by Samuel Shem
Rounds over, Fats headed to breakfast, and we headed out to the ward to get to know the patients on our cards. Potts, looking green, said, ‘Roy, I’m as nervous as a whore in church.’ My BMS, Levy, wanted to go see my patients with me, but I shooed him away to the library, where BMSs love to be. Chuck and Potts and I stood at the nursing station, and the hairy-armed nurse told Potts that the woman on the stretcher was his first admission of the day, named Ina Goober. Ina was a great mass of flesh sitting upright on a stretcher, wearing, like a uniform, a gown that had blazoned across its front, ‘The New Masada Nursing Home.’ Glowering, Ina clutched her purse. She was yelling a high-pitched: GO AVAY GO AVAY GO AVAY . . .
Potts did what the textbooks said to do: introduced himself, saying, ‘Hello, Mrs. Goober, I’m Dr. Potts. I’ll be taking care of you.’
Upping her volume, Ina screamed: GO AVAY GO AVAY GO AVAY . . .
Potts next tried to engage her using the other textbook method, grasping her right hand. Quick as lightning Ina struck him a southpaw blow with her purse, knocking him back against the counter. The sinister violence of it shocked us. Potts, rubbing his head, asked Maxine, the nurse, whether Ina had a private doctor who could provide information.
‘Yes,’ said Maxine, ‘Dr. Kreinberg. Little Otto Kreinberg. That’s him over there, writing Ina’s orders in her chart.’
‘The private doctors are not supposed to write orders,’ said Potts, ‘that’s a rule. Only interns and residents write orders.’
‘Little Otto is different. He doesn’t want you writing orders on his patients.’
‘I’ll talk to him about that right now.’
‘You can’t. Little Otto won’t talk to interns. He hates you.’
‘He hates me?’
‘He hates everyone. See, he invented something having to do with the heart thirty years ago, and he expected to get the Nobel Prize, but he hasn’t, so he’s bitter. He hates everyone, especially interns.’
‘Well, man,’ said Chuck, ‘sure is a great case. See you later.’
I was so scared at the thought of seeing patients that I had an attack of diarrhea, and sat in the toilet with my How to Do It manual spread on my knees. My beeper went off: DR. BASCH CALL WARD 6-SOUTH RIGHT AWAY DR. BASCH . . .
This scored a direct hit on my anal sphincter. Now I had no choice. I could no longer run. I went out onto the ward and tried to go see my patients. In my doctor costume, I took my black bag and entered their rooms. With my black bag I came out of their rooms. All was chaos. They were patients and all I knew was in libraries, in print. I tried to read their charts. The words blurred, and my mind bounced from How to Do cardiac arrests to Berry to this strange Fat Man to Ina’s vicious attack on poor Potts and to Little Otto, whose name rang no bell in Stockholm. Running through my mind, over and over like Muzak, was a mnemonic for the branches of the external carotid artery: As She Lay Extended Olafs Potato Slipped In. And even there, the only one I could remember was Olafs, which stood for Occipital. And what the hell use was that?
I started to panic. And then finally the cries coming from the various rooms saved me. All of a sudden I thought ‘zoo,’ that this was a zoo and that these patients were the animals. A little old man with a tuft of white hair, standing on one leg with a crutch and making sharp worried chirps, was an egret; and a huge Polish woman of the peasant variety with sledgehammer hands and two lower molars protruding from her cavernous mouth became a hippo. Many different species of monkey appeared, and sows were represented in force. In my zoo, however, neither were there any majestic lions, nor any cuddly koalas, or bunnies, or swans.
Two stand out. First, a heifer named Sophie, who’d been admitted by her Private Doctor with a chief complaint of ‘I’m depressed, I’ve got headaches all the time.’ For some reason her Private, Dr. Putzel, had ordered the complete Gastrointestinal workup, consisting of barium enema, upper GI series, small bowel follow-through, sigmoidoscopy, and liver scan. I didn’t know what this had to do with depression and headache. I entered her room and found the old lady with a balding little man who was sitting on her bed patting her hand affectionately. How sweet, I thought, her son has come to visit. It was not her son, it was Dr. Bob Putzel, whom Fats described as ‘the hand-holder from the suburbs.’ I introduced myself, and when I asked Putzel about the reason for the GI workup for depression, he looked sheepish, straightened his bowtie, murmured ‘flatulence,’ and, kissing Sophie, hurried out. Confused, I called in the Fat Man.
‘What is it with this GI workup?’ I asked. ‘She says she’s depressed and has a headache.’
‘It’s the specialty of the House,’ said Fats, ‘the bowel run. TTB—Therapeutic Trial of Barium.’
‘There’s nothing therapeutic about barium. It’s inert.’
‘Of course it is. But the bowel run is the great equalizer.’
‘She’s depressed. There’s nothing wrong with her bowels.’
‘Of course there’s not. There’s nothing wrong with her, either. It’s just that she got tired of going to Putzel’s office, and he got tired of calling at her house, so they both pile into his white Continental and come to our House. She’s fine, she’s a LOL in NAD—a Little Old Lady in No Apparent Distress. You don’t think Putzel knows that too? And every time he holds Sophie’s hand, it’s forty of your Blue Cross dollars. Millions. You know that new building, the Wing of Zock? Know what it’s for? The bowel run of the rich. Carpets, individual changing rooms in radiology with color TV and quadraphonic sound. There’s a lotta money in shit. I’m searching for a GI fellowship, myself.’
‘But with Sophie it’s fraud.’
‘Of course it is. Not only that, it means work for you, and Putzel is the one making the money. It sucks.’
‘It’s crazy,’ I said.
‘It’s doing medicine the House of God way.’
‘So what can I do about it?’
‘Start by not talking to her. If you talk to these patients, you’ll never get rid of them. Then sic your BMS on her. She’ll hate that.’
‘Is she a gomer?’
‘Does she act human?’
‘Of course she does. She’s a nice old lady.’
‘Right. A LOL in NAD. Not a gomere. But you’re sure to have a gomer on your service. Here, let’s see. Rokitansky. Come on.’
Rokitansky was an old bassett. He’d been a college professor and had suffered a severe stroke. He lay on his bed, strapped down, IVs going in, catheter coming out. Motionless, paralyzed, eyes closed, breathing comfortably, perhaps dreaming of a bone, or a boy, or of a boy throwing a bone.
‘Mr. Rokitansky, how are you doing?’ I asked.
Without opening his eyes, after fifteen seconds, in a husky slurred growl from deep down in his smushed brain he said: PURRTY GUD.
Pleased, I asked, ‘Mr. Rokitansky, what date is it today?’
PURRTY GUD.
To all my questions, his answer was always the same. I felt sad. A professor, now a vegetable. Again I thought of my grandfather, and got a lump in my throat. Turning to Fats, I said, ‘This is too sad. He’s going to die.’
‘No he’s not,’ said Fats. ‘He wants to, but he won’t.’
‘He can’t go on like this.’
‘Sure he can. Listen, Basch, there are a number of LAWS OF THE HOUSE OF GOD. LAW NUMBER ONE: GOMERS DON’T DIE.’
‘That’s ridiculous. Of course they die.’
‘I’ve never seen it, in a whole year here,’ said Fats.
‘They have to.’
‘They don’t. They go on and on. Young people—like you and me—die, but not gomers. Never seen it. Not once.’
‘Why not?’
‘I don’t know. Nobody knows. It’s amazing. Maybe they get past it. It’s pitiful. The worst.’
Potts came in, looking puzzled and concerned. He wanted the Fat Man’s help with Ina Goober. They left, and I turned back to Rokitansky. In the dim half-light I thought I saw tears trickling down the old man’s cheeks. Shame swept over me. My
stomach churned. Had he heard what we’d said?
‘Mr Rokitansky, are you crying?’ I asked, and I waited, as the long seconds ticked away, my guilt moaning inside me.
PURRTY GUD.
‘But did you hear what, we said about gomers?’
PURRTY GUD.
I left, and stopped by to listen to Fats on Ina Goober.
‘But there’s no indication for the bowel run,’ Potts was saying.
‘No medical indication,’ said Fats.
‘What else is there?’
‘For the House Privates, a big one. Tell him, Basch, tell him.’
‘Money, ‘I said. ‘there’s a lotta money in shit.’
‘And no matter what you do, Potts,’ said the Fat Man, ‘Ina will be here for weeks. See you on Visit Rounds in fifteen.’
‘This is the most depressing thing I’ve ever done,’ said Potts, lifting up a pendulous breast as Ina continued to shriek and attempt to whack him with her tied-down left hand.
Under the breast was greeny scumlike material, and as the foul aroma hit us, I thought that this first day must be even worse for Potts. He was a displaced person, from Charleston, South Carolina, to the North. He came from a rich Old Family who owned a dream house on Legare Street amidst the magnolias and yellow jasmine, a summerhouse on Pawley’s Island, where the only competition was between waves and winds, and an upriver plantation, where he and his brothers would sit out on the porch of a cool summer night and peruse Molière. Potts had made the fatal mistake of coming north to Princeton, and then compounded his mistake by coming to the BMS. There, over the stiffs in the Path course, he’d met a classy female BMS from Boston, and since up till that time Potts’s sexual experience had consisted only of ‘an occasional recreational encounter with a schoolteacher from North Charleston who was fond of my bluesteel throbber,’ he’d been assaulted by the female BMS in both intellectual and sexual terms, and, like a false spring in February when all the bees hatch and are killed by the next frost, there had blossomed in these two BMSs something each called ‘love.’ The wedding had been held just prior to both internships, his in medicine at the House, hers in surgery at the MBH—Man’s Best Hospital—the prestigious BMS-affiliated WASP hospital across town. Their on-call schedules would rarely coincide, and their joy of sex would curdle to their job of sex, for what erectile tissue could stand two internships? Poor Potts. Goldfish in the wrong bowl. Even at BMS he’d seemed depressed, and each choice since then had served only to deepen his depression.
‘Oh, and by the way,’ said the Fat Man, poking his head in again, ‘I’ve written an order for this.’
In his hand was a Los Angeles Rams football helmet.
‘What’s that for?’ asked Potts.
‘It’s for Ina,’ Fats said, strapping it on her head. ‘LAW NUMBER TWO: GOMERS GO TO GROUND.’
‘What does that mean?’ I asked.
‘Fall out of bed. I know Ina from last year. She’s a totally demented loxed-out gomere, and no matter how securely restrained, she’ll go to ground every time. She cracked her skull twice last year, and was here for months. Till we thought of the helmet. Oh, and by the way—even though she’s dehydrated, whatever you do, do not hydrate her. Her dehydration’s got nothing to do with her dementia, even though the textbooks say it does. If you hydrate her, she stays demented, but she gets incredibly abusive.’
Potts’s head turned to watch the Fat Man go, and somehow, her left hand free, Ina slugged him again. Reflexively Potts raised his hand to hit her, and then stopped himself. The Fat Man nearly keeled over with laughter.
‘Ho ho, did you see that? I love ’em, I love these gomers I do . . .’ And he laughed his way out the door.
The manipulation of her head intensified Ina’s screams: GO AVAY GO AVAY GO AVAY . . .
And so, leaving her tied down six ways from Sunday, the ram horns curling around her ears, we proceeded to Visit Rounds.
Being an academic House affiliated with the BMS, the House of God had a Visit for each ward team: a member of the Privates or the Slurpers, who held teaching rounds every day. Our Visit was George Donowitz, a Private who’d been pretty good in the prepenicillin era. The patient presented was a generally healthy young man who’d been admitted for routine tests of his renal function. My BMS, Levy, presented the case, and when Donowitz grilled him about diagnoses, the BMS, straight from the library of obscure diagnoses, said ‘amyloidosis.’
‘Typical,’ muttered the Fat Man as we gathered around the patient’s bed, ‘typical BMS. A BMS hears hoofbeats outside his window, the first thing he thinks of is a zebra. This guy’s uremic from his recurrent childhood infections that damaged his kidneys. Besides, there’s no treatment for amyloid, anyway.’
‘Amyloid?’ asked Donowitz. ‘Good thought. Let me show you a bedside test for amyloid. As you know, people with the disease bruise easily, very easily indeed.’
Donowitz reached down and twisted the skin on the patient’s forearm. Nothing happened. Puzzled, he said something about ‘sometimes you have to do it a bit harder’ and took hold of the skin, wadded it up, and gave it a tremendous twist. The patient gave a yelp, leaped up off the mattress, and began to cry with pain. Donowitz looked down and found that he’d ripped a big chunk of flesh from the guy’s arm. Blood was squirting from the wound. Donowitz turned pale and didn’t know what to do. Embarrassed, he took the piece of flesh and tried to put it back, patting it down as if he could make it stay in place. Finally, mumbling, ‘I . . . I’m so sorry,’ he ran out of the room. With a cool expertise the Fat Man put a gauze compression bandage on the wound. We left.
‘So what did you learn?’ asked Fats. ‘You learned that uremic skin is brittle and that the House Privates stink. What else? What do we have to look out for in this poor bastard now?’
The BMSs ventured several zebras, and Fats told them to shut up. Potts and I went blank.
‘Infection,’ said Chuck. ‘In uremia you gotta watch for infection.’
‘Exactly,’ said Fats. ‘Bacteria City. We’ll culture for everything. If it hadn’t been for Donowitz, that guy would be going home tomorrow. Now, if he lives, it’ll be weeks. And if he knew about this, it would be Malpractice City.’
At this thought the BMSs perked up again. The BMS now comprised a majority of minority groups, and ‘Social Medicine’ was a hot ticket. The BMSs wanted to tell the patient so he could sue.
‘It won’t work,’ said Fats, ‘ ’cause the worse the Private, the better the bedside manner, and the higher the patient’s regard. If a doctor buys the TV illusion of “the doctor,” so does the patient. How can the patient know which are the “Double O” Privates? No way.’
‘“Double O”?’ I asked.
‘Licensed to kill,’ said Fats. ‘Time for lunch. We’ll see from the cultures where Donowitz last stuck his finger before trying to murder that poor uremic schlump.’
The Fat Man was right. Colorful and esoteric bacteria grew out of the wound, including one species that was native only to the rectum of the domestic duck. Fats got excited about this, wanting to publish. ‘The Case of Duck’s Ass Donowitz.’ The patient flirted with death but pulled through. He was discharged a month later, thinking it usual, even a necessary part of his successful course of treatment in the House, for the skin to have been ripped off his arm by his dear and glorious physician.
When the Fat Man went to lunch and we did not, the terror returned. Maxine asked me to write an order for aspirin for Sophie’s headache, and as I started to sign my name, I realized I was responsible for any complications, and I stopped. Had I asked Sophie if she was allergic to aspirin? Nope. I did. She was not. I started to sign the order, and stopped. Aspirin causes ulcers. Did I want to have this poor LOL in NAD bleed out and die from an ulcer? I would wait for the Fat Man and ask him if it was all right. He returned.
‘I’ve got a question for you, Fats.’
‘I’ve got an answer. I’ve always got an answer.’
‘Is it all right to giv
e Sophie two aspirin for her headache?’
Looking at me as if I were from another planet, Fats said, ‘Did you hear what you just asked me?’
‘Yes.’
‘Roy, listen. Mothers give aspirin to babies. You give aspirin to yourself. What is this, anyway?’
‘I guess I’m just afraid to sign my name to the order.’
‘She’s indestructible. Relax. I’m sitting right here, OK?’
He put his feet up on the counter and opened The Wall Street Journal. I wrote the order for the aspirin, and feeling dumb, went to see a gorilla named Zeiss. Forty-two, mean, with bad heart disease, Zeiss needed a new IV put in. I introduced myself, and tried. My hand shook, and in the hot room I got sweaty, and the drops of sweat plopped onto the sterile field. I missed the vein, and Zeiss yelped. The second time, I went in more slowly, and Zeiss squirmed, moaned, and cried out:
‘Help, nurse! Chest pain! Get me my nitroglycerin!’
Terrific, Basch—your first cardiac patient and you are about to give him a heart attack.