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Cook County ICU

30 Years of Unforgettable Patients and Odd Cases

Chicago Review Press Incorporated

CLIMBING THE MOUNTAIN OF MEDICAL SCHOOL (AND FINDING IT IS JUST SNOW AND ICE)

* * *

"I'll tell you what it's like to be No. 1. I compare it to climbing Mount Everest. It's very difficult. Lives are lost along the way. You struggle and you struggle and finally you get up there. And guess what there is once you get up there? Snow and ice." — David Merrick

Every year, thousands of undergraduates who have worked extremely hard during college apply to medical school. It is a highly selective process and only the top students are accepted. While admission to medical school is the first step to a successful career as a physician, once students begin their studies, they immediately find themselves at the bottom of the rigid medical hierarchy. As such, they are subject to the whole host of indignities that the medical education system can inflict. It is a tough road, even for those of the strongest character. One of the favorite pastimes of residents in training and attending physicians alike is to harass and intimidate those on the lowest rungs of the ladder, and of course that is medical students.

Surgeons are particularly fond of abusing students, especially in the operating room. It is extremely uncommon for the students to talk back, because there is just not much percentage in it. To illustrate why, there is a story of my classmate from the East Coast with a New York attitude. He was once assisting a general surgeon who was performing a gallbladder removal in the days before laparoscopic surgery rendered a bunch of surgical assistants unnecessary. A student's role in the operation is minor, since he or she doesn't have enough experience to do anything important. Generally, it means holding retractors during the operation to give the surgeon better vision of the operative field while he identifies the organs. In this case, my classmate had to hold a large retractor pulling back the liver that covered the gallbladder. This job requires holding and tugging for a long time. It is boring, and your arms get tired. But the medical student must not let go of that retractor while the surgeon is identifying and removing the gallbladder. And in most cases, the student has to remain absolutely quiet. Speak only if spoken to.

That day, the surgeon was taking a long time and the student was getting fatigued and frustrated. His surgical mask covered his face, but beads of sweat collected on his forehead. Suddenly, the frustration boiled over and he broke the unwritten rule. He asked the surgeon, "Well, how are we doing?"

The surgeon, and everyone else in the room, looked up. They were stunned. A medical student talking — and not just talking, but talking with impertinence.

The surgeon, taken aback momentarily, regained his composure and continued operating. But he was not about to let the transgression pass unnoticed.

He shot back to the student, "What do you mean we?"

That was a clear signal for the student to shut up immediately. Perhaps it was his New York attitude, but the student ignored the cue and fired back with thinly veiled sarcasm, "I like to think I'm as much a part of the health care team as anyone."

The surgeon, now fully engaged, had never encountered such braggadocio from a medical student, and he was prepared to enjoy the back-and-forth.

Now he taunted the student, "Part of the health care team? You? You must be kidding. You are nothing. We could get a monkey to do what you are doing. You are nothing."

The battle was on. No longer feeling subservient, the student challenged the surgeon. "Oh yeah? I'm nothing? I'll bet if I let go of this retractor, you would have trouble finishing the operation." He made a point not to let go of the retractor, though.

The operating room was silent. The surgeon then decided it was time to pull rank.

"I'll bet if you let go of that retractor, you'd have trouble graduating."

Point, set, match.

A couple of days later in the surgical locker room, the student told me he just lost his head in the heat of the moment. I asked him if the surgeon retaliated in any way. No, he said, the surgeon actually liked him and didn't hold it against him. The student survived the battle, graduated, and became a successful physician in Manhattan. But not every surgeon would have been so gracious.

* * *

When I became an attending physician, it was not my style to harass or bully the medical students. I tried to help or encourage them whenever possible, figuring they were having enough trouble without grief from me. Once a student of mine, an especially earnest one, wanted to impress me. So I gave him a difficult assignment: to draw blood from a hardened gang member. It was challenging because we needed to draw from an artery to test the oxygen level in the patient's blood, which a routine blood draw from a vein does not provide. It was a test of the student's skill.

The assignment was to draw blood at the patient's wrist, from the artery where you take your pulse. The artery is close to the bone, so if the needle misses the artery and hits the bone, it can be quite painful. And it's not a good idea to inflict unnecessary pain on a gang member, especially when you are a student. He went to draw the blood from the patient's artery, and it took fifteen long minutes. It must have been agony for the patient — and a different type of agony for the student. When the fifteen minutes were over, he had a sample from the patient, but unfortunately he had missed the artery and the blood sample was from the nearby vein, useless for the information we needed.

The student was disconsolate. Unaccustomed to failure in his academic career, he came to me knowing that he had failed and was worried that he had let me down. Besides that, we still didn't have the sample we needed. I reassured him, told him how difficult obtaining those samples was, and said we could still get an arterial sample. He told me there was no way the patient would let him try another needle stick.

"The last five minutes I was trying to draw it, he was staring me down. I don't think he will let anyone draw his blood now."

I said, "Don't worry, I will draw his blood. Come on, I'll take you with me."

"But what are you going to tell him?"

"Watch."

We went to the patient's room and, as predicted, he gave us a nasty glare. His right wrist was extremely sore from the unsuccessful blood draw.

"Man, what'chu guys want?" He suspected we were there to draw blood again.

"I have to take another sample, Andrew."

"Hey, he already drew my blood. What'chu need more blood for?"

The student was visibly nervous. He thought I was going to tell the patient he had made a mistake by getting an erroneous sample. It would be devastating to the student's already shaky confidence.

"Andrew, he got the sample from your right wrist. We saw the results. But we have to draw a sample from your left wrist to compare it with the one from your right. I know that one was painful, but don't worry, I'll draw this one. We have to see if the right and left blood are the same or different."

Of course, there is no difference between blood drawn from the left arm and the right arm. Same blood. But I gambled that Andrew didn't realize that. He gave me a suspicious look, considered the problem a minute and said, "OK, Doc. Go ahead."

I drew the blood from the artery of his left wrist quickly and painlessly.

"Thanks, Andrew."

"No problem, Doc."

Andrew nodded approvingly at me, and then at the student. The gang member was actually happy he could be cooperative. He was satisfied, the student was relieved, and I had the necessary sample. The student thanked me for rescuing him. He went on to become one of the country's top physicians in his field, far eclipsing me and my career. I wonder if he ever tells his students that story.

* * *

One of the final indignities of medical school is the interview for residency positions in the student's senior year. This is not always an unpleasant experience, because some hospitals want to attract the best students and thus treat them well during interviews. But in my case, coming as a student from Chicago and interviewing in the highly competitive atmosphere of New York hospitals, I was forced to run the gauntlet. Manhattan has some of the best hospitals in the United States, and it is a wonderful place to live when you're young and single, so I had decided to interview there for my residency. New York, New York — even for a medical student — if you can make it there ...

It was right before Christmas. In Chicago, Mayor Daley — the first Mayor Daley — had just died. Chicago was grieving as I caught the early flight to La Guardia on a cold winter morning, greeted by a frigid wind whipping around the right angles of the downtown Manhattan skyscrapers. The morning of my first interview, I hailed a cab to St. Vincent's in Greenwich Village, a once-legendary hospital.

The legacy of St. Vincent's has faded, but in its day it was quite a grand place, one that recalled a different, more glorious era of medicine. Founded in 1849 with a mission to care for the poor and disenfranchised, it was world renowned for its care. The poet Edna St. Vincent Millay was named after the hospital. How many famous poets have been named after hospitals? Unfortunately, several years ago, after 163 years in business, the hospital closed unceremoniously, a victim of medicine's changing business environment.

But when I interviewed there in the 1970s, St. Vincent's was still a vibrant place. The intensive care unit was among the country's finest, and the hospital, which turned no one away, took care of the widest variety of patients: bohemians from the Village (the poet Dylan Thomas died there after a legendary bender); alcoholics from the Bowery; high-level professionals from the Financial District; and Chinese immigrants from Chinatown. Nobody knew it then, but St. Vincent's would soon become one of the major AIDS hospitals in the world, an ironic coincidence for a hospital that celebrated its strict Roman Catholic heritage.

The morning of my interview, I was sent to a basement cafeteria and told to wait there. I got a cup of coffee and sat down with a number of students from New York medical schools. It seemed they all were interviewing at the same hospitals and all knew each other. I was the nervous outsider, listening closely to the gossip about the pluses and minuses of the New York hospitals.

I was completely ignored until one of the students unexpectedly turned to me and asked in a thick Long Island accent, "So, wheah you from?"

"I'm from Chicago," I answered in my flat Midwestern tone.

"Oh, University of Chicaguh."

"No, actually, I'm from Northwestern."

This was my first taste of New York City provincialism. In those days, the common belief was that if you were from Chicago, you had to be from the University of Chicago. There were simply no other universities there. Saul Steinberg's famous New Yorker cover, "View of the World from Ninth Avenue," is not without some basis.

The student looked aghast, and proceeded to give me a geography lesson about exactly where my university was located. "Nawthwestun's not in Chicaguh, it's in Ohiuh."

One of his colleagues, looking to correct him, located Northwestern in the Great Northwest. "Nah, Nawthwestun's not in Ohiuh, it's in Warshingtun."

Thankfully, a resident with a slightly more refined Manhattan accent rescued me at that moment. "You can come with me, I'm going to give you a touah." A tour of the hospital, which I considered a pleasant gesture. How thoughtful.

It was still early, before 8 AM, and I figured my interview wouldn't be until at least 9. I relaxed a bit, opened the buttons on my sport jacket, and popped a stick of gum into my mouth, chewing unobtrusively while the resident led on. It was a mistake.

For the next ten minutes, the resident was sullen and rude. He didn't want to be there and answered no questions, but I found the hospital to be beautiful, immaculate and charming in its dotage. It was certainly cleaner than some of the new, Soviet-style hospitals at which I had interviewed. The hospital was festooned with Christmas decorations. A crucifix hung in every room, and there were reminders everywhere of the proud Catholic tradition of the Sisters of Charity, who had founded the hospital more than a century before. You don't see that much in hospitals anymore. It is a grand tradition all but gone from American medicine, never to return.

At the same time, I also sensed a real passion for patient care and quite a degree of medical sophistication and professionalism. Passion, sophistication, and professionalism with a tinge of rudeness — it's Manhattan. Even to a non-Catholic like me, the hospital was an extremely impressive place, and I saw why it had the reputation it did. I thought, "I would be proud to work here."

No chance of that happening.

About ten minutes into the tour, the dour resident brought me to a room and shoved me in with no warning. It was my interview. Unannounced.

The chief of medicine at St. Vincent's for many years was Dr. William Grace, the elderly scion of the Grace publishing family and one of the most brilliant cardiologists in the country. He was a pioneer in cardiac care and treatment for myocardial infarction — and, most notably, he founded the first mobile coronary care unit in America, basically a white-over-red Chevy van with monitoring and resuscitation equipment, capable of defibrillation. It could answer calls over a wide area of Lower Manhattan. While now routine, it was a revolutionary concept in the 1960s. It is a pity Dr. Grace is not better known today. He was a legend in his time, and he was one of the reasons I wanted to be at St. Vincent's.

And at that moment, he was sitting right in front of me.

To say the least, it was unanticipated — and intimidating. They say you don't want to meet your heroes because you'll be disappointed in them. In this case, it was the exact opposite. Flanked on each side by three nuns, he measured me up before I had time to swallow my gum and button my jacket. I certainly disappointed them.

It happened that Dr. Grace interviewed nearly every residency candidate personally. He died shortly after my interview, so I had the distinction of being one of the final candidates he ever interviewed; I think I also earned the distinction of having the shortest interview of all time.

He didn't ask me to sit down.

Since there was a chair in front of him presumably meant for residency candidate interviews, I took that as a bad sign.

He looked down at my résumé. "I see you are from Chicago."

"That's right, sir."

That was the high point. Everything went downhill from there. The nuns, who probably noticed I had been chewing gum, glared at me disapprovingly. They must have been wondering if there was a spare ruler around with which to rap my knuckles, or at the very least a couple of erasers for me to pound together after the interview.

Dr. Grace never looked up at me. He asked me one or two perfunctory questions and dismissed me summarily. Total interview time: four minutes.

I may have wanted St. Vincent's, but it was pretty obvious that St. Vincent's didn't want me.

* * *

There were still two other New York hospitals where I would interview that weekend. Columbia Presbyterian was different from St. Vincent's. It was, and is, one of the leading university medical centers in the country, prestigious doctors everywhere you turn. In truth, though, it was not as clean as St. Vincent's.

In my journey to and from Columbia Presbyterian, there was one incident I considered a potential omen. The hospital is on the north end of Manhattan, and my cab took the West Side Highway uptown. On the way there, I saw a nice, late-model car stalled on the side of the highway, no driver. I didn't think much of it. But this was New York in the 1970s. It was a different place from today, with a much rougher edge.

My "touah" and subsequent hospital interview took about two hours. I knew I was not at the top of their list; the university hospitals in New York got a tremendous number of applicants and had a preference for students from New York medical schools. After a short, unpromising interview, I was escorted to the hospital lobby, where I called a cab to head back to Midtown. The cab retraced the route on the West Side Highway. There, in the exact same spot, was the same late-model car I had seen abandoned a couple of hours before — now completely stripped, including the tires. Quite possibly a sign that New York wasn't for me.

* * *

My final interview was at Mount Sinai, located on the posh Upper East Side. To the south is one of the most affluent residential areas in the United States; to the north, Harlem is the site of some of the poorest neighborhoods in America. Mount Sinai is nearly as old as St. Vincent's, but is in no danger of closing. Its list of benefactors includes some of the country's wealthiest and most prestigious individuals, such as Wall Street power brokers Carl Icahn and Henry Kravis. This is reflected everywhere in the hospital.

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Excerpted from Cook County ICU by Cory Franklin. Copyright © 2015 Cory Franklin. Excerpted by permission of Chicago Review Press Incorporated.
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