Author Archives: admin

The Harder They Fall

Doctors make lousy patients.

I spent half the summer extolling the virtues of adequate hydration to pregnant woman whose urine specimens were as dark as Granny’s sweet tea, but then ignored my own advice.

Every August our church holds an outdoor mass at a local farm and family activity center owned by one of our parishioners. Several of us arrived early to move picnic tables and set up stands for hot dogs, drinks and dessert. The guys hauled out the four rusty barbecue grills made from steel drum halves and filled them with charcoal. The farm donated several dozen ears of corn which we soaked in Rubbermaid garbage cans half full of water.

We soaked the charcoal with lighter fluid and lit the grills about a half hour before Mass. If the coals didn’t seem hot enough, someone would squirt more fluid onto them, creating a fireball.

“Hey, I heard you’re not supposed to do that.” *wink wink, nudge nudge* Another shot of fluid and another fireball.

We loaded the grills with corn just as Mass started, turning the ears with gloved fingers as they roasted. I had my trusty grill tongs, one in each hand, and my heat-resistant gloves, which last year I discovered don’t work when wet. The heat became so intense none of us could stand close for very long.

The sun was hot and the sweat slithered down my neck. My arms started feeling heavy after about forty-five minutes and I knew I should probably drink some water. I trudged over to the table our family had commandeered and sucked down the rest of my McDonald’s iced tea from a large Styrofoam cup.

Now, I travel a lot for my work and often miss church functions. I didn’t want to seem like a slacker so I refilled my cup with water and headed back to the grills. Everyone else congregated around the covered wooden corn stand, sucking down bottled water. One would have thought that was an obvious sign from God: “Get out of the sun, dummy!”

I was staring at the grills, watching the corn husks charring, the heat blasting my face, when the world faded to black, and I felt the ground sneak up behind me. I imagined the cup was a stationary pole and grabbed for it as I went down, crushing it in my fingers. I thought This is going to hurt…and you’re going to look really stupid.

I grazed my shoulder on the antique plow surrounded by flowers, hit the grass and decided this was as good a time as any for a nap…

I heard voices which sounded far away.

“Hey, are you OK? What happened?”

“I think Jimmy must have pushed him.” There were a few chuckles but their concern was evident.

“He’s pretty warm. Someone get some water and pour it on his head and cool him off.”

“Do you think we should call 911?”

A small crowd had gathered. I still had my eyes closed when someone doused me with a couple of bottles of cold water. It felt good but I was still pretty toasty and asked for another bottle which I poured on my chest. A woman’s voice above my head asked, “Does anyone here know his medical history?”

By this time Peg had arrived and said, “I’m his wife.”

The other voice persisted, “Does anyone know if he has a heart condition?”

“I’M HIS WIFE!”

Lady if you don’t back off Peg is going to hurt you. Don’t poke the bear!

I opened my eyes and was looking up The Voice’s blouse. She was leaning over me, holding a tablecloth for shade. I said, “I’m still pretty hot.”

Someone handed me an open bottle which I poured onto my chest. I reached out for another one and lowered it to my mouth, I took a few deep gulps but then, momentarily forgetting I was flat on my back, lifted the bottle straight up and waterboarded myself. I struggled to turn on my side to drain my nose.

“What’s happening? Is he having a seizure?” The Voice again.

No, you idiot. I’m drowning.

I rolled to my side, snorted a few times and lay back. The Voice said, “His breathing is labored.”

“No, I’m not in labor.” This got a chuckle from everyone who knew me, but she didn’t and said, “He’s delirious.”

“Do you think we should call 911? Do you have insurance?”

Peg said, “Yeah, we have crappy church insurance,” which is true. Every year the premiums go up along with the deductibles and co-pays while the coverage gets more stingy.

“No, I’m fine. I’m just hot and a little dehydrated. Let me sit up for a few minutes and I’ll be OK.” I mentally imagined the cost of an ambulance ride and an emergency room visit; the dial in my head was running faster than a gas pump set for five bucks a gallon.

I heard a familiar voice at my feet. “I’m a personal trainer and my sister is a lab tech! We need to get his legs above his head.” She grabbed my feet and started lifting.

Oh God, no. That is the LAST thing I need.

Peg said, “Don’t do that; he has a bad back and you’ll hurt him.”

Listen to the lady and get your hands off me.

She persisted despite my wife’s objections and I foresaw another rumble.

Peg said, “Put something under his knees if you want but don’t lift his legs up.” One of the guys grabbed a couple of empty charcoal bags and chucked them under me. The personal trainer dropped my legs but tried another well-meaning but ridiculous intervention.

“I’m going to put a couple of bottles of water inside your groin. That will help cool you off.”

You gonna do WHAT??? Jesus, just leave me the fuck alone!

“We really should call 911.”

I knew I wasn’t going to win, but I didn’t want to give in and muttered, “Let Peg decide.”

She gave the OK and later told me, “I did it because if I said no they would have thought, ‘Gee, what a heartless bitch; she won’t call an ambulance for her poor husband.’ You’re a physician and I play one on TV but they aren’t going to listen to either one of us.”

So the call went out and about five minutes later the local ambulance and fire truck pull into the grounds. I’ve never understood why a fire truck always comes along since there’s nothing burning.

One of the paramedics asks how I’m feeling and The Voice says, “He’s cold and clammy.”

No shit. I’ve had four bottles of ice water poured on me.

Peg intervened, gave them a brief history, and I crawled onto the gurney. I’ve ridden in the back of an ambulance with a patient but I’ve never been the one being transported. Once inside they started asking me the usual questions: name; medical illnesses; allergies and any medications.

“Ranitidine; enalapril; aspirin; antihistamine and something for my prostate. It’s…uh…that blue one.” I couldn’t remember the name; maybe this was more serious than I thought.

“Ok, we’re going to start an IV, put some pads on you and do an EKG and check your blood sugar.”

They took their time, for which I was grateful because there’s nothing worse than trying to start an IV on someone with collapsed veins in a moving ambulance that rides like a 4X4 over railroad ties. We finally started moving and I watched the picnic grounds recede out the back window which reminded me of riding in the rear-facing third row seat of a 1960s-era station wagon.

The firemen, having nothing better to do on a Sunday afternoon, stayed around for another hour, feasting on roasted corn, sampling the desserts and socializing with the crowd. There’s much to be said for small-town life.

Peg arrived at the hospital long before the ambulance left and asked about me at the emergency room reception desk.

“We don’t have anyone here by that name.”

“Are you sure? I watched the paramedics put him in the ambulance.”

“Oh, wait. We had a call about a man who collapsed at a picnic. The ambulance should be here shortly.”

While she was waiting a man dressed in pajamas and carrying an old-time doctor’s bag walked up to the desk and said, “I’m Doctor Moore and I’m here to check into the hotel.” A woman behind him said, “No, I’m his sister and he’s here to see the psychiatrist.”

Just another day in the emergency department.

The ambulance pulled into the bay about ten minutes later. They pulled the gurney out and I shook hands with the paramedics before they wheeled me into an ER room. The nurse gave me a gown, asked me the same questions and said, “The doctor will be in shortly.” She hung a new IV bag before she left.

Someone brought Peg to my room; her sister showed up a few minutes later. They caught up on what happened after I left; I wondered where my barbecue tongs and gloves were.

The ER doc, a Denis Leary clone, came in a few minutes later and cut his spiel short when he found out I was a fellow physician. He ordered blood work and a 12-lead EKG, even though the one in the ambulance was normal, because there are protocols to follow and asses to cover. I’ve done the same even though I often think it’s a colossal waste of money.

Lab and EKG techs came and went. I dozed; they talked.

Then the woman who gets the insurance information entered. She may seem a humble employee, but she is the Most Important Person in the hospital since the hospital doesn’t get paid without her efforts. One would think the administrative suite would treat her like royalty, but to them she’s just another FTE, an interchangeable cog in the machinery.

My sister-in-law looked at the woman, paused for several seconds and said, “You look familiar.”

“So do you.”

“Do you go to Our Lady of Perpetual Trepidation?”

“Yes, I do.”

Suddenly it was Old Home Week and they chatted while I snoozed on the cart.

I was ignored for the next two hours. The nurse was staring at the computer screen when Peg went to tell her my IV bag was almost out. About 30 minutes later I needed to go the bathroom. Peg went back to the desk, found the nurse reading a book and the doctor futzing on the computer.

“My husband needs to use the bathroom. Do you have his labs back so we can get out of here?”

The ER doc came in after my potty break. My labs and EKG were normal – big surprise. He asked if I had a primary physician and I just snorted. (I told you doctors made lousy patients). We talked about ER patients and how he had to work another 20 years before he could retire. We finally left with instructions to make a follow up appointment with the primary care physician on call that day, something I had no intention of doing.

It’s probably just as well. Peg did some online research and discovered he was a Family Practice doc with three judgments and a state reprimand in only 11 years of practice. But that’s a story for another blog post.

A woman called the church office on Monday.

“I heard Peg talking about taking her husband to the emergency room and she seemed really worried about the cost. Do you think we should start a GoFundMe page for them?” Our insurance may not be the best, but it is far better than being uninsured

I got the tab a week later:

Ambulance ride: $1047
ER visit: $5681
ER Physician charge: $651
Humiliating yourself in front of a crowd: Priceless!

Bookends

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Many of my generation came of age with the music of Simon and Garfunkel. They provided a poetic and intellectual counter to the shallow, mass-market Top 40 hits on AM radio and the raucous, sometimes angry but certainly eardrum-shattering music of the late 1960s, which now we quaintly refer to as “classic rock” with the same disdain heaped on “your Golden Years.”

I listened to their Bookends album recently during a flight from Portland, Oregon back to Chicago. I hadn’t listened to it for at least two decades; I’d been trying to shed my sensitive side for a more curmudgeonly and safe persona.

I’m now ambivalent about Simon and Garfunkel. Yes, the music was poetic unlike anything I’d ever heard, but it could also be depressing and insistently New York City, an unfathomable existence to someone raised in the desert and then the Midwest. These are Walden’s “mass of men leading lives of quiet desperation.” People who read Emily Dickinson and Robert Frost while pondering if both God and the theatre have died; living in dingy, walk-up flats with noisy radiators and even noisier neighbors. I often imagined a grainy photo of Paul Simon in that black overcoat from the Sounds of Silence cover, walking on a rainy spring day near the Berlin Wal at Checkpoint Charlie past a sign saying “Eintritt Verboten” (Entrance Forbidden).

Bookends is one of Simon and Garfunkel’s more depressing albums, if such a thing is possible. America is a song of lost hope which, for some inexplicable reason Bernie Sanders chose as background for campaign ads. Did no one even listen to the lyrics?

“’Kathy, I’m lost’, I said,
Though I knew she was sleeping.
‘I’m empty and aching and
I don’t know why.’”

Sheesh.

The next song is “Overs,” a song about a relationship waiting to die:

“Why don’t we stop fooling ourselves?
The game is over…

…We might as well be apart.
It hardly matters,
We sleep separately.

And drop a smile passing in the hall
But there’s no laughs left
‘Cause we laughed them all.
And we laughed them all
In a very short time”

The first side of the album ends with “Voices of Old People”, followed by “Old Friends/Bookends.” The voices are those of elderly people – presumably New Yorkers, possibly Jewish or Italian – kvetching about their infirmities and resigning to their fates; they are waiting to die in a nursing home, in their adult children’s homes after a stunning role-reversal, or alone in a tenement, waiting to be discovered when the body starts to smell. I was a teenager then and now, fifty years later, we’ve vowed not to “go gentle into that good night,” but instead take Zumba classes, pursue the dreams we postponed as responsible adults raising families and acquire gonorrhea and chlamydia in retirement communities for “active seniors.” It’s no longer “terribly strange to be seventy.” We’re more like the lecherous old lady in the Playboy cartoons. Mick Jagger is still prancing around the stage and we’re 35-year-olds in our minds, wondering what the hell happened.

I’d completely forgotten “Mrs. Robinson,” which brought back a whole bunch of bad memories of cinematic dysfunctional adult relationships – Doctors’ Wives, Ordinary People Carnal Knowledge, Women in Love and The Graduate – and those I observed in real life. The bar in the Robinson’s house, well-stocked with liquor and the kitschy “Bar” light in the corner, symbolized the emptiness of their relationship. He was the successful, country-club-and-Cadillac businessman; she was the restless, neglected wife who could buy anything but what she really needed. It reminded me of an old girlfriend who lived in tony Glencoe, IL. The expansive house on an enormous, well-manicured lot obscured the psychopathology within.

Paul Simon reflected on American’s need for heroes in “The Silent Superstar,” a piece the New York Times ran the day after DiMaggio’s death as “subconscious desires of the culture.”

“Where have you gone, Joe DiMaggio
Our nation turns its lonely eyes to you…
…What’s that you say, Mrs. Robinson
Jolting Joe has left and gone away”

“At The Zoo” is the only uplifting song and it’s uncharacteristically humorous. Paul Simon adapted the lyrics for a children’s book in 1999. Who wouldn’t love this?

“…The monkeys stand for honesty
Giraffes are insincere
And the elephants are kindly but they’re dumb
Orangutans are skeptical
Of changes in their cages
And the zookeeper is very fond of rum

Zebras are reactionaries
Antelopes are missionaries
Pigeons plot in secrecy
And hamsters turn on frequently
What a gas, you gotta come and see
At the zoo…”

Sometimes I miss the music, but not the emotional vulnerability that came with it. Time to put this genie back in the bottle for another 20 years, eh?
All music/lyrics © Simon and Garfunkel

Paul Simon, The Silent Superstar. New York Times March 9, 1999, Accessed October 11, 2016.

Closing Up Shop

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Every physician eventually faces the decision to hang up one’s spurs and walk into the sunset to a life of less stress, less money and more time to aggravate one’s spouse by getting underfoot. Sometimes, because of physical infirmity or loss of mental capabilities, that decision is out of one’s hands. An old surgeon under whom I trained who was nearing retirement said, “I’d rather be missed than dismissed.” Others have either amassed a considerable personal fortune or, as a classmate who worked for a state medical school for 30 years and retired at 54, a comfortable public sector pension. But some of us wake up one day, decide “this isn’t fun anymore” and just quit.

I started thinking about getting out a couple of years ago after I overheard a nurse say, “Anyone who does an abdominal hysterectomy these days should be sued for malpractice.” I trained long before the era of the laparoscopic approach to everything and I’m comfortable with the abdominal approach. I’ve never liked vaginal hysterectomies; it’s like operating in a tunnel. I haven’t done major gynecologic surgery in almost ten years and I don’t miss it.

While I love obstetrics, it is a physically demanding specialty. Staying up all night becomes more difficult as one ages and near impossible by the time one reaches mid-fifties. My back doesn’t tolerate 8-hour surgery marathons like I did when I was in my thirties.

It can also be emotionally draining. I’ve had to tell more than one mother her baby has died, and I’ve cried with her and the nurses after the delivery. Our receptionist and her unborn son were killed when she was 38 weeks pregnant. An elderly man ran a stop sign and broadsided her car in a rainstorm. A colleague’s 18-year-old patient died from Group A streptococcal sepsis two days after delivering her baby. We’ve lived long enough that we know all the bad things that can happen and the prospect fills us with dread.

I’ve also known physicians who’ve gone through their entire careers with a clean record only to find themselves being sued when they are within a few months of retiring. That alone scares me more than anything else; like waiting for the walk down the Green Mile.

Medical practice has changed since I started and often not for the better. New physicians are likely to be corporate drones working 9 to 5 for large health care groups, potentially succumbing to a shift mentality, something I saw during my days working for a staff-model HMO. “It’s five o’clock and time for me to go home. You’re now someone else’s problem.” I always stayed until the last patient was seen, worked in emergencies and sometimes met patients after hours because it was more expedient than sending them to the emergency room, which would call me several hours later anyway. Now they call it “old school.”

Many physicians no longer take call or see patients in the hospital. They’ve been replaced by hospitalists who work 24-hour in-house shifts and go home. This arrangement might be preferable to having an overworked, sleep-deprived physician trying to juggle office and inpatients, but that personal connection many of us felt with our patients has been lost.

Smaller hospitals are not immune. As costs continue to rise and competition increases, they become “affiliated” with tertiary centers, if not bought outright, and the bean counters want a sizeable return on investment. One physician confessed, “I have men in three-piece suits telling me what to do—and I do it.” The hospital in which I worked in the early 1970s as an orderly closed recently, having held out too long against the regional behemoth’s advances.

Technology and guidelines derived from academic studies are making us obsolete. Seeing women every year for a pelvic and breast exam, Pap smear and a mammogram for older used to be the bulk of an Ob/Gyn’s office practice. Now, if a woman has a negative Pap and negative HPV testing the guidelines recommend another Pap in five years, even though I’ve seen women go from a negative Pap smear to invasive cervical cancer in a year. We no longer need to do an internal examination on a woman coming for birth control pills if she has no symptoms. The National Breast and Cervical Cancer Early Detection Program told us our clinical breast exams only “modestly improved” early detection of breast cancer. The United States Preventive Services Task Force (USPSTF) says we should teach women “breast self-awareness” rather than breast self-exam, because “the current evidence is insufficient to assess the additional benefits and harms of clinical breast examination (CBE) beyond screening mammography in women 40 years or older.”

A nurse practitioner can do eighty percent of what I do. A Certified Nurse Midwife can do ninety percent. So why the hell do you need me?

I can rise to the occasion when circumstances require expedient action, such as a woman with a liter of blood in her abdomen from an ectopic pregnancy or a baby needing to be delivered immediately to avoid certain death, even though it often leaves a knot in my gut. I probably have a few useful years left but that evening stroll along a beach looks more inviting every day.

Image (C) CanStockPhoto

Sounds of summer

Waking the dead

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My brother bought a black suit when he married at 45, remarking, “I’m going to be attending a lot of funerals,” a reasonable proposition at my age. We lost several people close to us last year, prompting me to reflect on my own mortality: how would I like to be remembered; what music I’d like at my memorial; whether to leave an estate or spend it all before I go.

I remember wakes more than funerals. It’s not the line of people waiting to comfort the bereaved and pay their last respects to the dearly departed. Rather, it’s the visual tribute and chronology of a life that leave more of an impression, particularly if one had been acquainted for a relatively short time. We used to assemble photo collages on poster board; now images can be digitally uploaded to a computer and played on a wall-mounted monitor, complete with soundtrack.

It usually starts with the square black and white glossy snapshots from the 1940s or 1950s, shot with a Brownie box camera. We were babies or little kids and death was an abstraction that never crossed our minds. I notice the backgrounds more often than the subject, recalling my own childhood. Living rooms with obnoxious floral wallpaper that was once trendy. The sturdy couch, armchair and ottoman, covered in a short-napped, rust-colored upholstery that felt like a fresh buzz-cut when you ran your hand over it. Sometimes there was a heavy mantle clock which required winding with a key. It was made with wood and the chime was real, not electronic.

Kitchens had refrigerators with rounded corners and latches, white gas stoves with pilot lights, and gleaming six-inch ceramic tiles (ours were yellow with black trim). Most average folk didn’t have a formal dining room like the Cleavers or Dr. Stone and his wife. More often a chrome and laminate dinette set with vinyl-covered chairs sat in the middle of the kitchen. At least one photo had a kid in a high chair, or, as with my sister, sitting ON the table while pouring out the sugar bowl. Often a little one sat on the lap of a father or grandfather, dressed in a white T-shirt and dungarees, both of them smiling for the camera. Or the look was more subdued, suggesting Dad wasn’t quite used to having a squirming tax deduction. Grandmothers with short silver hair wore a severe, disapproving look behind those black, butterfly eyeglasses. They always wore dresses; no jeans, slacks or pant suits.

Photographs evolved with the lives they recorded, becoming color prints or Kodachrome slides, which held up much better than the Instamatic pictures from the 1980s that would fade into various shades of red and brown. Siblings sat beaming in front of a real Christmas tree with those big clip-on light strings, surrounded by toys we’ve forgotten ever existed. There were snapshots of First Communion and Confirmation if you were Catholic, or the full-body dunk if you were Baptist. (I’ve never been to a Jewish funeral but I’m sure Bar Mitzvah pictures are prominent.) The years roll on with memories of family vacations; eight grade graduation; the first car if the parents had money or, more likely, a shot of the first driver’s license. High school prom if you were one of the cool kids. High school graduation and impending adulthood. Be careful what you wish for.

The paths often diverged from here. Some went to college, then got married. A few married right out of high school and went to work. The bride and groom looked so young in those photos. Then they started having their own kids, assuming the mantle of parenthood from those now content to be grandparents. As one photographic cycle continued another one began. Before they knew it, those kids were grown with kids of their own and the roles shifted yet again.For the most part everyone turned out OK. Occasionally a wayward child turned into a troubled adult despite the best efforts, something no one wants to talk about. Even more tragic was a child lost to illness, accident or war, a premature departure that remains painful and triggers tears.

Photos became larger and sharper in the twilight years. Digital cameras eliminated the trip to the developer for prints. Smart phones then surpassed digital cameras and entire albums were a finger-swipe away. Many a parent converted a shoe box full of memories to a digital archive; but they would never be anything like the originals.

By now our grandparents are long gone. Our parents are leaving us one by one, sometimes later than expected as they live into their eighties and nineties, instead of having the big one in their sixties like they did when we were kids. Ironically that’s where we find ourselves now. We’ve come full circle.

The final episode of the original Twilight Zone was “Passage on the Lady Anne.” A young couple boards an aging cruise ship only to discover the other passengers are all quite elderly and find their presence unsettling. The pair is eventually forced off the ship and into a lifeboat, because this trip is, for them, premature. The others are sailing towards the Final Destination

We’re all booked on the Lady Anne. Sooner or later we’ll find a ticket in our hand, waiting our turn to board.

Notes from Dr. Dave

Musings from forty plus years as an OB/GYN and a writer.

Author Archives: admin

The Harder They Fall

Bookends

Closing Up Shop

Sounds of summer

Waking the dead