Five Patients
Foreword
there has recently been a lot of fool-ish talk about something called "the new medicine." To the extent that it implies a distinction from some form of old medicine, the phrase has no meaning at all. Medicine has crossed no watershed; there has been no triumphant breakthrough, no quantum jump in science or technology or social application.
Yet there is, within medicine itself, a sense that things are different. It is difficult to define, for it is not the consequence of change, but rather the fact of change itself.
The first time I began to look at the Massachusetts General Hospital in the spring of 1969 I had the uneasy feeling there was too much flux, too much instability in the system. I felt a little like an interviewer who has come upon his subject at a bad time. Only later did I realize that there would never be a "good" time, and that change is a constant feature of the hospital environment. The true figurehead of modern medicine is not Hippocrates but Heraclitus.
To trace a history of change, one must go back about fifty years, to the time when organized research began to produce major new scientific and technological advances. Medicine has been revolutionized by those advances, but they have not stopped. Indeed, the pace of change has increased. Within the past ten years, social pressures have been added to those of science and technology, producing a demand for a new concept of medical care, a new ethic of responsibility for the doctor, and a new structuring of institutions to deliver broader and better care.
As a result, medicine has become not a changed profession but a perpetually changing one. There is no longer a sense that one can make a few adjustments and then return to a steady state, for the system will never be stable again. There is nothing permanent except change itself.
From this standpoint, the experiences of five patients in a university teaching hospital are most interesting. It should be stated at once that there is nothing typical about either the patients described here or the hospital in which they were treated. Rather, they are presented because their experiences are indicative of some of the ways medicine is now changing.
These five patients were selected from a larger group of twenty-three, all admitted during the first seven months of 1969. In talking to these patients and their families, I identified myself as a fourth-year medical student writing a book about the hospital. As they are presented here, each patient's name and other identifying characteristics have been changed.
I chose these five from the larger group because I thought their experiences were in some way particularly interesting or relevant. Accordingly, this is a highly selective and personal book, based on the idiosyncratic observation of one medical student wandering around a large institution, sticking his nose into this room or that, talking to some people and watching others and trying to decide what, if anything, it all means.
M.C.
La Jolla, California
November 15, 1969
Acknowledgments
I am greatly indebted to the employees and medical staff of the Massachusetts General Hospital for a kindness and patience that went beyond any reasonable expectation.
I would also like to thank Drs. Robert Ebert, Hermann Lisco, Joseph Gardella, and Mr. Jerome Pollock, all of the Harvard Medical School, for encouragement and advice in planning the book; Drs. Howard Hiatt, Charles Huggins, Hugh Chandler, Ashby Moncure, James Feeney, Joel Alpert, Edward Shapiro, Josef Fisher, Michael Soper, Jerry Grossman, and Miss Kathleen Dwyer for their suggestions at various points in my work; Drs. Alexander Leaf, Martin Nathan, Jonas Salk, and Mr. Martin Bander for their review of the manuscript at different points; Mr. Robert Gottlieb and Miss Lynn Nesbit for ongoing, tireless work on the project; and finally Dr. John Knowles, whose influence is everywhere in this book, as it is in the hospital he directs. With all this help, the book ought to be flawless, and to the extent that it is not, I am to blame.
Acknowledgments
The late Alan Gregg once quoted a former teacher as saying, "Whenever you say anything explicitly to anyone, you also say something else implicitly, namely, that you think you are the guy to say it." Such sentiments trouble all but the most egotistical writers; the others recognize that their sense of enfranchisement is a gift of the people around them, whom they can only hope not to disappoint.
Chapter 1
Ralph Orlando. Now and Then
In the early morning, The Massachusetts General Hospital was notified by Harvard University that some students, at that time occupying a university building in protest of ROTC, might be brought to the hospital for treatment of injuries after their forcible removal from the building. This occurred at 5 a.m., and although some fifty students were reportedly injured, none were brought to the MGH.
At 5:45 in the morning, the last of the emergency-ward residents got to bed, sleeping fully clothed, sprawled on a cot in one of the treatment rooms. Taped on the door to the room was a piece of paper on which he had written his name and "Wake at 6:30." Across the hall in another treatment room, two surgical residents were sleeping; in a third room, one of the interns.
Even without the Harvard students, it had been a busy night. Shortly before midnight, the EW had admitted two college students with pelvic fractures from motorcycle accidents, and both had been taken to surgery; later on, they had also admitted a forty-one-year-old man suffering from a heart attack, an eighty-year-old woman with congestive heart failure, and a thirty-six-year-old alcoholic with acute pancreatitis. An elderly man with meta-static carcinoma and renal failure had died at 3 a.m.
There had also been the usual number of patients with sore throats, coughs, abrasions, lacerations, foreign bodies inhaled or swallowed, bruises, concussions, dislocated shoulders, earaches, headaches, stomachaches, backaches, fractures, sprains, chest pains, and breathing difficulties.
At 6:30, some of the junior residents and interns were up, doing lab studies and checking on the patients who had been admitted for observation to the overnight ward, adjacent to the emergency ward. The ONW limited patients to a three-day stay; it was designed for patients who required a period of observation longer than a few hours, such as those with suspected gastrointestinal bleeding or those with severe concussions. However, in practice it was also used for patients who were severely ill but could not get a bed at the time they arrived, because the hospital was full.
At 7 a.m., surgical rounds were made in the ONW. Six patients were discussed during half an hour, but most of the time was given over to a fifty-four-year-old woman with a recurrence of bleeding ulcer. This was her second day in the hospital and her condition was now stable; she had received five units of blood the day before. Normally she would not be a surgical candidate, but on two previous admissions she had shown the same pattern of massive, unexpected bleeding, followed by stabilization in the hospital after transfusion. The residents were afraid that if this happened again, she might bleed to death before she got to the hospital.
The emergency-ward residents attended these rounds, for in the early morning the EW is least busy. A short distance away, however, the acute psychiatric service was in full swing. The APS always gets a group of patients in the morning; they are the people who, for one reason or another, have not been able to sleep the previous night.
In one of four interview rooms in the APS, a nineteen-year-old girl, separated from her husband, chain-smoked as she described her unsuccessful attempts to kill her three-year-old daughter: first by hanging, then by suffocation with a pillow, and finally by gas asphyxiation. She explained that she wanted to stop the child from crying; the crying was driving her crazy. She came to the APS, she said, because "I wanted to talk to somebody. I mean, it's not natural, is it? It's not natural-a kid that keeps crying that way."
In another room, a forty-year-old accountant was running down a list of eight reasons why he had to divorce his wife. He had written out the list so he would be sure to remember everything when he talked to the doctor.
In a third room, a college student living on Beacon Hill explained that she was depressed and troubled by a recurrent sensation that came to her during parties. She said she would have the impression that she was invisible and that she was watching the party from across the room, from a different viewpoint. She had attempted suicide two days before by swallowing a bottle of aspirin tablets, but she had vomited them up.
In the fourth room, a husky fifty-one-year-old construction worker discussed his fear that he was going to die suddenly. He knew the fear was groundless but he could not shake it, and his work was suffering, since he was afraid to exert himself and lift heavy objects. He was also bothered by sleeplessness, irritability, and bad headaches. On questioning it developed that his father had died of a stroke almost exactly six years before; the patient remembered his father as "a cold fish that I never liked."
In the lobby of the APS were three other people waiting to talk to the psychiatrists. One woman was crying softly; another stared vacantly out the window. A middle-aged man in a tuxedo and ruffled shirt smiled reassuringly at everyone else in the room.
At 8:30 in the morning, a sixty-year-old widow arrived in the EW and asked to have a doctor remove her hangnail. The administrators at the front desk shrugged and told her it would cost her fourteen dollars. She insisted it was sufficiently important to warrant the expense. But the triage officer flatly refused to do it and told her to cut it herself. Unsatisfied, she wandered around for another fifteen minutes until she finally cornered a resident. She linked her arm in his and demanded that, since he was such a nice young doctor, he please cut her hangnail. He did; she was billed.
Twenty minutes later, a thirty-five-year-old housewife was brought in by the police after she had collapsed in a subway station and suffered an epileptic fit. Soon thereafter, a desperately ill elderly man with disseminated colonic cancer was transferred in from a nursing home. He had a cardiac arrest in the emergency ward and died shortly before noon.
An eighteen-month-old infant with a skin rash was brought in by his mother at noon. The mother wanted to know if it was German measles; she was pregnant and had never contracted the disease. A diagnosis of German measles was made, but the mother, in her sixth month of pregnancy, was reassured that there was no danger to her.
At approximately the same time, an eighteen-year-old secretary arrived, accompanied by the head of personnel at the office where she worked. The girl had reportedly collapsed after lunch. At the time of her arrival she was conscious, but unwilling or unable to speak. She was placed under observation in a room where she lay curled up in bed, burrowing her head beneath the sheets. Medically, she appeared sound, and a psychiatrist was called. He diagnosed an acute psychotic break. By then, her family and some fellow workers had arrived. All regarded the episode as shocking in its suddenness and repeated the observation that she had never acted unusually in the past. The psychiatrist came away shaking his head.
By 1 p.m., a man with a deep laceration of his index finger had arrived; also a woman with a sore throat; another man with a dislocated finger (a taxi door had slammed on his hand); and an eight-year-old boy brought in by his mother. The child had fallen from his bicycle that morning and struck his head. The mother didn't know whether he had been unconscious or not, but she thought he was acting oddly, and noted that he had refused to eat lunch.
No patients more seriously ill arrived, and the atmosphere in the emergency ward during the afternoon was relaxed. The residents took the chance to take it easy, drink coffee in the doctors' room, and catch up on reports in the charts they had to write.
At 3:40, the atmosphere abruptly changed. The hospital's station at Logan Airport called to report that there had been an accident: a dozen construction workers had been injured and were on their way in police cars and ambulances. At least two of the injured were going to Boston City Hospital; as many as ten might come to the MGH. The extent of injuries was not known, but some might be very severe.
The emergency-ward administrator put out a disaster call, notifying the chiefs of all departments of the impending emergency and its nature. The chiefs in turn arranged for mobilization of all available hospital personnel from other wards. In a matter of minutes, interns, residents, and senior men began to appear in the EW. The nurses and staff were already clearing patients out of the treatment rooms; the corridors were cleared and supply carts checked. Privately, everyone agreed that it was fortunate the day had been a slow one, for there was practically no back-up.
Emergency-ward personnel are always concerned about back-up. The emergency ward is geared to treat a new patient every eight minutes, around the clock; the staff is prepared to admit to the hospital one out of every five of these emergency patients, or a new admission every forty minutes. This is a furious pace, but it is standard procedure for the hospital. And although patient flow through the EW is generally smooth, there is almost always a back-up. At any time-and this day was an exception-the emergency ward may have three to ten people in the lobby waiting to be seen; another six to ten in the various treatment rooms; another four or five in the back room waiting for X rays, orthopedic examinations, or sutures of minor lacerations. This is the back-up, and the residents keep an eye on it; when it begins to swell, everyone worries, because there is no way to predict when there will be a six-car automobile crash, or a fire, or some other disaster that will strain the hospital's facilities for emergency care.
It is a little like trying to direct traffic without ever knowing when rush hour will occur.
The first patient from Logan Airport to arrive was Thomas Savio, a twenty-seven-year-old bearded construction worker. He arrived in a state police ambulance and was wheeled in wrapped in a gray wool blanket. He was shivering and had severe facial lacerations.
"There's a worse one coming," one of the troopers said. Moments later, John Conamente arrived, groaning. As his stretcher came through the door, one of the residents asked him what hurt. He said it was his shoulder and his leg. Conamente was followed by Albert Sorono, also on a stretcher, complaining of severe pain in his chest and difficulty in breathing.