Confessions of a Gynecologist

Contents

P R O L O G U E

THE DEVELOPING YEARS

INTERNSHIP-PARKER

MEDICAL CENTER

THE DEVELOPING YEARS

RESIDENCY-ClTY

MEDICAL CENTER

THE DEVELOPING YEARS

OPENING A PRACTICE

THE DEVELOPING YEARS

GETTING A PARTNER

THE DEVELOPING YEARS

FEAST OR FAMINE

THE DEVELOPING YEARS

STRUGGLING THROUGH IT

E P I L O G U E

For my parents, Ruth and Arnold who gave me the spark oflife,for my wife Trudy who keeps that spark burning strong and true, and for my children who make it all worthwhile.

P R O L O G U E

Many of the events portrayed in this novel are true. They actually occurred. Painstaking care has been taken in order to prevent any relationship between events described in this book and people who were actually involved in those happenings. Names and locations have been changed. Settings have been altered. The chronology of events has been purposely modified so that there is no continuity or relationship to occurences. Fictional incidences have been developed so that it is impossible to separate the truth from the tale. Any recognition of similarity between real life events and episodes in this story are completely coincidental and without intent.

Nevertheless, this story was purposely written in the fiction format in order to give me latitude of expression and the ability to describe actual real life events without fearing retribution.

By changing names, locations, settings and chronology, and by mixing truth with fiction, I could avoid accusations of libel or, at the risk ofbeing paranoid, criminal prosecution by some over zealous prosecutor bent on self-promotion. Ironically, by taking the fiction format, I could more accurately maintain the thread of actual events.

The purpose of the story is twofold. First it is to tell an exciting story. Next and more importantly, it is to disclose the decay, injustice and inefficiency that exists in the delivery of medical services and the training of our physicians.

This story is many years in the writing. I started back in nineteen seventy to write the story line for events that were fresh in my memory. Although I was constantly busy and frenzied in my residency training program, I occasionally stole a few moments to jot things down as I felt them and experienced them. When I started practice in nineteen hundred and seventy three, I had almost half the story written. My full attention was then diverted to building a large and successful practice and the book was placed somewhere on a back shelf to gather dust. Somehow, I discovered the hand written pages a number of years later and had my office typist painstakingly transcribe my miserable handwritten prose onto the printed page.

Again, in the pursuit of greater deeds, I put the half-completed book aside on the top shelf of my closet and forgot about it. Many years later, my son Bryan discovered the text and read through it. He asked me why I didn’t complete the novel, since it was a great story to tell and I obviously had a gift as a storyteller. This spurred me on to read- dress the issue. I had the book successfully scanned into my computer and went from there. Upon completion, I asked Bryan ifhe would take care of the mundane and laborious task of getting the book published. As ususual, he rose to the occassion. I hope that you enjoy the result. Most of all, though, I hope that you learn something about the decadence and injustice in our medical system. Awareness gives us all a better chance to address the problems before they get totally out of hand and, hopefully, the people can raise enough of a voice to force government to do something about it.

THE DEVELOPING YEARS

My first subconscious recollection was that of battering my head against the wall. The quarters were confining. Later on in life, through a long process of deductive reasoning, I was able to discover the locale of those first experiences. The Uterus!

I was battering my head against a goddamn pelvis that was too small to accommodate it. Damn inconsiderate to say the least. The problem seemed unresolvable and with a deep sigh, I resigned myself to life in utero. At that moment, when all hope was lost, a sliver of blinding light stole in from above. Over me, I could see the razor sharp edge ofa knife plummeting through the opening and I hunched myself back into a corner. Too late! The blade nicked my scalp, and a sensation I later learned to call pain shot through me. With the help of a long pair of scissors, the sliver spread to a quarter moon. Careful you bastard, I thought. Then a hand grabbed me roughly around the head and twisted me around, as another fell on my rump and pushed hard, with an extreme lack of consideration for my private parts. Of course, at the time I didn’t realize that I had any parts at all that were private. The sliver, which changed to a quarter moon, took the shape of my head and then, snap. My head shot up and there was light all around and I could straighten my legs for the first time.

What followed afterward was a bit hazy to say the least; the feeling weak; the necessity to suck in what I would later learn to call air; the complete violation of all my orifices with a ball sucking at my mouth, a tube in my nose, a fingertip in my rectum, drops in my eyes, and this god awful pain right smack in my penis.

Never had I seen such commotion. One minute I’m alone, and then they wouldn’t leave me alone. Being too busy learning how to breathe, I didn’t get most of the repartee. But I do remember the voice saying. The pelvis wasn’t big enough, and the head was turned around posterior and would not come out that way.

Of all the gall, I thought. They were blaming the whole episode on me. How the hell was I supposed to know which way to turn.

Nevertheless, two good things came from that experience:

1) I resolved that I would become the helper of feti in distress and

2) I forgave my mother.

My initial intentions were good, but along the way my environment warped me and soon detoured me from my goal. I learned all too quickly that life was a system of rewards and punishments, and that my actions were geared to predicted outcomes.

For good marks I got a pat on the head and a smile. For scoring touchdowns I got laid. In either case room and board were provided. Obviously the quest for orgasm prevailed.

There was one conflict. Eventually I had to endure quite a bit of punishment before I got through the maze and got my just desserts. Don’t let anyone fool you. Football is a dangerous game, but to coin an old adage. You must risk a lot to gain a lot.

I made up an accounting sheet placing all my physical characteristics into an asset and deficit column, attempting to find the formula that would insure the greatest number of orgasms and secondary pleasures for the least amount of sacrifice.

My computer mind came up with quarterback. In prestige and glory the position was number one; in pain it was third from the bottom, just in front of holder and kicker. Besides, I was lithe, agile, coordinated, and fairly fast; attributes most essential to the position, while my lack of strength and weight had the least detrimental effect. At five feet ten inches, I was just borderline with regard to height.

With fierce determination, I set about my goal. Each day in school I would diagram plays in class like a general directing an army and try and appreciate, in three dimension, the flow of motion on the field for each given play and the time intervals at which spots in the defense would be weakest. The permutations and combinations were infinite and my total being was devoured by the problems at hand. There were temporary setbacks, such as chastisement by my teacher for not listening or for doodling. There were even occasional trips to the principal’s office for creating disruption and showing indifference in the classroom. Even my parents got into the act, but their words of wisdom fell on deaf ears. The little pear shaped kid with glasses, sitting in the corner with his nose in a book and his 96 average, got laughed at and abused. The captain of the football team, acne, cracked teeth and all, got laid.

My father warned me.

That roly-poly is going to surpass you and enjoy greater success.

But at fifteen, with each day a relative eternity, planning ten years in advance seemed like an absurdity. For effort to be persistent it must be coated with sugar and there were no immediate and few imminent rewards in view by pursuing the hard and tedious line of study, study, study. After school I practiced with the freshman football team. Me and another guy were battling it out for the first string quarterback job. He was bigger and tougher and could throw further. I was smaller, smarter, and faster but I knew it wasn’t enough. Intelligence helps, but all the brains in the world can’t make a football arrive at point X in Y time. That takes a natural arm, good vision, good timing, and depth perception.

I used all the sorcery at my command. After practice I threw balls into a tire for two hours before dinner and two hours after. I ate and

ate and ate, and prayed that I would grow. Most of all I prayed that the first string quarterback would break his leg or something.

God heard me. On the fourteenth play of the third game of the season, their middle linebacker did what our coach had been telling our middle linebackers to do for two months.

I like sportsmanship boy, but come up with that elbow under the shoulder pads. Catch him in the Adam’s apple. Let him know he’s in a ball game. Pointing a finger for emphasis, he added. Good, clean, hard fun. That’s what I like.

Our quarterback sailed backwards, eyes bulging, and fell in a lump. An accommodating defensive end sat on his extended leg and snapped it cleanly.

Thank heaven for prayer. With forehead furrowed, frown across his face, and tears welled up in his eyes, the coach resonated with conviction.

Get those bastards, an eye for an eye. All that lacked was a bible. The whole team was sad, but now determined to get revenge. Secretly I was elated. Second string quarterbacks don’t get laid.

Confusion, fear, and occasional abandon characterized that first game experience. Nevertheless, repetitive practice paid off, as reflex predominated over cerebral function. My mind was clouded but, almost instinctively, I knew what to call and my body carried out each task with mechanical precision. The end result was a 14-13 victory. My efforts, as viewed by others, while certainly not distinguished, were definitely not deplorable. Rather, despite my mental confusion, I came across as competent, methodical, and capable. From that day on I was number one. With each game I gained confidence. No longer were there many surprises. My mind caught up with my body and, within the framework of basic reflex action, I was able to develop a degree of flexibility that makes for surprise and excitement. My arm grew stronger, my body more relaxed but most importantly I acquired game experience. I could sense tacklers on my right or left or behind me. I could throw blindly to a spot and complete a pass more often than you would think. Some called it a sixth sense. The explanation though was simple enough. With repetitive exposure, you learn the basic flow of traffic during a play. You know where each player is at different time intervals, not because you see them, but because you have seen the same play hundreds of times before, and you have had a pass intercepted, or you have been creamed from the blind side to taste a mouthful of dirt, and to nurse sore ribs for a week or two. By my sophomore year a gap had developed between me and the unfortunate quarterback who broke his leg that could only be bridged if he were given equal playing time. While potentially he might have surpassed me, at the moment I was better and, since the varsity needed a quarterback with some experience, I would play and the gap grew greater until it was not negotiable. His friends called me lucky, but to me luck is when preparation meets opportunity My chance came and I was prepared. I used it to full advantage and because of that I remained number one. With each game, I continued to strengthen my position, and I learned one important lesson. Prepare and be ready and when opportunity or surprise confronts you, you will be able to grab hold of it and perform creditably until experience permits you to stand apart and above.

That first time, though, you must hold on or you may drown and never get a second chance.

INTERNSHIP-PARKER

MEDICAL CENTER

The headlines should have read January 1st, Hell Freezes over. At least it seemed that cold as I walked the hundred yards from the parking lot to the doctor’s entrance with the cold, biting wind ripping through my overcoat." It was a foreboding of the nightmare that lay before me. Thank God I was as unaware as the lamb going to the slaughter. Otherwise, I don’t think I would have taken those last strides through the doors of the medical center that would be my home for the next year. I found my way to the office of the director of medical education and presented myself to his secretary.

Please make yourself comfortable, she said, pointing to a row of chairs across from her desk. She never even lifted her head. I found a seat next to another fellow who was engaged in conversation with a girl sitting to his left. He looked about my age and was probably another intern. She looked stumpy of body and fleshy of face, common qualities found in a female Doc. Somehow, there seemed to be a direct correlation between ugly and smart, especially when it came to females. I sat down and introduced myself to them.

Hi, he replied, I’m Bob. Bob Norris and this is, Sheila? He paused for a moment. She filled in.

Canter.

New interns too, I asked.

"I’m afraid so. Seems nobody but you, Sheila and I have arrived yet.

I looked at my watch. It was 7:30 AM. We were supposed to arrive at eight.

We’re early, I guess.

Where are you from, Sheila asked.

Bologna.

Where? she asked with a confused countenance.

Bologna, Bologna Italy.

Oh, she replied in a supercilious tone that would typify the physician response upon finding out that someone was a foreign graduate. I’m from Flower Fifth, you know, the jungle. Bob and I were at school together.

She was referring to Metropolitan Hospital in the heart of Manhattan where Flower Fifth students trained. They dealt almost exclusively with welfare dependent and poverty stricken Puerto Ricans and Blacks.

I bet you got a lot of experience dealing with the variety of illness that you must have seen there.

Are you kidding me, Bob cut in. I got to the point where I could tell the difference between a man cut by a nigger and a spic. The nigger stabs but the spic carves.

Right away I couldn’t stand Bob. Those racial epithets made me sick. How about you Sheila. Did you have an opportunity to get your fingers wet?

Of course. In all American medical schools your last year is practically an internship. I’m used to taking care of people, writing all their basic orders, starting the IV, drawing blood and doing the CBC, urinalysis, EKG, etc. by myself.

Her reply startled me. I knew about those things but I had never done any of them. I hadn’t even performed a history and physical, which is the basis on which the physician forms his working diagnosis.

I had to learn it all from scratch and it became evident that I was way behind. I hoped that my lack of experience would not be taken for stupidity. I was willing to learn. All I needed was a helping hand. As we made small talk, the room began to be filled with would be house staffers, mostly foreign graduates. Most America graduates began their internship on July 1st right after graduation in June. Sheila and Bob were exceptions because they chose to do six months of research after graduation. Foreign graduates usually finished school in July, August or September and, therefore, had to wait until January to begin their year of internship. At eight o’clock sharp, we were all ushered into the office of the director of medical education and, following his indication, took seats in the various accommodations spread throughout the room.

Dr. Gardner was an imposing figure. He addressed us all as a group, as his gaze swept across the room. I felt disappointed that he didn’t offer me a wink of recognition. He had been so friendly at our luncheon engagement in Bologna last January. It was essentially that impression that convinced me to sign the contract to intern at the Parker Medical Center. Under him, I felt that he would offer concerned supervision and an empathetic ear to my individual needs. Speaking to me now, he seemed so disconcertingly distant. Little did I know that this posture was an omen of things to come. His major job was recruiting and he stretched the truth as far as he had to in order to recruit his quota of interns. Just like in college athletics, once signed, the rules changed. You were an indentured servant and there wasn’t anything to do about it.

Dr. Gardner opened on a positive note.

"I’m glad to see you all here this morning. I know that you are all anxious to get started and therefore I won’t make you to listen to a long speech. Let me just say that I wish you all luck and am looking forward to a successful and fruitful year. Now, if you’ll all speak to my secretary outside, she will give you your floor assignments and direct you to the laundry section where you can sign out for your uniforms.

Let me just add that I am proud to have this group here with me today. You were all hand picked and I am looking forward to a rewarding year both for you and for the Center."

With a nod of his head, our meeting had come to an end. I wouldn’t speak to him again until the graduation ceremony. We all got up and picked up our assignments from his secretary’s desk. She didn’t even lift her head.

After signing up for my uniforms, I headed to my on call room. They told me that it would be at least a week until we had our uniforms and, blood or no blood, we would have to make it with our own clothes until then. The on call room was small, aseptic and bare except for two beds, a phone, wall lamp and a chest. I deposited my belongings and left to find the medical floor that would be my home for the next three months. I approached the nurses’ station and introduced myself to the nurse behind the desk.

Good morning. My name is Dr. Robbins. It seemed funny sliding the doctor in front of my name. After all, until I learned something, I was just an imposter.

Good morning, Dr. Robbins, she replied and returned to her work on the desk. I fidgeted with my thumbs for a second and then spoke up again.

Um uh, I’m the new intern on the floor. She looked up and said with a somewhat twisted smile on her face.

Well Hallelujah, and returned her eyes to her work.

I milled around for an uncomfortable thirty seconds and then started to walk down the hall. I couldn’t help but let out a just audible, Well thanks for all the help, as I turned away from the desk.

The hallway was short and blind and I had to retrace my steps back toward the nurses’ station. I slipped unobtrusively behind it and found a chair in the small glassed in office in the back. The nurse behind the desk got up from her busy work and caught me with her left eye as she started toward the corridor. She changed direction and, with a determined step, approached the office, never removing my face from that icy penetrating gaze. I avoided her eyes, but nonetheless felt naked and vulnerable. What the hell are you doing in my office? she shouted, finger pointing, the whole bit. I waited for her to stomp her feet. I wanted to tell her to suck but, instead, I just returned a refractory stare. I asked you a question, she shouted, hands on hips, her face menacingly near mine. I looked about, ostensibly to see if anybody was watching. The softness of my voice magnified the intensity ofher own. I bent over and whispered, faces almost touching.

I’m sure I made a mistake. This must be a psychiatric ward?

Listen, she shouted again. I don’t have time to play games. You have no right to be in here. Now get out! I stood up slowly, obviously not intimidated by her diatribe.

You might even be pretty if you smiled, I offered, trying to find another way to break the ice. She managed to control her mouth and eyes, but most red heads can never control their skin. The blush came out blood red, and no matter how menacingly she tried to act, the cover was off. You almost made it that time, I added. The smile took full bloom but her voice, although less intense, defied it.

Will you please get out of my office?

Under one condition.

What’s that?

That somebody tell me what I’m supposed to do around here.

You don’t know, she asked incredulously?

Nope, I’ve never been an intern before.

So what; you’ve worked under them.

Nope to that one too.

Where did you go to school?

Italy, University of Bologna.

Oh no, not another foreigner, she said shaking her head in disbelief. I can’t take another one." Her tone rang with sarcasm.

You know, I can’t tell you how appreciative I am of all the assistance and support being offered here.

Listen here smart ass! she retorted. I’m not going to be your nursemaid. You’re going to have to do your own work.

I’m willing to but I hope that you’ll be of some help. Exposure to hospital wards is new to me but I’m willing to learn and I learn fast.

We’ll see. Why don’t you just start by picking up those thirty charts and get the hell out of my office.

Thirty charts, I responded although somewhat overwhelmed.

You heard me. We have a very busy floor. I nodded my head and walked out to the nurses’ station and picked up the first chart. I didn’t have a good start with Nurse Sutton, but I knew that I would try to do what I needed to do to get her off my back.

Forty five minutes later I was still stuck in the first chart trying to familiarize myself with the format let alone the diagnosis and treatment. I had never seen a patient chart before and didn’t realize that so much organization and thought had gone into its preparation. They seemed to leave nothing to chance.

The front sheet contained the admitting diagnosis as well as the discharge diagnosis, which of course was not filled in yet. This was for a triple purpose. It offered easy reference, easy comparison, and an easy method for compiling statistics for retrospective studies. Also included on the front sheet was all the pertinent data necessary for filing, billing, and further correspondence; i.e. name, address, phone, hospital number, insurance, admission date, discharge condition at departure, procedures and operations etc.

Behind the front sheet was the order sheet. Each medication or test, that the patient received, was ordered here by the physician. Occasionally, a busy practitioner might forget that he ordered a narcotic or antibiotic and forget to discontinue it. Therefore, as a matter of hospital policy, all medications needed to be reordered every week by the physician of record or they were discontinued.

Most doctors bitched about the added paper week. But a great percentage of them, if occasionally embarrassed by conflicting medications, were saved from medical malpractice suits. Conflicts and duplicated medications, as well as unexpected deletions were caught at a surprising frequency when two or more doctors wrote orders on a patient. More often than not, a busy consultant either failed to read or could not read the prior orders of another physician and, in haste, would occasionally duplicate or conflict with them. Occasionally, one physician would blatantly cancel out the order of another physician only to find it back on the chart. The renewal system was a check and a good one. It was here to stay. Behind the front sheet lay the Heat sheet with the records of the patient’s temperature and other vital signs (BP, pulse, respirations) taken at prescribed intervals. In back of this, the history and physical was recorded. This was usually dictated and typed out by secretaries located in the Medical Records department. Their job was a tedious and a monotonous affair. On arrival they went right to their desks, located in a windowless bare room in the basement, inserted their earphones, snapped in a tape, and began to type dictation. They could control the flow with the foot pedals. Each day they had to do so many pages of dictation. In an eight-hour day an average typist had to apply herself diligently to her task for at least six and a half-hours to finish her quota. In that time she had no contact with the outside world. There was no way in hell that I could do that job. Nevertheless, their contributions were invaluable. In the past, the physician was buried with necessary but menial paperwork. The continuous task was awesome and the history and physicals, operative notes etc. were shortened as much as possible. Furthermore, charts that were hastily done were usually illegible.

Now, with dictaphones available, information tended to be more complete. Naturally also, the typewritten word was easily legible and information regarding the patient was now practically available to all medical personnel. The availability of information to consultants as well as paramedical personnel obviously improved over all patient care. Furthermore, the activities of a physician and his method of thinking could be more easily evaluated and controlled by a review committee, if a clear and complete chart were available. In that way, errors in treatment were identified and discussed so that standards were kept high. A refractory physician, unwilling to adapt to new methods and insistent on perpetuating old mistakes, was eventually eliminated from the staff. All in all, both patient and physician benefited.

After the history and physical lay the progress notes. In these, the doctor was to give a daily summary of the patient’s condition, so that a chronological evaluation of the patient’s improvement or deterioration could be made. Following these were laboratory and X-ray data as well as reports from other studies.

Next were the nurse’s notes. Tempting to avoid, but scanned at least by all good physicians. There was no substitute for frequent attendance. An observant nurse often described signs or symptoms that the doctor missed. Sometimes, the information was invaluable, needless to say lifesaving.

If the patient were on a surgical service, the operative note was next in line. This described the procedure in detail. It’s value is recognized especially by the physician operating on a patient for an acute appendicitis only to find that the organ was incidentally removed 20 years before. The patient isn’t often aware of all that was done as well as the problems the physician faced in handling them. A second surgical intervention or, more importantly the avoidance of one, can hang on an operative note. Most physicians dictate this well and don’t spare the details.

Behind this, depending on the patient’s needs, are miscellaneous sheets followed by the final note, essentially a chart summary on discharge of the individual. Lastly comes the medication sheet, another check on the order sheet itself. Here, all drugs administered are marked and their times of administration noted.

In essence, the chart is crammed full of information. Its preparation is methodical and usually complete and affords a full description of the illness of that individual. Even without the patient there, a complete chart should paint the picture of a person’s illness, its severity, its course, its outcome, and its prognosis. From it the patient should spring to life, insuring the availability of an invaluable permanent record. I had only waded through the first chart before my stomach got the better of me and I went off to lunch. I had no idea how I was going to familiarize myself with all those patients, as well as the daily new admissions, but right now I was hungry and I was going to eat. The line moved at a snail’s pace and I fidgeted nervously waiting for the people before me to be served. With food steaming on my plate, and my stomach growling with excited anticipation, I found a seat at an empty table and was just about to bite in when I heard my name paged. Reluctantly, I stood up and moved toward the phone and called the operator, who told me to call my floor. Sutton answered at the other end.

Dr. Robbins. Mrs. Brown is having difficulty breathing doctor, she said hurriedly. I think you’d better come up and see her.

I responded in the affirmative and made my way out the door toward the elevators. My mind churned over the possible causes of shortness of breath as I ascended to the 6th floor. Everything seemed confused and a sudden fear rushed through me that I wouldn’t know what to do. Reluctantly I pushed toward my first confrontation with a patient in acute distress. Praying silently that emergency heroics would not be necessary, I rushed into the room. Sutton was administering oxygen by mask to Mrs. Brown, who was gasping for breath. I moved around to the other side of the bed and placed my stethoscope under her gown and began to listen to her heart. The sounds were jumbled, with interference coming from her noisy breathing and the gown rubbing against the tubing of the stethoscope. I couldn’t make out a thing. I listened to her lungs, the bases of which were filled with bubbling noises called rales. Her pulse was rapid and irregular.Do you want me to start an IV, doctor.? I paused before responding, weighing the possib1lity in my mind. I didn’t know ifit would help, but certainly it couldn’t hurt. I knew that in case she went into shock, with an IV, a vein would be available for intra venous medication.

Yes and what’s her blood pressure? The other nurse in the room responded.

100/60, doctor.

Maybe you’d better lie her down, I don’t want her to go into shock.

My hands were clammy and my thoughts were still confused, but like a vice, I crunched out all the noise and commotion around me and willed a clear-cut summation of the facts that I knew.

Her pressure was 100/60, slightly low. I grabbed her chart and saw that normally she ran 160/100. For her, the pressure was very low. Her pulse was rapid and irregular indicating a rapid irregular heart beat. Her lungs were filled with basilar rales. I quickly glanced at the impression in the History and Physical. It stated congestive heart failure. I looked at a previous EKG tracing. I couldn’t read them well, but the diagnosis below stated regular sinus rhythm with left ventricular hypertrophy. The rate was easy to read. It was slow and regular, differing from the rate today. Like the sun bursting through a sea of clouds, the diagnosis hit me. The patient was in congestive heart failure, probably as a result of atrial fibrillation, a cardiac arrhythmia in which the heart pumps inefficiently. This leads to back flow ofblood in the lungs and, when real severe, frothy pink sputum. Sutton cut into my trance. Do you want any medication Dr. and do you want me to call your resident?

Yes, give her a 1/4 grain of morphine IM, I said hesitantly, and sit her back up. And yes, get the resident. Mrs. Brown began to gag violently and, as I helped her sit up, she expelled a large mass of frothy sputum on my forearm. I swallowed hard and again listened to her heart. This time I pulled her gown up and held it away from the stethoscope. With intense effort, I tried to block out all the extraneous sounds around me including the gurgling noises, worse now, coming from her lungs. The heart sounds, somewhat distant, came through. Lub dub, lub dub, lub dub. The rhythm, always irregular, was rapid with a varying intensity of the first and second heart sounds. Please get an EKG, I said to the other nurse standing beside me. My neck was wet with sweat and a fine tremor ran through my limbs. Mrs. Brown seemed to be getting worse. I prayed the resident would get there.

The resident walked briskly into the room, a halo of confidence around his head. With his arrival I sighed with a gasp of relief and moved inconspicuously to the foot of the bed. The responsibility was off my shoulders, but for the first time I noticed my heart was pounding loudly in my chest. He listened briefly to Mrs. Brown’s heart and lungs, making sure that her gown was removed before attempting auscultation. He felt her neck, liver and extremities swiftly, and, at the same time, ordered medications as he went along.

Rotating tourniquets, Lasix 40 mg. IV. His crisp commands sharply contrasted with my own hesitant behavior.

Has she been on Digitalis? he asked. Sutton leafed through the chart to the medication sheet and responded with a curt,

No.

Give her 0.8 mg. IV of Cedilanid and add 500 mg. Aminophylin to the bottle. He then looked smilingly at Mrs. Brown. Don’t worry sweetheart, you’re going to be alright.

As Mrs. Brown responded miraculously before my eyes, I felt a deep sense of elation and relief. But I was also wrought with frustration and inadequacy. Everyone was moving busily about, giving medications, running the EKG, and administering oxygen. I felt like a third wheel at the foot of the bed, unneeded, and totally discarded. I seriously doubted whether I would ever be able to synthesize and analyze the symptomatology as rapidly as Dr. John Belli did that day and institute an effective method of treatment.

As Mrs. Brown improved, I walked out of the room and moved back to the nurses’ station with her chart. I started to read through it, hoping to learn something and look busy at the same time, when the other nurse, who was in the room, approached. She was slim and blond

with a cynical smile on her face. The name A. Hartung was written across her nameplate. Excuse me doctor, Dr. Belli needs the chart.

She placed her hand out to take it, not expecting a refusal. I gave it up without a battle. That was the crowning blow. My reading it was of no real importance. The despair that accompanies the sensation ofuse- lessness is difficult to describe. Let it suffice to say that tears welled up in the corners of my eyes and I wished only to vanish from the spot, never having to face these people with their critical stares again.

Belli came out of the room five minutes later and approached me at the nurses’ station. You the new intern I assume?

Yes, I responded, trying to get myself together.

His tone was serious and belligerent. Well what the hell were you doing in there? That lady almost died.

Trying to take care of her.

Well let me tell you something doctor, he said, pointing his index finger in my face We are not going to tolerate incompetence. You’d better find out how to treat congestive heart failure and find out fast, because you are going to see an awful lot of it. He made no effort to lower his voice and the aides and Hartung were all listening. I felt undressed and terribly small, but I refused to be bullied and intimidated.

I did the best I knew how.

Well that’s not good enough. Now make sure Mrs. Brown continues to do well. Write some orders and then learn the rest of your patients. I’ll be back at 5:00 PM to make rounds with you. He took off down the hall. I watched him disappear and then turned toward Hartung and asked,

Where is Mrs. Brown’s chart?

I think it’s in the room doctor.

The disdain in her voice, when she said doctor, cut through me like a blade. I ignored it and, since she made no effort to get the chart for me, I started off toward Mrs. Brown’s room. I found the chart at the foot of her bed and then walked over to her side, lifted her gown off her chest and listened again to her heart. The rhythm, though still irregular, had slowed. I concentrated on just the heart sounds and I was amazed how well I could hear, now that her gown was no longer interfering with the tubing on the stethoscope and the peripheral noise in the room had diminished. I vowed then never to let concern for modesty interfere with a physical exam and, if need be, I would insist that everybody shut up and stand still while I listened. Her respiratory rate had slowed considerably and the intensity and level of rales had diminished.

I picked up the chart and walked back to the nurses’ station, busily running over the orders given by Belli and actively committing them to memory. I made a note in my small pad to look up emergency treatment and management of this disease. For the meantime I looked up the drugs Belli had ordered in the Physicians Desk Reference that I accidentally saw lying before me. Time made it impossible for me to check them all in detail so I chose to read about Lasix and how to order it. Fifteen minutes later I wrote my first orders in the chart: 1st, Lasix 40 mg. po (by mouth) qd (once a day) and 2nd, electrolytes qd. I chose to order them later since diuretics can alter the electrolytes significantly. I then gave the chart back to Nurse Hartung and indicated that I had written orders. What do you want me to do with the IV, doctor? Doctor rolled off her tongue like she had a mouthful of shit and had to spit it out before it made her sick.

Uh, I paused, not anticipating the question. I could see no harm in keeping it open as long as I gave her only sugar water and no salt, slowly.

"Keep it going and run it slowly.’’

How slowly? she said disdainfully.

What’s usual? I had no idea. Hartung smiled, realizing she had scored her point.

I’ll keep the vein open at about 20 drops par minute, Okay?

Okay, I’d said relieved. "And thanks, your the first one to help me since I’ve been here.’’She smiled sympathetically and I was grateful.

In an atmosphere ofhostility, that small sign shone like a light from heaven. I turned back to the charts and began to review all the others I had missed before lunch. My stomach was knotted and I moved through them without any thought of food. Time flew and I just managed to familiarize myself with all the names and their illnesses when Belli appeared on the floor. I looked up at the clock. It was 5:00PM on the nose.

Let’s go, he said and started down the hall. I rose quickly and caught up with him. Rounds that first day were an indication of the living hell that he would put me through for the next couple of months. Belli made it clear to everybody that would listen that I was an absolute idiot and that he didn’t know how I would ever be smart enough to be an orderly, let alone a doctor. No matter how hard I tried, it was impossible to please him. I just didn’t have the time to study the things that he wanted me to know and still take care of all of my responsibilities.

Things went from bad to worse. There was nothing I could do to make Belli or the attending physicians happy. I was working at a feverish pace, fourteen hours a day on my nights off and thirty-eight hours in a row on my nights on call. Every other weekend I worked from Friday morning until Monday night with less than ten hours of cumulative sleep. I was a walking zombie and nobody cared. I was constantly harassed by Belli and the attending physicians and, despite