Bellevue Diary

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Contents

Fred....................................................xBellevue Hospital.......................................2The Room................................................4Doubts..................................................5The Chest Service.......................................8FUO.....................................................8Double Jeopardy.........................................13The Gift................................................14Good Offense, Bad Defense...............................17Tobacco's Addictive Grip................................18The Social Order........................................19Left Breast Coat Pocket.................................19The Dining Room.........................................20A Journey Not Kept......................................21Peking Duck.............................................22Doubts..................................................26A-3.....................................................27Night Sounds............................................28The Touch...............................................29Emergency Room Baptism..................................30No Problem, Big Problem.................................31Checks and Balances.....................................33Mine or Theirs..........................................34VIP Rounds..............................................35Schwarzewolke...........................................36Not My Job..............................................37Fecal Impaction.........................................38Goya versus El Greco....................................40Everybody Knows.........................................41Biggest Show in Town....................................42Coming Home.............................................43Oy, Oy, My Heart........................................45Bells Unrung............................................46A Circus Team...........................................47Hubris..................................................49Sugar-Coated Bagel......................................52My Lady.................................................54Female Medical Clinic...................................56A Grand Event...........................................57When Breath Permits.....................................57Night Becomes Morning...................................58Matthew Greene..........................................62Unanswered Question.....................................63The Front Porch.........................................65Wrong Direction.........................................66Here, Kitty, Kitty......................................67Proximity's Price.......................................68Mother by Necessity.....................................69Second Thoughts.........................................70Chutzpah................................................71Crashing the Gate.......................................72Little Words............................................74Sooner..................................................78New Year's Eve..........................................80A Different Bed.........................................81Miss PanAm..............................................82The Cup.................................................84Snow....................................................85A Drop of Truth.........................................87Reflections of the Father...............................88Not Bricks..............................................90Ashes to Ashes..........................................91A Matter of Pennies.....................................91Score: Country One......................................94Barton & Sons...........................................95Mayhem..................................................96Bellevue Nurses.........................................99Moses...................................................100The Rock................................................104That's It...............................................106The Ugliest Man in the World............................109Sunday Morning..........................................113The Poem................................................115

Chapter One

In 1736, Bellevue Hospital, the oldest public hospital in the United States, was founded. At the time, George Washington may have been four or five years old.

Following a fire that occurred sometime around the turn of the century, between 1906 and 1939 Bellevue was rebuilt in bits and pieces. She now shows her age: a conglomerate of brick buildings stretching along First Avenue from Twenty-Fifth Street to Thirtieth Street. The one architectural element that gives her an illusion of grandeur is the Administrative Building, which faces First Avenue. Its strong, vertical, inlaid concrete columns take one's gaze upward to a pseudo-Athenian temple facade that towers two stories above the adjacent roofs.

What makes Bellevue great is that she is the hospital from which "no one is turned away." She is an open-ended funnel into which New York dumps its poor, elderly, and dying. If an individual presents at another hospital for admission and it is apparent that he or she will demand a disproportionate amount of care, the admitting physician has only to write "No beds" and the patient is Bellevue-bound.

Competition for internships at Bellevue Hospital is intense. Its 2,500 patient beds are the medical equivalent of what was once the great library at Alexandria. Within each bed, a potential lesson waits—a lesson in which knowledge is exchanged for a dose of healing. Educationally, big-city hospitals are the Harvards of the medical world, and, as at Harvard, learning can come at a steep price.

The Medical and Chest Services are divided between three medical schools: Columbia University (since 1888), Cornell University (since 1888) and New York University (since 1898). Each institution has imparted to its house staff a unique profile. The Cornell interns and residents are dubbed the "All-American boys." By and large, they tend to be clean-cut and have the distinction of having been elected by their respective school faculties to the national honorary society, Alpha Omega Alpha (AOA). The New York University interns and residents emphasize academic brilliance over decorum and appearance. The Columbia interns and residents are called "the aristocrats of Bellevue." The latter image is largely fashioned by the predominance of Columbia graduates among its house staff. They are New York's response to the proper Bostonians.

My reasons for wanting to be part of the Columbia Medical Service had to do with something else. The Columbia Medical Service at Bellevue had produced more academicians than even the Thorndike Service at Boston City Hospital. In the 1950s, a Nobel Prize in Medicine had been awarded to its director and his collaborators for pioneering research in the area of pulmonary physiology. What I did not know when making my selections for the National Internship Matching Program was that his retirement was imminent.

The Chief of Service's replacement seemed a strange choice: an uptown physician whose patients had, more likely than not, frequented Harkness Pavilion at Presbyterian Hospital. At Bellevue, the patients, more often than not, called the Bowery home.

Despite having graduated in the top ten of my class and having very strong letters of recommendation, the absence of my election to the national honorary medical society should have raised a red flag. My election to Alpha Omega Alpha had been blackballed by two professors.

The Room

The house staff rooms are located on the fifth and sixth floors of the Administration Building. Five cartons of medical books and two suitcases of clothes quickly teach me that, at Bellevue, the elevators are more symbolic than functional.

Tired from carrying the last load of books up five sets of stairs, I quickly turn the key, push the metal door open, and begin carrying the items stacked outside the door into the room.

The light filters through the dingy, double-hung window that opens onto a ventilation court. The room is ten by twelve feet, if that. Immediately to my right is a built-in closet that can be opened only if the door is closed, giving the remaining room a nine-by-ten-foot configuration. A simple metal desk and chair, a metal bed, a sink, a two-by-three-foot mirror, a sixty-watt bulb on the ceiling, and a telephone compete for the remaining space.

Before unpacking, I start cleaning away the debris left by its former occupant: detached front covers of medical journals and loose sheets of notes written in a tight, careful scrawl. The dust on the desk and windowsill outlines where other books had been.

The single central desk drawer jams for a second time. With difficulty, I extract a small wad of paper that had been wedged in the drawer. In a scrawl I already know is written:

When you come into contact with a man, no matter who, do not attempt an objective appreciation of him according to his worth and dignity. Do not consider his bad will, his narrow understanding or perverse ideas, as the former may easily lead you to hate him or the latter to despise him; but fix your attention on his suffering, his need, his anxieties, his pain. Then, you will ...

The rest had been torn off.

Doubts

It's dark. I lie fully clothed, motionless on the bed. The outlines of the room's furnishings are barely visible in the reflected light coming through the window.

A little over three weeks ago, I was a medical student, with little true responsibility for patient care. The ultimate decision had always been someone else's. Tomorrow morning, that will all change. I will put on white pants, a white shirt, and a white jacket. To patients, the resultant vision is an illusion suggesting some sort of immaculate conception. They rarely see the very prominent feet of clay.

The lack of sleep last night loses its foundation. At the meeting for the new house officers that day, the piece of paper with my name on it states that my medical internship is to start in Siberia, otherwise known as the Chest Service. My adrenal rush fades.

Chapter Two

The Chest Service is the relatively recent name given to what had previously been known as the tuberculosis wards for the city of New York; now, in 1961, tobacco's gifts to the human race have changed the character of its occupancy list. Looking forward to repetitive encounters with tuberculosis, lung cancer, and chronic bronchitis and emphysema is not my idea of happiness.

What makes starting out on the Chest Service a really bad deal is that an internship in the Columbia Medical Division is part of a pyramid system in which there is no guarantee of a tomorrow. Twelve interns are selected annually for the Columbia Medical Service. At year's end, only six will be offered a first-year residency position. When I rotate off the Chest Service and into the Columbia Medical Service, my performance will be judged primarily against former Columbia students, who will have already had three months of relevant experience on the medical wards.

FUO

Twenty charts are mine to review. By tomorrow morning, an on-service note summarizing the key medical problems needs to be in place in each chart. At chart nineteen, repetition's monotony is interrupted.

Stephano Fassio is a twenty-nine-year-old Sicilian cook, who for the past two and a half months has been running fevers of unknown origin (FUO) between 102 and 104 degrees. His body has literally melted from 198 pounds to an emaciated-looking 145 pounds. His condition has already made him the centerpiece of medical grand rounds uptown, both at New York and Presbyterian Hospitals. Despite extensive scrutiny, his diagnosis remains unchanged: fever of unknown etiology. The chart makes fascinating reading, until I reach the previous resident's off-service note, which states that Stephano Fassio is to be transferred to the Columbia Medical Service in preparation for presentation to a visiting professor at the next medical grand rounds.

Stephano Fassio is the jewel in the package of charts assigned to me. I raise a masssive storm of discontent with the Chest Service's chief resident. He brokers a compromise. Stephano Fassio's transfer will be delayed until just before grand rounds, provided that everything possible is done to find out what is slowly killing him.

My on-service note covers five single-spaced pages. In exchange, Stephano Fassio stays.

All his medical information is based on the initial patient interview. The problem is that Stephano Fassio does not speak English. His story had been obtained using an Italian interpreter. Stephano Fassio is Sicilian. Italian and Sicilian do not necessarily mesh.

That night I walk down to a bar in Little Italy. The address was given to me by one of Bellevue's security guards with connections.

"Where can I find a Sicilian who ..." receives an initial blank stare from the bartender.

"Get the fucking ..." has just enough time to escape his lips when a deep baritone voice asks, "What do you want a Sicilian for?"

The body language of the two guys at the bar tells me that I am treading in deep water.

I now face a man who is dressed in an elegant three-piece black suit with thin blue stripes—a marked contrast to my jeans and sweater. Surprisingly, the man appears to have been listening carefully. His penetrating gaze is answered, but probably not for the same reason.

I tell him the story of Stephano Fassio rather quickly. I hand the man a card with my name, the chief resident's name, the attending physician's name, the hospital's address, the telephone numbers, and, lastly, Stephano Fassio's name.

The man asks if I want a drink. I respond that all I want is an interpreter. Looking at the now-interested observers who have edged closer, all I probably really want is out.

On the walk back to Bellevue, I console myself. At least I tried. Back to plan number two.

Plan number two is trying every conceivable unused diagnostic procedure. In one of my medical books, I had read that patients with retroperitoneal lymphomas, when given a substantial amount of alcohol, often experience abdominal pain. The next day, I am dealing with a completely smashed Stephano Fassio, singing at the top of his lungs while trying to dance with a nurse's aide, who is trying, without much success, to get him back to bed. The book never stated how much alcohol was required. There is going to be hell to pay for this fiasco.

Before I can act, the ward nurse interrupts me. "I've been looking for you. There is someone here to see you."

I follow her out into the corridor. Seated on a straight- backed green metal chair is a slender girl, probably fifteen to sixteen years old, in a high-collared pink and white cotton dress. The man from the bar stands next to her.

With hesitation, she slowly gets up. She takes two steps; her hand extends forward as if in slow motion. In it is the card. "I'm Sicilian." Her voice is barely audible.

Unconscious, stroked out, or senile, speaking Yiddish, Chinese, Spanish, Hungarian, or God knows what, Bellevue's unique clientele rolls through its doors, challenging you to figure out on your own what is real and not real. A famous physician named William Osler once said, "Let me take the history and let anyone else do the physical examination, and I will give you the diagnosis in 80 percent of the cases." The language barrier disappeared as Stephano Fassio told her the story of his disease; and then she told it to me.

Three hours later, a probable diagnosis is in place. Diagnostic tests are ordered. When finished, the Chest Service's chief resident's phone rings.

Three days to get past "go." I am excited. The next day, I can't wait to get out of clinic and check to see if any of the tests are back. When I get to the ward, Stephano Fassio's bed is empty. The freshly pressed sheets announce that he is not returning. The chief resident of Medical Services for the Columbia Division had used his leverage to have Stephano transferred. With a VIP visiting professor, the Division is taking no chances on a subpar presentation by a new, untried intern.

If the Chest Service's chief resident is pissed, he hides his emotions well. "If it's any consolation, they were impressed with your workup," he says in a consoling tone. "It got us two possible concessions."

There is no missing the use of the word us.

"Firstly, you may or may not be asked to comment before the visiting professor dissects the case, and ..." And then comes a long pause. "Oh, yes. If by any chance we establish the diagnosis, Fassio comes back to the Chest Service." The smile at the corner of his lips says it all.

As I start to get up, the chief resident of the Chest Service hands me a familiar piece of paper. "By the way, the last page of Stephano's chart appears to have been misplaced. Give this to the ward secretary and have her forward it to First Division."

Given the internal inefficiencies inherent in the system, that piece of paper will not be reunited with its chart anytime in the near future.

Two days of data preparation are just that. The night before an ego battle is to be waged for possession of Stephano Fassio, we slowly consume two cups of the best Turkish coffee that $1.35 can buy.

First Division's monthly medical grand rounds are a big deal. The auditorium is filled to standing-room capacity.

The First Division's chief resident gives a very comprehensive, detailed presentation, followed by a lengthy summary of all the previous medical discussions.

Finally, the prayed-for misstep occurs. "Does the Chest Service have anything to add?"

As rehearsed, the Chest Service chief resident motions for Stephano Fassio to be wheeled in. Once in place, Stephano Fassio's previously untold story of muscle and joint pain is presented. His subdued cry of discomfort when his triceps and calf muscle groups are compressed speaks to the veracity of diagnosis. Then come photomicrographs from the skin-muscle-nerve biopsy, slides of the electromyelogram, and, finally, the reading of an unofficial consultation from one of the NYU's rheumatologists.

Without discussion, fever of unknown origin becomes fever of known origin. Stephano Fassio has polymyocytis, an inflammatory disease of the muscles and joints.

For what is probably just a few seconds, nothing. Finally, the squeak-squeak of the wooden wheelchair breaks the auditorium's silence as Stephano Fassio is pushed home to the Chest Service.

Double Jeopardy

The previously hot political frying pan got hotter.

The new director of the Columbia Medical Division has made a reputation in the field of rheumatology with the use of corticosteroids, drugs that reduce inflammation. When the order that steroids are to be used is transmitted down the chain of command, another brief firestorm breaks out.

Stephano's chart contains two instances in which his temperature had precipitously dropped to normal and stayed there for approximately four to five hours. In each case, he had been given a single aspirin. Large doses of antipyretics had produced only a partial response. When the final push of authority is applied, Stephano Fassio goes to First Division, but not until he has been without fever following twenty-eight hours on a regimen of one adult aspirin every four hours.

He does great on low-dose aspirin. Two months later, I am asked to write, as the coauthor, a draft of Treatment of Polymyocytis with Low-Dose Aspirin, which is to be my first academic publication.

Only after everything is really over does reality creep into my consciousness. Victories leave behind the vanquished, who do not necessarily forget and perhaps don't forgive.

The Gift

My junior-year medical school roommate gave me the gift of assassination with two-by-two slides.

After five generations, John was the first of his family to have escaped the Welsh coal mines. Despite his talent and brains, he was nearly relegated to spending his entire life in the mines. When he won a scholarship to a university, he almost did not take it. His family was not in a good position to lose the money he was making in the mines.

At the university, John became a star swimmer. In time, he made the 1950 British Olympic team as an alternate. There, he met the Yale University swimming coach, who brought him to the United States.

Not having completed his degree in England, he needed to get a degree if he was to become a head swimming coach. At Springfield College, he found that his interest had gone beyond sports. As a junior, he applied to Harvard. They turned him down, but Boston University did not.

(Continues...)

Excerpted from Bellevue Diaryby Gilles Monif Copyright © 2011 by Gilles Monif. 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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