Three Times

Three times in medical school I was right when no one else was. They didn’t involve coincidental obscure academics, untangling a technicality, luck, or some such that evaporate in unremembered conversations but were failures of first, simplest ABCs of looking and touching, each in a life-threatening circumstance.

They happened devoid of satisfaction or “success,” in the isolated anxiety of the near surreal that they could have happened at all as tragic frightening reminders of our universal susceptibility to failure in fundamentals, forever prey to the unanticipated pounce of uncomplicated interfered attention. That is their warning. These are the stories that constantly need the repeating around our campfires, whatever they may be.

If everyone, including a full professor, could so easily blunder, how easy blundering is, how easily distraction or preconception can so suppress obvious and available ordinary information. They left me gratefully apprehensive for the rest of my life. They were the beginning of Principia Primum as my guiding principle.

Doctors do not cure. They cannot cure. Only God cures. The doctor’s obligation is to be alert to what is available - to facilitate – to study the patient as carefully as possible under the existing circumstances and then to apply that knowledge that s/he considerately concludes is in the patient’s best interest.

Skill, for lack of a better word, happens best by keeping one’s Self out of the way, by retaining a quality of innocence in the quest – even as a child first listens to a seashell. The danger begins when the newness wears off and knowledge becomes assumed. That is the trap. That is when carelessness – arrogance –so easily insinuate and jeopardize the one who comes in trust.

He sat still and seemingly content in the waiting room of the brand spanking new UCLA Outpatient Surgery Clinic, the only patient scheduled for my first day. If he were a cartoon, he would have been Porky Pig: cherubic and pink, bright-eyed, wide-eyed, looking straight ahead at the receptionist’s vacant desk.

I went out and greeted him. He remained silent for a long moment as he composed himself, and then he looked up at me, his hands remaining quietly on his lap. He spoke sincerely, and his benign expression never changed as he related his dreadful story, as he told me that a few years before he’d had colon cancer and had surgery.

A little more than a year later, the rectal bleeding recurred. Soon, it was a daily occurrence. It had terrified him for the previous nine months, and finally he had resolved himself. He was there for his examination and whatever had to follow.

I returned to the adjacent clinic room and presented the history to the resident and the attending, a surgeon in private practice, who, for a few hours a month, receives a credential, in this case, Clinical Instructor in General Surgery, UCLA School of Medicine. He was newly Boarded (as Bobby had been), a personification of what the fantasy of many might look like: tall and athletically built, handsome and well tanned, impressively attired.

He listened, leaning impassively against the wall adjacent to the open door and barely perceptively responded to my presentation with a flattening expression. Then, his head tilted back so he could look down his nose a little more, as he crossed his arms on his chest with almost obvious insolence and lazily rolled onto his right shoulder, he turned his head just sufficiently to get a glimpse, which was more than enough for him. When he turned back, his features were hard, street-smart, someone catching a con.

His voice caustic, he retorted likely loudly enough for the poor man to hear, “If you expect me to believe for one minute that someone who’d been bleeding for nine months could be sitting there so pink and pudgy, you’d really better start thinking about what you want to do with the rest of your life... If this is the only patient, I’m not about to stick around just because someone thinks it will be fun to get a tube up his butt!” He strode out never looking back, not even nodding to the resident. I never saw him again.

I looked up at Dr. Roscoe Webb, the resident. He was a large bulk of a man, and our fates would cross a few times, particularly and poignantly with Little Stanley. And, as I did then, I wondered what was going on behind his small, sad eyes.

He stood quietly, almost dejectedly, uncomfortably, and I knew he knew we couldn’t just send the man away, but he’d just been subjected to the same onslaught, and his “gullibility quotient” had also been challenged.

I told him I had never done a sigmoidoscopy, but I knew the procedure and, I asked, “Where’s the harm in looking?” He paused for a few seconds and to his credit nodded. I set up the scope and the suction. The man came back quietly and put on a gown. Without a word, he knelt flexed-hipped on the bent examining table, and I pressed the foot lever to incline him head down.

I gently pressed my gloved, lubricated index finger against his rectum and waited. The sphincter reflex usually contracts when externally touched. Gentle pressure is like respectfully knocking on a door.

Touching someone – palpating - is coming onto, or into, their private space. If we truly desire to maximally learn about what is available and valuable from those tissues, it is proper and advantageous to first “ask permission” and await acceptance. I was just beginning to learn how important that is.

The sphincter softened, and my finger descended as I swept 360° before palpating his prostate, directly under my fully inserted finger. Normally it is felt as two symmetrically textured, somewhat firm, oval shaped, approximately almond-sized lobes. Urologists tease that they are the only specialty in which the anatomically favored long-fingered have special advantage. Porky’s prostate was normal.

I lubricated the outside of the sigmoidoscope, turned on the illumination and placed the end of it gently against his now prepared rectum. It slipped in easily, and I directed it initially towards his umbilicus (belly button) and pulled out the cannula, the removable rounded plastic front piece that facilitates the entry, closed the glass viewing lens and pumped in some air to dilate the bowel away from the scope.

The rectum is the last short passage out after the final curve of the colon, the sigmoid: resembling an “S.” Today, scopes are malleable and can travel the full distance of the colon, but the only ones available then were limited by rigidity and had to literally be negotiated in, encouraging the bowel to “thread” itself on, all the while circling the scope to observe the entire surface.

It went easily, and as it traversed the last curve into the long straight descending colon, I stopped. The marking on the outside showed 15 centimeters.

Dr. Webb had been standing quietly on the other side of the table. As I took my eye away and looked at him, and he looked back at me, I don’t know what my expression communicated to him, but he paused, then bent low to put his eye to the scope as I held it, as I watched him pale as sweat began to pour from his forehead.

To this day, I have never confronted an angrier, more obstructive cauliflower of a carcinoma.

The second time was during the period I was positive I would specialize in ObGyn. I was on the service at Harbor General Hospital, in Torrance, California, then “the farm” for UCLA Medical School. It was my third year. That morning, I was the last of a long line following a particular Professor of Obstetrics and Gynecology on his weekly rounds.

He was the standard bearer of the stereotypical Napoleon complex, armored - as another opportunity to afflict - in neurotic religiosity. He couldn’t care less if a woman already had fourteen children and was so torn up that her uterus would hang out when she stood. He would crucify anyone who contemplated a sterilization procedure, worse yet, a hysterectomy unless it was, at least, a near-life-saving procedure. Not on his watch. He could decide the fate of the residents every day for four years, and he could certainly seal my fate with hardly a breath.

Maybe it was for fear of him that it happened, but I will make an absolute declaration: There is never justification for a physician to relinquish his or her conscientious thinking - or conduct - to the overbearing influence of another. The needs of only one individual must dominate – the patient’s!

And so the Professor was leading his entourage on ward rounds through the labor suite. Closely behind him came the senior resident, then the juniors, then the interns and finally the lowly about eleventh in the long line.

A young woman had been in labor throughout the night. Her contractions had been regular and intense, but nothing was happening. Her cervix had neither effaced nor dilated, and she was nearing exhaustion. The Professor heard the history, put his hands on her abdomen, nodded and moved on - and everyone after him had done the same.

Then I put my hands on certainly certain that I would feel what I was certain they had to have felt and be similarly reassured although it bothered me that her labor had been so arduous but unproductive.

That is not what happened.

Instead, I was suddenly light-headed and sweating. There could be no doubt about what I palpated, more precisely, what I didn’t. It was irrelevant that I had spent the previous summer at “L.A. County” and stayed nights in obstetrics where I delivered sixty-seven infants – once, nine in one hour, because I was more than willing to do the paper work. The fact was that the “A” of the “ABC” of normal labor wasn’t there.

This was no stumbling into a transient, time contingent event that just happened coincidentally to my examination but the reality that everyone in that long influential line had just blundered the blunder of all blunders.

No matter what might transpire, I knew that I, personally, was the loser - the ill-fated messenger who would die for bearing news that would maximally disgrace all his superiors, most particularly the Professor.

My legs felt so sweaty, for a few seconds I thought I'd wet my pants. They were all disappearing into the next ward while a child was dying and possibly the mother.

Labor cannot proceed at all until the fetus is engaged in the pelvis. If neither the head nor the buttocks line up with the pelvic canal, mommy can contract until the cows come home, but the baby won't slide down the chute because it’s not lined up on the skids. Checking for engagement into the pelvic entrance is so simple and incidental a young child can reliably do it.

With one hand gently stabilizing the fundus (the top of the pregnant roundness), the thumb and index finger of the other is placed just above the pelvic bone, just above the pubic hair, and pushed inward just a little to almost immediately encounter the obvious full resistance of baby’s presenting part filling the pelvic rim.

My hand hadn't stopped. It just kept going into sickening emptiness until my fingers were down around her spine. With that, there are no basic questions, only the answer. The fetus was transverse, the dreaded lie. Every contraction is useless except to exhaust the mother and eventually kill the unborn child.

I looked at the line disappear. The senior resident had stayed behind momentarily to talk to a nurse.

"Dave?"

"Yes, Paul?"

"I'm sorry, Dave, but I'm not able to feel the head… would you please help me?"

He walked back casually and smiled, apparently oblivious to what had to be my obvious anguish. "Sure, Paul, no proble.....uuh" as sweat then began to pour down his sudden pallor.

He also was large, like Webb, and his sag almost collapsed his knees. He slumped from the cubicle, out the room. He and the Professor returned. They closed the curtains around the long-suffering woman who the professor would very soon teach the most awful woes of the word. He came out grim, refusing to look or talk to me. He wouldn’t for a few years, and, in retrospect, all that time he would seethe.

The innocents were taken to the operating room where the Professor inverted her on the table. With neither narcotics nor anesthesia, first externally, then externally and vaginally, he labored to restore his authority by attempting to turn the fetus all the while her agonized screams seared the air sending horrified shudders throughout the wing. They continued for longer than an hour until only gurgling throaty groans barely escaped her savaged lips.

Only when his desperation was exhausted did he finally relent and allow a Caesarian section. Who could tell the effects of such an unspeakable atrocity on the mother, the infant and all who were exposed to it? It was a climactic experience for me. Never did I believe that from a professor at a medical school would I see such near-insane, arrogant, self-justifying barbarism.

What explains such monstrous behavior? Perhaps the answer is easier with the dictatorial professor. The others? Perhaps he had inculcated such fear of him that they had unwittingly relinquished inquisitiveness. They couldn’t conceivably believe he missed what he had.

And – if they realized it - they would incur what I would face from there on out. So perhaps they disappeared into another case of “negative knowing.” I don’t know.

Two years later, I was an intern at Harbor General and in my second month of obstetrics. We’d had to apply for our service rotations during our third year, the one during which I was certain that I would be an obstetrician, so I’d elected for the redundant month to enhance my chances for the residency.

Two of us worked a twenty-four hour shift. Ted was going to specialize in psychiatry. He hated obstetrics. I could never reconcile how someone dedicating to sensitivities of the mind could logically deplore witnessing the miracle life, but he did.

It was almost midnight. I delivered mine, and he was up. I told him I was heading for the cafeteria and would be back soon to relieve him. I was just sitting down with my sandwich when he walked in, responding to my questioning look with an expletive expression just as the horn blasted that there was “Red Blanket” delivering in the ambulance. I sprinted the corridors and arrived just in time to deliver the baby on the Gurney just inside the ward door.

As I was leaving in the morning, I was told to go the staff room. I had barely closed the door when the professor, rigid and red, raged. Oh, the simmering, stewing and the brewing - now, finally, he was spewing.

“ Outrageous…disgusting….Who the hell…..disgraceful……”

It didn’t start to stop for a long while.

Residents who’d been in the infamous line two years before were there. The whole staff knew what had happened during the night, that I wasn’t the one who had deserted his post, but they just sat hunched or skulked against the wall, focused glumly – silently - at the floor.

I wasn’t offended, and I surely wasn’t defensive. I got angrier as he fed his fury, as he excrementally expended his revenge into our microcosm: the self-possessed aggressor, the undefended attacked while a self-absorbed world looked away.

I have no idea what they were thinking, but not one of them acted. Not one of them felt compelled to explain or anything else. Their own backsides were just too damned important. There, in that small room, was a reason for medicine’s debacle today – no guts to insist on fundamental principles implicit in uncomplicated integrity.

The professor was finally almost out of venom when he did himself in, “… For two cents, I’d throw you out of here right this minute!”

Just about then, my hand dropped into my pocket - and I will never know how they got there - but that was exactly what my fingers fiddled. I confirmed copper and jolted the room as I smashed them onto the table.

“You got ‘em!” And I was out the door.

Harbor General in those days was a spread of WWII interconnected single-story wood Army barracks. I was outside in the early morning cool, walking fast to get away, trying to dissipate the heat before I got home, two blocks away, when he caught up with me.

I didn’t know what happened in the few minutes since I’d left, but the fact was they had no replacement for me, and I’d already had my obligatory month. He was expended. Whatever he said, I let it pass as an attempt at an apology and finished the rotation.

For whatever their reasons, including having to acknowledge their cowardice, none of them ever spoke to me again. They couldn’t handle what they had self-inflicted, whatever they eventually decided they had not done.

And so to the third episode, that happened during my week on the Emergency Ward at UCLA, where we remained on duty for seven days without leaving. It was my last of three weeks of our harshest rotations - which I had the misfortune to draw consecutively.

It was near the end of the week, and I lost track of time, but she came in late one evening complaining of low abdominal pain, and fairly early it was clear that she was bleeding somewhere as her sequential hemoglobins dropped.

She was young and attractive, and residents of various specialties had continued to examine her into the night, each appropriately requiring a pelvic exam. Each had stepped away saying she was “clean” before disengaging and disappearing to other parts of the hospital.

It wasn’t until general practice that I began to realize the practical problems of early specialization. Sir William Osler, a Canadian, arguably considered the greatest physician of the 20th century, warned against it. He compared it to a fruit picked from its tree too soon. It produces tunnel vision.

There are no divisions in the body. There are no boundaries. All is related. It takes a breadth of experience to realize that, but it was the time of rush to specialization, and all the residents had been products of “straight internships” in their intended specialties. Otherwise, they wouldn’t have been accepted at UCLA - and that may have been part of the problem. But the real reason was far more fundamental.

It was the late hours into the long night when “never-never” time comes to the exhausted, when everything seems to stop. She was alone in a semi-darkened room, and the truth of it, obviously, was that the clock hadn’t stopped, and neither had her bleeding. Nature doesn’t care. Nature grants no absolutions.

I had remained remote because of all the horsepower that had been around and in her, but about 4 a.m. I entered her room. She lay there alone exhausted and pale. I palpated her abdomen. It was soft and non-tender. There wasn’t a hint of rigidity or other findings, and her bowel sounds had remained normal.

I knew how many pelvic examinations she’d endured, and I had seen how rough some of them had been, but softly I asked her permission to also perform one. She barely nodded as she slowly flexed her knees and opened her legs.

Carefully, I introduced my gloved fingers, and gasped another anguish of my soul. “My God, what had they been expecting to find?”

Sometime during the night, someone had to have suggested the possibility of an ectopic pregnancy, the abnormal implantation of the ova in a fallopian tube, which conducts the ovum to the uterus. Someone else had to have deprioritized it because some of the findings didn't fit someone’s criteria, maybe her menstrual history. Then, they had to have forgotten to continue to “sift the sands.”

As I palpated back to the fornix, the cul de sac behind the cervix, deepest in the vagina, most closely approximate the pelvic cavity, my fingers encountered a large blob of gross boggy fullness, like the feeling of a soft water-filled balloon. That’s not at all what it’s supposed to feel like. Normally, palpating there feels like nothingness unless the uterus is positioned posteriorly.

Her pelvic cavity was full of clotted blood, a prime sign of a ruptured ectopic pregnancy, regardless of her history or other signs. The precise diagnosis could be discovered at surgery, but the site of her bleeding was established.

They certainly hadn’t wanted to miss. Nobody wanted her to so terribly jeopardize her, but they had obviously tragically trapped themselves in their preconceptions. Whatever they had felt for, it wasn’t the reality of what was. For whatever reason, their fingers had insisted on their own criteria. They hadn’t come with the innocence of true ignorance and “asked” her tissues to teach them. None of them had been trained to palpate.

To my surprise, the junior resident in ObGyn asked me what I'd do. I told him, without equivocation, that I'd secure the cervix with a tenaculum (a long single clamp), apply a little tension on it and insert a syringe with a large bore needle through the fornix and aspirate. I was sure it would fill immediately with blood. He’d crossed his eyes and said he'd call in Dr. Art Petoyan, the Senior Resident.

Art arrived from home promptly, examined her and rushed her to surgery. I watched from the amphitheater, and Art did something that never before, or again, would happen to me under any similar circumstance. Without any hesitation and nothing but complimentary admiration, he'd turned and looked up at me, "You done good, Paul!"