Jeffrey A. Brown
Doing the thing right got me into this. Do it the right way, else why go through the ordeal. Trapped in bleak Chicago winters that were followed only by sticky, steaming summers. Maybe it was worth it. That was how most of my classmates felt about their years. It was part of the experience- just another disease. Most of my fellow medical students were convinced that they were stricken with a disease they were studying sometime in their first two years. Gastritis, hepatitis, rhinitis, so many "itises" and so little time to study was the typical student philosophy and it led to a rather boring life if adopted. This time I had spiced it a bit heavily.
"The Bouncing Lady" was my presentation for the afternoon rounds. My Austrian-strict attending physician had assigned each of the three third-year students on the Neurology rotation a patient to present. Most of it was mundane, "stroke right, stroke left, stroke out." It was cynical, but typical medical-student speak. It made most of us feel that we were part of a fraternity of intellectuals with a secret vocabulary equal to our importance. The majority of the thirty patients on the Neurology service at The University of Chicago had suffered some catastrophic stroke, on one side or the other. If it happened on both sides they were down for the count, like the Harry Carey chant at the seventh inning stretch at the Cub games, "One, two, three and you're out at the oldâ€¦ Ballâ€¦ gaaaaame!" I made a mental note to take a Saturday off for a CTA trip downtown and a bleacher seat in the stone-walled, lightless stadium. Someday, I would get there.
The bouncing lady was about fifty years old, African-American, emaciated and lying on the far bed of room 4107 for the last five days. Whenever she stood up, she began to bounce on her feet. Slowly at first, she would gradually cycle faster and faster until she collapsed to the dark brown linoleum floor. I remember seeing Richard Burton do this routine, while standing on a table and reciting, "to be or nor to be" wearing a "bare bodkin" and getting paid a whole bunch to play Hamlet on Broadway. I couldn't find this one in the textbook anywhere, but I suspected my bouncing lady to be just as mad-or maybe not- as poor Hamlet.
I was in my third year of medical school. This was my clinical rotation, an exciting time actually. Time to put into action all the theoretical stuff that had been outlined on chalk boards, flicked by in rapid sequence slides on Saturday mornings when we were mostly asleep, except for George who was always good for a few pointed questions. George was different. He was brilliant. He liked to go into the basement of his South Side apartment and shine a bright light on the wall. This would, being the South Side, inevitably attract a huge cockroach that would freeze to attention in the light-beam. George would then beebee gun it down against the wall, assassination style. In the lab he had developed a technique for cutting the connections of the two-halves of the cockroach brain. He created a herd of cockroaches crawling in continual circles. George wanted to be a neurologist, too, so we were assigned together on this rotation. Barbara filled out the group of three. She was probably the brightest of all, but had a self-effacing style that led you astray. She was rarely without a definitive fact when she needed it but she did not supply it unless asked. I liked her for it.
"Your bouncy lady thing is cute. Have you figured it out?" Barbara was obliquely prodding me before rounds while we sat in the basement cafeteria. Cafeterias are always relegated to the basement. The faculty used to have a very nice one that had oak-paneled walls and a view of the green trees in the quadrangle. Students could eat there too at lunch and dinner. Within a year of my arrival they made it into the library and put the faculty dining room in a windowless room adjacent to the basement cafeteria.
We ate our chocolate-covered doughnuts and drank orange juice traditionally after early morning work rounds. I liked chocolate-covered doughnuts. It had become my dessert of choice nightly during my lean first-year of medical school, after my usual can of Campbell's soup and rare roast-beef sandwich.
"Why don't you talk to her some more?"
Neurology was a five-floor walkup. Elevators were for the patients. I hiked up coat flapping, crepe-soled shoes squeaking, stethoscope ritually stuck in the right-hand pocket. In the left pocket was the black notebook with all the clinical pearls I could cram in to be available to rescue me at two in the morning when I needed their comfort. It was time for a careful "review of systems." I took out my 3X5 card from the breast pocket of my white coat. The hand-pencilled card had an outline of questions relating to health starting with problems of the brain and working on down to the genitals. It was less intrusive to start in that order. The bouncing lady was in her bed, by the window. The window looked to an interior courtyard of other windows and other patients. The hospital was designed as a series of boxes composed of corridors for the side slats. Land was cheap in the early century. The university was in the distant suburbs of the not-yet-sprawling city, at the end of the train line. She seemed quite composed, ready for her morning entertainment. She had grown used to the hospital routine and I was her diversion for the day.
"Do you take any medications?" I asked her.
"Just my vitamins. I get them at The Clinic. They have a famous doctor there. He comes on Wednesdays to prescribe them for me."
"What is your doctor's name?" We are supposed to get medical records from a patient's primary physician. My bouncy lady had not listed a primary physician. This then was new and helpful news. I figured I could get her records from him.
"I don't know, but he is a famous neurologist."
"OK, where is The Clinic?"
"Around 98th street and the train tracks."
This seemed an accurate way of describing anything in the South Side of Chicago. The neighborhood was a mixture of burned out buildings, train crossings and forlorn apartments, once well constructed and maintained until the social revolution of the sixties. It had happened in every major northern city. I wondered what famous neurologist would be practicing in the South Side and providing vitamins to my aging patient.
I could not learn anything more from my interview. I had no other morning assignments. George and Barbara had finished their work and were off reading obscure articles with which they could "pimp" the residents. "Pimping" was a well-appreciated game of medical rounds. It required the medical student to quote a fact from a research article relating to their patient. The resident was expected to immediately recognize the article from his own background reading. He would then turn the tables around. "Oh yes. That was what was thought last year, you-know. If you would read so and so's more recent article, you would realize that your article was based on a totally incorrect assumption." The game, if played well, would then move up the ladder to the attending. He would humble the resident by quoting his own, yet unpublished, research on the subject. That would end it and everybody would be put right back into the hierarchy where they belonged, but proud that they had tried to move up. If there was a junior and senior resident, it could get hairy if they got in to the game before the attending. The patient would be totally lost in this chess match as the battling intellects stood round their bed ignoring the reason that they had come in- to help their patient.
I got the telephone number of The Clinic. Easy enough, it was in the White pages. I called, hoping to get something I could during rounds. I got an interesting response.
"Could I speak to the doctor please?"
"He's not here."
"Well, I have a patient of his. I am a doctor at The University Hospital. My patient, who is hospitalized here, tells me that she gets her medicine from your doctor. I need to know what she takes so that I can help her."
I may have blown my image up a bit, what with the "doctor" bit, but I was feeling proud of my role.
Something odd happened at the other end of the phone.
"You know," said the woman nervously, "We aren't actually a Clinic. We are really just a pharmacy and there is a doctor who comes here on Wednesdays."
I should have listened more closely and just dropped it. But, as I said, I was foolishly innocent and proud and wanted to do things right. "What's his name?"
"Frank O'Hara, I think."
"Where does he come from?"
"From the Northwest suburbs I think."
"Ok, thanks." I hung up and went on to several next things without thinking further on the subject. I should have.
After some more work rounds, I looked up Frank O'Hara in the Yellow pages of the Chicago directory. There was only one doctor by that last name. He practiced in Palos Heights, a fashionable northwest suburb. I called him.
"I am calling from The University Hospitals (pride again) for Dr. O'Hara about one of his patients." I told the efficient female receptionist on the other end. O'Hara came on the line quickly.
"This is Dr. O'Hara"
"I am calling about my patient at The University Hospitals whom I believe you see at The Clinic on 98th Street."
"You must have the wrong doctor, sorry, good bye." he rapid-fired at me and hung up.
Well, I was nothing if not persistent. I made some more phone calls and let it sit for the afternoon.
Rounds came. We gathered at the conference room and marched to the room round the corner with my patient. The military arrangements for the procession were quite rigid, of course. The intern led the court since he controlled the floor for the month rotation. Just behind, the Attending, Senior Resident and students. At the bedside, to the patient's left, stayed the attending. The rest spread out round the bed, leaving me at the lady's right.
"This is a case of a bouncing lady," I began. "She is 64 years old and has been in otherwise good health until she developed a peculiar disorder of her gait. She has had no forgetfulness, no double vision, no speech difficulty, no abdominal distressâ€¦"
"Get on with it Gale," barked Mark, the Senior Neurology Resident. He had not been basking in the sunlight for the last half minute, so life was uninteresting to him. It occurred to me that I should have talked to him about this presentation so he could offer me his pearls of wisdom and convince the Austrian-compulsive of his worthiness as a teacher of floundering medical students.
I continued. "Her neurological examination is essentially normal except for the cyclical knee-bounce that develops as soon as she stands and grows in amplitude until she collapses within a minute of onset. Her laboratory studies are all normal including bilirubin, SGOT and SGPTâ€¦"
"So what about the tox screen?" Mark again. I knew of no toxic drug screen. I had been pimped.
Mark, had not bothered to tell me that he knew the results of my bouncing lady's toxic drug screen or even that he had drawn one himself- without having written the order. No order, no evidence of the test being done. No reason to look for the results. He was good at this game. He was waiting for me to glorify him with my request for advice. No request, no offer for results of unknown toxic drug screen (pride again).
"Your mystery lady has Phenobarb toxicity. Her Phenobarbital level is quite high, over 40 milligrams percent." Mark ignored me, speaking directly to the Austrian-compulsive. They both stood at the same six-foot level off the floor, and I was feeling like I needed to hide under it.
The attending launched into a mini-lecture on barbiturate toxicity. "The woman's peculiar bounce is a form of myoclonus, a consequence of the barbiturate overdose. It is to be differentiated from myoclonic epilepsy, for which barbiturates have often been used as a treatment, quite unsuccessfully. In Austria, we saw several such cases."
"What about serotonin?" began Mark. "There have been several publications in the recent literature regarding the effect of low serotonin levels on such movement disorders." He launched into a lengthy review. This was Mark's show and his stage.
George and Barbara were grinning at me from the top of the bed. I had been set up and they were enjoying it.
"We could easily cure her just by leaving her in the hospital and following her drug levels serially over the next week until the drug was gone from her system along with the myoclonus," Mark advised.
Trouble was, after five days, her blood levels were unchanged.
George had the answer this time. He was African-American and from New Jersey. He grew up in the South Side and played basketball at college in New York City before medical school. He had that teasing approach to conversation, just a little edge to it, a kind of street talk that was quite different from the rest of my classmates. Nobody would dare ask him how he got his beebee gun technique down. George knew about being secretive.
"Send her for an X-ray and search her room!" he said with his peculiar lilt. George was slender and tall. His personality was endearing and his wit quick. He was already married and to a very pleasant graduate student in biology, also bright and low-keyed, unlike George.
I cleared it with the Austrian-compulsive. It seemed up his alley. He agreed. Off she went for an abdominal flat plate to evaluate the size of her liver. Maybe she had trouble metabolizing the stuff because of some liver disease. The X-ray at least was medically indicated. I wasn't too sure about the room search.
The dozen neatly printed vitamin packets I found piled loosely in her bedside table-drawer listed all their ingredients quite carefully: Vitamin C, Vitamin E, Vitamin B6, Sucrose and a special kicker, Phenobarbital. My bouncing lady had a reason to love her vitamins and her vitamin doctor. She was addicted to the stuff and hiding it from us.
I called back Dr. O'Hara's office. I got him. I asked about the Clinic again. He assured me that, as before, I was mistaken.
"But, Dr. O'Hara, I double checked your name with The Clinic. I called the Illinois State Medical Board, too. They assured me that in Illinois there is only one licensed physician named Frank O'Hara, so it must be you. The line went dead.
The Bouncing Lady stopped bouncing when her Phenobarbital drug level returned to normal. My next patient was no less a challenge, but for different reasons. She was having continuous seizures and was in coma. She was admitted early in the morning, enough to interfere with doughnut rounds.
"First Valium!" barked Mark. "Three doses, 10 milligrams each. Gale get the IV. Use a large catheter. Remember the drug level Gale. Have you learned that yet?"
After three doses of Valium, the seizures continued. Our patient's regular breathing did not.
"We can intubate her. We do not need anesthesiology. Call respiratory for the ventilator. Break open the Code Cart for the tube." Mark's show again. He slid the breathing tube in, taped it down, connected the ventilator and dialed in the settings while humming something from 'The Wizard of Oz'. I had not quite gotten the song yet, but was focusing more on it than anything else in the experience.
Our patient was still seizing and Mark was still barking. "Dilantin! Cardiac monitor while we push it. Gale, get out your favorite drug. Show me how it can be used for some good." He wanted Phenobarbital to be given with the Dilantin. The seizures persisted. Mark was getting bored. "If they haven't stopped in the next 45 minutes call anesthesia." He left. The nurses followed. The Junior Resident picked up his clipboard and headed to the nursing station to put this whole experience down in a lengthy note, one that no one will ever read. I was left alone with my patient, an African-American woman of about 55 year with arms and legs jerking regularly, eyes closed, ventilator humming.
A tall, gangly, strutting man appeared at the doorway. He was a caricature of a dude, even wearing a wide brimmed black hat with black boots, black pants and shirt, but a white jacket.
"You the doctor?"
"Yes I am." (pride again)
"Well, that's my Mom there. She don't look good. I hope she don't die. Cause I just got out a Joliet, prison I mean. If she should die, I ain't sure what I would do. I just mightâ€¦. shoot somebody."
"Oh, you really want the resident." I fired back. "I am just the medical student. You really want someone who knows more than I do. He's down the hall, that way." I briskly turned toward the doorway, leaned out and pointed left toward the nursing station. As my friend looked left, I took off right, found the first stairway and fled to join the doughnut brigade, which is where I figured everyone had headed.
"Hey Gale, your lady stop setting off alarms yet?" George tweaked me on arrival. I decided not to relate my story. "Any idea why she is seizing?" he asked. This was quite a good question, actually. Why was she? That would be worth investigating. I stayed for breakfast, only in the back of my mind was I listening for stat calls for "Security to the fourth floor." or loud gunshot-like bangs in the distance. None heard I finished my doughnut.
Barbara spoke of her patient. "She's only twenty-five and married three weeks. She returned from her honeymoon in CanCun with her vision suddenly blurry and her speech slurred. This does not bother her, only her husband who insists on bringing her in. I looked in her eyes with my ophthalmoscope. It's MS. She has Multiple Sclerosis. No doubt about it. The warm weather and water precipitated it."
"I am glad they got warm weather" piped in George. "When I was in CanCun, it was in February, I got an ovation for passing through the swimming pool with my ski parka on and zipped up."
"You look better that way than in a bathing suit, George. That's probably what they were applauding." tweaked Barbara.
"What will you do for your patient?" I asked.
"Nothing. She thinks she's fine. As long as she comes to the hospital when she needs to, then she doesn't need to know what is wrong. That is so long as she does not ask. If she asks, I tell her she has MS. If she doesn't ask then I don't tell her anything except that she can go home. At least that's what Mark told me to tell her, or not to tell her if you follow. If I can't help her why bother her?"
"Do you think that is better than telling her the diagnosis?" asked another student.
"Mark says it does one no good to force information on a patient. Always be open for questions. Answer all questions honestly. Don't hang crepe if it isn't needed."
"You mean don't give them crap." said George. "By leaving out information, you leave the patient thinking that there is something that you do not wish to discuss. You imply to them that they should not ask about it, so they don't. That way you save yourself the time and difficulty of explaining the problem fully. Leave it to Mark to come up with a story that fits his personality."
"I disagree," said Barbara. If a patient isn't ready to hear that they have cancer, it does you no good to hit them over the head with it. They will either not hear you or will be angry with you for telling them. They know it anyway. It's just that they are not ready to face it. You know about the four stages of death. Denial is the first stage. If you tell someone they are dying during denial, it does no good. They will not believe you."
"That is different from your patient with multiple sclerosis. By not telling them the diagnosis, they are missing opportunities to seek out care from others that may be more helpful than what you have to offer. You are being presumptive to assume that you know everything available to help them and that none of it will help. That's what I mean by thinking like our beloved pompous resident, Mark."
"But wouldn't you want him as a doctor? He is smart and knows the field of neurology better than anyone."
"Being smart does not make you a good doctor. Being compassionate. Being considerate. Being competent does. Don't make the mistake of assuming intelligence is the defining characteristic. You all were not selected for medical school here based on your IQ, believe me. You are not being evaluated by the results of any test except how well you take care of your patients. Being a good doctor takes something else. It takes character." Peter Furer, leaned over the long table and spoke clearly and without accent this time. Alias the Austrian-compulsive, had stopped by our breakfast seminar, overheard our conversation, and given me newfound respect- enough, I think, to stop thinking of him by his third person title.
I figured out what Mark had been humming. It was Ray Bolger's strawman song delivered dancing before Dorothy, "If I Only had a Brain."
"Gale, see if you can figure out why that lady is seizing in 4101. And why, by the way did you send her son over to see Mark?"Chapter 3
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