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M-81

iUniverse, Inc.

Chapter One

At six forty-five a.m., the air was already warming. Virginia's summers are usually uncomfortably hot, sticky, and humid, especially in the city. This July Monday in Richmond was no exception. Obie Hardy crossed the intersection as the light turned green and turned into the McGuire Veterans Hospital entrance. He drove slower than the other vehicles entering the hospital complex because he was searching for the parking area designated for medical students. The frequent speed bumps were welcomed, helping conceal his unfamiliarity by forcing him to slow down. After three-quarters of a lap around the complex, he found what he believed to be the appropriate lot and parked his gray-blue Chevette. He gathered his equipment that he had assembled, trying to anticipate any possible need that could arise, since this was to be his first experience at taking care of patients. He donned his white jacket—essentially a short-sleeved, snapup, smock-like garment he felt was more fitting for a dentist than a physician. Most medical students wore this type of jacket, probably because they were the cheapest and lightweight, and all their pocket references and medical instruments could be carried easily. Obie liked these jackets because they were cool cotton and unpretentious, not wishing to create an image he could not live up to. Outfitted in his jacket, pockets full of paraphernalia, and black bag in hand, he walked up the sidewalk to the Veterans Hospital, Ward 63, Psychiatry.

The McGuire Veterans Administration Hospital, VAH, was typical of the 1940's style government buildings. It could easily have been a post office or high school by appearance; only its overall size implied a greater function. The complex was largely one-story passages connecting two story wards, sometimes fifty yards apart. The buildings spanned lengths of up to half a mile. The ward entrances had cement steps and stoops with waist-high brick walls. The brick exterior had symmetrically positioned, multi-paned windows, wood-framed, with no screens. The institution spread out over about a hundred and fifty acres, including grounds and parking lots.

Obie turned right upon entering and saw John Morgan, a classmate, standing down the hall—a familiar face that might sedate the butterflies in his stomach. John was short, about five feet, seven inches, with short brown hair and a thick mustache. His white jacket was standard medical student uniform. He stood in an almost bowlegged stance, shifting weight from one foot to the other repeatedly.

"Hardy!" he chirped out. "This is the place!" Obie smiled and walked toward him. The floor was white tile with a waxy shine, the walls pale yellow. "Are you on this rotation or here as a patient?"

"I'm not sure," answered Obie. "This is quite a maze of buildings!"

"Yeah. They spread it out like this so that one bomb couldn't take out the entire hospital," John explained. His Blue Ridge Mountain accent gave his explanation a common sense, simple, earthy flavor. He was anxious to get to know Obie. They had been in the same classrooms for two years with 166 other medical students. Since John sat up front and Obie in the back, they hadn't become much more than acquaintances. Different study groups and social patterns had kept them distant. "Put your stuff in the lecture room here," he offered.

The third student, Cheryl Wright, was waiting in the lecture room already. There were a dozen metal, table-like desks with Formica tops in the room, each with a matching chair. A slate blackboard and bulletin board completed the classroom image. Classrooms were familiar to medical students after four years of college and two years of medical science lectures. But now, this was merely a briefing room for them; the real learning was to take place on the wards with real patients. Live human beings would replace the textbook concepts, lecture descriptions, color-slide pathophysiologic images, and therapeutics that comprised their medical education so far.

The attending ward psychiatrist arrived shortly to orient and brief the students. She was a middle-aged woman with graying, dirty blonde hair and a pleasant face, calm and unwrinkled. A motherly radiance emanated from Dr. Andrea Blanton. She outlined the schedule for the six-week rotation, including the drug detoxification unit, outpatient clinic, emergency night call, and the inpatient ward. "Feel free to come by my office and talk any time, especially if you have any problems during this rotation. Now I'd like to introduce Dr. Carl Anderson, our second year resident. He'll work closely with you on Ward 63." She beamed at Dr. Anderson and the students, and then faded out of the room, rarely to be seen again during the rotation.

Dr. Anderson was a tall, average-built young man in his late twenties. He had straight, sandy hair and somewhat retracted lower teeth, so that it seemed saliva would drool from the corners of his mouth if he wasn't careful when speaking. With himself, he was fairly secure, but in charge of instructing medical students in psychiatry, he was somewhat unsettled. Each student would take turns doing admission histories and physicals, dictations, and writing orders on the veterans admitted to Ward 63. He would supervise the process and be in charge of morning rounds each day. Since it was Monday (they soon discovered psychiatrists don't work weekends), there were already admissions waiting. He wrote three names and bed numbers on the blackboard and scampered off.

So that's it? thought Obie. No swimming lessons, life jackets, or kickboards? Jump in and sink or swim! He tried to picture Dr. Anderson seated on a lifeguard stand with sunglasses, a whistle, and zinc oxide on his nose. No way. He picked up his black bag, wrote down "Leroy King - 20B" on his clipboard, and walked out to the nurses' station to review his patient's chart. The admission sheet supplied the demographics: age, fifty-seven years; race, black; address, Greenville, SC; diagnosis-________. "What? No diagnosis?" He quickly flipped through the pages of the rest of the chart, all blank.

He walked down the hallway to the ward area, a large open room like a warehouse. There was a wide passage down the center with a four foot-high partitioning walls running left and right to meet the exterior walls, dividing the ward into four sections on each side, each with six beds. The second section to the right, second bed, was 20B. Mr. King's bed was empty, but Mr. King had spotted Obie from the lounge area at the end of the ward and came walking up behind him.

"Mr. King?" Obie inquired.

"Why sure, doctor. Why sure," he answered. He was a short, black man with droopy eyelids and a large grin.

"I'm the medical student who will be working with you. My name is Hardy."

"Why sure. I'm Leroy King."

"I need to talk with you and do a complete physical exam. Can you tell me why you're here?"

"Why sure. I'm depressed." He smiled cooperatively. "It happens to me a lot, 'specially after I been drinking."

"How does it bother you?"

"Voices. I hear voices. They says I'm no good ... oughta be dead."

The questioning continued for thirty minutes with little further information exchanged. Mr. King didn't know if his family had any health problems. Possibly he had a reactive skin test for tuberculosis, TB, some years back and he had a morning cough that he attributed to smoking two packs of Marlboros a day.

Each medical specialty has its own specific patient examination routine. Medical students learning to perform physical exams are taught the entire cardiac exam, urogenital exam, connective tissue exam, orthopedic exam, and so forth. Unsurprisingly, students often spend one and a half hours completing a routine physical examination, not knowing which short cuts to take, fearful of missing a diagnostic clue. Obie did a thorough exam and tried to justify in his mind skipping the undesirable rectal exam—without success. It is part of the gastrointestinal exam. He had been taught that there are only two instances where a rectal exam may be excluded: 1- when the patient has no asshole; or 2- when the doctor has no fingers. Mr. King was pleasant and quite cooperative; it shouldn't be too difficult. Obie turned his back to Mr. King, reaching into his black bag for a rubber glove and KY lubricant.

"Well," he said, "we're almost done. We just need to put a finger up in your rectum, and we'll be done."

"Why sure, doctor. Why sure."

He turned to face Mr. King, and found him fully cooperative, with his own index finger placed in his rectum!

Cheryl Wright was in the briefing room when Obie returned to write up his notes. She was an attractive girl with long, straight light brown hair. She was obviously upset, her face flushed and eyes glaring.

"What happened, Cheryl?" asked Obie.

"Mr. Satterwhite in room six," she fumed forth. "Bipolar affective disorder ... First, he called me 'nurse' saying, 'How about a date sometime, nurse?'; and, 'I like white women, nurse.' I discussed the case with Dr. Anderson, and he told me to draw a lithium level on him. So I go to this semi-private room, and this six-foot-tall, 230 pound black man is fondling his genitals through his gown. I tell him that I needed a blood sample. He stands up, pulls up his gown, and says, 'I got a vein you can sample, nurse!'"

Obie laughed, and his feelings of uncertainty about his own patient dissipated some. John came in with a chart under his arm and his black bag in hand. "Hi, guys!" he chirped as he walked over to the shelf-like counter that ran along one wall of the room. "They start us hopping right off, don't they?" They affirmed his remark, and he methodically turned to a specific area in the chart and began writing. "Have you done any of your dictations yet? No? Well, the directions are listed by the phone here. You can stop and hold, reverse, edit, or whatever. It goes kind of slow at first." At this, he lifted the phone receiver, dialed some numbers, and began reciting smoothly and briskly. "This is John Morgan, M-81, dictating for Dr. Carl Anderson. Admission history and physical on patient Steven Gardner, patient number 922-17-6505, admitted 7-16-79, Ward 63. Mr. Gardner is a forty-eight-year-old black male paranoid schizophrenic who was well until three weeks prior to admission when ..."

Cheryl and Obie looked at one another and then at John, almost bewildered. Their task of appearing as competent medical students would certainly be more difficult now. The sink-or swim-image returned to Obie, but now he was splashing about in the water as John sped by in a motorboat, the waves of the wake splashing upon Obie's face. Cheryl leaned toward Obie, having regained her composure now, and said, "I'd like to draw a lithium level on him!"

"Why sure, nurse. Why sure," answered Obie.

Obie found Dr. Anderson in Dr. Blanton's office (Dr. Blanton was not in) and suggested that Dr. Anderson examine Mr. King. Obie explained, "I've only done four physical exams before today, and I'm not sure about some things. I think Mr. King's liver is enlarged, and I'm not sure about ..."

"Just write down what you find. I'll co-sign it. Look through his old chart and restart his regular medications. If you have anymore questions, order a medicine consult. I'll sign your orders." Dr. Anderson smiled at him, patted him on the shoulder, and said, "Thanks, bud!"

Obie wandered back to the nurses' station, trying to organize his thoughts and develop a plan of care for his patient. He was apparently on his own; it was up to him to arrange this patient's hospital care. He asked a nurse for the old chart and sat down to decipher it. Incredible! Why hadn't he looked for the old chart before? Up front was a typed synopsis of Mr. King's last admission, a "discharge summary." A plethora of information was there ... medications, diagnoses, blood chemistries, X-rays, and more. He had been on several drugs for TB, recommended for a one-year period. He had used an inhaler for his lungs during episodes of colds and was on an anti-depressant. Now Obie easily formulated an admission note and orders, guided by the patient's past management. He doubted Mr. King completed his twelve-month course of TB drugs, but he was concerned about his possible liver enlargement and chose not to reorder these medicines. He could always start them the next day.

Dictating the admission history and physical exam, or H&P, was awkward and took three takes or editings. Now it was late afternoon and, after clearing it with Dr. Anderson, Obie left for home.

Obie arrived at seven thirty Tuesday morning so he could see his patient before eight o'clock rounds. John was in the students' room already, writing in one of three charts he had on the counter. He grinned at Obie, eyes sparkling too brightly for that morning hour, and lifted a Styrofoam cup of black coffee.

"Good morning," he said, "checking the patients' charts before rounds, too, huh?"

"Yeah," replied Obie as he deposited his black bag and books on a desktop. In the nurses' station, he found Mr. King's chart and noted how it looked like a "real" patient chart. There were vital signs, nurses' notes, physician's orders, and lab reports on the pages. The chemistries were reported as bar graphs—as well as numerically—and the liver enzyme graphs were off the top of the page. Obie was pleased that he had not written for the TB drugs and noted that the medical consultant had ordered some sputum cultures, vitamins, and an arterial blood gas. He spoke briefly with Mr. King, who was preparing to go shower, and reported for rounds.

Morning rounds were made by Dr. Blanton, the attending physician, accompanied by Dr. Anderson, the medical students, the head nurse, and the psychologist ... quite a crowd. Dr. Anderson had three-by-five index cards on each of the thirty-two patients, imprinted on one end with their nameplates, which were the blue hospital cards with their names and data in raised letters. His brief notes were written underneath this. The group started in the ward, moved down the hall with the six semi-private rooms and communal bathroom, and circled the ward at the opposite end of the hall, filled mostly by patients on the neurology service. The students gave awkward, fumbling presentations of their admissions. John introduced Oscar Smithfield, admitted for decompensation of his paranoid schizophrenia. Several bedsides later, Obie presented Leroy King's case, since his bed was empty at the time. Again, John reported on George Harville, senile dementia awaiting placement in a long-term care facility, i.e. nursing home. Dr. Anderson summarized all the patients in between. Cheryl explained Marvin Satterwhite's problems, bipolar affective—also known as manic-depressive—disorder whose lithium level had fallen to three, subtherapeutic. His dose had been raised, and he would be observed for resolution of his manic behavior. John's third patient was a bizarre man, Jerome Olsen, who was neurotic. He had obsessive-compulsive behaviors and was recently fired and divorced. He shared a semi-private room with an unfortunate patient, Roger Mills. Mr. Mills was a paranoid schizophrenic who became disturbed by any breaks in the routine. He feared that every change was somehow threatening, especially with his new roommate, Mr. Olsen.

"Please, doctor," pleaded Mr. Mills to Dr. Anderson. "Help me!" He was a thin, small white man, middle-aged and unshaven. His eyes appeared desperate, as did his tone.

"Everything will be fine soon," assured Dr. Anderson.

"But ... he says he's going to burn up the room!" Mr. Mills said, pointing to Olsen. Mr. Olsen was a black man in his mid-twenties—cool and unshaken. He grinned and shook his head in apparent pity over Mr. Mills's misconceptions. He placed a cigarette in his mouth and, when lighting his lighter, was interrupted by Dr. Anderson.

"Please, Mr. Olsen, we only allow smoking in the lounge."

"Oh. Okay, no problem," he answered and walked off down the hall.

"We've caught him smoking in the room several times," reported the head nurse to Dr. Anderson.

"Well, let's see if this has helped," answered Anderson. As the team moved out of the room, Obie looked back at the frightened Mr. Mills. He was sitting on his bed, but, underneath the springs, a mass of crumpled newspapers had been shoved.

(Continues...)

Excerpted from M-81by Willoughby S. Hundley III Copyright © 2011 by Willoughby S. Hundley III, MD. Excerpted by permission of iUniverse, Inc.. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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