almost always a fatal disease, Pasteur and his colleagues thought that the child had little to lose and everything to gain by getting vaccinated. Thus, they vaccinated him, and the child survived. Because of its initial

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success and the great fear of rabies, the vaccine never underwent a fully controlled trial. When Pasteur and his colleagues vaccinated people with the altered virus, they inadvertently injected some of the rabbits’ central nervous system tissue. In addition to making antibodies against the rabies virus, some of the vaccine recipients made antibodies to the rabbits’ neural tissue. These antibodies can attack a person’s brain and cause autoimmune encephalitis, a severe autoimmune disease of the brain, which can disable and even kill. Because it’s rare for the animal that bit a person to be caught so that it can be tested for rabies, physicians often did not know whether bite victims were at risk of developing rabies. If the animal was not rabid, treating the person with the vaccine might cause severe brain disease. Still, many people were treated with this vaccine because they and their physicians feared rabies more than the encephalitis, despite the fact that those bitten by rabid animals and not vaccinated have less than a 10% chance of developing rabies. Because no controlled trials were performed, it is possible that Pasteur’s rabies vaccine caused more death and disability than would have occurred if no one had been treated with this vaccine. These were not the only problems with the vaccine. It took many daily injections over several weeks before a person developed adequate antibodies to kill the rabies virus. If these viruses entered the nervous system before the antibodies could reach and destroy them, the vaccine would be ineffective. Thus, a treatment that could kill the virus before it got into the nervous system was needed. From the nineteenth century it has been known that infection in humans could be controlled by passive immunity, using the serum from an animal or human who was infected and whose serum now contains disease-fighting antibodies. To prevent rabies, animals such as horses were infected with rabies virus, which triggered the development of antibodies, and the animal’s serum was then given to people exposed to the virus so that the animal’s antibodies would kill the virus before it got into the nervous system.

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More than 40 years ago, several investigators began a controlled trial to learn the safest means of preventing rabies in people who had been bitten by rabid animals. The subjects were treated with immune animal serum, the altered virus, nothing, or both. The study was stopped because of concerns that this type of controlled study was unethical. However, the preliminary data seemed to indicate that the animal immune serum was the most successful treatment and the vaccine had little or no influence on the patients’ outcome. If the rabies vaccine is given before exposure, it might prevent a person from developing the virus if bitten by a rabid animal, but it is unclear whether anyone treated with Pasteur’s original rabies vaccine ever benefited, thus underscoring the importance of Max Gottlieb’s observation that if you want to help the most people, you need to do a controlled trial. Today Gottlieb’s insight is referred to as “evidencebased medicine.” Jimmy, another resident who participated in our discussions, was not happy with the idea that the efficacy of all medical treatments required a controlled trial. He suggested that an in-depth understanding of a disease’s natural history should enable researchers to observe whether the treatment has altered its usual progression and do away with the need for placebos. Several of us disagreed because of what is known as the “placebo effect.” For example, when suffering from an attack of painful angina, 50% of patients who had known coronary artery disease and were given a placebo rather than therapeutic nitroglycerine reported relief of chest pain. In the case of cancer, if Northland was correct and cancer is caused, in part, by a failure of the immune system, which is known to be affected by stress, taking a medicine that one believes will work might reduce the stress and thereby enhance the body’s immune response to cancer. I recently thought back to these ethics discussions when I had to take a medical ethics course to renew my Florida license. The online course included an account of one of the most notorious medical experiments ever conducted in the United States, the Tuskegee

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Syphilis Study. The U.S. Public Health Service began the study in 1932 when it enrolled 399 poor African American men with syphilis. The men were never told that they had syphilis, and they were not treated for it. Although beginning in 1947 penicillin was available to treat syphilis, it was withheld from these men because the researchers wanted to observe the natural history of the disease. Untreated, syphilis causes terrible damage to the central nervous system. Although most people who read about this experiment would agree with Jimmy’s contention that the performance of this study was a disgrace, the investigators who were performing this study might have noted that many people with syphilis do have spontaneous cures, even without antibiotic treatment, and that not everyone with syphilis comes down with serious complications. In addition, although penicillin is a relatively safe medication, when treating syphilis it is given by injection; and some people who receive an injection of penicillin can die of anaphylactic shock. These National Institutes of Health–supported investigators did not want to give all these people with syphilis antibiotic treatment because they wanted to know how the treated group of patients differed from the untreated group and if the expense and risk of penicillin shots were overshadowed by the positive results of the treatment. When the public found out about this study, it was stopped. The investigators were treated like criminals, and the story is now told as an illustration of unethical behavior by clinician– scientists. The second case history in the online medical ethics course told the story of Dr. Northland. After I finished the course, I thought more about the ethics of research. I concluded that although the Tuskegee Syphilis Study and the Northland melanoma transplant experiments are especially egregious violations of research ethics, all clinical research done on humans and animals has a price, whether or not it is a controlled study. If the experimental medicine or procedure is successful, those who are the control subjects pay the price of not having been treated expeditiously. If the experimental medicine

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or procedure does not work or is harmful, the experimental subjects pay the price. Fortunately, often the price is small and the rewards great, but not always. When investigators plan clinical research, they rely on their own judgment and that of their institutional review board to help determine whether the risks are worth the possible rewards. However, it remains unclear how anyone can balance all potential risks against all potential rewards, especially when some of the risks and benefits may not be known until the study is under way. Recently, I lectured at Dartmouth’s summer Cognitive Neuroscience course. Afterward, I stayed to hear the other lectures. One of the lecturers, Marc Hauser, was interested in the activities of the brain when it is attempting to make ethical decisions. During his lecture he described several hypothetical but plausible situations and then he questioned people about how they would respond if they took part in these events. The scenarios went something like this: A trolley is speeding down a track and just ahead are five young deaf people who are walking on the track; they cannot hear the trolley. Unfortunately, by the time the driver sees them, it is too late to stop, but if he continues down this track, the trolley will probably hit and kill all five people. The driver is coming to a switch that will enable him to move the trolley to a side rail that runs parallel to the main track. There is, however, one deaf person on the side rail. If the driver makes the switch, there is a good chance this person would be killed. If you were the driver would you make the switch and kill one person instead of five?

Almost everyone who listened to this story said to save five lives they would switch the trolley to the other track without the consent of the person walking on the side rail. Seeing five people on the rail, though, gets the driver so nervous that he has a heart attack and passes out before the trolley comes to the side rail switch. There is another switch on the side of the rail itself that will allow the trolley to be diverted. If you were standing by this

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switch and saw what was happening, would you reroute the trolley to the side rail to save five people at the expense of one life?

Although in this situation the observer is not the driver, almost everyone said that they would switch the trolley to the side rail. And again, there is no informed consent from the person who will be killed, but the action saves five lives. In this next scenario, there is no side rail, but there is a bridge over the trolley tracks and there is a heavyset man on the bridge. The man is so large that, if he falls in front of the trolley, his body would stop the trolley from progressing down the track While this man is watching this scene, he slips and starts to fall off the bridge. If you were on this bridge would you catch him or let him fall. If you let him fall, he would save five lives, but he would probably die.

Many people who heard this scenario had more mixed emotions than they had with the side rail set-up, but still a majority stated that they would let him fall and die to save the five deaf people. This next story is very similar to the last, except this time the large man didn’t start to fall, but he was looking over the bridge and could easily be pushed. You considered jumping onto the rail yourself, but you are too small to stop the trolley. There is no time to get this man’s consent and you are pretty sure if you asked for it, he would decline. If you pushed him, he would land on the tracks, stop the trolley and save five lives, but he would die. Would you push him?

The vast majority of people said it would be unethical to push the man off the bridge and they would not do it. However , it is unclear why pushing a man off a bridge would be any different from switching a trolley so that it kills someone. In both cases, you are sacrificing the life of one person to save five. The only difference between the last scenario and all the others is that it involves physical contact with the person who is to be sacrificed. Should physical contact be the basis of an ethical judgment?

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If you thought it was ethical to push the man off the bridge to save five lives, how do feel about this next scenario? You are a surgeon on a transplant service. You have five people who are dying because of organ failure. One patient needs a heart, an other a lung, one needs a liver, and two need kidneys. Like most transplant services there is a shortage of organs and you have none for these five people. A young healthy man comes into the hospital to make some deliveries. You give him an anesthetic injection and, while he is under anesthesia, you remove his heart, lungs, liver, and kidneys. By killing him you would save five lives. Would you do this?

No one who heard this story thought that killing the healthy man to save five lives was ethical However, is this young healthy man any different from the man walking down the side rail? Both are healthy and neither gave their consent. Someone made a decision that by sacrificing one life he or she could save many lives. Why are the acts described in the last scenario unethical and those in the earlier scenarios ethical when both have the same outcome? What about Dr. Northland? If, after demonstrating that people with metastatic cancer have a defective immune system, he found a way to improve the immune system and thereby cured millions of people with cancer, would that be different from the woman throwing the switch? When a person decides to throw the switch so that the trolley goes on the side rail, he or she is killing the man walking on the side rail to save five lives, and does this without his consent. Dr. Northland also did not get consent, but in his study patients like Maria Rodriguez, unlike the hypothetical man walking on the side rail, were already destined to die of terminal cancer. Thus, unlike the person who switches the trolley to the sidetrack and kills an innocent healthy man, Dr. Northland’s actions did not even adversely affect Maria Rodriguez. Why then are his actions so repugnant and the action of the person who threw the switch so righteous? Perhaps it was because he had the ability to obtain informed consent but did

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not. In contrast, the person who switched the trolley to the side rail did not have time to obtain consent. But if he or she did have time and the man walking down the sidetrack refused, as he probably would have, would it have still been morally correct to throw the switch? Upon graduation most physicians who have attended American medical schools recite the Hippocratic oath, which states, “Whatever houses I may visit, I will come for the benefit of the sick, remaining free of all intentional injustice. . . .” Good advice, but neither this oath nor anything we learn in medical school or during our training helps us with the moral dilemmas that we as physicians and researchers face almost daily. The list of moral dilemmas is huge: stem cells, abortion, mercy killing, living wills that state “do not resuscitate” even though a disease state might be reversible, triaging care based on wealth and having corporations, such as insurance companies, make money by finding reasons not to provide care. Although this list of moral dilemmas is long, the list of universally accepted answers to these dilemmas is short or even nonexistent.

17 Suffering: Phantom Pain February 1964

J

enny lived in the Forest Hills section of Queens, New York, and was a senior in high school. In addition to being extremely smart, she was a very talented artist. Her favorite medium was watercolor. She applied and was admitted to the High School of Music and Arts, one of New York City’s most prestigious high schools, but did not want to spend all the hours riding on the subway when she could be painting, reading, or spending time with her family and friends. Therefore, she decided to go to the local Forest Hills High School. She also liked to run. Running gave her time to think. She liked to run long distances and joined her high school cross-country track team. At the end of the academic year there was a big cross-country race in Van Cortlandt Park in the Bronx, in which almost all of the New York high schools competed. Jenny was looking forward to this

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race, and to prepare for it, each day she ran for an hour on the outdoor track at her high school. After her run, she would shower in the girls’ locker room, put her school clothing back on, and walk home with her girlfriend and teammate, Rebecca. One day after running, while they were in the showers, Rebecca looked at Jenny’s arm and asked, “What’s that?” “What’s what?” “What’s that thing on your arm?” Jenny looked at her arm and noticed a lump in the back of it just below the shoulder. “I don’t know. Maybe I hit something.” “Is it sore?” “No. Not much.” “Are you going to see Dr. Schwartz about it?” “No. I bet it will just go away by itself.” Jenny got dressed and went home but did not tell her parents about her arm because she knew that her mother was a worrier. Each day when she awoke she would feel for the lump, hoping that she would not be able to find it; but instead of getting smaller, it was getting bigger. Each day in school Rebecca would ask Jenny about the lump. When Jenny told her it was still there and getting bigger, Rebecca asked if she had spoken with her parents. When Jenny told her no, she said, “Jenny, you have to tell them. It might be serious. If you don’t tell them, I will.” Jenny assured Rebecca that she would tell her parents when she got home. When Jenny told her mother and showed her the lump, she was again reminded why she did not like to tell her mother these things. Her mother became terribly alarmed. Jenny did not like seeing her mother upset, and seeing her mother upset made her worry about herself. The next day Jenny took off from school and with her mother went to see their family physician, Dr. Schwartz. Jenny told Dr. Schwartz

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that although she could not recall injuring her arm, she might have hit it against something. When Dr. Schwartz examined the lump, his face showed concern. Ladies, I really don’t think this is from an injury. I think you have a tumor. The most common tumors we see like this are called lipomas. This feels a little hard to be a lipoma, though, and it might be a fibroma or a fibrolipoma. These tumors are usually benign, but we ought to have it taken out so we can make certain. Removing the tumor will also rid you of that ugly lump. I’m going to send you to see Dr. Lipshitz. He’s a general surgeon at Long Island Jewish Hospital.” Three days later Jenny and her mother met with Dr. Lipshitz. He felt the lump and examined her body for other lumps but did not find any. He told Jenny that he wanted her to get a chest X-ray and to return tomorrow so that he could remove the lump. He explained that it would be a minor, outpatient procedure and that he would use a local anesthetic so that, except for the little sharp pain of the needle stick, she would not feel anything except for some pressure. The next day Jenny and her mother returned and went to the minor procedure room. The walls and floor were covered with white tiles, and the room contained an operating table and a surgical light. The nurse asked Jenny to put on a hospital gown, explaining that she could leave her bra and panties on but everything else had to come off. After Jenny got into the gown, the nurse washed her arm with soap and water, and then sterilized it with an iodine solution. Dr. Lipshitz came into the room dressed as if he were going to do major surgery, wearing a gown, mask, and latex gloves. He warned Jenny that the Novocain would sting when he injected it into her arm, then proceeded to administer the local anesthetic. He asked her to look at the opposite side of the room so that she could not see him cutting her. The entire procedure, including suturing, took about 15 minutes. After he covered the incision with a bandage, he asked, “How are you?”

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“Fine. It didn’t hurt at all. What did you find in there?” “Well, I did find a tumor, but the tumor seemed to be coming from the muscle. I’m not sure what type of tumor it is. Let’s wait until we get the report from pathology.” Two days later, Jenny and her parents came to see Dr. Lipshitz in his office. “I was hoping this would be a benign tumor, like a fibroma, but it looks like it’s a tumor called a ‘rhabdomyosarcoma.’ ” Jenny’s father asked, “Since you removed it, is she all done with the disease?” “Maybe, but I want her to see an expert at Memorial SloanKettering. His name is Dr. Greenberg. I’ll call now and set up an appointment.” Two days later Jenny and her parents went to see Dr. Greenberg. He reviewed the records that Dr. Lipshitz had provided and used the microscope in his office to look at slides of the tumor. He then examined Jenny’s arm and neck, feeling under her armpit for enlarged lymph nodes. After the examination, he explained that, although he found no evidence of residual tumor, rhabdomyosarcoma is not usually cured simply by removing the lump. Before Dr. Greenberg could continue, Jenny asked, “What else has to be done?” Dr. Greenberg hesitated. “The margins around where Dr. Lipshitz removed the tumor aren’t entirely clean. It looks like the tumor is spreading into the muscle. We could try taking out more muscle, but the best hope for a cure is to remove your entire arm.” Jenny’s mother cried, “Oh, my god!” and her eyes filled with tears. Jenny asked, “When should we do this?” “What about next week?” asked Dr. Greenberg. “Fine,” said Jenny. As Jenny and her mother left the office, Jenny’s father stayed behind and asked Dr. Greenberg, “What is the chance of curing her?”

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Dr. Greenberg looked down and said, “Not good, but this is our only hope.” Jenny had her arm removed. She healed well and was discharged from the hospital but developed terrible pain in the stump. The pain was so severe that she stopped eating and drinking. She became so severely dehydrated that she was readmitted to Memorial Medical Service so that we could treat her malnutrition, dehydration, and pain. I was her intern. When she was admitted and I saw how dehydrated she was, I started an IV to get fluids into her body. I gave her 100 mg of thiamine (B1) as well as a combination of other vitamins through the IV tube. I asked her what she was taking for the pain, and she told me, “Nothing.” I said there was no reason for her to suffer and that I would order pain medicine; if she was having pain, she was to ring the call button and ask the nurses to give her a shot of the pain medicine. Because she had not eaten, I started her on a clear fluid diet but ordered her to be put on a regular diet the next day. Except for her missing arm, her examination was normal. Her chest X-ray was also clear, and there was no evidence of metastasis. When she was admitted, I asked her to tell me how much pain she was having, a dollar being the worst pain and 0 cents no pain. She told me about 80 cents. I ordered a morphine shot, and about 10 minutes after the injection, her face relaxed and she fell asleep. The next morning, before we started our rounds, I went to check on Jenny. The minute I walked in, I could tell from her face that she was experiencing pain. I asked her if she had called the nurses. Yes, she had, but the nurse who came in said she had to wait a couple of hours for her next shot. It was now 7:00 AM, and I asked her when she’d had her last shot. She said about 2:00 AM. I explained that I wanted to check my orders and would be back in a few minutes. In the order book, I had written “Morphine 10 mg Q 4 H [every four hours] PRN [as needed].”

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I walked over to Regina McDonnell, who was the nurse assigned to Jenny. I said that Jenny seemed to be in severe pain and that I had ordered morphine for her on an “as-needed” basis and didn’t understand why Jenny’s request for the painkiller had been turned down. “I’m not sure she needs it,” McDonnell responded. “Why?” “Last night she called me at about 2:00 AM to ask for more pain medication. Because she didn’t look like she was in so much pain, I gave her a shot of normal saline. I told her that I’d check back in 15 minutes to see if the injection was working. When I returned, she was falling off to sleep and told me the pain medicine was working.” “Just because she got relief from a placebo injection doesn’t mean that she wasn’t in pain.” Before I could continue, she pointed her finger at me. “Dr. Heilman, that young girl has your number, and she’s just asking for morphine because she likes the way it feels.” I tried to explain that studies had demonstrated that a placebo injection could reduce pain in patients with severe pain because the brain was known to put out its own type of morphine—endorphins (“endogenous morphine”). McDonnell looked at me like I was some kind of idiot. “Dr. Heilman, do you want to turn Jenny into a morphine addict?” “If Jenny lives long enough to turn into an addict, I’d be delighted.” “What do you mean?” “Jenny has a rhabdomyosarcoma. Only about 5% of people with this disease live five years. If she’s going to die or even if she lives, I don’t want her to suffer. She’s already suffered enough, and if she asks for a shot for her pain, please give it to her.” “Okay, Doctor, I hear you.”

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Even though she was now eating and drinking, Jenny continued having severe pain. The morphine helped, but we frequently had to increase the dose. One evening when McDonnell was again Jenny’s nurse, she approached me while I was writing notes near the nurses’ station. “I noticed you increased Jenny’s dose of morphine. See, she’s building tolerance. You’re going to need to give her more and more of it.” “If we needed a tanker truck to supply her with enough medicine, I’d arrange for it.” “Aren’t you worried that because of the high doses you’ll have a lot of trouble getting her off narcotics?” “No, I’m not worried about addiction. As I told you, very few people with rhabdomyosarcoma live, and if she lives, it would be a blessing to be able to withdraw her from these drugs.” I tried to reassure the nurse that Jenny’s pain was a far greater risk to her health just now than the potential for addiction. At this time, during the early 1960s, some, but not all, oncologists had experience in dealing with patients suffering with metastatic cancer and severe, intractable pain. One of them was Dr. Schacter who was at Memorial. I called his office and asked if I could speak with him about one of my patients. His secretary got him on the phone. “Sure, why don’t you come to my office right now.” I presented Jenny’s history and asked what he thought was causing all her pain. He explained that when you amputate an arm, you have to cut the nerves. Afterward, the nerves form little benign nerve tumors called neuromas, which send pain messages to the brain. I asked what could be done about it. He recommended that I keep trying the narcotics and that adding a phenothiazide such as chlorpromazine, (Thorazine) which was usually used to treat schizophrenia, might make the pain medication work better. However, if the medications didn’t work, Jenny might need neurosurgery. “What kind?” I asked. He told me that there were several types. One option was to operate on the arm again to try to remove the

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neuromas, but he had never seen this type of surgery work. The neurosurgeon could also perform a cordotomy, in which the ascending pain fibers that travel in the spinal cord are cut. In his experience, this surgery would work only temporarily; he had patients who several months after having a cordotomy had even worse pain than they did before the surgery. The third option was to remove a part of the brain in the middle of the frontal lobes. This surgery did not seem to stop the pain, but for some reason, it seemed to decrease suffering. None of these surgical options seemed great. I hoped that with time Jenny’s terrible pain would spontaneously decrease, but it did not. One night when I was not on call at Memorial, I went with some friends to dinner at Tommy’s, one of our favorite eating places on Third Avenue. There were no empty tables, but one of my friends recognized two interns from Bellevue’s NYU service sitting at a large table with several empty chairs and asked if we could join them. One of my friends knew that I was upset about Jenny, and as we sat down he asked me how she was doing. “Terrible. We’re using tons of narcotics, and they barely control her pain.” One of the NYU interns asked me what was wrong with her, and I briefly told him her story. Afterward he said, “You know, when I went to medical school at NYU, I heard one of the doctors from the Rusk Institute speak about phantom limb pain. I wonder if this is what she has.” I asked him for more information, but he could not provide many more details. He did, however, give me the name of the doctor who gave this lecture, Dr. Mueller. The next day I happened to see Dr. Schacter in the hallway. I ran to catch up with him because I wanted to ask him about phantom limb pain. He had heard about it but was not sure how to treat it. I asked if he had ever heard of Dr. Mueller at the Rusk Institute; he had not.

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I thought the best thing might be to invite Dr. Mueller to see Jenny at Memorial and asked our attending physician if we could invite him. He explained that because Dr. Mueller was not on the Cornell faculty and did not have attending privileges at Memorial, I would first have to get permission from the chief of staff ’s office. After rounds I went to the chief ’s office, where one of the secretaries instructed me to write a letter explaining the reason for the request. In this precomputer era, we looked up articles in the Index Medicus, a series of books that indexed the journal articles that were published each month. I wanted to research phantom limb pain but found little when I searched the Index. The day after I wrote the letter, I received a page from the chief of staff ’s office; when I called, the secretary told me that my request had been approved. I then called down to the Rusk Rehabilitation Institute and spoke with Dr. Mueller. I told him Jenny’s story and asked him if he could come up and see her. He told me that he was honored that I called him but that I would have to get permission for him to see her at Memorial. I said this had already been done. He gave me a time to meet him by Memorial’s main entrance, and I told him that I was looking forward to meeting him. At the appointed time, I met Dr. Mueller as we had discussed and brought him to Jenny’s room. I had mentioned his visit to several interns and residents, who were already gathered outside of Jenny’s room when we arrived. Our attending physician was also there. Dr. Mueller was a short man, about five feet five inches tall. He had a slight accent that sounded South African. He was in his early fifties and, although bald, had a goatee. He also had bushy eyebrows. He wore a dark blue suit with a matching vest. I introduced him first to our attending and then to the residents and interns. I then introduced him to Jenny. “I’m sorry to hear that you are having such awful pain. Can you tell me about your pain?” he asked her. “It just hurts where they took off my arm.” “Can you feel it?”

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“Yes.” He felt the stump. “When I touch this, does it hurt?” “Just a little.” “Jenny, please tell me the type of pain you are having. Is it a sharp pain or a burning pain?” “Neither. It’s hard to describe.” “Do you still feel like you have the arm that the surgeons removed?” Her eyes brightened. “Yes, I do, but I haven’t told anyone because I was worried that they’d think I was crazy.” Everyone in the room moved closer to her bed and listened intently. “Jenny, where is the arm?” “I don’t know what you mean. I have no right arm.” “You told me that it feels as if your arm is still present even though it has been removed. Your experience isn’t new. Many people who have had an arm or leg removed still feel like they have that arm or leg. We call it a ‘phantom limb.’ I want to know the position of this phantom limb.” “It’s behind my back, and it’s twisted.” “Is that what’s giving you the pain?” “Yes! How did you know?” “I’ve seen this in many other people who’ve had an amputation. I’m going to give you and your physical therapist some exercises. I want you to do these exercises with your phantom arm so that you can get it in a more comfortable position. After a while, the arm will start to shrink and telescope back into your body. Once this starts to happen, your pain should lessen or might even go away.” For the first time, I saw a smile on Jenny’s face. Somebody understood what she was experiencing, and this helped to relieve some of her pain. All of us were amazed by the entire event. I had planned to read more about phantom limb pain during my internship, but it always

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seemed I was too time-poor to look up articles. While Jenny was describing to Dr. Mueller an arm that was no longer physically present, I recalled a patient whom I saw as a medical student. He had had a large right hemisphere stroke that paralyzed his left arm. However, he was unaware that there was anything wrong with his left arm. When I later took training in neurology, I found that this phenomenon was first described in 1914 by a French neurologist, Joseph Jules Dejerine. Dejerine called this phenomenon anosognosia (lack of awareness of a deficit). The patient I saw in medical school also demonstrated one of the most interesting phenomena I have ever seen in medicine. He found his left arm in bed with him but did not recognize that it was his own arm. Because he did not want someone else’s arm in bed with him, he would pick up his left arm with his right hand and try and throw it out of his bed. When I went into neurology I learned that this phenomenon is called asomatognosia (lack of recognition of one’s body). To explain these phenomena, neurologists have suggested that the brain stores knowledge about the physical characteristics of the body. With some strokes, the area of the brain that stores knowledge about the opposite side of the body is destroyed. As a result, the person has no awareness of certain parts of the body and thus does not recognize them as part of “me”; they are seen as foreign objects. If our brains store knowledge about a body part and this body part is removed, it does not mean that the brain no longer has a representation or memory of it. In Jenny’s case, her brain’s memory of her arm had it placed in a very uncomfortable position, but because the arm was gone, she could not reposition it to alter her brain’s representation of how it felt. The day after Dr. Mueller’s visit, my Memorial rotation ended. Although I loved working at Bellevue, I wanted to know how Jenny did. One of my co-interns, Tim Dugan, took over her care. I told Tim the entire story and asked him to keep me informed. Tim was an excellent intern, and I knew Jenny would be in good hands. When

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I did not hear anything from Tim for two weeks, I decided to call. I asked how she was doing, and he told me, not so well. Although her pain had improved, she had developed pneumonia. When they took a chest X-ray, they found that the rhabdomyosarcoma had traveled to her lungs. Two weeks later I learned that she had died. I felt sad that this vital young girl was gone but took some comfort in knowing that at least she would no longer suffer. When all hope is gone but suffering persists, death can bring peace. Physicians’ major goals are to prolong life and relieve suffering. In many patients with terminal diseases, such as metastatic cancer, these two goals are in conflict. While most physicians are against “mercy killing,” there is no need for physicians to prolong suffering. In these cases the patient must decide if prolonging life is worth the price.

18 Gratitude: Thank You, Doctor March 1964

M

r. Kennedy was a 46-year-old African American man who worked by day at the Fulton Fish Market and attended school at New York University (NYU) three nights a week. His dream was to be a certified public accountant, and he was going to NYU so that he could get a degree in accounting. Mr. Kennedy had two sons, who were 19 and 21 years old. He was extremely proud of them because they were both going to City College in New York and the older one was about to graduate with a degree in social work. The younger one still did not know what he wanted to do. Mr. Kennedy’s wife had died of breast cancer about 10 years ago, and since then, he had brought up the boys by himself. In high school, Mr. Kennedy was a terrific athlete who also maintained a high grade point average

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in one of New York’s best public high schools, Stuyvesant. He received a full scholarship to Columbia and Cornell, but in his senior year of high school his diabetic mother, who was raising him and his younger brother by herself, had a massive heart attack, developed severe congestive heart failure, and could no longer work. Thus, he had to go to work to support his family. I got to know Mr. Kennedy because, like his mother, he had diabetes and periodically would come to Bellevue Outpatient Clinic to get his insulin prescription refilled. One day in the clinic he developed crushing anterior chest pain and became terribly sweaty. He did not say or do anything while waiting his turn to see me, but the patient sitting next to him came back to the examining room and asked the nurse to come get me. When I went to the waiting room, it was immediately apparent that he was having a heart attack, so I got a gurney to transport him to the Emergency Ward (EW). Mr. Kennedy was a big man. He was six feet four inches tall and weighed 235 pounds. I had several interns and residents help me lift him onto the gurney. I strapped him on, then wheeled him to the EW and got an electrocardiogram (EKG). It showed Q waves in three leads (II, III, and AVF) as well as elevation of the ST segments. These were the EKG signs of a heart attack. I explained to him that he was having a heart attack and that we would keep him in the EW so that we could monitor his heart and blood pressure and treat him if he developed an abnormal heart rhythm or his blood pressure dropped or he went into heart failure. I asked the nurse to give him an injection of morphine to reduce his chest pain and his anxiety. Forty years ago, we could do little more than this to treat heart attacks. However, Irving Wright, one of the best-known and respected professors of medicine at Cornell, thought that blood thinners might help patients with heart attacks by preventing the formation of additional blood clots and perhaps even stopping the blood clot in the heart’s arteries from growing bigger. Thus, we started Mr. Kennedy

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on warfarin (Coumadin), an anticoagulant. About an hour later his severe chest pain subsided, but he was becoming short of breath. I listened to his lungs. With each breath I heard moist, crackling sounds (known as rales), suggesting that he might be going into heart failure. To strengthen his weak heart muscle, I started him on digitalis. Heart failure can also be helped by ridding the body of extra fluid; thus, I used the strongest diuretic we had then, which was meralluride (Mercuhydrin). I also ordered another diuretic, hydrochlorothiazide, an oral water pill still used today. Another means of treating heart failure was to reduce the volume of blood returning to the heart by putting tourniquets on the patient’s limbs to compress the veins and reduce blood flow back to the heart or by draining a pint or two of blood from the patient. Mr. Kennedy was not terribly short of breath, however, so before performing these procedures, I wanted to give the digitalis and diuretics some time to work. I watched him for the next hour. His shortness of breath abated, and when I listened to his lungs, the rales were no longer present. When he was feeling better, Mr. Kennedy asked me if he could go home. I smiled and said, “I don’t think it would be a good idea. I want to keep you in the emergency ward so that we can watch you closely. Sometimes after you have a heart attack, your heart muscle is weak and can’t pump enough blood. If this happens, we want you here so that we can treat it. Also, sometimes the heart beats irregularly following a heart attack, and if that happens, we want to know about it so that we can try to control it.” “Okay, I’ll stay here tonight, but I’d like to go home tomorrow.” “Another thing we’re doing is giving you a blood thinner called warfarin (Coumadin). According to one of our most famous doctors, Irving Wright, this medicine might prevent you from developing another clot in the coronary arteries. These are the arteries that bring blood to the heart. However, it takes several days before we can figure out the correct dose.” Mr. Kennedy agreed to stay a few more days. He did well. He did not develop any further evidence of heart failure and never developed

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a cardiac arrhythmia. The Coumadin therapy was also going well as there was no evidence of bleeding into the kidneys or intestines. When I was making rounds the morning of his fourth day in the hospital, Mr. Kennedy said, “Doctor, I want to go home today. My kids are grown, but I’d still like to be there if they need me.” “Your sons visited you last night, but you were asleep because of some of the medicines we gave you, and they didn’t want to wake you up. They told me that they’d visit you again tonight.” “It’s not the same as being home for them.” “Is there any way that I could talk you out of leaving?” “No. I appreciate your concern, but I’m going home.” Before Mr. Kennedy left the hospital, I gave him prescriptions for his medicines and drew some blood to check if he had the correct dose of Coumadin. I asked him to wait for the result, but he said that he would call me and left the hospital. A few hours later, I got a call from the lab telling me that his prothrombin time, which indicates the level of anticoagulant in the blood, was very high. This suggested that he was receiving too much anticoagulant and was at risk for internal bleeding. I checked his hospital chart for his phone number but, for some reason unknown to me, it had not been recorded. I knew his first and last name and that he lived in Manhattan, so I thought I would look up his number in the phone book. There were more than 25 listings for people with the name of Larry or Lawrence Kennedy. I recalled that he lived in Harlem. I found three Larry or Lawrence Kennedys who lived in Harlem, one of whom matched the address in his chart. I called several times, but no one ever answered. I finally had the operator check to see if the number was working, only to be informed that service was out on the entire street. I asked her when service would resume and she said, “It’s anyone’s guess.” It occurred to me that this may have been why Mr. Kennedy never called me as he said he would. I had been on call the night before and was off this evening. I thought I would drive to his apartment to discuss with him in person the things I was planning to tell

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him on the phone. I must admit that it was with a little trepidation that I, a white man, would be driving and walking around this African American neighborhood. Once there, I realized my worries were unjustified. While I knew Mr. Kennedy’s address, I did not know his apartment number and so asked one of the people I saw in the hallway of the apartment house. The gentleman brought me up to Mr. Kennedy’s apartment, and after I thanked him, I knocked on the door. “Who is it?” I heard Mr. Kennedy ask. “Mr. Kennedy, it’s me, Dr. Heilman. I’m the doctor who was taking care of you while you were at Bellevue. I need to speak with you. It will take only a few minutes.” Mr. Kennedy opened the door. “Doc, I know who you are, but why did you come all the way up here?” “I tried to call, but the phone system on your street is out. I wanted to give you the test results—your blood is too thin and you should take just one of those Coumadin pills each day. I also wanted to tell you that I need to see you next week to check your blood again.” “I’ll be there, doc. Thank you so much for making this extra effort.” He came to the clinic the day I asked him to come. His examination was normal. He had no evidence of bleeding, his heart rhythm was normal, and he had no signs of heart failure. I checked his blood studies. Not only was his blood sugar good but the dose of anticoagulants he was taking had thinned his blood to the therapeutic level. His kidney function was also good, and there was no blood in his urine or stool. I was glad to be able to tell him how well he was doing. He kindly said it was my good care and that he had already been back to work and school. Mr. Kennedy continued to do well for the next six months, but then on a Tuesday morning, while working at the Fulton Fish Market, he again developed crushing anterior chest pain and profuse sweating. The ambulance took him from the Fish Market to Bellevue

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as he requested, and he was again admitted to the EW. Because I had cared for him and written many notes in his chart, the EW intern paged me. I did an EKG, which showed that he had had another heart attack. This time, the clot was the left anterior descending coronary artery. People who have a thrombosis in this vessel often die suddenly, which is why cardiologists sometimes refer to it as “the artery of sudden death.” This is because one of the areas to which the artery brings blood contains the portion of the heart that determines the heart’s rhythm. Thus, when people have a blockage of this artery, their heart might beat abnormally (ventricular fibrillation) and fail to send blood to the brain or other vital organs, causing death. This is the reason defibrillators are now carried by paramedics and are now also found in planes, airports, and other public places. Mr. Kennedy did well the next day and was sent from the EW to Ward 1B in the Medical Building of Bellevue. The wards in Bellevue in 1964 were large and contained about 20 to 30 beds. Between each bed was a nightstand and curtains that you could pull around the bed for some privacy. Mr. Kennedy was in the bed closest to the entrance. The wards at that time had no means of monitoring a patient’s cardiac status, but a nurse whose desk was at the end of the ward could see if anyone was in trouble and would also periodically take the patients’ vital signs. Because I was still worried about Mr. Kennedy, I wrote orders that his vital signs were to be taken hourly. Unfortunately, the nurses had so many patients to look after that it was difficult to measure vital signs this frequently, and as a result, the interns on call would often be asked to help. I had been on call Tuesday night and was off on Wednesday evening, so I went on rounds to make certain that the 10 patients I had on this ward were all doing well. The last one I visited was Mr. Kennedy. I checked his vital signs and listened to his heart and lungs. “You’re really doing well.” He looked at me for a few seconds. “Dr. Heilman, in case I don’t see you again, I want to thank you for all you’ve done for me.”

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“Mr. Kennedy, are you making plans to go home tonight? Are your boys having trouble?” “No, they’re just fine, but I’m not sure I’ll see you tomorrow morning and wanted to tell you that you’re a fine doctor and I’ve been blessed to have you as my doctor.” Although Mr. Kennedy was always very polite, this behavior was unusual for him. I wondered whether something was happening to his heart. “Mr. Kennedy, do you have chest pains?” “No, Doc.” “Do you feel your heart is skipping beats or beating very rapidly?” “No, Doc.” “Then why do you feel you’re not going to be here tomorrow morning?” “I don’t know, but I thought I’d tell you goodbye, just in case. You go home now. You had a busy night last night.” I was not reassured by his comments and worried that he was having a silent heart attack or an arrhythmia. We had no specific enzymes as we do now to help diagnosis damage of the heart muscle, and because there were no monitors available on the wards, I attached him to a portable EKG and made an EKG recording. It looked unchanged from the one he had shortly after he was admitted. I ran a rhythm strip for 20 minutes to see if he might be having an intermittent arrhythmia, but his rhythm looked perfectly normal. I told him that everything looked fine and that I would see him tomorrow morning. I thought about transferring him back to the EW, but there was no change in his status to report, except his feeling that he was going to die. I was worried about him. I left the hospital and went to a little Italian restaurant on Second Avenue near my apartment for dinner and a beer. I was tired and headed home when I finished. I set my alarm for 6:00 AM, read for a while, then fell asleep. When my alarm went off, I had been asleep for eight hours, but I was still tired and dreaded the thought that

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I would be on call again tonight. I showered, put on a new pair of white pants, a freshly laundered light blue button-down shirt, an orange and blue tie, and a clean starched white jacket. I headed to the hospital for a quick breakfast and rounds. Rounds usually started at 7:30 AM, but whenever I started to feel sorry for myself I thought about the surgeons who had already been in the operating room for more than an hour. After breakfast I headed to the wards. The minute I walked through the doors, I realized that Mr. Kennedy’s bed was empty. I walked over to Tom Malloy, the intern who was on-call that night. “Tom, did you have to move Mr. Kennedy back to the EW?” Tom shook his head. “No, he’s not there. When I walked around the wards last night about 11:30, I noticed that he wasn’t breathing and had no pulse. I turned on the EKG that you left beside his bed, and there was no activity—not even fibrillation. The nurse and I tried to resuscitate him, but we couldn’t. The orderlies moved him to the morgue about an hour ago. We didn’t call his family because I knew that you were close to them and thought that you might like to do this. I’m sorry, Ken. I know how much you liked him.” I was going to call his sons, but just as I was walking to the phone, I saw both of them coming to the ward. I met them in the hallway and told them the sad news. Both boys’ eyes filled with tears. The older one said, “He wanted to get his accounting degree so badly.” I described how sick he was, with both diabetes and bad heart disease. They said they knew he could die any day and that their grandmother had died at the exact same age. “Without him working, will you guys have enough money to finish school?” “We’re both almost finished, but Dad was so concerned about dying before we finished school that he took out an insurance policy that would pay for our education and expenses. He didn’t want what happened to him to happen to us.” Both of his sons were tearful and stood silently for a few minutes. The older one then asked, “Doctor, when we were visiting our father

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yesterday, he told us all the things he wanted us to do after he was gone. This was the first time he ever did anything like that. How did he know he was going to die?” “He also let me know that he wouldn’t be here in the morning. He knew he was going to die, but I’m not sure how he knew.” The younger son spoke. “Do you think he heard Jesus calling him?” “I’m not an expert in religion. This is something you might want to speak about with your minister.” The older one asked, “Is there any medical explanation?” “I’ve heard other doctors speak about similar situations. If the knowledge of one’s impending death is a real phenomenon and not a chance occurrence, there should be a medical explanation. A medical explanation, however, might not be different from a theological explanation. God may speak to us through our body.” Both of his sons nodded their heads. “I have to get back to the other patients, but I wanted to tell you that your dad was very proud of his sons. He was a wonderful man. I know you’ll miss him, but you have been blessed.”

19 Intimidation or Invitation April 1964

D

r. Bernard Lown, who received the 1985 Nobel Peace Prize for cofounding International Physicians for the Prevention of Nuclear War, an organization that had as its goal “ridding military arsenals of instruments of genocide,” was also a cardiologist and inventor. In the early 1960s he invented an instrument that allowed physicians to treat patients with abnormal heart rhythms by shocking the heart through the chest wall. Normally, the heart beats between 50 and 100 times per minute at fairly regular intervals. Although the brain and circulating hormones can modify the heart rate, the body’s pacemaker that produces the electrical impulses that signal the heart muscle to contract is located in the top part of the heart (the atrium). The pacemaker sends electrical impulses to the various parts of the heart, where they stimulate

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the heart muscles to contract in a systematic fashion, sending the blood in their four chambers of the heart to the appropriate destinations. Heart disease can interfere with this natural pacemaker and conduction system so that the heart beats abnormally. This is called an arrhythmia. There are many types of arrhythmias, including irregular heartbeats or heart rate disorders, where the heart beats either too rapidly or too slowly. Some arrhythmias can be treated with a jolt of electricity applied to the chest wall, but if the shock is given at the wrong time, the heart can stop contracting and the patient can die or sustain serious brain damage. Dr. Lown’s invention made certain that the shock would be given at the correct time in the contraction cycle, thus dramatically reducing the risk of heart stoppage and increasing our ability to safely restore normal heart rhythms. For reasons that I never understood, Friday nights at Bellevue were extremely busy. A few of the people we admitted were there as a result of excessive celebration of the end of the work week. One Friday night my co-intern John Zegel admitted a 63-year-old woman who came to the emergency room because she felt her heart was beating too fast. She did not have any other complaints about her heart, such as pain, and she did not complain of being short of breath. When John examined her heart, he heard a rapid beat; but her heart did not appear to be enlarged, and her lungs were clear. She also did not have any swelling of her feet (edema). The absence of these signs on physical examination suggested that she was not in heart failure. In addition, John noted that her rapid heartbeat was very irregular. The only other abnormality he noticed was that the woman’s respirations were irregular. She would start breathing very slowly and take shallow breaths, then take progressively more rapid and deeper breaths. After a period of hyperventilation, she would stop breathing for a few seconds, and the cycle would start all over again. This periodic, or cyclic, breathing pattern is called Cheyne-Stokes respirations. When John finished his physical examination, we attached electrocardiogram (EKG) electrodes to her extremities and chest and recorded

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her EKG. The EKG records the electrical currents that are coming from the heart as different parts of the heart muscle contract. We noticed that the top parts of her heart, the atria, were beating very rapidly and irregularly, which caused the bottom of her heart to also beat rapidly and irregularly. This condition is called atrial fibrillation. We gave her medication to slow up her heartbeat (digitoxin) and shocked her heart with our new Lown converter. Immediately after being shocked, the woman went into a normal heart rhythm, and we noticed that her Cheyne-Stokes respirations stopped and normal breathing resumed. However, in a few hours, she returned to the abnormal heart rhythm and Cheyne-Stokes respirations. We gave her another dose of medicine to stabilize her heart and again shocked her. Her heart rhythm and respirations again returned to normal. That night John and I were very busy, and except for writing notes and orders, we never got off our feet. I had five admissions and John had six. Both of us were looking forward to Saturday afternoon when we could leave Bellevue, go to our apartments, take a shower, and get some sleep. The previous neurologist-in-chief at Cornell had been Harold Wolff, the world authority on headaches. He did excellent research on classifying headaches, finding the cause of some of them, and developing some treatments. He also wrote one of the best textbooks on the diagnosis and management of headaches. However, just before I started my internship, Dr. Wolff died, and Cornell was searching for a new neurology chairperson. The Cornell Neurology Service at Bellevue was fortunate, however, to have Dr. Fletcher McDowell as the attending neurologist. Dr. McDowell was an excellent neurologist, a kind person, and a superb teacher. As interns, we had to rotate on his service, and every one of us was extremely fond of him. In the middle of our internship year, Cornell hired Paul Bloom as the new chair of neurology. Dr. Bloom, who originally trained with Dr. Wolff at Cornell, had left New York City and spent many years on the West Coast, where he developed an excellent neurology program. Even before he

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came back to Cornell, we heard rumors that he was a brilliant young neurologist who would be able to fill Dr. Wolff ’s shoes. Usually, Cornell’s neurologist-in-chief spent most of his time at New York Hospital and only came down to Bellevue on Saturdays to round with the Bellevue interns and residents. Although we were on the Medicine Service, not the Neurology Service, if we could stay awake after working all night, we would often join these rounds. We were all looking forward to Dr. Bloom’s first visit to Bellevue as the new chair of neurology. After Harold Wolff died, there was a period when Cornell-Bellevue had no neurology residents. Dr. Bloom had a residency training program on the West Coast and convinced many of his residents to follow him to New York. On Saturday morning, John and I were making rounds on the women’s ward, Ground B, discussing our new admissions with the residents and the interns who had been off last night but would be on call over the weekend. John presented his patient who was in atrial fibrillation and had Cheyne-Stokes respirations. He told the house officers how we converted her heart rhythm to normal with our new Lown defibrillator. During rounds, she was still in a normal rhythm and was doing very well. John, however, had another patient who had clots (thrombophlebitis) in her right calf and who had one of these clots break off and travel to her lungs (pulmonary embolus). This is a very serious condition which kills many patients, but she survived. John had treated her with the anticoagulant heparin to prevent her from having another pulmonary embolus. When we got her to bed, she seemed to be doing well. However, while examining her calves to see if the swelling had gone down, he noticed that there was black stool on her bed. Black stools can be caused by blood entering the gastrointestinal tract, a serious complication of anticoagulation drugs. However, some foods, such as spinach, can also make stools look black. To learn if she was bleeding, John took a stool sample to the

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lab to see if it contained blood. If it did, he would have to reverse the anticoagulant and then do diagnostic tests to see what might have caused her bleeding. While John was testing the stool, we took the patient’s pulse as she was both lying down and standing up; when people lose blood, their pulse becomes very rapid when they stand up. We also took her blood pressure. Both her pulse and blood pressure were normal, suggesting that if she bled, it was only a small amount. Just as we finished, David, one of the new neurology residents, came on to our ward and walked over to where we were standing. “Hi, guys! Our new chief of neurology, Paul Bloom, will be coming down to Bellevue in a little while to make rounds. We don’t have any really interesting cases on the neurology ward, and I was wondering if you guys had any interesting admissions last night that we might be able to present to him?” Because presenting a case to Dr. Bloom would keep John and me at Bellevue longer than necessary and we were both exhausted, my first inclination was to say no. However, David had already performed some consults on my patients and had done a good job. He also seemed kind, and most of us liked him. I asked, “What kind of patient are you looking to present to Dr. Bloom?” “He’s most interested in disorders of consciousness and coma, but he also has an interest in the control of respiration.” “I had several admissions who were confused because they had infections but no one who was in coma.” “What about John?” “John has a patient who was in atrial fibrillation and had CheyneStokes respirations while she was fibrillating. When we converted her to a normal rhythm, though, her respirations also became regular.” David smiled. “Terrific! Do you think John could present her?” “I don’t know. He was up all last night. But he’ll be back in a minute and you can ask him yourself.”

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John came back from the laboratory and, after saying hello to David, said, “Good news. No blood. Let’s finish rounds so I can get out of here before some disaster happens.” “John, can you do me a favor?” David asked. “You know Dr. Bloom is coming down to Bellevue today. Do you think you could present your woman with AF and Cheyne-Stokes respirations to him at noon?” “She’s all better. She’s now in normal sinus rhythm and isn’t having any abnormal respirations.” “That’s okay. She’d still be an interesting case for him to discuss.” “I really need some shut-eye. I’ll let you look at her chart, and you can present her.” David thought about this for a moment. “John, she’s your case. You really should present her.” I tried to convince John to present her. “John, Dr. Bloom is brilliant. He’ll be able to teach us a lot.” “Okay, but I’m not sure we can finish everything that needs to be done on the service by noon.” I told John, “If we’re not finished by the time Dr. Bloom comes, I’ll finish whatever has to be done.” “Okay. I’ll ask her. If she doesn’t object, I’ll present her to Bloom.” John and I finished all our busy work by noon so that the fresh and hopefully well-rested crew could take over. The residents and interns on the Medical Service were excited about meeting and hearing Dr. Bloom and began gathering on the ward a few minutes before noon. Exactly at noon, several of the neurology residents walked onto the ward with Dr. Bloom. Everyone gathered around John’s patient’s bed, and one of the neurology residents asked John to begin the presentation. John began to relate the woman’s medical history when Dr. Bloom interrupted and told him, “Dr. Zegel, you look terrible. Couldn’t you have shaved and changed into some fresh clothing before you started this presentation?” Surprise and dismay registered on the medical interns’ and residents’ faces, all of whom knew that John appeared this way because

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he had been up for more than 36 hours and had not had a chance to shower, shave, and change his clothing. Bloom’s comment so angered me that I wanted to leave rounds, but I didn’t want to abandon John. Others also looked like they wanted to leave, but then John spoke. “I’m sorry, Dr. Bloom. I very much would have liked to have been well groomed for this presentation, but I was so busy I did not have the time. Do you want me to go on with my presentation?” “Yes, I do, but the next time you present to me, I expect you to be presentable.” “I’ll try,” John responded and then continued his presentation. When John mentioned that the patient’s cranial nerve examination was normal, Dr. Bloom again interrupted him. “Did you perform caloric testing?” From John’s expression, you could tell that either he did not understand the question or he had no idea why Dr. Bloom had asked it. He looked over to me. I also didn’t know why he’d asked the question, so I shrugged. John quickly looked at David, who had asked him to present, and David pointed to his ears. Finally, John said, “No, I didn’t, but I’m not sure why you ask or why you think this might have been necessary.” Dr. Bloom let out a long sigh, then in a very condescending tone replied, “Dr. Zegel, this woman showed evidence of brain-stem dysfunction, and cold water caloric testing is a means of assessing the brain stem. Your examination of this woman matches your slovenly dress and hygiene.” “I’m sorry, Dr. Bloom. I’m a medical intern and didn’t know that this was important, but I’m here to learn.” Dr. Bloom replied, “Just continue.” After Dr. Bloom’s second insult, I was seething with anger. I looked around at the medical interns and residents. They also appeared angry and restless. John finished his presentation by explaining what happened to the patient’s Cheyne-Stokes respirations when we converted her heart from fibrillation to a normal sinus rhythm. I think we were all relieved.

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Dr. Bloom tried to describe the mechanism that accounted for the patient’s Cheyne-Stokes respirations while she was in atrial fibrillation. He favored the metaphor of electronic circuitry and spoke of rheostats, variable condensers, and tuners. I was so angry and irritated that I had trouble paying attention. I kept thinking about whether I should say something about his rudeness or just leave during his discourse. He must have noticed my lack of attention because he asked, “Dr. Heilman, what do you think of this explanation of her abnormal respirations?” “I’m sorry, Dr. Bloom, but I didn’t fully understand. I haven’t been trained as an electrical engineer. I’m just a medical intern.” “Apparently,” Dr. Bloom replied, “you’re not knowledgeable in either profession.” I was enraged. “Dr. Bloom, you don’t know me or my skills. I think it’s time for me to finish working on my charts.” I turned around and left without waiting for Dr. Bloom to respond. As I walked back to our doctors’ room on the side of the ward, I noticed that John as well as most of the medical interns and residents were leaving rounds and heading in the same direction. The only people left listening to Dr. Bloom were his neurology residents. When we gathered in the room, we all just looked at each other, shook our heads, and went on about our business. John and I had returned to writing notes in our patients’ charts when we heard Dr. Bloom’s voice. We turned around and saw him standing in the door. “Doctors, I think we all got off on the wrong foot. Hopefully, next time things will go better.” John and I nodded, and Paul Bloom left with his neurology residents. A few minutes later we left Bellevue and headed to our apartments to get some sleep. When I awoke in the evening, I felt very disappointed about what had happened earlier that day and even wondered if I had been overly sensitive because I was sleep-deprived. I later learned from the neurology residents that the behavior Dr. Bloom had exhibited

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on rounds that day was his modus operandi and that he had offended many people at New York Hospital with his insults. I also felt sad about this encounter because I was interested in neurology and before Dr. Bloom’s visit was even considering taking my training in neurology at Cornell. After I finished my internship, I decided to take at least one year of medical residency and stayed at Cornell-Bellevue. During the remainder of my internship and my medical residency, I always tried to avoid Paul Bloom and seldom attended his Saturday rounds. After two years of general internal medicine training, most of medical residents took specialty training. I enjoyed cardiology but could never hear some of the heart sounds, like the opening snaps and, thus, felt I would be a failure. I very much liked the people who worked in the Division of Infectious Diseases but was convinced that all the new antibiotics and vaccinations would lead to their unemployment in a few years. Little did I know then that viruses and bacteria are always a step ahead of us. Despite Paul Bloom and people’s caution that there was virtually no disease that neurologists could successfully treat, I remained intrigued by this specialty. At the same time, the war in Vietnam was heating up, and the military really needed doctors. Although I was in the Air Force Reserves, I was enrolled in the Berry Plan, a deferment program that let you complete your training before serving at least two years in the military. I decided to go on active duty. To terminate my deferment prematurely, I had to go to Washington to sign some papers. In the summer of 1965, I took basic training in Montgomery, Alabama, then was sent to Izmir, Turkey, to be chief of medicine at a 75-bed hospital. Because NATO had its southern headquarters in Izmir and we took care of the NATO troops, the hospital was called “NATO Hospital.” During the time I practiced there, I had the opportunity to take care of many men with treatable diseases, including strep throat, middle ear infections (otitis media), and gonorrhea, which the solders called the “clap.” I didn’t find treating these diseases to

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be particularly exciting or challenging and started thinking again about taking a neurology residency when I was discharged. After I had been in Turkey for about a year, I received a letter from Dr. Thomas Almy, the chief of medicine, inviting me to return to Cornell-Bellevue to complete my medical training. I wrote him back, thanking him for the invitation, but explained that I would like to train in neurology. He wrote back another very kind letter in which he stated that he would miss working with me on the Medical Service but that he would tell Paul Bloom that I’d like to start a neurology residency at Cornell when I was discharged in the summer of 1967. After I received Dr. Almy’s letter, I quickly wrote a letter to Dr. Denny-Brown at the Harvard Neurological Unit, asking if I could start a neurology residency there in 1967. Afterward, I wrote back to Dr. Almy, expressing my appreciation for advocating on my behalf with Dr. Bloom but that ever since medical school I had wanted to train with Dr. Denny-Brown. I explained that I had already written to Dr. Denny-Brown requesting admission to his program and asked if he would write a letter of recommendation about me to Dr. Denny-Brown. Fortunately, after receiving my medical school records and the letter from Cornell (which was not from Paul Bloom), Dr. DennyBrown admitted me. After finishing my neurology residency at the Harvard Neurological Unit, I joined the faculty at the University of Florida. One of my major reasons for going there was that, in speaking with their neurology residents, each one told me that Dr. Greer, the chair, was kind, generous, gentle, and giving. Since I joined the faculty at the University of Florida, I have advised many students who wanted to become neurologists about where they might want to take their residency. Some were interested in going to New York, perhaps because so many of their families came from New York; and when they asked me about Cornell and Dr. Bloom, I advised them against going there. I explained that some

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programs teach by intimidation and others by invitation. Paul Bloom at Cornell used the intimidation method, and I strongly recommended that the students select a program that uses invitation. In spite of my advice, several former medical students took their neurology training at Cornell, and most are excellent clinicians. I know of many other people who trained at Cornell with Dr. Bloom and are not only excellent neurologists but also, in several instances, outstanding academicians and leaders in American neurology. I’m not sure of the moral of this story, except that some plants do better in neutral soil and others do well in acidic soil. For some people, an educational environment that uses intimidation appears to work as well as, or even better than, one that uses invitation. Fortunately, unlike plants, people can select the environment that best allows them to flourish.

20 Decisiveness: Don’t Confuse Me with the Facts April 1964

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ergeant John Murphy was a New York City policeman who had been investigating a robbery on 24th Street and First Avenue when he suddenly experienced crushing chest pain and became sweaty. His partner drove him to Bellevue. We admitted him to the Emergency Ward and obtained an electrocardiogram, which revealed that he was having a heart attack. Back in the early 1960s, we did not have clot busters or stents, so our only option was to treat the complications of a coronary occlusion. Although Sgt. Murphy’s heart attack damaged some of his heart muscle, he did very well: He developed neither shock nor heart failure. We offered him anticoagulation medication, but he refused it because he feared its effects; he wanted

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to go back to work and was worried that if he got injured or shot while on this medication, he might bleed to death before getting to the hospital. In retrospect, I think he made the correct decision because although antiplatelet agents such as aspirin have been shown to prevent heart attacks, anticoagulants such as warfarin have not. His blood pressure was a little high, and his cholesterol was elevated. We treated him with a low-fat diet and gave him a water pill (hydrochlorothiazide) to reduce his blood pressure. He was then discharged toward the end of March and told to return to our medicine clinic in about two months. About six weeks after his discharge, I received a page asking me to call the General Surgery Service. When I responded to the page, expecting a surgical intern or resident to answer, I instead reached a secretary who, to my surprise, told me that Dr. Richter wanted to speak with me. Dr. Richter was a very senior surgical attending, who was a full professor at Cornell. When he came on the line, he said with a deep voice and a southern drawl, “Dr. Heilman, Sir. You had a man on your service that you treated for a heart attack. His name is Police Sergeant Murphy. Do you remember him?” “Yes, I do. He did very well, and we discharged him several weeks ago.” “Well, the reason I had you paged is because we now have him in the hospital and are considering the possibility of operating on him, but before we operate, I wanted to get your approval.” “You want my approval? Dr. Richter, I think you might want to speak to our attending or my resident. I am just an intern.” “Yes, I know, but you are the intern who took care of him. That is why I called you and not them. No one knows a patient like his intern.” “Dr. Richter, I think it is best not to operate on someone shortly after he’s had a heart attack, but if this is a life-or-death emergency, you have no choice.”

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“No, Doctor. This is not emergency surgery. He has a hernia, which since his heart attack has been really bothering him. He wants to get it treated.” “Doctor, I am not an expert; but this same question came up about a week ago, and I had a chance to look over some of the literature written about this problem. Let me tell you what I read about some of the risks and about the percentage of patients who get into serious trouble from surgery that is performed several weeks after they’ve had a heart attack. Now, according to one article in Lancet . . .” “Doctor Heilman, please,” Dr. Richter interrupted. “Do not confuse me with the facts. Can we operate or not? Yes or no?” “Well, it depends . . .” “Please, Sir, no equivocation. I do not have the time. Yes or no?” “Dr. Richter, you might want to check with someone more senior than I am, but I would say if this surgery is elective, the answer would be no. Hold off.” “Thanks, we will discharge him today.” Prior to this conversation I had never spoken to Dr. Richter. Afterward, I became very curious and asked several people about him. Everyone agreed he was a brilliant surgeon. He was decisive and had little patience. He was a perfectionist, but from surgical “opening to closing,” he could complete a case quicker than anyone else at Cornell. Of the many stories that I heard about Dr. Richter, the most revealing one emerged during a conversation I had with a surgical resident in the Bellevue cafeteria. One time, according to this resident, two surgical residents were operating on a man whose intestines, for some reason, had become severely twisted. When this happens, since some of the blood vessels get squeezed and cannot replenish the intestines with oxygen and glucose, these parts of the intestine die (infarction). This might be painful for the patient. Worse, unless the dead sections of the intestines are removed, the intestine might rupture, spilling out feces and bacteria into the abdominal cavity. The infection

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produced by this rupture, called peritonitis, is often fatal. Thus, surgeons often take out the dead bowel, and if there is a sufficient length of undamaged intestine, they hook the two cut ends of the intestine back together. If, however, there is insufficient living intestine to make this end-to-end attachment, surgeons connect the living section of the intestine to an opening they make in the skin (colostomy). The patient attaches a bag to this opening. This bag collects the fecal matter coming out of the intestines, and the patient periodically empties these bags. Since it would be better for the patient to have an end-to-end attachment, the less intestine that has to be surgically removed, the better chance that surgeons have of sewing the intestines together and of avoiding a colostomy. During the operation on this particular patient at Bellevue, the surgical residents had trouble determining the dead from the living sections of the bowel and even the chief resident could not come to any conclusions about what to remove. Thus, they decided to call Dr. Richter into the operating room. Just after arriving, he asked the residents, “So you want to know how you can tell if a piece of bowel is dead or alive? The answer is simple and applies to everything you do in life. Cut it and see if it bleeds. If it bleeds, it is alive.” Although Dr. Richter and some of his surgical residents live by philosophic principles of “Don’t confuse me with the facts” as well as “Cut it and see if it bleeds,” others never learn to think or live their lives in the way that Dr. Richter advised. Personally, I am still often confused by the facts and think twice before taking an action that may have precipitous results: I still worry, for example, that if I make a cut, it might never stop bleeding. I suspect, however, that medicine needs both types of approaches—the decisive and the cautious.

21 An Afternoon Off May 1964

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any New Yorkers who spend most of their lives indoors or on the subways only know by looking at their calendars when spring is arriving. But interns working in New York’s city hospitals, such as Bellevue, have another means of knowing. In these hospitals, which take care of many of New York’s homeless, spring is the slack season and homeless admissions seem to drop with the advent of warmer weather. This slack allows many interns to have some time to themselves. One spring night that I was on call, it was so slow that I was able to go to the on-call room, do some reading, and then sleep through the night until my alarm went off in the morning. I then made rounds, wrote notes, and took care of a few things that my patients needed. That afternoon, I was supposed to attend a lecture by a

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hospital administrator on Medicare, which was new at the time, and about Medicare billing. I did not think this topic was very interesting, and since all my patients were stable, I had no new admissions, and there was no clinic that afternoon, I decided to take the rest of the day off. Jim, my co-intern who was on call that night, agreed to cover for me. After I gave him some instructions about my patients, I left the hospital, still in my hospital whites, and walked down to 25th Street between First and Second Avenues, where my car was parked. I had not used my car for about a week, during which time several green parking tickets, for failing to park on the opposite side of the street on Tuesdays and Fridays, had accumulated under the wiper blades of my 1954 Ford. I removed the tickets from the car, and I was pleasantly surprised when my car started without needing a battery boost or a push. After filling the car up with gas, I headed off to Central Park. When I got to the edge of the park, right off Fifth Avenue, a miracle happened: I found a legal parking spot. Unfortunately, the parking meter only took dimes and quarters. Since I only had nickels and dollar bills, I walked into several stores on Madison Avenue and asked for change. It seems no one in New York had change for a dollar. I considered begging on the corner but was sure that I would either have an embarrassing encounter with a relative or get arrested for not having a beggar’s license. So, I went back to my car and tried putting the nickels into the meter’s quarter slot, in the faint hope it would magically give me some minutes. No dice. I finally stuck a handwritten message—“Meter will not take my money. Out of order”— into the quarter slot, threw my white jacket into the back of the car, locked the door, and headed off to the park. It was a beautiful, cloudless day, and the temperature was in the high 60s. The park looked beautiful. The grass and trees were newly green, and the air smelled of spring. There were the sounds of children playing after school. I took a deep breath and tried to be aware

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of all the sights and sounds. I closed my eyes so I could better feel the gentle breezes around me. Suddenly, I felt someone tugging on the back of my pants. I turned around and looked down. There was a little blonde-headed girl who was probably about five or six. “Mister, can you give me an orange popsicle?” I looked at this girl and said, “What do you mean?” She replied, “Let’s go to your Good Humor Ice Cream truck so I can get a popsicle.” Seeing my white pants and white shirt, she had mistaken me for the Good Humor man. Her mother, who had been sitting on a bench, came over to me. “I am sorry she is pestering you. She thinks you sell ice cream.” I had in fact seen a Good Humor man on Fifth Avenue just as I’d entered the park, so I suggested that we all walk to his truck and that I treat her to a popsicle. The mother asked, “Do you really want to do that?” I replied, “It would bring me joy.” After I bought the popsicle, the mother asked her daughter, “What do you say?” I knelt down, and the little girl said, “Thank you.” She then gave me a little kiss on my cheek, and I said goodbye. The popsicle purchase now meant I now had change, courtesy of the Good Humor man, but I talked myself out of wasting the time needed to go back to my car and feed the meter. It was just too beautiful a day to bother with that contraption, so back into the park I went. Nearing the boat pond, I heard the sound of children and saw many toy boats in the pond, including sloops, ketches, yawls, and power boats. The boat that really caught my attention, though, was a gaff-rigged schooner. I could tell it was made by hand—and by a builder who knew more about what went above the waterline than about what went below. The boat appeared to be unstable, suggesting that either it did not have a keel or the keel was not sufficiently weighted. A boy, who was about 10 or 11 years old, watched this boat closely and anxiously. His schooner was right in the middle of

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the pond, and every time a breeze came, his boat keeled over too far. Finally, the wind blew it over so that the sails were now in the pond; the boat did not right itself but remained motionless on its side. The boy looked on in horror. Within the next 20 minutes, he threw every nearby stick at the boat, hoping somehow to right it or help propel it to the side of the pond so that he could retrieve it. But this strategy failed. By now almost all the other children, together with the parents or nannies, as well as their boats were leaving the pond area and the sun was starting to set. The boy then leaned over the water and tried to splash the boat toward the edge of the pond. This strategy failed, too. He stood up, and although I was on the other side of the pond, I could tell that tears were coming to his eyes. When the boy saw me walking over to him, he quickly wiped his eyes and tried to hold back his tears. I said, “She’s a beauty, but you should have put more weight on the bottom of her keel.” This comment only made things worse. The boy’s bottom lip drooped, and he started to cry again. I then told him, “Hey, listen. Don’t worry; we will find a way of getting her back to you.” In the eyes of many residents and attending physicians, the difference between a good and a bad intern depends on how well he or she anticipates the resident’s or attending physician’s needs. Who knows when a resident or attending will need tape, a pair of scissors, a clamp, a latex tourniquet, needles, syringes, tongue depressors, sterile gauze, cotton applicators, or other paraphernalia? Thus, as an intern I carried all sorts of things with me, including a sterile roll of sutures. Most of these I kept in the pocket of my jacket, which was in the back of my car, but I did have a 50-yard roll of sutures in my pants pocket. I found a little stick to put inside the spool, giving the free end of suture to the boy. I told him to hold the suture and to walk to the other side of the pond while I stayed in place, holding the spool. When he got to the other side, I held one end of the suture and he the other end while we both walked in the same direction. The suture snagged the schooner, and we were able to nudge his boat

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to the edge of the pond. The boy ran to pick it up out of the water, and I rolled the suture back onto the spool. Holding his boat, he came over to me and said, “Thanks. You are a lifesaver. After I put more weight on the bottom, we can sail it together.” “Okay, young man. Some day we will sail it together, but you need to get home now. It will be dark in 15 minutes.” The boy walked down one path, and I started down another to head back to my car. After a few steps, I yelled to him, “Do you want me to keep you company until you get home?” “No, thanks. I always come and go to the park by myself. I will be home in 15 minutes.” “Be careful,” I yelled. The boy waved and yelled, “Thanks again.” I had a longer walk than did the captain of the schooner. When I reached my car, it was already dark, but I could see that familiar green parking ticket on my windshield. Next to the ticket was my “out-of-order note,” on which the cop had written, “Bullshit.”

22 Know Thyself: Not Cut Out To Be a Physician May 1964

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ummer was coming to New York and the days were getting longer. One Saturday morning I awoke, and seeing how bright it was outside, I knew I was late for work. I looked across the bed at Carolyn, who was curled up fast asleep. I watched her breathe a few seconds, then leaned over and gently kissed her cheek, slipped out of bed, quickly took a shower, and got dressed. I was about to leave the apartment, when I turned around to look at Carolyn one more time. At that moment, she opened her eyes, blinked a few times, rubbed her eyes, and asked, “Can’t you have breakfast with me?” “I would love to, but I am already late.” Carolyn yawned, stretched, and asked, “I flew all the way here to spend time with you. Can’t you call the hospital and tell them that you are sick or something?”

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“No,” I told her, “I really have to go.” Carolyn got up from the bed, walked over to me, and gave me a hug. “Please stay.” “This is not the easiest thing to do, but I really have to go.” “Will I see you tonight?” “I hope so. I am scheduled to be on call tonight, but Rosenberg, who is my co-intern this month, owes me a night and hopefully he will be able to cover for me. I will try to call and let you know.” I kissed her goodbye and left the apartment. It was already 7:45 AM, and since I was late for rounds, I ran to the hospital. Once there, I ran past the Emergency Ward to look for Jonathan, the co-intern who was on the wards with me this month, but I did not see him. I also looked for Walter, our resident; but he wasn’t there either. I then ran up a flight of stairs to our ward and looked around for them there, but again, I didn’t find them. I saw Kathy, the day-shift nurse, at the other end of the ward, giving out medications; and we waved to each other. In the large open wards that Bellevue had at that time, you could look around and see all the patients in one sweep. I quickly surveyed my own patients to make certain that they all were there and that none was in acute distress. I noticed that not only were all the beds on both sides of the room occupied but other beds had been added. The beds were so close to each other that there was only room for a two-foot-wide nightstand to be wedged in between them. Clearly, the night before had been extraordinarily busy with patient admissions. I went to talk to Kathy, who by now was putting the medication tray on her desk near the entrance to the ward. She wore a freshly starched white nurse’s dress and a white Bellevue nurse’s cap. Shaped like the paper surrounding a cupcake, this nurse’s cap was almost falling off her head. Fixing it to her hair with some bobby pins, she greeted me again. “Good morning, Doctor Ken.” “Good morning, Kathy. Do you know where the other doctors are?” “No, I don’t.”

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“Have they made rounds yet?” “No, not yet. I guess they are really busy. Dr. Jonathan had eight admissions last night. All are on this ward. I am not sure if he has other patients in the EW. Maybe they are down there.” “No, I went by the EW before I came up here. I did not see them.” “Would you like me to page them for you?” “No, thanks. I will page them.” In the corner of the ward was a little room with several small desks where doctors could write notes in the patients’ charts and view X-rays. There was a shelf with some medical textbooks and journals, as well as two phones. I went to one of the phones and paged Walter because I thought he might be less busy than Jonathan. A few minutes later, Walter called back. “Where were you this morning?” he asked. “I’m sorry, Walter. Carolyn came in. I stayed up too late and overslept. Did I hold up the works?” “No, we have not made rounds yet. Ken, could you start making rounds by yourself and see what needs to be done. I will join you in a little while and give you a hand.” “Where is Jonathan?” “He is with me.” “Is anything wrong?” “I will talk with you later.” I hung up the phone, took all the charts, and put them in the mobile chart rack. I also picked up the order book, medication book, and vital signs charts and started making rounds. The first three patients were Jonathan’s. They were all stable and awaiting disposition to a chronic disease hospital or nursing home. As I was beginning to check the next patient, Walter arrived. “Where is Jonathan?” I asked. “Up in his room.” “Is he sick?”

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“No, upset.” “Why?” “Something happened last night. He refuses to tell me anything about it, except he wants to quit. He knows, however, that if he quits now, we would be short by one intern and he doesn’t want us to suffer, so he’ll wait until he finishes his internship at the end of next month.” “Did he tell anyone else about this?” “Yes, that’s how I found out. On the way to the wards this morning I saw him in front of Dr. Almy’s office. He told me that he wanted to tell Dr. Almy that he decided not to become a first-year resident. I tried to stop him, but he went into Dr. Almy’s office anyway.” “What happened in the office?” “I am not sure. He was in there for about 10 minutes. I waited outside the door. When he came out, he said, ‘Let’s make rounds.’ You know Almy treats Jonathan almost like he was his own son. Jonathan did not tell me what Almy said, but I’m guessing that Almy told him to hold on and wait for a few days before he made such an important decision. The whole morning Jonathan was upset. Really upset. All this year when working with him, I never saw him upset. It troubled me to see him that way, so I asked him to come up to the on-call room so we could have some privacy and I could try and talk with him; but I could not get anything out of him.” “Where is he now?” “Still upstairs. He wanted to come on rounds, but I told him to stay put. Ken, you have been closer to him than I have. Maybe after we make rounds, you could go up and speak with him.” The rounds went quickly. Although Jonathan had had eight admissions while on call the night before, all had been worked up beautifully. All had excellent and detailed notes, and he had performed their admission laboratory work. All the patients had detailed orders, and all were taking the proper medications.

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After we finished rounds, Walter started to write his resident’s notes in the charts of these new admissions. I excused myself and took off for Jonathan in the on-call room. When I reached the room, I knocked on the door gently at first; but when he did not come to the door, I knocked louder. Still no response. Worried, I decided to turn the door handle and, finding it unlocked, I walked in. I saw that Jonathan was fast asleep in an easy chair near the window. A clipboard was on his lap, and when I went to remove it before it could fall to the floor and perhaps wake him up, I noticed he had drafted a resignation letter to Dr. Almy. I tried not to read it, but he had written only three sentences and I could not help seeing them. He wrote, “After speaking with you, I have considered this matter carefully, and although I had always thought that I wanted to be a doctor, I have decided that I am not well suited to be a physician and practice medicine. I will finish my internship, but would like to resign after next month and not start my medicine residency.” I really wanted to speak with Jonathan before he gave Dr. Almy this letter but thought that, after the busy night he had had, he needed his sleep more than he needed to talk with me. I decided not to take the clipboard out of his hands and started to tiptoe out of his room. Just as I was closing the door, Jonathan called out, “Ken, is that you?” “I am sorry I woke you.” “No, it’s a good thing you did. I want to finish a letter I am writing and get down to the wards and see how my patients are doing.” “Don’t worry about your patients right now. Walter and I made rounds just before I came up here, and all your patients are doing well. In addition, as usual, you did a great job.” “Ken, what are you doing up here?” “I came up here to talk with you. What’s wrong? What’s going on?” “Nothing.”

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“Come on, Jonathan. This is not your routine day. Walter told me that you spoke with Dr. Almy this morning. When I found you asleep, I wanted to remove the clipboard from your lap and could not help seeing what you had written.” “I really appreciate your interest, but this really does not concern you.” “It does concern me.” “Well, I guess it is no secret. I spoke with Dr. Almy about not taking my medicine residency. He asked me to just think about it more, and now I am writing to tell him that I thought about it and I still would like to be excused from starting a medicine residency.” “Jonathan, you’re one of our very best interns. Your patients love you. Why would you do this?” “When I was on call last night, I realized I am just not cut out to be a physician.” “What happened last night, besides getting eight admissions?” “What happened was not important.” “If it was not important, why can’t you tell me about it?” “Look, Ken, I really do not want to talk about it. Would you excuse me so that I can finish this letter? Then I will see you on the ward for attending rounds.” As I started to leave, Jonathan said, “Ken, I’m sorry to be so abrupt. Maybe we will talk later.” “Can we talk tonight?” “You’re on call tonight.” “I know, but Rosenberg owes me a night and I will ask him to cover. Also, Carolyn is up here and she has to go back tomorrow, so I would also like to spend the night with her.” “Look, Ken, it’s no use.” “You know me. I will not give up until I have a chance to talk with you, and what’s more, if I were acting like you, you would do the same. Please!”

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“Okay, why don’t you and Carolyn come over to my place about 7:30 tonight, and I will have my wife make us some dinner.” “No, please, let’s go to Harvey’s, just you and me. We will get some of those thick burgers with the grilled onions and a cold Budweiser. I will meet you at 7:30. We’ll eat and be home by nine.” I then left the room and went back to work. Although he joined us for attending rounds so that he could present his new admissions, I did not see Jonathan the rest of the working day. I got Rosenberg to cover for me that night and called Carolyn to tell her that I would be back about seven. When I got to my apartment, she hadn’t yet returned from her day at the Metropolitan Museum of Art. Anxious to get to Harvey’s on time, I left her a note explaining that I had to meet Jonathan and speak with him, alone, and that I would be back about 9:00 PM. Harvey’s was a place that had a bar on one side and a restaurant on the other side. The floors were covered with sawdust and peanut shells. Old pictures of Manhattan hung on the walls, and the tables had red tablecloths. The waiters were dressed in vests and straw hats. When I arrived, the bartender greeted me with his usual, “Hi ya, doc.” His greeting always sounded a little like Bugs Bunny’s “What up, doc?” I didn’t recall ever wearing my whites into this restaurant and did not know how he knew I was a physician; perhaps bartenders just have a special ability to recognize people’s occupations from their appearances. I got a corner booth, and from there I could see the front door and watch for Jonathan. When he hadn’t arrived by 7:40, I went ahead and asked the waiter for a bottle of Budweiser along with a glass and a menu. I thought Jonathan had stood me up, but then he arrived and sat down. “Hi, Ken. Sorry I’m late. My wife made dinner for me, and I decided to have dinner with her before coming here. What did you want to speak to me about?”

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“I had hoped that you would do the talking.” “Ken, I really appreciate your interest and concern, but I have already made my decision. I think you know that.” “Look, I do not understand. You are probably the best intern in the entire hospital. I do not understand why you are quitting. What happened last night?” “It is not what happened. It was the way I reacted to it.” “Could you please tell me how you reacted to whatever happened?” When the waiter came over with a cold bottle of Budweiser and a cold mug for me, Jon asked him for the same. The waiter brought Jonathan his beer and put two menus down on our table. “Jonathan, please tell me what happened and how you reacted to whatever happened. I have to make sense out of this.” Jonathan took a few sips of beer, picked up a coaster, and started to bend it back and forth as he spoke. “Well, as you know, I was kept very busy until about 5:00 AM. There were two gastrointestinal bleeders, one acute myocardial infarction that became hypotensive, and two patients with pulmonary edema. When I finally got all those patients stable, I went to my room to lie down. I felt a little sick. I started to doze off when the phone rang. Marge, the EW nurse who was on call last night, told me I had a new admission that was in shock. I asked her to have someone start an IV and I would be down in three or four minutes. I ran out of the room and down the stairs as quickly as I could go, but as I was rushing, I had the same thought over and over. I hoped that this hypotensive person would die before I got there. Then I would get credit for the admission and would not be next up for a new patient. If I had no work to do with this patient, I could go back to bed. That’s it.” “That’s what?” “That’s all that there was.” “What happened when you got to the EW?” “The patient was dead.” “So you feel like you killed him?”

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“No. I am not that naive. I did not think my wishing for his death killed him, but I did realize last night that anyone with this type of attitude should not be in medicine.” I noticed that both of us had finished our beers, and I motioned to the waiter to bring us two more bottles. Then I asked, “Can I tell you something that happened to me in medical school?” “Sure. Go ahead.” “When I was in medical school, we had to deliver 20 babies in our last year. One of my good friends, throughout medical school, was on call with me for delivering babies. Except for little catnaps, we were up two days and two nights. The next morning another team of two students came in to replace us. My friend went to the locker room to pick up some dirty clothing he had left there. We met in the hallway just outside the delivery rooms. When I saw him, he said, ‘Do you smell daisies?’ I looked at him and said, ‘Daisies do not smell.’ He said, ‘Are you contradicting me? They sure as hell do smell.’ After a few more insults that we threw at each other, we were standing in the hallway, our fists up, squared off, and ready to go at it . . . all because we disagreed as to whether or not daisies smell. Luckily, one of the ob-gyn residents came out of the delivery room, saw us, and started to laugh. His laugh made us understand how silly we must have looked, so we put down our fists, hugged, and went home to sleep. Whenever I see my friend, we still laugh about this incident.” “What’s your point?” “Jonathan, why do you think we acted this way?” “I don’t know, and I do not see how it has anything to do with my decision.” “Sure, it does. If you leave internal medicine, please don’t go into psychology or psychiatry. You would be lousy. Sleep deprivation can cause serious lapses in judgment and even a temporary psychosis. When we had that disagreement over the daisies, we were probably psychotic.”

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“I was not psychotic when I wanted that patient to die before I got there. I was rational . . . too damn rational. I moved down there as quickly as I could, knowing that I could not be blamed if he died before I got there but still hoping that he would die so that I could be relieved of what I considered to be a burden. Does that sound psychotic?” “No, it was reasonable, but the lack of sleep affected your judgment. “My judgment was fine. I did not do anything that was irrational.” “No, I’m not getting my point across. You were seriously sleepdeprived, just like the people in the North Korean prison camps and concentration camps. It has been repeatedly shown that with such sleep deprivation there is a lowering of ideals. You are not being fair to yourself because now, under nondeprivation conditions, you are judging how you acted during deprivation. Does that make sense?” “Logically, yes, it does make partial sense, but it does not change my decision. I was not in a concentration camp, and anyone who can change his ideals with such slight deprivation does not belong in medicine.” “What will you do?” “I’ll go back and resume the bacteriology research I was doing before medical school.” “Jonathan, the reason I wanted to speak with you so badly tonight is that I really think you are needlessly wasting five years of your life and a lot of talent.” “No, Ken, these were not wasted years. I learned a lot about myself.” By now, Harvey’s was crowded and noisy with patrons. In the din, Jonathan and I sat silently for a few minutes. I did not know what else to say to him. He tossed the coaster he’d been continuously bending, which now was in two parts, into an ashtray, finished his beer, and then motioned to the waiter for the check. Despite my protests, Jonathan paid the bill and said, “Thanks for your concern, Ken. I’d better be going.”

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After he left, I finished my beer, ordered some take-out for Carolyn and me, in case she had not eaten, and headed back to my apartment. I took my first year of medicine residency at Cornell, but Jonathan was not one of our coresidents. I still think about what a wonderful physician he would have been and what a terrible mistake he made, but as Carolyn told me, “He had to do what he had to do.”

23 The “Disposition Problem” May 1964

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uring my year as a medical intern, one of the major problems that I and my co-interns continually faced was what to do with our patients after they received optimal medical care. Many of these patients were poor and old and thus required care for a chronic disease or just help performing their activities of daily living. Many had no family nearby or no family with the resources needed to properly care for them. As a result, these patients hung in limbo at the hospital until their disposition could be determined. They were, in short, considered “disposition problems.” Every hospital has a limited capacity, and many large hospitals that care for indigent patients, such as Bellevue, cannot fulfill their mission if, because of a lack of available beds, they have to turn away acutely

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ill patients. Therefore, the interns at these hospitals are constantly struggling to discharge patients who no longer need to be in the hospital but who still fill hospital beds. During my internship Bellevue did have a Social Service Department, which handled these disposition problems by attempting to find a place for the patients, depending on their needs, in nursing homes, chronic disease hospitals, mental hospitals, group homes, or rehabilitation hospitals. The social worker who was assigned to our medical service was Adrianne Brooks, a dour woman in her mid-fifties who seemed to wear the same black dress almost every day. No one knew if she wore a black dress because she was a widow or because she liked it. Her glasses hung from a string around her neck, and her face and eyes always seemed to look tired, perhaps the result of too many dealings with the city’s bureaucracy. She seldom showed interest in our patients and only rarely came to visit them or the interns and residents who were working on our Cornell (Division 2) wards. When we wanted to know if she was making any progress in finding a new place for our disposition problems, we had to visit her in her little cubical in the administrative building. During these visits, she almost always appeared disinterested and apathetic and would give the same progress report: “The papers are in, and now we just have to wait.” If I said that we had already waited too long, she would reply, “There is nothing more that can be done.” If I thought a place that she had finally found for one of my patients was inappropriate, she would say, “We can put in new papers, but I don’t think it will do any good.” Many of the interns and residents used a variety of means to motivate her, but nothing seemed to help. In May 1964, on what started as a quiet Sunday afternoon, an unkempt man stumbled into the hospital, collapsed, and died before he could reach the front desk. Several minutes later, two other men entered the hospital, one carrying the other in his arms. Both of these men were terribly disheveled and reeked of alcohol. The one who was being carried was pronounced dead on arrival. The other,

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a Mr. C. L. Jones, looked like he was about to die himself. He was confused and could not give a cogent history but kept repeating, “Those dirty bastards . . . fifty cents a fifth. Those dirty bastards.” Other than severe hyperventilation and lice in his hair, his physical examination was normal. Our diagnosis was wood alcohol (methanol) poisoning. We started an IV and gave him bicarbonate to treat severe acidosis and pure grain alcohol (ethanol) to displace the toxic methanol. We then took him to the hemodialysis unit so that the methanol could be removed from his blood. During the time that Mr. Jones was undergoing hemodialysis, many other people were being admitted to the hospital with methanol poisoning. Almost all of them were inhabitants of the Bowery and were suffering from chronic alcohol addiction. Some walked into the hospital, and others took public transportation. Still others were brought in by ambulances or by the police in their squad cars. Many of those brought by ambulance were dead on arrival or died shortly after being admitted. Those who survived past admission were critically ill. There were not a sufficient number of dialysis units for an unexpected epidemic such as this, and the units we had were used to capacity. Those patients who could not be treated by hemodialysis were treated with peritoneal dialysis, but because there was also a shortage of this equipment, some patients had to be treated solely by IV fluids that contained bicarbonate and grain alcohol (ethanol). Despite the great effort by our doctors, nurses, hospital staff, medical and nursing students, and even volunteers, many of these unfortunate people died; but a few were saved, including Mr. Jones. After Mr. Jones was treated with dialysis, he was brought to our men’s ward, where he fell asleep. It was now late at night. His vital signs were stable and he was breathing normally. I went to attend to my other patients, and early the next morning, while walking to the laboratory, I heard my name being paged over the loudspeaker. I called back to the ward and spoke with the nurse, who told me that “Mr. Jones is crying and appears to be very upset. He is asking . . . demanding to see you.”

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When I got back to the ward a few minutes later, he had stopped crying. He was sitting up in bed and holding his arms in an extended position out in front of his body. He seemed to be groping for something. I watched him for a moment and noticed how much better he looked than when I had first admitted him the day before. I said, “Mr. Jones, the nurse said that you wanted to speak with me.” He moved his arms in my direction as if he wanted to touch me. I took his right hand in mine and said, “I am right here.” He moved his head in the direction of my voice and said, “Doc . . . I can’t see. I’m blind in both eyes.” I examined his eyes and found that he could see when my flashlight was turned on but that he could not count my fingers or even see my hands wiggle. I told him, “Sometimes wood alcohol can cause an impairment of vision. You can still see light, which is a good sign. Let’s give your eyes a few days to heal and see what happens. You still might get back some vision.” Mr. Jones remained silent for a few seconds, then lowered his head and said, “Those dirty bastards!” “Mr. Jones, how did you and all those other people get that wood alcohol?” I asked. He replied, “Those dirty bastards. They had several cases of booze in the alley. They said it was good stuff, pure alcohol. They said that since they did not have a license to sell it, they were giving it away fifty cents a bottle. Hell, that is even cheaper than a bottle of Thunderbird wine. Those dirty bastards.” “They poisoned and killed a lot of men,” I said. “But the police haven’t found them. Do you know who they are?” He shook his head and said, “No, never seen them before.” He then asked me, “Doc, what happened to John?” “Who’s John?” “The man I was carrying.” Reluctant at first to answer Mr. Jones, I then decided that he probably already knew what happened to John and just wanted confirmation. “I am sorry, but John is dead. He was already dead when

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you got here.” Tears came to Mr. Jones’s eyes, and he again said, “Those dirty bastards. Do you know, Doc, that this poor old fellow never knew anything about the world outside the Bowery. Because I went to college, he used to call me ‘Professor.’ He thought I was the last word in truth and wisdom. He did not want to drink the stuff we bought for fifty cents. He said, ‘Couldn’t be any good for fifty cents.’ I thought I knew better and told him it had to be okay because the bottles had government tax stamps on them. The poor guy believed me and drank it. Now he is dead.” Mr. Jones then stopped talking, closed his eyes, and put his face in the pillow. I left his bedside and attended to other matters. In the next few weeks, ophthalmologists tested Mr. Jones’s eyes almost daily and reported that he had a central scotoma (a loss of central, high-acuity vision). This is a typical effect of methanol poisoning, which destroys the fovea, the part of the retina that allows us to see details. The ophthalmologists thought he would never recover useful central vision and was legally blind. They had nothing with which they could treat him. Other than his blindness, Mr. Jones had recovered fully from the methanol poisoning. He was now a disposition problem. I walked over to the administration building to tell Ms. Brooks about him. Before I could even finish my story, she asked, “Did you put in the papers?” I replied, “No. I didn’t. I do not know where to apply. He is not a candidate for a nursing home or a chronic disease hospital. He needs rehabilitation and training for the blind.” She thought for a few seconds about what I had said and then bluntly uttered, “No.” I was annoyed at her apathy and negative attitude and said with an irritated voice, “Why not?” She took the glasses that were hanging on her chest, put them on, and peered over them as she said to me, “Because he is an alcoholic. These places have enough work just trying to train the blind to be independent. They do not need the additional problems that an

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alcoholic will bring, and they do not like to admit alcoholics to their programs.” I slapped my hand on her desk and said, “Look, this man lost his best friend and his vision from alcohol. What else does a man need to stop drinking? He swore off the stuff. He is a well-educated man who needs a chance. You are not here to shuffle papers all day. Try and give this man a chance. Please, just speak with him.” Something that I said must have altered her opinion because she said, “Okay. I will go to the ward and speak with Mr. Jones to see if he is really appropriate for one of these programs, but I do not want to promise anything. I’ve tried to work with too many of these people before, and it always seems to end in disaster.” For several days, Ms. Brooks would come to our ward and speak with Mr. Jones. Our house staff and I were pleasantly surprised at the amount of effort and interest she demonstrated. When she came in wearing a new rust-colored dress, we were all tickled. We wondered if she put it on for him, despite the fact that he had lost his foveal vision and could not see it very well. All the house officers who worked on the men’s wards, however, enjoyed seeing this change in her. Each day, after visiting with him, she would come by to tell me how the paperwork was progressing. She eventually reported that she thought she could get him into one of the finest institutes for the visually impaired, where they would teach him Braille, give him a seeing-eye dog, and train him to use this dog and to develop skills for a new occupation. Two days later, Mr. Jones was transferred to this special institute. In the weeks that followed, she would often come to the ward and tell me how wonderfully he was progressing. She would also visit all the other disposition problems on the ward and now seemed to wear a different-colored dress each day. Then one day she called me. “I think Mr. Jones needs some help,” she said. “Can you prescribe something for him that can calm his nerves? The training, as you know, can be terribly frustrating, and he

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is quite nervous. They did find a bottle of whiskey in his room, but thank god it was still sealed. I visited him several time this week, and he looks so nervous; but he promised me he would not drink.” I told her, “Ms. Brooks, I will call in a prescription for Librium, which should help calm his nerves.” Before hanging up, she said, “Doctor, I don’t know if I thanked you for all the care and interest you have given Mr. Jones. After he starts taking this medicine, I am sure he will do fine. Thanks again.” About two weeks later, I was called down to the Emergency Room (ER) to see a patient who had specifically asked for me. The nurse told me that the patient had been brought in with multiple lacerations and contusions. When I got to the ER, I saw that this patient was Mr. Jones. He was drunk and pretty badly cut up. When I came over to his bedside and told him my name, he said, “Yeah, doc. . . . They threw me out. Don’t blame them. I broke up the whole damn place. I don’t think I left a glass unbroken. I really . . .” I didn’t wait around to hear the rest. He had one of our general surgical residents looking after him, and there was nothing I could do for him medically. After leaving Mr. Jones’s bedside in the ER, I walked over the Social Service office. Ms. Brooks was not in her cubicle, but lying on her desk was an opened message about Mr. Jones from the institute. For the next several days, I went to the administrative building to see Ms. Brooks, but her little cubicle remained empty and even the letter was now gone. Some time later, when I checked her cubicle again, I found instead a young woman sitting at Ms. Brooks’s desk. “Where is Ms. Brooks?” I asked. This woman smiled at me and replied, “Oh, you mean the social worker who was here before me?” I nodded and said, “Yes.” “Well, she resigned . . . poor dear thing. I am her replacement. I just got my master’s in social work from NYU and I can’t wait to get started. Do you have any problems on your service that I can help with, or are there any patients you would like me to visit?”

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A little upset, I did not feel like discussing some of my disposition problems and said, “No, not right now.” I started to walk out but then stopped and asked, “Didn’t Ms. Brooks go to the same school?” The young woman smiled again and said, “Yes, I do believe she did . . . but it was a long time ago.”

24 Nirvana: The Last Day June 30, 1964

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n the very top floor of Bellevue’s administration building is a large ballroom. It was there that all the interns from the Cornell Division decided to throw an end-of-year party. We wanted to celebrate the successful completion of one of the most difficult years in our lives. Although several of us planned to stay at least for another year as medical residents, many people would be leaving to take residencies at other hospitals. Our internship was so intense and at times conditions were so adverse that many of us felt close to one another, sharing the kind of esprit de corps that combat solders or firefighters have for each other. This party would give us a chance to say our goodbyes and exchange new addresses and telephone numbers. We invited many of the Bellevue nurses and even some nursing students, as well as our residents. We also invited some interns from the Columbia

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and New York University services. The party was scheduled to start about 7:00 PM, on the last day of our internship, with people bringing things to share, including food, beer, wine, and whiskey. I was on call that last day but hoped I’d be able to squeeze in time to go to the party. It was now about 4:30 PM, and I had already admitted two patients to the Emergency Ward (EW), one who was in a diabetic coma and another who had a stiff neck and fever. The diabetic man was treated with intravenous insulin to reduce his high blood sugar and bicarbonate to treat his acidosis. He seemed to be improving. I performed a lumbar puncture on the man with the stiff neck and found, in addition to white blood cells, that his spinal fluid was full of pneumococcus bacteria, indicating that he had bacterial meningitis. I started him on high doses of intravenous penicillin. After getting these two men stabilized, I called the wards to find out if any patients had been admitted directly to our ward. Kathy, our ward nurse who usually worked during the day, was still there. She told me that three men in wheelchairs were waiting for me to do the admission work on them. Two of them had been admitted from clinic, with one man appearing to have leukemia and the other iron deficiency anemia and blood in his stool. The third man, admitted from the emergency room, was in renal failure for unknown reasons. As I walked up the stairs to the men’s ward, I came to a large window that overlooked a factory across the street. This factory had a machine shop with lathes and power drills. The men who worked there were turning off the power to their machines, cleaning up, and preparing to leave. A feeling of envy came over me. Maybe I should be working in a place that closes at 4:30 PM. Then, if there was a party, I could definitely go to it. Or I could go with my friends—at least those who, unlike interns or residents, actually had spare time—to the beach or the mountains and enjoy life rather than be sleep-deprived, time-pressured, and stressed. My mind flashed back to the time I decided to apply to medical school at the University of Virginia (UVA). I was in the first semester

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of my third year at UVA and had thought I wanted to become a research medical biochemist. A course on advanced organic chemistry squashed that plan. Listening to the professor lecture about quantum mechanics, I had no idea what he was talking about. I realized that if I could not understand this material, I’d have no chance of becoming a successful biochemical investigator. After the class, I went to lunch at a restaurant and on the way to this restaurant, which was in an area of Charlottesville called the Corner, I passed by the medical school. Having heard that the medical school had a new program where they were going to admit two students after their third year in college, I went into the Admissions Office to learn more about this program. The secretary gave me some application forms to fill out right then and there, while she called over to the College of Liberal Arts and Sciences to get my grades. By the time I finished filling out the forms, she had received my grades, and noting that I had done very well in college, she offered to arrange two interviews for me that day. Because the admissions committee would be making its final decisions at the end of the week, she urged me to undergo these interviews now, so I did. After the last interview, the surgeon who interviewed me said that I would probably hear from the Admissions Office the next week. After leaving the medical school and heading to the Corner for a late lunch, I mulled over my idea of becoming a biochemist. Was that really what I wanted to do with my life, or would it just fill a career vacuum? Why was I so excited about the idea that they might accept me to medical school? Had I previously chosen to pursue biochemistry because I didn’t think I could get into medical school in the first place and wanted to avoid that crushing disappointment? I felt that deep down I really wanted to be a physician. But why? As I ate my lunch, I thought about my interests and ideals in life. I recalled that helping people always gave me a wonderful feeling. I also recalled that since boyhood I had hated the fact that people suffer and die.

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Then I thought about a book that had had a great influence on me in high school, J. D. Salinger’s The Catcher in the Rye. Perhaps being a physician would allow me to do what Salinger’s protagonist, Holden Caulfield, wanted to do—to help save others (in his case, children) from the dangers of life. “Better stop thinking about what it would be like to be a physician,” I thought to myself then. “You might not get into medical school and you’ll be disappointed. After all, they’re only accepting two third year students in this program.” A couple of days later, the admissions secretary wrote me that Dr. Sandusky, the head of the admissions committee, wanted to speak with me. After greeting me and motioning me to sit, he asked me why I wanted to go to medical school after only three years as an undergraduate when I could enjoy and benefit from another year at UVA’s College of Arts and Sciences. I did not want to tell him about my personal disappointment with biochemistry but did tell him that each semester I took a lot of courses and that by the end of my third year I would just be a few hours short of graduation. I also mentioned to him that if they did not admit me, I would have no choice but to stay in college. It was then he told me that I had been admitted. A feeling of tremendous joy welled up inside of me. Until my children were born, this was the most joy I had ever experienced. The euphoria was so strong that I wanted to get up and shout but instead thanked him for his interest and for this wonderful news. He came around his desk, shook my hand, and said I would be getting a formal letter. He also wished me good luck. I left the medical school in a hurry, and upon reaching a parking lot behind the Corner, I jumped and yelled, “I’m in! I’m in!” It is amazing how quickly old memories can flash through our brains. All these thoughts had emerged in the short time that it had taken me to climb one flight of stairs. As I was going up the second flight, I remembered that as a boy I had trouble falling asleep. My mother would turn off the lights, and I would just lie in bed thinking

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and listening to the sounds of the night. I would occasionally hear a passing car, a cat in heat, or the elevated train that ran along New Utrecht Avenue, about a half-block from our apartment. I hated the feeling of forced inactivity and tried to think of the job I could have when I grew up where there would be people working all night. The career that came to mind even then was medicine. Entering the ward from the stairwell, I recalled another book that I had read in high school, Hermann Hesse’s Siddhartha. Siddhartha Gautama, or the Buddha, left his palace and was confronted by the sight of sick and dying people and of corpses all around him. Shattered by this sight, he attempted to find meaning in life by absorbing himself in various activities, from the hedonistic, with indulgence in all forms of sensual pleasure, to ascetic practices and self-mortification. Then one day, while resting under a bodhi tree and listening to the sounds of the river, he found meaning in life. He found nirvana. On the ward, I found the three patients who had been awaiting my evaluation. Sequentially, I took their histories, examined them, performed diagnostic studies, and initiated therapies. Completing these activities five or six hours later, I walked to the small doctor’s room to write these three newly admitted patients’ history, examination, and laboratory findings in their charts. I again thought about Siddhartha and realized that, for me, practicing medicine was the closest I could get to his experience while sitting under the bodhi tree. I returned to the EW to see how the two patients admitted that afternoon were doing. The patient who had been in a diabetic coma was now awake, but there was little change in the patient with meningitis. By the time I finished writing follow-up notes about them, it was 11:45 PM. The party, scheduled to end at 11:00, was over. I decided to go up to my on-call room and try to get some sleep because if you do not sleep when you can, you might not sleep the rest of the night. Just in case a miracle would happen—a night of uninterrupted sleep—I set my alarm for 6:30 AM, read some journals, and then fell asleep.

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Nirvana: The Last Day

The next thing I knew, the alarm went off. A minor miracle had in fact occurred. I took a shower, got dressed in a new white uniform, and headed down to the wards. When I got to B1, our men’s ward, the new chief resident introduced me to two new interns. “Frank and Jim, this is Ken. He will be your resident.”