RobWiddowson

Author of Heaven's Tale

Crazy Bob, M.D.

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This is Part 2 of my misadventures in medical school.

My second year at Jefferson passed in a blur.  I started out great.  On the first set of exams, I had the highest grade in microbiology and third highest in Pathology, the two most important classes.  During this time, four of us Nu Sigs had moved to a really cool townhouse right next to school.  My old friend from Lanesville and Bowdoin College Davy Doughty wound up at the Philadelphia Naval Yard taking some special courses for about six months. Susie, now my fiancée, was safely tucked away in New Jersey.  We partied like beasts.  Even after Davy left, I continued in the party tradition.  Eventually the year ended.  I had barely passed, even after my stellar start.  Maybe the love of a good woman would save me.

Susie and I were married in August. We went to Norwich Connecticut a week early and stayed with her family. Her dad, retired Navy, was a ramrod rigid prick with a big taste for alcohol; her mom was sweet and docile, a victim of spousal abuse for years. The crowd from Bowdoin made up my contingent, and they took me out for the traditional stag party. They were all tired, so we just had drinks and went home. But Tom Oxnard had painted a landscape of Lanes Cove, The Shack, & Tide Edge from a photograph he’d taken years before. It was huge 4’ x 3’ and very professionally done. I carried it with me for years. It was the most wonderful present I’ve ever received in my life. My mother put on the rehearsal dinner with her usual excellent touches. Name tags at each place were held in tiny bows and arrows, and before the meal she read from Kahlil Gibran about parents sending their children into the world like arrows slung from bows. All that was left was the ceremony.

We held it in a beautiful chapel on the Naval Base lined with gorgeous stained glass. The whole affair was traditional, and Susie looked stunning in her gown. We continued all the traditions at a big reception party. The band played; Susie threw a bouquet; we cut the cake; I drank 18 gin and tonics. We left in a shower of rice and confetti and drove to a nearby Marriot where we had the honeymoon suite for two days. We had wine and drinks with dinner and just as we got back to the suite, there was a commotion outside the door. Some members of the wedding party wanted to continue the celebration While I sat up drinking with them, Susie went to bed alone. It was a harbinger of things to come.

We both had to get ready for school, so those two days made up the honeymoon. We drove to Philly and moved into a big old apartment right near campus. She had a contract teaching high school in Cherry Hill NJ just across the river. We bought a cool dog and settled down to married life. School for me now consisted of clinical rotations. These varied widely in the amount of responsibility we were given and our interest. Six weeks of pediatrics at Philadelphia Childrens was good. We were assigned to work with busy residents and intern who believed in the formula: See one. Do one. Teach one. I found that I had a nice touch with kids. I liked working with them. Six weeks of psychiatry was awful. Twice a week we sat in on lack-luster group therapy sessions. The rest of the time we stood around bored trying to get the attention of residents who studiously avoided us. Our twelve weeks of obstetrics and gynecology at massive Philadelphia General was surprisingly excellent. The clinics were jammed with lots of interesting cases while the residents were overwhelmed and happy to have our help. I must have done a hundred gynecological exams. And obstetrics was a revelation. So many women suffered in child birth, and so many had problems with labor. We were always inducing contractions with chemicals and giving epidural anesthesia. Sometimes we had four or five women giving birth at the same time, and I had the privilege of delivering two babies by myself. It was an excellent rotation, and I learned a lot.

At home Susie and I fell into a reasonably steady routine. We’d walk the dog, prepare and eat dinner together. Then she’d work on lesson plans, and I’d study background information for my rotations. I had trouble concentrating but managed to get by. And I was gone a lot. Most rotations we spent one or two whole nights at the hospital, and I still had my job as overnight lab technician. Susie had expected to be alone often; that’s why we bought the dog. And she had a friend who often stayed with her. On weekends we still partied like beasts, and my drinking continued out of control. I was still erratic and marginal.

 

The crowd that I hung with at Nu Sigma had a legendary academic privilege.  A surgeon named John McCloughlin had retired as a Navy surgeon.  He partnered with another legendary Jefferson surgeon Walter Stayman who’d been chair of Jefferson Surgery Service for years.  He’d done a lot of cardiovascular surgery and even had some techniques named after him.  They ran a thriving practice in a small suburban hospital at Chestnut Hill, just outside Philadelphia.  McCloughlin a.k.a. The Chief had decided to use their practice to teach a cadre of young doctors interested in surgery.  Every quarter he accepted two junior students to run his service, and they were supervised by a senior student.  There was always a resident handy in case the students got into trouble, but basically the students ran the show.  They had the legendary ‘first call’.

In teaching hospitals, the first person called to see a patient is a coveted position.  Med students were usually the last to see a patient, after the resident, the staff surgeon, the intern, several nurses, the dietician, and the radiology technician.  By that point, most sick people are usually sicker or sick and tired of being harassed.  Then the student enters and gets a food tray thrown at him.  Especially because the student has to examine the patient the same way every other person has, ask exactly the same questions, and annoy the patient exactly as everyone else has.  It was one of the biggest problems that I had in school.  I had no self-esteem.  How could I enter a room and demand more of a suffering person’s time for no earthly reason?  OK the reason was to practice and to know what was going on with the patient for conferences and discussions.  I hated it, often didn’t do it, and of course, it showed in my all-around performance and grades.  Being hung over a lot didn’t help either.

The way the Chief ran the service, the team that was working selected the next two junior students. The Chief selected senior students from the previous year’s juniors.  For the past three years, only Nu Sigmas had the privilege.  I was selected for the third quarter, my junior year.  Joe Julian and I would be supervised by Jack McCloskey, another excellent Irishman from Philly who was the senior.  He’d worked with The Chief the year before. We were set.  We commuted from the city except that we were on call every third night – all night – and often had to stay over on other nights.

The first morning, Jack met us at the front door and took us into a doctors’ lounge.  He assigned us lockers and then pulled out our first great prizes.  We got to wear long white lab coats.  In teaching hospitals with their rigid hierarchy, even the uniforms signified your status.  The short white coat meant student, and patients soon figured out the code of codes.  I’ve walked into a patient’s room and had him throw me out and demand a “real doctor”.  It happens often.  So it was a solemn occasion when Jack presented us with our long coats.  Then he had another surprise –a  nametag that said, “Dr. Widdowson”.  I felt like the gods of old Olympus must have felt.  He took us to the reception area and introduced us to the operator.  We were to let her know where we were at all times so she could reach us.  Ominously, she took our home phone numbers.

As we walked to meet the Chief for coffee – a ritual repeated over and over every day – Jack told us that he had split the patients between Joe and me.  During the day, we were responsible for just our own patients; at night, we covered the entire service, so we had to know about all the patients. Jack would take call one night, then Joe, then me.  And we’d rotate like that for three months.  A dorm sat right next door, so we had a place to sleep and bathe.  But if patients had problems or the emergency room was busy, you didn’t sleep or even bathe usually.  And of course, in the morning, the Chief arrived at 6 AM as usual and the day began normally – except for the lack of sleep.

The Chief had unfathomable depths of energy.  He walked and talked at breakneck speed.  He’d been trained in the military and it showed.  He drilled us. “Bobby, run the house.”  This meant to describe each patient on the service – name, room #, chief complaint, differential diagnosis, course, prognosis, current status.  Each patient should be done in 2-3 minutes so when all our beds were full, you’d talk for at least an hour.  Of course, there were interruptions.  McCloughlin would ask questions, tell stories, correct us, prod us.  He was an excellent surgeon, a great teacher, and a real character.  We told Chief stories for years.

One night about three weeks into the quarter, I was on-call.  I’d had a terrible night; a patient had started hallucinating and tried to hurt a nurse, and we had to restrain him, but it looked like he would hurt himself when we tied him to the bed.  We finally got hold of a resident in psychiatry who agreed to come in and help, but I hadn’t gotten to bed till nearly 3 AM. I collapsed on the bed; I think I still had my shoes on.  I woke to the ringing of the phone.  It was 4:10 AM.  “Hello,” I mumbled.

“Bobby?  What do you know about calcium?”

“Huh?”

“We’re admitting a patient in the morning that has an elevated serum calcium.  Run to the library and find out all you can about elevated calcium.  I’ll meet you at the front door at 6AM.” And he hung up.

I did it.  I trudged to the library, studied up on calcium, met him at the door, and spilled what I know.

“Excellent,” he said. “You take this patient and do all the tests you need to get to the bottom of the calcium problem.” I did it.

The Chief never took the elevator.  The stairs are faster he said as he raced up them two at a time.  He exhausted us.  And we were just there for three months.  He exhausted all of us, rotation after rotation.  The Chief was on fire. We didn’t really worship him; we were kind of afraid of him.

Anyway, that first day on the Chief’s service was going fine.  I was trying to learn about all my patients when I heard something remarkable come over the intercom.

“Dr. Widdowson, please call the operator.  Dr. Widdowson.” I felt the tail of my long white coat swirl as I stepped around a family to get to a telephone.

I picked it up and said, “This is Dr. Widdowson,” in a loud voice.

“Oh hi Dr. Widdowson. They’re looking for you on 2 West.  It sounds urgent.”

“OK, I’m on it.  Thanks.”  The hospital had 3 floors and a basement.  I was on three so I headed for the stairwell and found my way to 2 West.

At the nurses’ station, a pretty nursing student said, “You must be Dr. Widdowson.  It’s Mrs. Simpson in room 213.”

I stepped quickly in the direction she’d pointed and soon heard a strange, high-pitched, whistling sound like a pump, but in and out very fast and hard.  I couldn’t guess what was making the sound – a broken air conditioner, maybe.  It came from Room 213, and when I entered, I could tell it came from a bed that was completely surrounded by drapes.  The noise was quite loud.  I hesitated at the door, but the patient in the other bed – an elderly woman with bright eyes and henna hair said, “In there.”

I pulled at the curtains till I found an opening and stepped into a scene from Hieronymus Bosch.  Sitting on the edge of the bed was a tiny old woman.  Her skin had wrinkles like macabre strands of twine hanging from her limbs.  Her gown had slipped off one shoulder and her pitiful, sunken, wrinkled left breast slumped on her ribs.  The obvious thing about her skin was its color.  She was bright blue.  Not blue like the sky – a bit grey and cloudy but blue nonetheless.  It was she, of course, making that horrible sound.  She was trying to breathe and couldn’t.  I don’t know if she noticed me.  Her eyes round and gaping like her mouth – concentrating all her energy on finding enough oxygen somewhere to feed her brain which was feeling symptoms of lack of oxygen.  That was her immediate problem, and she had apparently cropped out any other sensations.  So her eyes stared with bright and hyper-focused attention inward – concentrating on the task at hand.

 

She was dying on the edge of that bed about three feet from me.  In a minute or two, that woman with the wispy hair would die.  My knees turned to rubber; my lower jaw started to sag toward the floor.  A large black nurse stood on the other side of Mrs. Simpson, adjusting a bottle that was dripping.  She looked over at me like we’d just bumped into one another at the mall.

“ Hi; you must be Dr. Widdowson.  I’m Miss Pearl.”

I didn’t respond.  I was still waiting for the old woman to stop making that noise and die.  Miss Pearl looked me over, took a breath, and said, “As you probably already know, Mrs. Simpson has congestive heart failure, her diuretics have caused her to pee out too much potassium which her digitalis medicine needs to be effective.  Since her digoxin is not working, her heart can’t pump.  Her blood circulation has slowed down and water is oozing out of her blood and filling up her lungs.  Mrs. Simpson is drowning – inside-out.”  I still stared with my mouth open.  Miss Pearl paused a beat, then continued, “OK, we usually prescribe 15 mgs KCL intravenously and maybe a little digoxin.”  She gestured to a tray on the bed.  “I took the liberty of preparing the medications.”  There were two syringes.  I must have nodded because she grabbed the syringes, injected the liquid into one of the tubes going into Mrs. Simpson’s arm and stood back.  In less than 10 minutes, Mrs. Simpson turned flesh-colored again and stopped making that terrible sound.  She began breathing normally, lay back in the bed, and immediately fell asleep; she was tired, poor dear.

Miss Pearl fussed around, plumping pillows while I attempted to listen to that poor woman’s chest with my stethoscope.  Finally, I spoke for the first time.  “Let’s let her sleep, and I’ll check her later.”  Miss Pearl nodded, and we slipped out of the room and back to the nurse’s station.  There, she handed me Mrs. Simpson’s chart – about the size of War and Peace – and mentioned that I ought to write a note on the chart.  I tried, but I honestly didn’t know what to write because I was still lost; I could still hear her breathing in my head, and besides, my hands were still shaking too hard.  I shut the chart and ran to the library.  For the next 3 hours I studied about congestive heart failure.  Then I went back to 2 West and wrote a proper note in Mrs. Simpson’s chart.  By then it was dark out, and I still had to learn my other 14 patients.  I called Susie, and told her I had to stay over.

After a few weeks, I had the routine down, and it was fun having first call.  Most of the patients had no inkling of our status as students; it was really Dr. Widdowson.  A few folks found out that we weren’t licensed and nobody minded…except Mr. Jackson.  He had taken an operation about one year before to remove a piece of his intestine.  Often, instead of sewing the cut ends together right away, the surgeon will bring the two ends of the intestine to the outer skin to give all the tissue time to heal. During this time, the shit drops into a bag that the patient wears pasted over the hole that comes out on your belly somewhere.  Now, a year later, Mr. Jackson checked in to get his bowel re-attached.  I admitted him, drew the blood, and gave the nurses all their pre-operative instructions.  Mr. Jackson was quiet and seemed fragile.

The next morning, Dr. Stayman and I went in to see Mr. Jackson.  Stayman reassured him with his excellent bedside manner.  Then Stayman motioned me to Mr. Jackson’s abdomen.  Stayman took out a marker and, after asking permission of Mr. Jackson, proceeded to give me a fabulous mini-lecture on reattaching anastomoses.  He described the muscular layers that had to be peeled back, asking me several anatomy questions.  Then he continued to discuss the pros and cons of each entry into the abdomen, and so forth.  For a while, Mr. Jackson listened contently, his head moving back and forth like a tennis fan.  Suddenly, he exploded.

“You’re a student,” he shouted. His pointing hand and finger trembled and the tape and IV made his hand look like a bad science fiction movie.  I looked at him past his hand, and his face was twitching.  He was terrified.  Stayman stood and put a hand on his shoulder.

“These are special students from Jefferson in the City.  You don’t think that I would allow anything dangerous to a patient on my service do you, Mr. Jackson?”

“No, no….uh, no.”

OK, good.  We’ll operate tomorrow, and if there are no complications, you should be able to go home in about 7 days.”

That night, I went to see Mr. Jackson to check that all of the pre-operative orders had been carried out.  When I walked into his room, he began screaming.

“I checked with the nurse.  You’re a student, and I don’t want you to touch me.  No amateur is going to put a hand on me.”

I tried to calm him but it was hopeless.  I called Stayman, and we increased the pre-operation sleeping medications.  The nurse gave him the injection right away, and in a few minutes, we were at peace.  The next morning the surgery went well.  Mr. Jackson did fine post-operatively.  I started avoiding his room to the extent possible. Every time he saw me, he began screaming.  But his post-operative course was uneventful as they say in the charts.

 

Both of my fellow students – Jack and Joe – had shamelessly flirtatious ways, and soon the three of us had a coterie of nurses and nursing students wanting to party.  One night I worked in the library till 8PM; the last bus back to City was 9PM. when the phone beside me rang, it was Julia Benedetto who was “bored and lonesome at a party right next door.  Dr. Julian is here.”  Soon after, we began drinking bathtub gin made from laboratory ethanol. Joe was on call, so he only stayed for a few hours. Not long after, we got serious about our party.  A few hours later, Julia had passed out against my arm and was snoring contently in the bedroom we had found.  I gathered my clothes from around the room and made it to the living room couch where her roommate was still drinking; it was 3 AM.   She took over where Julia left off.  I woke there about 6:30AM still drunk and late for rounds with the Chief.

I found aspirin and mouthwash in the bathroom, cold pizza in the fridge. I grabbed my Dr. Bag and split.  On the way I stopped to see Mrs. Aronstein and make a note which I backdated 15 minutes.  I caught up to them in Pediatrics, and the Chief didn’t seem to notice.  I had a busy and difficult day.  Then poor Mrs. Crowley needed her colon dug out with a teaspoon and lots of dressings to change and work up new patients and saw Mrs. Simpson who was still in the hospital and had periodically fallen into congestive heart failure.  Close to 2 AM, I staggered to the bedroom and collapsed.

I’ve thought about it a lot since that night.  I think I remember answering the phone once, but I have no recollection of conversing with anyone.  But the first ringing phone that I was truly conscious of woke me at 7:30AM.  It was the operator and her voice sounded strange – impersonal.  She told me to meet the Chief in his office in 5 minutes.  That old feeling of dread set in.  I trudged to the Chief’s office which I had never before entered.  He sat at the desk in scrub blues. His face was dark and his eyes shot fire that seared my skin.

“Mr. Jackson who was scheduled to leave the hospital tomorrow after we removed his sutures, woke this morning at 4:30AM.  His belly ‘felt funny’. He asked for the doctor on call.  That was you, and you did not respond.  The operator rang your room five times and you never answered. They finally called me at home because they couldn’t find Stayman.

“I arrived at the hospital at 4:45AM.  They called you again – no answer. When we removed the dressing to check Mr. Jackson’s sutures, his entire small and large intestine lay shining on his belly. He must have coughed in his sleep, and the entire incision burst open, spewing his guts out – literally. I have just come from the operating room where we sewed him up again.  I don’t know if he’s going to make it.”

I said nothing.

“You’re a fraud.  You don’t know anything.  You walk around here preening like a peacock, and you’re just a piece of shit.  The penalty for not taking a call is expulsion.  What do you have to say for yourself?”

I looked him right in the face.  I said, “You’re absolutely right. I missed the call.  I have no excuse.  I’m very sorry.”

He said, “I’m not going to throw you out.  I’ll punish you in a much more constructive way.  You still come to Chestnut Hill every single day, but don’t you ever even talk to a patient.  You go straight to the library and study.  Stay there all day until at least 7 PM.  On nights when you used to be on call, stay in the library all night.  And make sure you know all our patients’ charts.  Just don’t go in their rooms. If you can do it for eight weeks you might learn something.  If you don’t want library duty, then just go now.”

I did it. Really didn’t have a choice, but I did take it seriously.  I stopped partying, organized my reading, took notes, studied all our patients’ charts.  The Chief was right; I was a fraud.  So I studied, and I liked it.  A month passed, then five weeks, and I still stood library duty. At about six weeks the Chief started calling me and asking questions.  Then he’d ask me to look something up for him.  He was checking up. One night when I had to sleep in the library ( I was still spending the whole night in the hospital, just in the library), the phone rang about 8 PM.  The operator told me to go see the Chief in the operating room.  When I arrived, the Chief, the Resident, and Jack were all up to their armpits in a patient’s abdomen.  He looked at me hard.

“Bobby, I want you to start on the third floor and see all our patients then come here and run the house for us.  We’re occupied.”

He then gave me special instructions for about five of the patients.  If I hadn’t been reading the charts and keeping up, I’d have been completely lost, and he would have known.  Still I wrote everything down as soon as I stepped out of the OR.  In an hour, I was back.  I ran the house like a pro.  They all grilled me, and I answered everything.  The Chief cocked his head around Jack.

“Meet us at the door in the morning for rounds.” I was back in. It was a great month for me; I was doing good work, and I had really interesting cases.  The most spectacular patient turned out to be one of the most tragic.  Mr. Tilton appeared in the emergency room one night about 8 PM.  He was a paunchy white man in his fifties; he complained of pain in the lower, left abdomen – both crampy, gut pain and sharp, searing pain.  I remembered a conversation with the Chief about two weeks back.  When you have a difficult diagnosis, he told us to think anatomically: What organs are there?  What problems could they have?

Well, not much lies in the lower left except intestine and a branch of the aorta – the body’s main artery.  The minute I touched it, I felt the blood drain out of my face.  My hand had touched a pulsating mass about the size of a softball in the man’s lower left abdomen.  Arteries carry blood from the heart to the body.  The blood is under relatively high pressure. His main artery, the one that comes directly from the heart, had a weakness in its wall, and the pressure caused it to swell out.  Just like a balloon, the bigger it blows up, the thinner the wall becomes until eventually the bubble burst.  Mr. Tilton would bleed to death inside his abdomen in less than 60 seconds if his aneurysm were to burst, and I had just touched it.  It felt extremely fragile.  When I called the Chief, I had already ordered 20 pints of blood and the gear to start four IVs so we could pump a half gallon at a time into him.  My voice was shaking as I told the Chief. He gave me a list of other instructions including getting Tilton to sign his own consent form and told me to meet him at the door to the ER.  I went back in. Mr. Tilton was getting anxious.  His blood pressure was rising and his pulse rate going up.  I got him to sign the consent form.  When I met the Chief at the door; he had Stayman with him.  As we walked down the hall, McClaughlin said, “Bobby, 5% make it to the OR, 20% of those make it off the table and into the recovery room, and 50% of those survive.

“You and the orderly roll him straight to the OR, Stayman and I will change and scrub; we’ll meet you there.’

I had given Mr. Tilton a sedative, so he stayed relaxed as we bundled all the bottles and bags on his cart.  We rolled down the narrow corridors till we reached the OR and wheeled him in.  The anesthesiologist was waiting and immediately began attaching electrodes and hooking Mr. Tilton up.  As I slipped back out of the OR, I heard a mutter then a shout – kind of a scream actually, “Chief.  He just blew.”

I heard McClaughlin reply, “The blood.  Give the blood,” and he and Stayman burst in the door.  Stayman told the nurse, “Just cover him with a sterile drape, expose the whole abdomen, and paint with disinfectant.  Do the best you can then get out of the way. I’m going to cut him in 30 seconds.”

The gas giver was frantically trying to keep some blood pressure.  McClaughlin peered around the corner at me and said, “Bobby.  Go talk to the family.  Make sure they understand.  Tell them you’ll keep them informed.”

He pulled up his surgical mask, turned, and the nurse had a sterile gown held out to him.  He jammed his arms into the sleeves and spun so she could tie it in the back.  Another nurse opened a pack of gloves for him.  He peeled them on and stood opposite Stayman who was waiting with his scalpel poised.  As Chief took his place, Stayman cut.  He cut deeply even though Tilton wasn’t completely under and grunted at Stayman’s stroke.  It didn’t bleed much.  There wasn’t any blood left to circulate; it had all poured out into Tilton’s belly.  Stayman made another cut and the shiny lining of the abdominal cavity flashed inside the wound.  He looked up and said, “I have to clamp off the blown-out end.”

With that, he sliced the lining and buckets of blood began sloshing out.  Stayman grabbed the big clamp, took a deep breath, and plunged his hand into the pool of blood, looking for the broken vessel.  He had to do it by feel, but somehow he managed to locate the correct shred of flesh and then, using his finger as a guide, clamped off the blown out vessel working blind in the blood.  Now the pints of blood that were still pouring into Tilton’s arms and legs could be pushed to his brain and keep him alive.  Two nurses had suction wands in the wound pulling out blood.  Stayman selected the Dacron tube that he would sew in to replace the blown-out artery. He carefully trimmed the blown out ends and sewed many tiny stitches connecting the Dacron to the aorta.  When that join was complete, he cut the Dacron to the exact length, then sewed the lower two ends together.  He slowly let blood begin to fill the tube, watching carefully for leaks.  He and the Chief even put a cloth over the wound and stood back from the table to give the aorta and its artificial section time to stabilize.

In the meantime, I had gone to speak with the family:  Tilton’s wife, daughter, and son-in-law.  They were extremely worried, but reasonable and well-informed.  The first question they asked was, “What are his chances?”

I remembered what the Chief had said.”5% make it into the OR, 20% of them reach the recovery room, then half survive longterm.”  I explained to the family, and they got it.  They pressed me with a few questions which I was able to handle, and I became the primary physician in their eyes.  We had a few patients that needed attention, so I went and handled them.  By the time I got back to the operating room, Mr. Tilton was in the recovery room. He’d made it.

Even the Chief and Stayman were hyped.  It’s nearly impossible for a blown aorta to survive, and they’d done it.  The family was so grateful, weeping with joy, thanking us over and over.  The scene was right out of the movies.

The next morning Mr. Tilton had a heart attack and died. Since I was the primary physician, the Chief let me tell them. When I went into the reception room, they saw the look on my face; his wife blanched.  I told them, and suddenly, we were all hugging and weeping.  The life of a surgeon must be filled with these moments.

 

That last four weeks at Chestnut Hill I was good, really good, maybe for the first time in my life.  It wouldn’t last of course, but for at least those few weeks, the Chief had conjured magic.  I was good.

 

 

 

By the time I left the Chief’s service, I had decent surgical skills. My time in the library had helped me a lot. Chestnut Hill had been effective, and my next rotation was 12 weeks of surgery at Jefferson, and for about two weeks I excelled. I was on-call one night when a lovely and elegant black lady about 45 came in complaining of severe nausea and vomiting for two days. This was her third episode, each worse than the other. From x-rays and history I suspected that she had a complete blockage of the small intestine probably caused by tumor. In this case, the intestine just in front of the blockage gets stretched out and irritated by food & stomach acid that can’t pass. It’s extremely dangerous to operate to cut out the blockage because you can’t suture that sick tissue properly so you can’t connect the ends. Stitches tear through the flesh, and the intestines leak into the abdomen which is often fatal.

The correct procedure is to pass a very long tube through the patient’s nose, down into the stomach, then into the intestine all the way to the blockage. Then you can pump all that nasty liquid out of the ballooned area. In 5-6 days the tissue is healthy and strong and ready for the procedure. And the nausea goes away, so the patient can rest and be ready for the operation. Inserting that tube is excellent surgical medicine, but it’s really hard to do. Luckily, the Chief had let me put one in, and I was ready. I got set up, wrote extensive notes on the chart, and got permission from the intern who had been impressed by my work. About 11pm, I started. It’s tricky, and it can be painful. This lady was weak and sick, but when I promised that the tube would take away her nausea, she cooperated. Once I got the end in her stomach, I had to find the exit into the intestine. There needs to be enough tube but not too much. I rotated the tube, and the end spun right into place. The intestine is very convoluted, so I could only push a few inches at a time, rotate, then proceed a few minutes later. All the time I talked to her about her life, her families, drawing her in so that we were working together. It’s a unique kind of intimacy, and after a few hours, I felt really close to her. It was nearly 3AM when we reached the blockage; she had nearly 11 feet of tube in her. I secured the tubing and hooked it up to a pump. Within 45 minutes her nausea was gone, and after thanking me fervently, she fell fast asleep for the first time in 48 hours. I wrote my notes in the chart, checked in with the intern who congratulated me, and went home to refresh myself. It was nearly 5am, but I was fully energized and glowing with pride and satisfaction. Maybe I could be good at this.

I took a shower, had breakfast with Susie. Then I hurried back to Jefferson to check on my patient. Her bed was empty. Frantic I finally tracked down the head nurse who told me that George Cowans, the arrogant and impetuous chief resident on the floor, had arrived at 6am, decided to operate immediately, pulled out my tube, and had her in the operating room as we spoke. Two days later, she died. I asked every surgeon colleague I could find about the case, and they all agreed with me. And Cowans was brought before a hospital committee and censured. But the lady was dead, and I soon found myself sliding back into self-destructive mode. My performance became erratic again, and my attendance was intermittent.

At this point I had completed three full years and had passed everything. But I had developed a bad reputation in my clinical rotations, and I had a whole year left to go. Susie’s contract had been continued, and we kept our apartment. I could feel myself pulling away from her. I was beginning to feel really bad about myself, and there was no room for someone who was trying to love me. I just didn’t deserve it. My school work and attitude continued to be erratic. Then one night in February, I went to the local shop about 5pm to get coke and told Susie I’d be right back. On the way, I met my friend Joe Julian who was on his way to a party. With hardly a second thought, I went with him. The booze flowed, and we got lots of attention from women, and I didn’t get back home for 36 hours. Poor Susie was crushed and never really recovered. We saw a psychiatrist at Jefferson a few times (as a student, I was eligible for free services), but our relationship was irretrievably damaged.

 

At the end of the school year, Susie moved into an apartment in Cherry Hill, taking the furniture and the dog. I moved into the fraternity house for the summer and really started deteriorating. Halfway through the summer I borrowed a friend’s car to take a girl to a party, and on the way home at 7am, swung too wide on a curve and side swiped another vehicle. It was nearly head on. Then a few weeks later, I passed out in bed with a cigarette. When I woke up, the bed and the entire room were in flames. I almost didn’t get out. The whole house nearly went up, and the damage was extensive. They threw me out of the fraternity.

 

Not long after, the Dean called me in. He told me that even though I was passing, my behavior was unacceptable, and they were not going to let me graduate. I was to continue seeing the shrink and repeat another year of rotations. They would watch me carefully, and if I straightened out, I could graduate with the following class.  If I didn’t change, I would never be a doctor.

 

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