And I get to be a widow again
Praise
“Not since The House of God has there been such a ferociously funny look at the world of hospital medicine.”
Dedication
Voices were muffled. There was a greater sense of control here. We were surgeons. This was our turf.
I tried to put everything else out of my mind. It didn’t matter how much sleep I got the night before. It didn’t matter what else I had planned for the rest of the day. This poor kid, barely alive, was lying unconscious on an operating table with some stranger about to decide whether to cut off his leg.
Year One
Crammed into this room were fifteen incredibly bright first-year orthopedic surgery residents— and me, a twenty-nine-year-old ex-cabdriver and ex-construction worker long on dreams but short on credentials.
He concluded by saying, “This is the Mayo Clinic. Our patients expect a lot from us, and we are going to expect a lot from you.”
A stocky, freckle-faced man with an unruly mass of red hair held out his hand. “Bill Chapin,” he said. “I guess we’re going to be inmates together.”
At Mayo, rounds are made twice a day. The attending surgeon accompanies his residents on rounds every morning except Sunday. The residents make rounds by themselves every afternoon plus Sunday morning.
He must have seen the look of horror on my face. “Don’t worry. If you have any problems, just call one of the senior residents, they’ll help you.”
Patti rubbed the back of her hand against my cheek. “That’s why they have residencies.”
Well, at least I knew what it was, but could we get her up? I hadn’t a clue. I didn’t know if “we” always got people up on the third day or if we never did. Mrs. Wiltshire was probably the wife of the president of Switzerland or something. What if I did the wrong thing?
She was silent for a moment and then must have taken pity on me. She let the opportunity to humiliate me pass. It wasn’t the first time a nurse had helped me and it wouldn’t be the last.
And so it went, patient after sleepy patient.
“Listen,” he said, “you’re gonna do fine. Stop worrying. First of all, orthopods aren’t like fleas. Everyone isn’t out to pimp you every minute of every day.”
“Flea” is a pejorative term for an internist. Surgeons claim internists travel around in annoyingly large groups, like fleas, buzzing much and accomplishing little. They are notorious for one-upmanship.
“Nobody expects much from the junior residents anyway,” John went on. “Just do what you’re told, be prepared for every surgery, and read about every case on your service.”
Technically, only residents who had been on call the night before, or who had started work before 6:00 A.M., were entitled to free breakfast, but when Art saw me reach for my wallet at the checkout line the first day he said, “Pay no attention to that bullshit. When you work as hard as we do, breakfast is free.”
What a strange world: blood, bone, body parts, saws, hammers. How totally different from what I had expected. We seemed more like carpenters on a construction site than surgeons in an operating room. And yet I found it incredibly exciting, and was disappointed that to everyone else it seemed so routine. I wanted them to feel as I did, that this was something extraordinary, something reverential. We had opened a human body, cut away parts of it, discarded them, put in new ones, and then closed everything up again. And in a day or two this person would be walking, her pain gone. It was incredible. I wanted to keep this awe and fascination forever. I didn’t want it to ever become routine.
Patti was excited for me. She was a nurse, and she spoke the language. For the first few months of my residency, Patti probably knew more orthopedics than I did. She loved hearing about my work. Most young couples talk about movies or books or sports. We talked orthopedics. Constantly. In the car, over dinner, feeding the baby, doing dishes, in bed at night.
“She may be on to something,” Bill Chapin said as he filled our glasses from the pitcher. “I’ve been up on Seven, and the place is crawling with Commies.”
Patti said. Like most women she could carry on three conversations and still know what is going on at all the tables around her. “A fondue party is where people gather to taste fondue. Fondue is a sort of melted cheese.”
The Mayo work week was divided into surgery days and clinic days. We either operated all day, or we saw patients in the clinic all day. On surgery days I was the second assistant on all cases. Art would get to operate once in a while, but I did nothing more than hold retractors and write post-op orders. On clinic days I tagged along behind Art and Dr. Harding as they saw patients.
I wasn’t even sure if Big John knew my name— but I didn’t blame him. I needed to get myself to a certain level before it was worth his while to teach me.
Art was always a bit impatient with my constant barrage of questions. He knew if he encouraged me I would pepper him with questions all day long. But he did one thing that helped me immensely: he dumped responsibility on me. He constantly took off and left me to handle things on the service. “Heck of a deal!” was his comment on almost everything.
“what can’t be helped must be endured.”
There were certain surgeons to whom every resident at Mayo wanted to be assigned. Tom Hale and Antonio Romero were up-and-coming stars in the department. They loved to teach, and they let their residents do a lot of operating. Fred Hastings and Garrett Freiberg were world-renowned hand surgeons. Bob Filmore was making a name for himself in the world of shoulder surgery. But the plum of them all was Mark Coventry.
He had pioneered a number of surgeries, and had performed the first total hip replacement in the United States. Although in the twilight of his career, Dr. Coventry was probably the most highly regarded orthopedic surgeon in the country. In mid-August I finished with Dr. Harding and started with Dr. Coventry.
From the very first day on his service, I loved being with Dr. Coventry, but I trembled to think what would have happened if I had been assigned to him first. He would have been appalled at my ignorance. Where Dr. Harding largely ignored me, Dr. Coventry constantly challenged me.
Dr. Coventry demanded a lot from his residents. If there was a problem with bleeding, drainage, pain, or an abnormal lab, God help us if we didn’t know about it, have an explanation for it, and have already instituted treatment for it by the time it came to his attention. These high standards were Dr. Coventry’s way of reaffirming the importance of what we did. By his attitude, by his bearing, and by his insistence on perfection, he impressed upon us the seriousness of our calling.
When he moved to Rochester he played semi-pro hockey for the legendary Rochester Mustangs. He told me the only reason he quit playing was because of pressure from the Clinic. After a particularly rough game, the headlines of the Rochester Post-Bulletin sports section read: “MUSTANGS WIN. MAYO DOCTOR IN BRAWL.” That was the final straw for the Clinic administrators who objected to the unfavorable publicity. Dr. Coventry was forced to give up his hockey career.
“He didn’t say a word. He wired the trochanter back down, closed the incision, and did the other hip. Then he went out and talked to the family. He told them what happened and took all the blame himself.”
I was about to say something patronizing about how bad breaks can happen to even the greatest of surgeons, but the look in Cuv’s eye told me he didn’t want bullshit. I took a deep breath.
“This,” he said, “is what happens from a lack of vigilance on the part of the surgeon.” I could tell he was speaking as much to himself as to us. “Everything that happens in that operating room is your responsibility. Everything. On the operating table lies an unconscious, helpless patient who has placed his confidence and trust in you— not in the resident, not in the anesthesiologist, not in the institution, but in you.”
I had chosen surgery instead of internal medicine because I wanted to do things. Too often internists seemed interested only in the process of discovery. They wanted to learn things. What was the diagnosis? What caused it? The emphasis was always on examining and discerning, not fixing. “Internists diagnose and surgeons treat” is the old expression. Of course, internists put it another way: internists think; surgeons act.
I attended Loyola Stritch School of Medicine in Chicago. Every year on the feast of St. Luke, the patron saint of physicians, the school held a big dinner. Skits were performed lampooning each specialty.
The attendings knew that every resident wanted to do every case. At the beginning of the quarter, the attending would observe his senior resident, assessing his competence and confidence, judging his ability to operate. If the resident seemed to know what he was doing, if he answered anatomical questions correctly, if he was attentive and respectful, the attending would usually turn over more and more cases to him.
As junior residents we dreamed of someday doing our first total hip or rotator cuff repair, but we knew it wasn’t going to happen until we paid our dues working the suction and the cautery, cutting sutures and maybe sewing the skin. Frank and Jack had already done a couple minor procedures. So far Bill and I had never even touched a scalpel.
I had heard one of the other residents at breakfast doing an imitation of Joe: “Trauma big time gotta move on this guy full code type-and-cross cut-down crack his chest get the lines in subclavian large-bore pump the fluid where the hell is anesthesia?”
“Morituri te salutant,” Mac whispered to me. “Semper ubi, sub ubi,” I replied.
It worked. We made it work. We did whatever it took to cover for each other. We made up stories. We worked twice as hard. But our best resource was the shameless commandeering of medical students.
What I should have said at that moment was, “Patti, although I am terribly tired, you are the most important thing in my life. I apologize for seeming so disinterested, but in a few weeks I will be off ERSS and our life will get back to normal.” What I actually said was, “Patti, I… uh… just…” I couldn’t remember what I wanted to say next. I ate my dinner and went to bed.
I tried to spell it out as clearly as I could for the father. “Look, Mr. Larson,” I said, “if you don’t want another tragedy on your hands, you go to your son and tell him that you know it was an accident and you forgive him.”
I was with Jeff when he died later that night. It was the first time I had ever seen someone die, and it wasn’t what I expected. It was so matter-of-fact, so ordinary. His pressure dropped, his heart quit, and he died. That was it. I stood there waiting for something momentous to happen, for someone to say something profound, but there was nothing. The nurse sighed and turned off the IV, the respiratory tech disconnected the oxygen, and the secretary called the morgue.
Joe had his bearings about him. I did not. Joe knew when to fight and how to fight and when to quit fighting. He knew just how much of himself he could afford to pour into each case. But I knew none of that. I was still used to winning every fight, and those past few weeks on the ERSS were killing me.
Of course, it would have been easier if we didn’t care, and sometimes we actually pretended we didn’t. We would try to do our job and be detached. But we didn’t go into medicine to be detached. We went into medicine because we cared. But caring kept bringing us pain and frustration and anguish.
There were a few snickers. But I also noted there were several players who said nothing. Presumably they had spent some time in proctology and recognized an asshole when they saw one. Wilhelm laughed again and strode out of the locker room.
This wasn’t the best time for us to be having visitors. Patti had just given birth to our second daughter, Mary Kate. The delivery went smoothly, but Pat was tired and sore. I tried to get her to look at things philosophically.
“Look,” I said. “Nature, in her infinite wisdom, has decreed the manner by which babies are brought into this world. I did my part willingly and cheerfully. I think you should do the same.”
She mentioned something about “willingly and cheerfully” performing an operation with a rusty knife that would allow me to sing in the Vienna Boys Choir.
I had made two extravagant purchases with my first paycheck in August. The first was a pair of Sorrel boots from the local Feed and Seed Store. Sorrel is the Canadian manufacturer of a legendary rubber-soled, felt-lined boot made to withstand the most extreme winter conditions. Minnesota ice fishermen swear by them. No matter how drunk they get, no matter how many other body parts become frozen stiff, their feet stay warm.
As a junior resident I took home $981.48 a month. It wasn’t a lot for a guy with four mouths to feed— but, on the other hand, it was a hell of a lot more than I had made in medical school. I had three part-time jobs during my senior year in medical school: janitor, construction laborer, and dockman. I made enough money to keep a roof over our heads and buy a lot of meat loaf and potatoes.
It was funny in a way. We thought we should be paid more, but every one of us would have worked for nothing. We were being trained at the best place for orthopedic surgery in the world— and we knew it. We weren’t just employees. We were students as well. The clinic owed us something for the work we did, but we owed them something for the education they gave us. All in all, $2.50 an hour seemed fair to both parties. They got cheap labor and we got a tremendous education. But, fair or not, I was having a hard time paying the bills on $2.50 an hour.
Steve Tucker said Mayo took a more sensible approach. “They know we don’t moonlight so we can buy new Ferraris,” he said. “We moonlight so we can buy food and pay mortgages. If you do your job and don’t draw attention to your moonlighting, they’ll let it slide. But if moonlighting starts interfering with the job you do as a resident, then they’ll come down on you.”
There are twelve cranial nerves: olfactory, optic, oculomotor, trochlear, trigeminal, abducens, facial, acoustic, glossopharyngeal, vagus, accessory, and hypoglossal. Medical students and nursing students always struggle to remember these nerves.
We had learned a cruder version in medical school: “Ooh, ooh, ooh! To touch and feel a girl’s vagina— ah, heaven.”
There were only two things I could remember from the entire two weeks. One was that nymphomania was not as common as my classmates and I had hoped. The other was my locker partner Joe Coyne’s comment on dyspareunia. “Dyspareunia,” he observed, “is better than no pareunia at all.”
What a strange word, and an equally strange custom: to “pronounce” someone. When a patient dies it isn’t good enough to say, “Yup, he’s dead.” A doctor, an MD, has to formally “pronounce” him dead.
Year Two
A new crop of residents had arrived— nice guys, but as Bill Chapin said, “Were we really that green when we started?”
It’s not about the problem, and it’s not about the surgeon, Dr. Wilk was telling me. It’s about a human being who needs our help, not our judgment.
It’s not much of a choice, but there it is. There is your late-night menu for you. Thank God for the mind-numbing weariness that leaves you unable to engage in such introspection. You do your work and when you’re done, you lay your head on a pillow. But, while you wait for sleep to come, the ghosts of all your whirling memories vie for possession of your fading consciousness. They are patient, those ghosts, and if they don’t have their say tonight, they have a way of returning nights or years later.
Why couldn’t I just take things as they came? Why was I continually looking for reasons and meaning? Reasons and meaning are not pragmatic. They are not the stuff of residencies. BJ Burke was not interested in what I thought or understood. He was interested in what I did.
“Shit happens,” he said with a shrug. And then, looking up, “Fuck shit.”
But this was all silly sophistry and I knew it. Appearance matters. Never mind why. It matters.
There is a rule in most hospitals that forbids anyone from removing the tubes or lines that have been inserted during resuscitative attempts. They are supposed to be removed only by the pathologist or the coroner or God-knows-who. It is a rule I have always despised, and I was not going to obey it now. I was not going to let the parents see their little boy with all those things sticking out of him.
He was so remorseful, so devastated, that I couldn’t find it in me to hate him. The two Mankato cops, however, didn’t have that problem. “Thanks, Doc,” one of them said when I put in the last stitch. “Now this bastard is going to jail and I hope he rots there.” The prospect of his rotting in jail seemed to please them. It did nothing for me. Why do we always think our pain will be less if we can make others suffer more?
But it hadn’t been all work. During those six months I had also managed to get my handicap down to a twelve, and to spend countless hours reading Hemingway, Yeats, Woolf, Flann O’Brien, Neil Gunn, Shakespeare, Wordsworth, Matthew Arnold, and, I’m not ashamed to admit it, Louis L’Amour. Frank Wales was the guy who got us hooked on Louis. There were so many Louis L’Amour paperbacks in the ortho call room at St. Mary’s that we had begun referring to Louis as the Patron Saint of Orthopods.
“A couple more beers,” Jack said to Sharon, “and he may run for pope.”
“Well, hon,” I said finally, “tomorrow I go back to the real world— this time as a senior resident.” She sighed. “And I get to be a widow again.”
Year Three
But oncology is a different story. Oncology means cancer, and cancer usually wins.
Oncologists, I concluded, were better people, stronger people, than I. They did their job, they treated their patients, but they reaped none of the adulation we orthopods took for granted.
I tried to act casual, as though I were asked about hemipelvectomies all the time. “Hemi,” I began, “is from the Greek. It means half. Ectomy means to remove something. So hemipelvectomy means to remove half the pelvis.”
But for months afterward I would see the black suture line running across the stump of Sarah’s left pelvis; and I would wonder just what it was Sarah thought she hadn’t lost.
“Relax, Mike. You’ve probably scrubbed on a hundred hips. You’ve done parts of this operation plenty of times. The only difference is this time you’re going to do them all. Hell, I watched you do that subtroch fracture last month. You looked like you had been doing them your whole life. Those are a hell of a lot harder cases than total hips.”
There was an unwritten rule among the residents that if the senior resident got to do the case, the junior resident got to do the closure. I had watched Steve assist, and though he was a little too raw to do the abductor repair, I was sure he could handle the rest of the closure. Of course it took him ten minutes longer than it would have taken me, but he had fun doing it and I had fun helping him.
Hell, in a pinch I could probably do a rotator cuff repair, although I didn’t feel too sure about that.
I felt a growing confidence, a feeling that all these years of work were starting to pay off. Four years of high school, and four years of college, and four years of medical school, and a year of internship, and two years of ortho with two more to go. That’s seventeen years. Sometimes it seemed like I would never be done, that I would be a student forever. But after today I knew that wasn’t true, for the first time I didn’t feel like a student. I felt like a surgeon.
I bent down, kissed them both, tickled them in the armpit, and said I was glad to be home because I hadn’t spanked a kid in two days.
The poor thing needs his rest— and this from a woman who had just given birth to her third baby in three years, a woman who had defied her parents to marry a guy with no money, a guy who then tore her away from home, moved her four hundred miles away, and then left her alone for days at a time.
Like the mailman, the garbageman, the ladies at the grocery store, and every shopkeeper in Rochester, he loved Patti. They all did. And they all felt responsible for her. They all harbored the sneaking suspicion that her husband wasn’t quite worthy of her (a suspicion her husband also harbored).
Death, suffering, failure. They were the enemy, but they didn’t play by the rules. Sometimes, even when I did everything right, they still won. I couldn’t give up the childish notion that things ought to be fair. When I ran a perfect code, when I did everything right, the patient ought to live. What more could be asked of me? What more could I give? Day in and day out I did the best I could, the best anyone could— and so often it wasn’t enough.
Maybe that’s why I liked fixing fractures so much. Fractures appealed to me in a way no other part of orthopedics did. Unlike other areas of medicine (and other areas of life), everything about fractures was straightforward. Cardiologists might bullshit about whether the patient actually had a heart attack. Neurologists might bullshit about whether the patient actually had a stroke. But with fractures, there was no way to bullshit. As soon as the X-ray was developed, everyone knew exactly what the problem was, and exactly what the solution was.
“I don’t get paid enough to put up with this,” she panted.
I am a dumb shit, I realized finally. Of course that isn’t my job. I have been missing the boat.
Year Four
“If you ain’t drunk, you ain’t fishin’” is the Minnesota fisherman’s creed.
“No, I grew up in Chicago, remember? People are more civilized there. They don’t shoot animals— only other people. Anyway, isn’t there a law against shooting geese around here?”
I was shocked. Is this how the alpha male, the provider, is welcomed back to the cave? “Pat, it’s a fresh goose. It’s meat.”
One good thing about being a resident at Mayo is that there is never a shortage of job offers: Seattle, Colorado, Chicago, Tampa, Dallas, Boston. I pretty much had my pick of places. It felt strange to be looking for a job. Even though I was now chief resident, I still felt as if I had just started, and now I was making plans to leave.
The patient did not always come first— especially in the surgical specialties. If the Mayo Clinic’s primary concern was patient care, then how could they ever let a resident do a case? The resident is virtually never a better surgeon than the attending surgeon. Now that I was chief resident I was pretty good at doing most orthopedic operations. But I never for a moment thought I was better than Antonio Romero or Tom Hale or Mark Coventry. So how could the Clinic justify letting me do cases when everyone knew I wasn’t as good as those guys? And how could I justify letting Alan do cases when I knew he wasn’t as good as I was?
And yet at every training center in the United States residents do cases; and at every training center in the United States administrators continue to proclaim, “Patient care comes first.”
Chris took a long pull on his beer and laughed. “I get it,” he said. “As long as you don’t feel competent doing a case, you do it; but as soon as you get good at it, you turn it over to your junior resident.”
“Yeah, what a system. It guarantees that all cases are done by the least competent person— a kind of medical Peter Principle.”
I’m an orthopod, I thought. I fix things. Big deal. Everything I fix winds up in a coffin anyway.
But being chief resident also meant being a little schizophrenic. The younger residents thought of me as an attending surgeon. They constantly came to me for advice, wondering how to treat this or repair that. But the attending surgeons still thought of me as a resident, a convenient place to dump things. As elsewhere in life, that brown stuff kept flowing downhill— and I had to be there to catch it all. Every goofy case, every undesirable consult, was shunted to the chief resident.
The problem, I realized, lay in my conception of what a doctor should be. I wanted to be the guy people came to when life dealt with them unfairly. I wanted to be the guy who confronted the arbitrariness of life and strangled the unfairness out of it.
Anyway, Eddie goes to the doctor and finds out he’s got a sinus infection. Eddie says it’s too bad he wasn’t drinking flaming shots: they might have cleared his sinuses right out. The doctor is some Czechoslovakian or Nicaraguan or something. He isn’t used to the Irish. He says Eddie is an idiot and needs to see a psychiatrist. Eddie tells him he is a psychiatrist and can he have a professional discount? The doctor gives him a prescription for an antibiotic and tells him next time he gets an infection from drinking beer upside down he should find another doctor. Eddie says, ‘Thanks, Einstein.’”
The room was quiet save for the sigh of the ventilator and the steady beep of the cardiac monitor. From behind the drape at the head of the table, the anesthesiologists looked at me questioningly. The other residents stood silent, some looking at the ground, some staring at the gaping wound in front of us. No one moved. No one spoke. They all waited.
“I worked with you Friday night,” she said, “then I went home and slept, did some shopping and visited the grandkids. I worked with you Saturday night, then I went home and slept, went to church, and had dinner at my sister’s. Now I come back on Sunday night and you’re still here. You look like shit, you know. What the hell is wrong with you to work like this?”
By Monday morning at five I had been working fifty-eight straight hours. I had managed a few hours of sleep, but was coasting in on fumes, stubble-chinned, bleary-eyed, and working by instinct. I was neither awake nor asleep, neither alive nor dead— a condition not unlike that in which I had spent much of the past four years.