by Madaline Harrison
Days of the giants. When I was in training, the attendings used that phrase, often after telling a story from earlier days in medicine, describing a harrowing night on call or a now-legendary professor who could pull a diagnosis out of his hat like a rabbit. I was there, the phrase implied, a sign, like a secret handshake.
I have just indulged in such an anecdote. As the team continues through the hospital on morning rounds, I can see the residents mentally rolling their eyes, and I imagine they are thinking, “Dinosaurs,” or something less polite. For a moment, I imagine myself tilting at windmills, riding a sway-backed, spavined charger across the plain toward an illusory enemy—defending a vanishing tradition.
We move to the next room. There is no shortage of real enemies here and elsewhere: war, famine, pestilence, and death. We concern ourselves in the hospital mostly with the last two. As the residents dip and hover over their tiny screens, I look past them down the years to a corridor of hospital rooms or, earlier still, into a wide room filled with curtained alcoves, each one containing a stretcher.
Medicine still contains an oral tradition, passed down in stories: the stories patients tell us, the ones we tell them, and the ones we tell ourselves. There is also the story of medicine—Medicine with a capital “M”—the history we place ourselves in as we construct our own narratives of becoming physicians. The names of early physicians, embedded in the names of diseases or now-obscure signs used in physical diagnosis, hint at that history: Friedreich’s ataxia, the Babinski sign. My own field, neurology, is particularly notorious for eponyms. There are hundreds of them. Today, advances in technology allow us the illusion that we can see what is hidden, no longer depending solely on our eyes and ears, just as sailors no longer rely on scanning the waves to detect a change in the current or the subtle difference in the color of the water that signals a sandbar. But the doctors before us did, and their stories echo in the names we use for the diseases they defined.
When I talk about Huntington’s disease, I like to tell the story of George Huntington, making rounds with his father and grandfather by buggy, returning later to study the disease that devastated those families on Long Island. We know now that his ancestors and those of the families he described came over from East Anglia in the same fleet, their stories now permanently joined. I think of the Huntington’s families I have known, pedigrees stretching over pages and across the boundaries we place between ourselves and illness. I have a high school friend whose mother’s cousin I have followed for years, although she does not know and I cannot tell her. A family who lived just a mile from me found their way to the Huntington’s clinic. My patient danced every Friday at the free concert, his uncontrolled choreic movements submerged in the dance. I passed his wife on the road and at back-to-school night, always alone.
I did not start out intending to become a doctor. I graduated from college in the 1970s with a degree in psychology. It was a time filled with uncertainty. Unemployment was high and gas was rationed. In a borrowed car, an old turquoise Studebaker with one cement fender, I arrived at the local mental health clinic to interview for a federally funded position as a psychiatric emergency services coordinator. Not many college graduates showed up for those interviews and they hired me on the spot. The regional administrator and the psychiatrist who ran the clinic shared space on the third floor of a small local hospital and, when the funds ran out, I stayed on at the clinic as a counselor.
There are a few stories I find myself telling from those days. During my first week on the job, I made the rounds, introducing myself to the local agencies. One of my first stops was the state psychiatric hospital, a complex of towering Gothic brick buildings right out of a Hollywood set. The administrative offices lined a cavernous hallway paneled in dark wood. While I waited on a bench outside the nursing director’s office, a tiny woman approached me and asked for matches. I already knew enough to know the answer to that question, but I did offer to light the cigarette she was holding. She inhaled deeply, blew the smoke out close to my head, and said, “I wish I could get this woman out of my body.” I don’t remember what, or if, I answered.
I made home visits with the clinic psychiatrist to see a woman who had not left her house in years, except for occasional forays to find a doctor who would amputate the contaminated toe that drove her to spend hours each day relentlessly scrubbing herself and the house. Another time, I accompanied the small town police on a psychiatric emergency call and watched as they retrieved a terrified exchange student from the closet where he had been hiding for three days. After we arrived at the state hospital, I pushed the button to close the elevator doors, as five attendants struggled to hold him as he fought, convinced that the doors were closing on a gas chamber. I could never have imagined such afflictions.
Later, as a medical student, I was intoxicated by the panorama of science, enchanted by the glowing console of the electron microscope, like the control panel of a spaceship exploring the smallest imaginable spaces. I marveled at the neuroanatomy professor who could draw the brain or spinal cord two-handed, the outline appearing from under his chalk like a butterfly. I was astonished by the intricate machinery of the body and the infinite variety of ways in which things could go wrong. But it was in the hospital that I became a doctor.
As a second year medical student, I went to the VA Hospital with two classmates every Tuesday afternoon for physical diagnosis rounds. Our preceptor was a renowned specialist in diseases of the liver, a useful skill in a hospital filled with every possible consequence of alcoholism. He must have been close to 80 at the time I knew him. We would start each session in his office, and I watched my fellow students roll their eyes or nudge each other while he talked. I knew from their comments as we walked over that they thought he was a doddering has-been, an old man rambling on. And perhaps he was. I don’t remember now what he would say in those sessions. But I will never forget watching him in the hospital.
We would enter the ward, rows of beds lining the sides of the large room. Without hesitation, he would stride toward the nearest occupied bed, knowing nothing about the man sitting or lying there, or his illness. After a hand shake, he would draw out the outlines of each story in a few questions, followed by a respectful approach to the problem area, including us in the laying on of hands. Many of those men faced an uncertain fate, but we left them reassured, at least for the moment, by the doctor’s interest and the certainty he conveyed that whatever the outcome, their doctors were good ones and were doing their best to help. Week after week, I watched him work that same magic and tried to uncover how he did it, the hidden panel in the floor of the safe or the back of the box. But as I gradually understood, there was no trick. He cared about those men, and all the others like them he had cared for, and knew the power of hope when there was little else to offer.
The following year I began my work in the hospital as a clinical clerk, rotating from one part of the hospital to another to learn about the various branches of medicine. This was the work for which those sessions at the VA were to have prepared me. My time was divided between Jackson Memorial Hospital and the VA. Jackson Memorial Hospital in the 1980s was a war zone. By now, similar stories have been told in any number of TV medical dramas, but to a student, there was nothing cliché about it. In those days, Jackson was a sprawling complex dominated by a fourteen-story tower that was surrounded by low buildings housing the older wards and the emergency room. An endless polyglot stream of patients flowed in from all over Miami and beyond. Miami itself was filled with immigrants from Latin America and the Caribbean, and more arrived daily. They came from Cuban jails on the Mariel boatlift or floated over from Haiti on makeshift rafts. The sickest came straight from the docks to the Jackson Emergency Room.
With little in the way of preliminaries, the students were thrown into this teeming mix and expected to put their hand to whatever task most urgently required attention: starting an IV, sewing up a laceration, drawing a blood gas, pushing a patient to X-ray, or running a tube of blood to the lab. We struggled to complete the items on the “scut” list. On surgery, we trailed the teams, the pockets of our short white coats stuffed with gauze and tape, hurrying to catch up after changing a dressing. The trauma service overflowed with GSWs, young men admitted with gunshot wounds, shackled to the bed with handcuffs to receive our ministrations. The surgeons worked shifts unimaginable now: thirty-six-hours on, twelve off, if that. Even after the on-call team came on, they lingered around the nurses’ stations, laughing and telling stories.
The pediatric surgery service was legendary for the skill and dedication of the attendings. I signed up for two weeks, although I was not interested in either pediatrics or surgery as a career. I watched as they bent over their tiny patients, some barely bigger than the hands of the 6’ 4” attending, with what seemed to be infinite patience and tenderness. The fellow had already completed a full surgical training in Brazil. Ironic, with a hollow face and ageless eyes, he admonished the students. “Hurry up,” he’d say as we wrapped up the day’s work. “I must get home. My kids are crying.” But I’d see him later, stopping by once again to check on a sick infant before he made his way home.
Upstairs on the obstetrics floor, chaos reigned as women arrived in every conceivable stage of labor, delivering in the elevator or the prep room, flying down the hallways to the delivery room on stretchers, the OB teams calling out, “Primip on the table!,” primiparous referring to a first-time mother. On the maternity wards, the halls were lined with stretchers cordoned off with portable curtains as the deliveries approached 10,000 that year. We learned push/don’t push in Spanish and Creole and took turns “catching” the slippery newborns.
On the medicine wards, among the uncontrolled diabetics and the asthmatics struggling for breath, a growing number of patients were arriving with a puzzling set of complaints: Haitians with intractable diarrhea, a persistent cough, and weight loss; young gay men with strange purple splotches, sudden crises of fever, and rapid collapse. At night the ward was filled with faint ghostly coughing. In those days we didn’t wear gloves to draw blood or start IVs, but when a young Haitian woman was admitted, a resident took me aside and warned me to wear gloves this time. It was another year before this disease had a name—AIDS—and even longer before such precautions became routine.
The emergency room was the filter through which this flood of humanity had to pass, under the watchful eyes of the Miami-Dade County police. Teams of battle-hardened doctors and nurses triaged the patients in order of urgency, directly to the trauma bay or cardiac suite, or into the tank of insecticide for delousing. One veteran nurse wore a Barnum and Bailey button on his scrubs, proclaiming this “The Greatest Show on Earth.” On the wall was a bulletin board with a line of cockroaches pulled from ear canals and neatly skewered with hypodermic tips, next to a worn piece of paper on which a key to Cuban prison tattoos was printed. In the parking lot behind the ER stood rows of refrigerated trailers belonging to the medical examiner’s office.
In the ER I performed my first spinal tap, the intern narrating my instructions as if speaking to the patient, an elderly black man who lay on a stretcher, a sheet holding his knees in place. “You’ll feel a little pinch as we put in the anesthetic…” and so on until we were done. It went well, and the intern was so pleased that once we had finished, he hurried around to the front of the stretcher and congratulated the patient.
“You are a lucky man,” he said. “That doctor has golden hands.” The patient stared.
“You mean you let a woman put that needle in my back?” The intern laughed, clapped the patient on the shoulder, and we headed upstairs.
As students, we were often the only members of the medical team who saw the patient for much of the time, the interns and residents busy with newer or sicker patients. It went without saying that it was up to us to get the job done, whatever it was. In the face of this, the students banded together, trading insider knowledge: tips for tying a surgeon’s knot, for finding a vein, or for getting along with this or that attending. We watched in awe at morning report as the seasoned interns presented their admissions, reciting labs from memory which were, if not identical, at least close to the actual values, and confidently reeling off a list of increasingly esoteric possibilities in the differential diagnosis.
The patients looked to us for help, for explanations, for reassurance. There were few translators available, one of the consequences of a law passed prohibiting the use of county funds to promote any language other than English. I got better at patching together a hybrid medical Spanish, often trying out the medical term with what I hoped was a passable Spanish pronunciation: “Bomitare? Tachycardia?”
I returned to Jackson Memorial for my internship. The resident, a gruff Cuban woman who had been one of the toughest, most respected interns, met me when I arrived at 7:00 that morning. “Your first admission is in the emergency room,” she said, sending me off with a list of the other patients I was assigned.
I arrived and was sent over to a corner of the holding area where patients awaiting admission were lined up on stretchers. My patient was a thin black man in his 50s, with blood pressure so high it had caused swelling in his brain and bleeding at the back of his eyes. He was one of the few judged sick enough to require ICU admission, but until then, my job was to sit by the stretcher and take his blood pressure every ten minutes as medication was dripped in through an IV to lower his blood pressure enough but not so much that he would suffer a stroke. Seven hours later, a nurse stopped by to tell me that the MICU had a bed for him, only to return a few minutes later with the news that the bed had gone to someone else. Numb with despair, I resumed my task, dutifully pumping up and releasing the cuff, adding to the column of numbers on the clipboard by the stretcher. Three hours later, the resident arrived just as the orderlies showed up to take my patient to the unit. She handed me a sign-out sheet with the names of my next five admissions and the other interns’ patients for whom I was responsible overnight. With a brisk “See you in the morning,” she was gone.
At that time, the on-call interns handled new patients from the emergency room until midnight, often taking on two to three more in a frantic countdown between 11:00 and midnight. Through the rest of the night, we worked them up, asking our questions, listening to heart and lungs, reviewing their hospital charts, wheeling them to X-ray, starting their IVs, and drawing blood. This was before electronic medical records and a world away from hospitals with IV nurses or even transportation aides, at least after midnight. The charts were piled in stacks like telephone books, the X-rays in slippery piles behind counters in the darkened film room. Once the work was completed, the patients tucked in, we sat down to write up each admission and, with any luck, had time for a shower or breakfast before rounds the next morning. My last chore after each on-call night was to stop by the ward to check on my patients and enter any remaining lab values in my write-up. Often I would find them already filled in, the attending having gotten there before me.
But even he did not accompany me to Ward D, the prison ward. Once morning rounds were completed, I would make my way to the concrete corridor that led to the entrance marked by a sign that admonished “Do Not Loiter in This Area.” The guard buzzed me through the door and, once it closed behind me, buzzed again to admit me to the ward from the entryway, windows reinforced with wire mesh. I had one patient there, an IV-drug user being treated for a heart infection caused by bacteria from contaminated needles. He was getting worse. The nurses called and I came, but I did not know what else to do beyond the drugs he was already getting. He was scared and so was I.
One night on call, I told the cross-cover resident about him. “Would you like me to go see him with you?” he asked. There was nothing I wanted more. Within minutes, the resident was on the phone arranging emergency surgery to remove the irretrievably damaged valves in my patient’s heart, but he never returned from the operating room.
I don’t tell that story on rounds, but I often think of it. I have other stories of times after I had learned what to do and, with varying combinations of skill and luck, brought my patients through, at least that time. I have others from times when there was nothing anyone could have done. There were moments of comedy, the black humor variety now frowned on. “Did I ever tell you about the time I was almost peed on by a leper?” True story. I don’t tell that one on rounds either, although sometimes I imagine the startled looks I would get, the residents lifting their heads in surprise from the flickering screens.
For better or worse, that is the tradition to which I belong. And it was as often worse as better—exhausted young doctors doing an impossible job, but pulling it off more often than not, night after night. We learned the hard way and paid a price, as did our patients.
I am not sure when in the course of this sometimes brutal initiation I began to listen differently, to hear the other stories. In the CCU, I took care of an Israeli pianist after he had a heart attack. I don’t remember now which coronary artery was involved. I don’t remember if he had heart failure or not. I do remember he survived, as he had before. As I had been trained to do, I took a history—when the chest pain started, nausea or not, shortness of breath or not. And then I got to the arm—not the one he had, but the one that was missing. His wife was sitting next to him as I ran through my questions. It was impossible not to notice that she too was missing an arm. I asked and they told me. Before the war, he was a pianist and she was a violinist. In the camp, each had an arm amputated, to prevent them from continuing their music. They survived and after the war they settled in Israel. He learned to play one handed, and she became a singer. They toured in Israel and in Europe, performing the music of their survival and songs for those who did not survive.
Not all the stories span an epoch in history or the full eight octaves that the human spirit contains. Sometimes it is a simple detail—the time that my patient took off for a West Virginia bar on the riding mower before Huntington’s disease confined him to a wheelchair, or the name of the parakeet that fills my ataxic patient’s housebound world. One day going through my mail, I opened an envelope and out fell a picture of my patient, the parakeet sitting on her head.
Remembering these and so many other stories, what I feel now is compassion, for my patients, for myself as a young doctor, and for the students and residents coming behind me. Their world is different. A thin veil of protocols and policies is draped over the rawness and chaos of injury and illness. The residents clock in and clock out, tracking “duty hours” at the behest of a huge bureaucracy that looms behind the scenes ready to impose sanctions on any program whose residents spend an additional unauthorized hour caring for their patients. There are elaborate procedures to pass on information among the rotating teams of doctors who are caring for patients they haven’t met before and won’t see again. Residents log in the supervised procedures they must perform before being authorized to attempt them on their own and complete required computer modules on everything from hand-washing technique to the protocol to be followed in the event of a bomb threat.
And yet there is much that hasn’t changed, as I am learning still, from my patients but also from the young doctors I am charged with teaching. A third year medical student stayed behind after rounds to be with a family when their 20-year-old son was declared brain dead. Home after her last night on call, an intern returned to the bedside of a young man wracked with uncontrolled dystonic muscle spasms to relieve his parents so they could have dinner together. Before she left that night, she ordered the medication I had told her wouldn’t help, and it didn’t. But the next morning I knew she had been there, and why.
Days of the giants? A myth – there are no giants. But like an epic poem, passed down and changed by each teller, this history links the legendary physicians of the past to the students and residents standing beside me outside the next room where another story is unfolding. I step inside, uncertain what challenge I will find and whether I will be equal to it. I ready myself to listen. The story begins, and I hope for the heart to see it through.