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July 4, 1959

Memory is wonderful, mysterious and sometimes completely unreliable. We start to remember things around two years of age but something called childhood amnesia makes recalling most of those memories impossible. The recorder may be running but there are Nixonian gaps in the tape.

My life, at least that which I can remember most clearly, starts around age five. I can recall the house in which we lived, the neighbors on either side of us and significant events like Gaynell Wright’s surprise birthday party or Anita Tillman giving me my first kiss. But anything before that is largely gone, save for a few unforgettable moments that emerge from the fog that remain because they were either traumatic (being scared witless by a loud motorcycle engine when I was two), or they touched my soul on a very deep level.

I’m almost four years old and we are going to watch the fireworks somewhere outside of town, away from the insistent glow of street lights. It’s very dark; the only thing I can see out the window are thousands of tiny, winking lights in the trees—fireflies whose numbers will dwindle in the coming decades. We stop by the side of the road, parking behind a long line of cars. He stops the engine and kills the lights, but leaves the radio on for amusement or just to pass the time until the fireworks begin.

Losing one sense often enhances another; I cannot see but I can hear and that makes all the difference. Three gentle electric guitar chords, followed by piano triplets reminiscent of “Chopsticks” but haunting, ethereal. Then a soft voice crooning:

My love must be a kind of blind love

I can’t see anyone but you…

But it’s the background refrain that stays with me forever.

She-bop-she-bop, doo-bop-she-bop

Doo-bop-she-bop, doo-bop-she-bop

I don’t remember the fireworks or the trip home, or anything else for the next year. But whenever I hear the Flamingos singing “I Only Have Eyes For You”, I remember brick streets and iron lampposts, the shadows of people from a small Midwestern town gathering by the cornfields and a sense of peace that would be lost for forty years.

Photo Credit: Canstock Photo

The best teachers aren’t always in a classroom

I became a hospital orderly the summer before my seventeenth birthday. I’d been a busboy at a local restaurant but seventy-five cents an hour wouldn’t be enough for college and medical school. One of my high school classmates worked a part-time as a hospital phlebotomist and suggested talking with someone in administration, but whomever I met with wasn’t interested.

However, in late spring 1971, the hospital was looking for orderlies. I applied and was accepted.  I don’t remember my training beyond learning medical abbreviations and why one should never let go of a thermometer when taking a baby’s temperature rectally. Yes, we used glass thermometers with red tips for rectal temperatures; the oral thermometers had blue tips, and they were all kept in stainless steel containers of alcohol—separately, of course.  (Do you know the other difference between an oral and a rectal thermometer?  The taste…)

I learned how to make beds, give baths, serve and collect food trays and other things that made the nurses’ lives easier. I kept track of patients’ intake—a standard hospital cafeteria glass of liquid was 240cc–and output—measuring urine emptied from a bedpan or a Foley catheter bag. I answered call lights and took reports or requests back to my nurse.

That summer I worked the midnight shift on one of the medical floors and it was one of the best times of my life.  The nurses and other aides treated me as a responsible adult instead of a “useless” teenager. Nurses with more seniority worked the coveted 7-3 shift; supervisors were conspicuously absent at night. While the patient to staff ratio was more than double that of the day shift, the patients were usually sleeping and not much trouble.

The man I worked with taught me more about patient care than any physician. His first name was Paul; I don’t remember his last name.  I couldn’t tell you how old he was—I’d guess late 50s or early 60s. Everyone looks old when you’re 17.  He had lived through the Great Depression and served in World War II, acquiring life experiences I couldn’t imagine. If he’d seen terrible things, you would never have known it. His face was worn but kind; he reminded me of the man in Norman Rockwell’s Freedom of Speech.  But what surprised me most was that he was an older white guy who didn’t seem to notice that I was a darker skinned kid with kinky hair.

Paul talked to me earnestly about the night’s routines: how often to check on the patients; who needed their temperatures and blood pressures taken; what to do when the occasional call bell rang.  He took the job seriously and would never think of violating the trust of those who depended on him.

One of our patients was a bed-ridden elderly lady, Winnie, who had developed an enormous bed sore in her back while residing at a local nursing home.  She lay in a fetal position because of permanent muscle contractures.  Her eyes would open but she didn’t speak or react.  Yet Paul was very careful to tell Winnie what we were about to do. “We’re going to turn you to your other side, now, Winnie,” or “We need to clean you up a little.” He was always gentle; he never rushed patient care or treated it as a necessary evil for a paycheck.

I never thanked him for what he taught me because I didn’t realize how important that experience was until many years later.

I think anyone contemplating medical school should have to work as an aide for six months minimum. If you can’t approach people at their most vulnerable with understanding and compassion, without being irritated or disgusted, then you shouldn’t be in medicine.

© Can Stock Photo Inc. / Frankljunior

Crimson Tides

Another day in the life…

Few things in my profession are more terrifying than obstetrical hemorrhage.  Every year more than 144,000 pregnant women bleed to death, even here in the U.S. Sometimes we anticipate problems; more often we have no warning.

I aged ten years one afternoon treating one such woman.

Marylou was in labor with her third child and everything was going well.  Her cervix had dilated to 6cm and I thought she’d deliver in the next two hours or so.  Suddenly, she said, “I can’t breathe,” and the baby’s heart rate dropped to 60 beats per minute or bpm (normal baby heart rate is 110-160 bpm).  Her cervix was completely dilated but the baby wasn’t looking any better and too high in the birth canal to deliver with forceps, so we took her to the operating room.

The baby came out screaming and we were all relieved…for the moment.  We closed the uterus but the suture line slowly oozed blood.  The bleeding seemed to improve after a few minutes, so we finished.  We noticed a little bit of blood around the staples that closed her skin, but it wasn’t unusual.  The nurse pushed on her uterus to expel any remaining blood before taking Marylou to the recovery room. Everything seemed fine.

Blood started gushing from Marylou’s vagina about 30 minutes later and it wasn’t clotting. I ordered another four units of blood—we had two units already waiting from before surgery—while her nurse started a second IV.  We then wheeled her to the Intensive Care Unit (ICU) and called one of the critical care specialists.

The specialist was a man of few words who, until that day, wasn’t known for anxiety under pressure. When he pulled the sheet off Marylou, blood was visibly welling up between her thighs.  His eyes widened as he quietly said, “We need more blood.”  That’s when we knew Marylou was in trouble.

I ran to the blood bank and came back with four units, but her blood was pouring out as fast as we replaced it.  I was starting to worry she might bleed to death and took her back to the operating room. I asked a physician on the unit, who had also been my senior resident in training, for help. We tried packing her vagina with laparotomy sponges, but the blood soaked through them and ran onto the floor. He looked at me and said, “I think it’s time to give up and take it out.”  We quickly prepared her for surgery.

One of the hospital’s hematologists brought a portable refrigerator to the operating room and directed the transfusion while we took her uterus out.  We emptied the hospital blood bank of Marylou’s blood type; then we emptied out the local Red Cross. By the time Marylou was stable and out of danger, she’d received 30 units of blood and several liters of IV fluids.

Marylou suffered from the “anaphylactic syndrome of pregnancy,” something we used to call an “amniotic fluid embolism.”  Baby’s skin cells and amniotic fluid get into the mother’s circulation, causing a severe reaction in a small number of women, much like that in someone with an allergy to penicillin, peanuts or bee stings. The afflicted patient has trouble breathing and her blood pressure can fall low enough to put her into shock.

Marylou’s blood wouldn’t clot because the reaction used up most of the blood’s clotting factors, creating a potentially fatal complication called disseminated intravascular coagulation (DIC). Red blood cell packs lack those clotting factors, so we need to transfuse other blood products—fresh frozen plasma, cryoprecipitate and platelets—to treat massive hemorrhage.  Since then hospitals have developed transfusion protocols based on the military’s battlefield experience.

The survival statistics for amniotic fluid embolism have never been good.  One hundred percent of women with an amniotic fluid embolism who aren’t treated die; up to seventy percent die in spite of treatment.  Sometimes babies have been delivered by Cesarean section after the mother has gone into cardiac arrest and died.

Marylou woke up in the ICU four days later and asked me, “Did I scare you?”

More than you will ever know.

 

 

Image:© Can Stock Photo Inc. / Frankljunior

Sometimes God Wants Angels

Stories from thirty years of being a physician.  This is one.

José was a Certified Surgical Assistant (CSA) who helped me with Cesarean sections. He was a big guy with a little white in the scruffy black stubble on his face, and a man of few words.  I usually had to ask him to repeat the occasional amusing quip because, unlike the nurses whose hearing was far more acute, all I heard was a low rumble.  José always thought I should sew the abdominal muscles back together after we did a Cesarean.  I didn’t see any reason—sewing muscle is like sticking a needle through a stick of butter—but I didn’t see any harm. I’d give him the needle holder after I’d closed the peritoneum. He would neatly bring the pyramidalis and rectus muscles together with the same care one would use embroidering a shirt.

One evening Maria came to the hospital from the office. Her doctor couldn’t find the baby’s heartbeat, and an ultrasound confirmed the baby had died. Her first baby, a girl, had died from a brain hemorrhage when she was 11 months old. She had two boys at home, both delivered by Cesarean section. Sadly, this turned out to be another girl.

She insisted she’d felt the baby moving on her way to the hospital and repeatedly asked if there was some mistake.  We checked again with a bedside ultrasound exam, found no movement and no heartbeat, and her tears finally began to flow. I felt a little useless because she spoke no English (and I only know a little German), but her nurse, Molly, spoke fluent Spanish and gently consoled Maria.

I explained another Cesarean section would be the best way to deliver. We gave her the option of waiting until the morning but she didn’t want the baby inside her any longer than necessary.  We waited for her family arrive and gave everyone time to grieve, and then took her to the operating room. The anesthetist made her comfortable with a spinal and we prepped her for surgery.

It took about 5 minutes to open the uterus. The odor coming from the amniotic fluid indicated the baby had died a few days earlier.  We found a large clot in the umbilical cord where it entered the baby and a very tight constriction in the cord farther down near the placenta.

She began sobbing again as she felt the baby leave her body.  José leaned over the drape talked to her in the low, quiet voice.  I couldn’t follow what he was saying, but I caught “Dios”, Spanish for God.  We finished the operation in near silence.  We moved her to a regular bed after dressing the incision and took her back to her room.  I sat on a stool in the hallway because my back was aching; José came out of the operating room a moment later.

I asked, “So, what did you say to her?”

He replied, “Sometimes God wants angels, too.”  He paused, weary.  “This is tough for us; I can’t imagine what they go through.  Even when your kids are grown, you worry about them and don’t want them to die before you do.”

I thought I saw a faint glimmer of tears in his eyes, but my own tears obscured my vision.


What Does The CBO Say?

Last week the Congressional Budget Office released “The Budget and Economic Outlook: 2014-2024.” Conservatives and the right-wing media got an instant woody over Appendix C – Labor Market Effects of the Affordable Care Act: Updated Estimates. The ACA would kill 2.5 million jobs, take away the incentive to work and put millions more on the dole.

The White House, predictably, embraced the report as a victory of sorts for the beleaguered American wage slaves who have been worried they will die chained to their desks.  Meanwhile, Politico accuses both sides of “cherry-picking” the data in the report.

(C) Can Stock Photo

(C) Can Stock Photo

So what to make of all this?  Here’s my take.

First, CBO’s projections are educated guesses about the future based on current data and realities that are likely to change, requiring further analysis and adjustments.  Indeed, the CBO admitted:

“…estimate(s) of the ACA’s impact on labor markets (are) subject to substantial uncertainty, which arises in part because many of the ACA’s provisions have never been implemented on such a broad scale and in part because available estimates of many key responses vary considerably. CBO seeks to provide estimates that lie in the middle of the distribution of potential outcomes, but the actual effects could differ notably from those estimates…”

The claim that there will be 2.5 million fewer jobs by 2024 can be blamed on conservative animosity towards the ACA, aided by the CBO’s authors’ poor choice of words.  The report forecast workers voluntarily reducing their labor by 2.5 million full-time equivalent hours. That will likely happen mostly among low wage workers, amounting to 1.5 percent to 2.0 percent of total hours worked.

“…The estimated reduction stems almost entirely from a net decline in the amount of labor that workers choose to supply, rather than from a net drop in businesses’ demand for labor, so it will appear almost entirely as a reduction in labor force participation and in hours worked relative to what would have occurred otherwise rather than as an increase in unemployment (that is, more workers seeking but not finding jobs) or underemployment (such as part-time workers who would prefer to work more hours per week)…”

Those workers are NOT quitting altogether to go on the dole. Some may go to part-time jobs; others may retire early. There are 10,000 Baby Boomers retiring every day through 2031; their exit from the workplace could potentially create job openings for younger, qualified currently unemployed workers.

However, any potential job changes come with trade-offs.

Full-time employees whose income is more than 400% of the Federal Poverty Level (FPL) or whose employers offer health insurance are not eligible for subsidies for health insurance purchased through the exchanges. So they will either continue to work full-time, switch to a different full-time job, or go to part-time jobs and purchase their own insurance, especially if the net result is working fewer hours while maintaining their desired standard of living.

Employees whose income is less than 400% FLP or whose employer does not offer insurance can obtain insurance through the exchange, and they are eligible for tax credits and subsidies, which decrease as income increases. They might work less to avoid crossing the FLP threshold which means losing their subsidies and credits while effectively hiking their taxes. But then again, they might decide the extra income is worth the tax bite

People living in states that agreed to expand Medicaid are now eligible for Medicaid benefits if their income is less than 138% FLP. If they earn more, they’ll be eligible for insurance subsidies, ensuring they won’t lose coverage. People living in states that did not expand Medicaid, however, can only get insurance subsidies, not Medicaid.

I think the real issue is: conservatives and their corporate overlords hate losing the leverage that health insurance once gave them over workers.  How many people have endured “job lock,” staying in a thankless job, working more hours for less pay, working for condescending employers who’ve made it abundantly clear employees are unimportant, easily replaced, but a necessary evil?  Have you ever been told, “Bend over and like it because there are ten other people out there waiting for your job?”

Employers might be a little more considerate now that health insurance isn’t always tied to the job. I’m not holding my breath.