Thursday, December 30, 2010

Calling Rampart

Growing up, I wanted to be an astronaut, a United States Senator, and a doctor, preferably all at the same time. As fate would have it, the chance to be the latter came first. I was a senior at Shawnee Mission East High School just over the state line from Kansas City, Missouri, and there was a new and innovative medical school on the Show-Me side that took you in after high school and six years later sent you back out with a medical degree. And during my interviews I was asked the inevitable questions of, "Why do you want to be a doctor?'' The problem was that I didn’t have answer, and still don’t. It’s not like I was impacted as a child by some friendly family physician that came to my bedside, nor was my life saved by the swift intervention of a skillful surgeon. I was not born into a medical family. The only things I ever remembered (or at least haven’t suppressed) about going to the doctor's office were shots, being bribed to get shots with butter cookies, and reassurance that yes, someday he will hit puberty (it did happen, and last week was a life-changing experience, to be sure). About the best I could do was recall drawing arteries and veins on a Valentine’s Day heart, causing the girl across the street to say she'd never play with me again, and absorbing all the reproductive details in the Better Homes and Gardens Baby Book the adoption agency sent home with my brother. So I gave the admissions folks the honest answer, "I really don't know. It's just something I've always thought I should do.” The answer, no matter how truthful, provoked frowns all around, and I was sure it was time to pack up the bags and head to the closest state university with a drinking age of 18 willing to give me some scholarship cash. (I did have some standards.)

(Frankly, I also had crap answers to other questions the interviewers would ask. One of them, a female psychologist, would have you tell a story about something that happened, and then say “Tell me more.” On several occasions I had to say “There isn’t any more. The story’s done,” which seemed to displease her. A second interviewer, who was an older African-American pediatrician, asked if I ever had any experience being a minority. The only thing I could think of to say was, “Does being a Jew in Kansas count?” Apparently it did.)

So how did I get into medical school? Truth be told, I have no idea. I‘m not sure I would have taken me. Nonetheless, the official reason would be that they saw my potential as not only a physician, but as a person, and wanted to help me fulfill my destiny. To this day I’m convinced that the real reason was simply dumb luck. The University of Missouri-Kansas City School of Medicine was designed to turn out primary care doctors for Missouri, and it had always taken exclusively Missouri residents. However, there was a small, never used clause somewhere in the Admissions Manual that said every year, they could take up to four kids from the Kansas side of the metropolitan area. (Kansas City, Missouri and Kansas City, Kansas, are just across the Missouri River from one another; the Kansas suburbs of KC are separated off from the main city by a two-lane street called State Line Road. When Kansas was a dry state, the police used to sit just over the Kansas side, watch cars with Kansas plates go into liquor stores on the Missouri side, and bust the drivers when they came back into the Sunflower Realm.) The year I applied, the daughter of one of the Vice-Chancellors of the University, who happened to attend high school in Kansas, also wanted to go to medical school. So the clause was dusted off for her, and a few other Jayhawkers were let in for show. They sent me a letter of acceptance, I called my parents who were on vacation in the Caribbean (the message they got from the hotel operator was “Mr. Howard’s in the hospital”), and a mere thirty years later I’m writing about it all.

I have the same difficulty in describing why I chose emergency medicine as a specialty. It just seemed like something I was always supposed to do. Now, with over twenty years of practice under my belt, I can think of a number of reasons I stay in it (and a few more to get out, but until I can convince my son that trade school would make him happier than a four-year college and a graduate degree, I’m still at work.) The truth is I still don't know why I do this, except it makes me happier than anything else in clinical medicine. I suppose that happiness is the only reason you should do anything for a living, and it probably doesn't matter if you know why you're happy or not.

But since there’s a requirement that everyone has to have an anecdote about why they chose to do what they do, here’s mine:

I remember watching the show “Emergency!” when I was eight or nine years old. “Emergency!” was about a group of LA County paramedics who saved lives and stamped out disease. Their medical base was the fictional Rampart General Hospital. Rampart is the only hospital I’ve ever known that was staffed 24 hours a day, 365 days a year, with two physicians (Kelly Brackett, MD FACS and Joe Early, MD FACS) and a single nurse (Dixie McCall, RN), complete with starched white cap and dress. (The nurse, I mean.)

I can remember not being terribly interested in the paramedics. Roy DeSoto was a boring guy, and Johnny Gage was always chasing girls. Who has much use for that when you’re eight? My girl issues back then consisted of making sure I had the requisite shots against cooties. But the doctors really impressed me, mostly because of the initials after their name besides the usual MD. At the time, I though the more letters you have, the cooler you are. I didn't know that FACS meant fellow of the American College of Surgeons, which in turn means you allowed yourself to have the personality sucked out of you during five to seven years of surgical training in exchange for the ability to rummage around someone’s innards, and that you then get to pay a large chunk of money in dues each year for continued use of the letters. And there was no way to know they were surgeons, for they weren’t ostensibly arrogant and could occasionally relate to patients and admit mistakes. But I knew that someday I wanted lots of initials after my name.

I think that the drive to work in the ED was solidified the day that Kelly and Joe saved a goat. For some reason that escapes my memory, Johnny and Roy had brought a goat to the hospital. I suppose the goat was dying of some dread goat thing, and needed immediate goat surgery to save its bleating little life. So they've put the goat under, and Kelly has his hands somewhere within the goat's entrails, and Joe is about to administer some sort of goat drug to do some sort of goat thing when suddenly Kelly has what can only be described as a veterinary version of an LSD flashback. "Wait!” he cries to Joe, who is busily keeping the goat asleep with anesthetic gases and chewed up tin cans and soothing goat noises and such. "Don't give that drug!” Whereupon Joe replies calmly, holding up an uncapped syringe, "Don't worry Kelly. I just remembered my animal physiology."

That was it for me. I can save people and goats, too. If the people didn't make it, I could still have food. And in retrospect, I got my initials. I became a Fellow of the American College of Emergency Physicians, or FACEP. That is, until I got tired of paying over $700 each year for the initials that nobody asked about, and when I realized they were best pronounced in a rhyme with “duck up.”

So with all this being said, what’s the main reason people go into, or stay, in emergency medicine? I think the bottom line is that emergency medicine is fun. We have the wildest stories, the closest sense of family, the highest highs and the lowest lows, the most food per capita of anyone in the hospital, and more laughs per hour than an episode of “Scrubs.” It’s like being in a perpetual amusement park. Sure, you spend a lot of time waiting in line for the fun, but the ride at the end of the queue is worth it. The risk of barfing when it gets too fast or twisted adds excitement and mystery. And always stay away from the deep fried Pepsi.

Monday, December 20, 2010

Bak to Skool

A while ago I went to my 30th Anniversary High School Reunion. I had only been to one previous gathering, the 10th, and had a rotten time. The people who wouldn’t talk to me in high school still wouldn’t talk to me, depriving me of any chance to engage in condescendive posturing at my early successes in life and my collegiate-aged growth spurt. It was also the night that I got a phone call from one Florida girlfriend saying she had run into the other Florida girlfriend asking which one I wanted to keep. In retrospect, I gave the wrong answer, which was confirmed not only by short-term loss of relationship and long-term demolition of any chance of reconciliation with said blonde, but also because I learned that it’s not a good sign when you come into your apartment after a weekend away to find a stuffed brontosaurus hanging by the neck in a noose made of a silk tie, swinging a lazy circles from a ceiling fan. I also fumbled a lingerie-scented pass from a beautiful woman I had a crush on for years, but had suffered in silence while she dated one of my friends. So I really don’t have good memories of the experience at all. The only moments that I enjoyed were found sitting at a corner table with one Laurie Thornton who, while not really close friends in high school, I now had a common interest: I was an ED doc, and she was an emergency veterinarian. So we talked quite avidly about various organs and body fluids possessed by various two and four-legged species, and drove away everyone else at the table. (I personally think it was the topic of why cats hiss when you intubate them that did it. Incidentally, this is why you can always tell the ED people eating breakfast after a night shift at Cracker Barrel. In a room full of tables, theirs is the one that nobody wants to sit next to. )

Anyway, I hadn’t been back for any of the other reunions, but the Magic of Facebook got me in touch with some folks from high school, and though it took some doing I got talked into going. I’m glad I did. If it was pretty clear that if the 10th, 20th, and 25th reunions would be about keeping score, this one was more about survival. We’re all on the back side of forty, pushing the half-century mark. Now it’s all about rejoicing not in our achievements, but simply in our continued presence on this earth.

Overall, it was a very nice affair, and I’m very glad I went. I met up with a few friends for a drink beforehand…Jim Cramer, Roger Ramsayer, Missy Webber, Bill Koch… and we all thought we looked pretty good. This was a test hypothesis, or course, but as we came into the hotel ballroom to see the whole group I was glad to see it was generally true. We did look pretty good, for folks older than our parents were when we got out of school. The only thing that could have been better…and this is a very minor and quite selfish point, for the Planning Committee did a great job…is if they had music and dancing, so this nerd could finally sidle up to the hot chicks. (Would have done it, too...had permission from The Bride to flirt my brains out to make up for lost time.)

Later in the evening I’m talking to Brian Youll, who was very close to a good friend of mine who didn’t make it to the party, and up comes Laurie Thornton. It’s wonderful to see her. She looks great. And within ten minutes, we’ve done it again. We start talking our stuff, soon we’ve been left alone, somehow the traffic pattern has pushed us into a corner, and we’re having a grand time. Later in the evening, we get into a conversation with Steve Silbinger, a former classmate who has made his fortune in direct-to-TV products such as Urine-B-Gone. As clinicians intimately acquainted with the bodily fluids of various species, we were probably his most appropriate audience. (Neither of us remembered it, but it also turns out that Laurie and I sat next to each other in the class picture taken in the gym 30 years ago. So maybe it’s fate, and not just fluids.)

A somber part of the evening came with a slide presentation of the dozen or classmates who have already attended the Celestial Graduation. It was very well presented…high school pictures followed by photos of them later in life as well. A few of the people I knew peripherally, but one I knew quite well. You know how in high school you can have people who are your best friends for a month or so, and then you just drift apart, no harm, no foul? For me, Jeff Serrault was one of those guys. Jeff always carried a brief case to school, and we were all convinced he was going to be wildly rich the right way and we would all come beg him for money. He was the one who took me to get my driver’s license one afternoon my senior year. He passed away, and nobody knows where he was or what happened to him. It’s pretty sad.

But given that there’s humor in everything, a curious pattern began to emerge. With several of the deceased…including my friend Jeff Serrault…they showed old photos of them involved in school activities, such as sports teams or the yearbook. And in every photo they showed, whether it was the Literary Society, Student Council, of the Chorus, someone in the “Roll of Gone Before” was sitting next to Ann Lowry. As was I at that very minute. Coincidence? Maybe. I shifted in my seat.

Ann was my “friend who was a girl but not my girlfriend” in high school, although by all rights we probably should have been (and we were, for about three hours one post-pubertal night in college, but even that only went so far. I mean, it was ANN). Both student council nerds, both literary nerds, both short, both cute as a button. I often went over to Ann’s house to pick her up to do stuff together because, well, we could. Her folks were always great to me, and I still remember they had a small dog named Taffy that, as best I recall, barked and nipped and did very little else, at least while I was around. And so when the plans were made to meet up for the reunion, of course Ann was there, and of course I was going to be sitting next to her, which meant I had unwittingly placed my backside in the Hotel Banquet Chair of Doom. This was confirmed when they handed out a copy of the last issue of the student newspaper of our senior year and there was Ann once again, signing her choral heart out next to another decedent. And as I’m soaking up this tidbit of fate, the evening’s moderator, in a wistful moment, notes that “We’re getting older, so look around because next time some of us won’t be here.”

I had a great time, and I have concluded that I would very much like to attend my 40th high school reunion. But when I do, Ann had better be on the other side of the table.

Saturday, December 18, 2010

Washday Blues

This piece is coming to you from the Non-Creepy Laundromat in Hays, Kansas. Hays actually has two laundromats. One is down by the Student Ghetto of Fort Hays State University (home of the Tigers, another school celebrating an animal native to it’s environs just like the Pittsburg State Gorillas) and has been labeled by the natives who are advising me on washday destinations as Creepy. The Non-Creepy one is in the north part of town, where the hoi polloi…such as can be mustered in Hays (one hoi, two polloi)…dwells in placid isolation from the cares of student life. It’s a fairly nice place to spend an hour washing your scrubs, especially if you’re able (as I am) to work through the fact that it’s a Sunday evening of hunting season, and the parking lot is full a pickup trucks with gun racks and men washing their cammos clean of blood and feathers before they bring their outdoor gear into the house.

Anyway, this evening I’ve come to realize that the great paradox of the laundromat, and probably a money- making scheme in it’s own right, is that it’s hard to get stuff out of the washer to the dryer. Here’s what I mean. When you wash a load of clothing, things get tangled together, right? Pant legs get caught in the arms of shirts, socks get meshed inside of sweats, and the whole thing becomes a jumbled mess. It’s nearly impossible to extract one article of clothing from another. And it’s not like the washer and the dryer and next to each other like at home, so you can simply scoop stuff from one appliance to the other. At the laundromat, the washers and dryers and physically separated, washers along one wall, dryers on the other. So when you try to remove the wet and wadded ball of clothes from the washing machine and cart it the ten feet across the room, something invariably trails behind in the tendrils of fabric and falls to the floor.

If this is your floor, the floor at home that you’ve kept immaculaltely clean, or at least has your personal dirt on it, this is no problem. But this is a public floor, full of anonymous sticky stains of God knows what, into which your favorite pair DC Comic Heroes underwear had fallen, and now you have to think if you’re willing to put them in the dryer with all your nice clean non-floor contaminated clothes and get those sticky-old-soda-I-think-but-what-else-could-it-be-after-all-its-hunting-season germs on your other stuff, and then go ahead and wear them knowing that maybe-they’re full-of-disease-and-I’m-pretty-sure-the-dryer-isn’t-hot-enough-to-kill-the-plague, or buying another small box of detergent (75 cents, more for bleach), putting another three dollars in quarters into the washer, one more buck in the dryer, and killing another hour (and $1.25 for a Coke and a stale Lance Peanut Bar) in order to have pure underwear.

Well worth it, I say. Aquaman’s colors have never been so bright.

Monday, December 13, 2010

Eyes Wide Shut?

Best moment of my ER night: A transfer patient arrived from an outlying hospital. He had multiple facial injuries from a motor vehicle accident, and among these were deep abrasions to his eyelids , to the extent that the local facial surgeon thought he might require a skin graft. And where might you get such a graft, he wondered aloud? Perhaps the skin of the penis, he reasoned. It was the only skin thin enough to be appropriate for the eyelids. He even had a real medical word for the procedure, but to be honest I was too busy working through the implications of the procedure to remember what it was called. A phallograft, perhaps. That sounds good.

Anyway, think how this works. You see a hot girl, and then your eyes stay open, unblinking, for a long time. In the short term, you’re a sure bet to win any staring contest. But if your eyes stay open for more than four hours, please call your physician.

Sunday, December 12, 2010

Aging with Style

In the past I’ve been guilty of ageism. Before I hit the age of 40, I tended to view my elders as something different than me…not worse, by any means, but just different. Not as up-to-date. Not as funny. Not as earthy. Certainly not as hormonal. Which is why I could never figure out why one of my Dad’s mother would laugh uproariously at my Saturday Night Live Cast Album. I mean, she must have been all of 55 at the time, and we all know that’s old.

I think what finished this illusion once and for all was hanging out with my other grandmother. Grandma Theresa was a social animal, and for a while she dated a gentleman from Belgium we’ll (respectfully) called Nick the Frog. Old Nick wasn’t much to look at, hence his epithet; but Nick had bucks and wasn’t afraid to use them, and Grandma wasn’t afraid to benefit, either. He was good to her, to be sure, and having lost two previous husbands to cancer Lord knows she deserved everything she could get. But it was still kind of…well, creepy…to think of Nick the Frog kissing my grandmother. So one day, when I was in one of those intergenerational-bonding-question-moods, I asked her how she could stand kissing Nick the Frog. “I wouldn’t know, really,” she said with a wink. “He tires easily.”

Theresa was the kind of Grandma who would set me up on a date the same night she had one. Usually her date would come pick her up before I took her car, so I played the role of the father, inspecting the date before she left the house. (And yes, I did reject one.) Before she would leave, she would turn to me and say, “Now don’t do anything I wouldn’t do.”

One night I decided to call her bluff. “And what exactly is it that you do?” I asked.

Her eyes sparkled. “A hell of a lot more than you think.”

Date nights would end when we both got home, drinking hot tea laced with peppermint schnapps. She would complain about how all the men her age were sick with something or another and just wanted someone to take care of them. I would wonder how in the world she could think it was okay to set me up with a seventeen year old no matter what her fake ID, kissing abilities, and breast size had said otherwise. (The answer, of course, is that she was Jewish.)

My grandmother’s comments came back to me a few weeks ago as I went to examine an 87 year old woman who had suffered a fall. The right side of her face black and blue, with a bruise going from just above her eye down to the girlishly prominent cheekbones.

“Hello, ma’am, I’m Dr. Rodenberg. What happened to you?”

With a smiling face and a knowing look, she answered. “Rough sex.”

There was no comeback. I stood there stunned for a good thirty seconds as she laughed out loud and her family stared at her with horror. Finally, I looked at her with all the compassion I hold for those elders who are the kind of old person I want to be: Crotchety, independent, and racy as hell.

“Ma’am, if I was 40 years old I’d date you.”

She eyed me up and down, with special attention to the waistline.

“And then you’d see what I mean” she answered back.

Thursday, December 9, 2010

Middle Ground

I’ve often heard the phrase, “If you’re young and you’re not a liberal, you have no heart; and if you’re old and you’re not a conservative, you have no brain.” And I do believe there’s a certain amount of truth to it. One of the reasons I chose Emergency Medicine as a career was that I liked the “White Hat” part of it all…I was the one guy who would take care of anyone at anytime. The Stetson has been solied, however, by years of reality, and so I have begun to morph from what I like to call the Hard Rock CafĂ© of Medicine…Love All, Serve All…to a more nuanced view that while there are both people we absolutely need to help and some totally beyond redemption, that personal responsibility is on the wane, and that nobody quite understands the concept of an “emergency,” in general people earn what they get out of life. That’s why I’ve become increasingly fascinated by pundits and politicians, as well as ordinary citizens, who are able to state with metaphysical certitude (thank you, John McLaughlin) that the solution to our social ills is to either throw handfuls of money at more government programs to positively impact more people or to slash every entitlement program out there and let people fend for themselves. They find no room for compromise in between. I have no idea what world they’re living in.

(If you and I are “ordinary” citizens, it’s important to note the policymakers and pundits are not “extraordinary” because, like Superman, they possess “powers and abilities beyond those of mortal men.” Instead, I like to think of them as extraordinary in a Twilight Zone sort of way, as “not like us” but resembling extraterrestrial fully willing to devour the heart and soul of their fellow humans while quoting “To Serve Mankind.” IT’S A COOKBOOK!)

So here’s what I think I’ve figured out. It’s really easy to be an extreme liberal if you live well and don’t see the poor, the abused, and the homeless. It’s easy to see them as the victims of racism, xenophobia, substance abuse, and rampant capitalistic greed. And it is equally easy to be a radical conservative under the same circumstances, except now you see them as abandoning the work ethic that built America for an entitlement mentality and draining the fiscal and cultural life from the land. What they know of the social ills of this land they know mostly from clever statisticians and reinforcing media, supplemented by “listening tours” and the occasional goodwill visit. Both sides are perfectly willing to manipulate the dispossessed as political tools and voting blocks to advance their own agendas. And after their obligatory daytime hours spent in tearful condemnation of or strident fury against the system, they go home to nice neighborhoods, full larders, kids in good schools with every chance to go to college, health coverage, and paid vacations.

The whole thing seems a little hypocritical to me, and I say this fully aware that I’m one of the ones who’s not worrying about my next meal. But if I don’t know how to live in poverty, at least I see it every day. Sometimes I’m sympathetic with what I see, and want to do all I can to help someone; sometimes it makes me furious, and I’m equally enthused about wanting to tell another that they’re abusing the system and they can expect no further handouts from me. But at least I know something of which I speak, and I have some “stake in the game,” as it were. Improving these social ills makes my working life easier. But when problems get fixed, politicians and pundits are out of work, and special interests cease to wield power. So it’s in everyone’s interest to keep the system going exactly as it is. Everyone’s, of course, except those in true need, and those rare individuals in public life actually interested in making positive change.

So what’s really out there? Based on my totally unscientific observational study of the socioeconomic needs of people who drop through the ED. About a third of folks are truly in distress and need all the help we can provide. A third are abusing the system. A final third really have no clue where they fit in and are just trying to get by the best that they can. And as a result of these observations, I have come to believe that our system does often entitle people to services that are undoubtedly excessive, but also places significant roadblocks in the way of those who truly need additional help.

I fully recognize that this subtlety…also known as reality…goes against the current “sound bite” dialogue we’ve come to expect in our public policy debates. And we accept that lack of substance, because these issues are hard to think about and even harder to solve, and if Americans have been trained to do anything in the media age it’s it avoid independent thought. Which is clearly one thing we excel at.