Hospital politics: the infamous memo. Part three

Where was I? Something about trauma centers....

So this Level Two thing was occurring at a time when the hospital was in a major funk. Nurses, as I said, were feeling lousy. Care was spotty, despite the presence of a bunch of the best nurses I'd known: they were overwhelmed with work, frustrated by lack of support. And despite this, because of the combination of sustained growth in our area, and the recent converting of many of the beds in the former competition to long-term care, the hospital was jam-packed much of the time. Having made commitments to using those beds across town for other purposes, and still running deficits, locked into an old building, the options for increasing bed space were few. And weren't happening. The ER (soon to become a high-level joint, evidently) was not rarely on "diversion," meaning the medics were told not to bring in new patients because there were no beds in which to put them. Elective operations were occasionally cancelled. Postoperative patients were sometimes kept in the recovery room for hours or overnight because there was no place to send them. Patients who might have otherwise gone to the ICU (intensive care unit) were kept there as well, for the same reasons. So among the least important issues for administration was attracting more patients. Patients, they had up the wazoo.

One more piece of the puzzle: trauma is, mostly, a money-loser for hospitals. Following a rule mentioned in a book I recommend, trauma happens to people who are asking for it (more of a county hospital rule, actually, but still...), meaning they have no insurance and governments don't pay well for them. Off the top of the head, it wouldn't seem like a desirable thing for a hospital already hurting financially. And this: whereas trauma is the lifeblood of surgical training, and something people in surgical training love, for most surgeons in busy practice (which describes all the town docs, clinic or not), it's not always welcome. If it happens in the night, it means you face the next day's schedule tired; if during the day, it throws already-busy schedules into chaos. Because unlike training (as described in a particular book), where the trauma service hangs around waiting to receive the next case, in practice you have a million other things to do. So the idea of doing more trauma, and having, on the days you were the designated trauma doc, basically to write off the whole day so as to be available by the rules of Level Two, was received -- let's see -- unenthusiastically. The anesthesia docs were similarly hypo-ebullient. Unlike any other issue including what time it was, on this everyone agreed, across all party lines.

Seeing danger down the road if its reputation didn't improve (several smaller hospitals line the periphery of the area, and they were salivating), the hospital embarked on an all-out effort to...... market itself. Not address care issues (OK, it's not as if they were totally unaware or making no attempts at all: but cost-cutting was the ne plus ultra, so not much was becoming apparent.) Marketing was where it was at.

I'm guessing the person who came up with it didn't last long in the advertising game, but the new slogan up with which the hospital came was "Nobody Cares More." Banners and posters appeared all over the hospital, and, of course, in TV and newspaper ads. I suppose you can guess how the hospital ones were defaced, in short order (not by me, I'd add: too mundane): Either the "More" was crossed out, or "Any" was added between Cares and More. Among the staff, it was a running joke. And it bears remembering, for later on.

I may have exaggerated when I said the move toward a Level Two Trauma Center united the medical staff. Fact is, since it didn't affect a lot of docs one way or the other, they didn't care. But those most affected -- surgeons of many specialties, and anesthesiologists -- were horrified at the prospect, and were of one voice in expressing their displeasure. And truly, it wasn't just about the work-load. It was very, very much also about concern over the hospital's ability to provide the resources to do it right, and the fact that the best around was within shouting distance. I wasn't the only one who'd had experiences like the one I described. But of this "one voice" it must be said that one vocal chord was paralyzed. That's because half of the docs in town, as mentioned earlier, were in bed with the hospital. So much so that if the hospital CEO had gotten the clap, they'd all have had to take penicillin. So much so that when they walked into the hospital, they were handed tubes of KY jelly. So -- and don't doubt that administration didn't know this very well -- when the hospital did something that the medical staff didn't like, half the staff kept their mouths shut. And the medical staff officers pretty much spent their time sending out memos telling us what plans the hospital had, with no input and no feedback. Puppet government? Puppet something: government seems a little generous.

So I was elected. The surgery department of the medical staff consisted of all surgeons in town, regardless of affiliation. Everyone knew I'd speak out and would say what was on all their minds, while allowing the rest to sit mute and enjoy deniability. "Sid, go talk to the CEO, and tell him why it's a bad idea," they all said, to man. And a couple of women. Give 'em hell, while we lube up. A meeting was scheduled with me, the CEO, and the hospital medical director. Armed with a well-prepared list of questions and issues that needed addressing, I spoke my piece, and was surprised by the candor of the response. "It's about market share, doctor. Our business plan is to be the referral center for the area, and being a level two trauma center will impress people, convince them we're the real deal." Or words to that effect. "Market share" is a verbatim quote. Providing service to the community was never mentioned, per se. What arguments did I have to counter "market share?"

The one thing they had done is to spiff up the ER a little: made it bigger, bought a couple of cool monitors. New paint. Being the second busiest ER in the whole state, it needed it, trauma center or no. What they hadn't done is make any effort to get the surgeons, et al, on board; no need, really. They held the cards, in terms of doling out staff privileges, and they had the other guys by the balls, and by whatever parts were available on the feminine side of the equation.

As I was talking with the rest of the surgical department and considering how to deal with the inevitable, what steps could be taken at least to ensure the best care possible, the hospital started running ads in the newspapers, when the paint was dry in the new ER. Here's an exact quote: "State of the art in every way, the ER is backed by an acute care hospital... We all hope that life-threatening traumas and illnesses never befall us or our loved ones. But if the unthinkable happens, isn't it nice to know that the very best help is available, right here at home." Let's be clear: "state of the art" does not mean Xray facilities five hallways away from the ER and which may or not be available, lack of onsite lab, or absence of clear protocols for handling given situations. The ad also listed the services available at the hospital. On the list was the term: Trauma Center. I suppose I can be self-righteous. I'm a surgeon, after all. But this really struck me as awful. To call the facility a trauma center, and to claim it was state of the art and that the very best help was available was, in my opinion, fraudulent. Premature at the very, VERY least. So I wrote a letter to the medical staff president and his executive committee. I included a copy of the offending ad, and said I thought it was time for the medical staff to step up and take a stand. Going ahead with a trauma center was a decision that seemed to have been made; but there was no reason we should be silent in the face of false advertising. I got a letter back. You shouldn't write letters like that, was the gist of it. My within-the-system wad was shot, I figured. I'd gone to meetings, I'd written letters, I'd talked formally and informally to administrators, physician officers. I felt the hospital was behaving as if all it had to do to be a trauma center was to hang up a sign in front of the ER. I'd lost the war.

So I distributed a memo to all of the doctors at the hospital. Put it in their mailboxes. From which it got pulled so fast hardly anyone saw it....

Hospital politics: the infamous memo. Part two

In offices all over town, doctors were busy trying to survive. The clinic, of course, had a significant advantage in many ways: we had excellent management, and we were getting large enough that we could throw our weight around. In a move that sent shockwaves across the entire US -- since it had never been done -- we'd actually fired an insurance company (ironically, the one with which we'd a few years earlier signed that exclusive contract): having had enough of the annual cuts in reimbursement, and having figured out that we were actually losing money on their patients (Old joke: how do you survive when you're losing money on each widget? Anwer: you make it up in volume) we told the insurer that that was it, sent letters to all our patients covered by them, offering help in hooking up with a new insurer. Set up a special phone line. Set a date. The insurance company caved. Of the bad new days, those were the good old days.

As private docs and small groups got into more financial trouble, some of them joined us. A few closed up shop. And the hospital, deciding that the clinic represented some sort of threat, began first a primary care network, and then a cadre of specialists as well. I can't say, from one point of view, that I blame them: they felt if the clinic became the only game in town, they'd have no leverage. (There was a time when all the rage was pre-paid healthcare, wherein the insurer paid a given amount to the docs to manage a patient, and the doc assumed the risk for overspending. The clinic bought into the idea, and went so far as to assume risk for hospital costs as well, which meant trying to negotiate daily rates with the hospital. More irony: the data for this concept looked great for a few years, and we thought we were better than anyone on the planet at controlling cost. Turns out it was an obvious accounting peculiarity: sign up a bunch of people, and for a few years it looks great. Then they start getting sick. That model is pretty well dead throughout the country now.) So on one level, I understand the hospital's thinking. On another, I thought it stupid for them to be underwriting practices all over the country with money that would be much better spent on improving their product. They were the only game in town. All they had to do was be excellent, and they'd be fine. And the clinic, believe it or not, didn't WANT to be the only game in town. We thought competition was good for everyone. As I recall.

Among other things, the effect of having the hospital support virtually every doc in town but us was to heighten the already great tensions between the doctor groups, and between the clinic and the hospital. To me, it began to feel like enemy territory whenever I walked into the place. Making matters worse, the hospital gave an enormous payoff to the specialist group, by paying them an outrageous amount of money to "manage" their outpatient operating room, a place at which I frequently worked. Scheduling time there suddenly became more difficult, on the one hand, and more unpleasant on the other. (Full disclosure: we eventually opened our own outpatient surgical center and, as one of its prime planners, I consider it one of my great accomplishments. As I wrote to them when I retired, "You are an island of excellence in a sea of despair.")

So that's pretty much the soil in which this story is growing: things are going to hell in a handbasket in town. Docs aren't talking to one another, everyone is paranoid and doing whatever they can -- even when it makes bad policy -- to survive. Insurance companies are loving it: trying to undercut the other, each party is willing to take less and less in payment. For a while, I used to imagine board meetings in top floors of skyscrapers, the air filled with cigar smoke and the self-satisfied farting of large and wealthy men, saying, "I was in their town yesterday, talking to such and such group. I offered them so and so in reimbursement. And guess what! They TOOK IT!!!!" High fives, yuks, and farts all around.

And then, improbably, the hospital made a move that united all the docs in town.

"Ladies and gentlemen, we're going to become a level two trauma center," said the CEO at a staff meeting, to the gasps of nearly everyone there assembled. Looks were exchanged, of the "they can't be serious" kind. If it weren't for the fact that trauma care was so lousy, making the act potentially fatal, people would have fallen out of their chairs. OK, I was wrong: I need to till the soil a bit more to have it all make sense.

First: the state had recently adopted a system of trauma-center designations. (Coincidentally, the main promoter of such systems was a good friend and mentor, from my training days: Don Trunkey. Yes, a character in my book -- here I am selling it again.) Level one was basically a world-class center with dedicated ORs and crew standing ready at all time, and having surgeons and anesthesiologists in house around the clock. Level two was nearly the same in terms of systems and facilities, but with the docs available within twenty minutes, 24/7, under pain of water-boarding and dismemberment. Level three was, more or less, where we were: take care of stuff pretty well, usually. If things fell into place. There was a level four as well, and, I think, a level five. Hard to imagine what those would be. Significance of trauma-level is that, among other things, medics in the field are required to triage a given level of injury to a given level of center, bypassing lesser facilities in most cases. Second important fact: twelve minutes away by readily available medic helicopter, and about twenty-five minutes by ambulance with lights flashing, was one of the best trauma centers in the world, level-frickin'-one, and then some.

I used to say that if I were run over by a truck, or shot in the belly at the entrance to our hospital, I'd want to be choppered to that trauma center down the road. And I meant it. Oh, if the stars aligned properly -- namely if a person had their major surgical emergency at 6 am, when the crews were all there but the day's patients weren't yet in the OR -- we could do as good a job (in terms of conduct of an operation) as anyone around. Not a couple of hours later, when the ORs were likely full, or in the middle of the night, when crews had to be called in. And not necessarily if the patient needed complex Xrays right away, or -- God forbid -- more than a couple of pints of blood. Not long before this jaw-dropping announcement, I'd had one of the worst experiences of my surgical life: called in to the ER at around midnight to care for a man gravely injured in an auto accident, clearly bleeding internally and massively. Because the OR had just finished some case or other, the crew was there. We got him ready in short order. I called ahead to get blood and emergency instruments available. I opened him up, unzipping his belly in a maneuver well-described in a certain book. (Note to reader: despite what you think, I suggest you take a second and click those book links. It's not what you think.) It was obvious he had a monstrous liver injury. I called for an aortic clamp, which, it turned out, wasn't in the pack supposed to contain it. In a cost-cutting move, the hospital had recently decided that having a bunch of instruments all cooked up and ready to go outside the rooms was expensive: they wanted everything centralized in the basement; and a lot of it -- believe it or not -- in a suburb a few miles away. So there was -- as there had been before the new idea -- no extra clamp on the OR. A call to the basement got this reponse: none. NO ONE ANSWERED THE GODDAM PHONE! Meanwhile, I'd sent word to the blood bank to send ten more units of O-negative blood (generally able to be given to anyone, without taking the time to crossmatch.) "You need to send us another clot," was the reply from the lab. (That's what you need to do a crossmatch.) Understand, I was in the process of losing the patient, and feeling very, very unsupported, to say the least. The list of things wrong is so long that I won't take up your time. Suffice it to say, the hospital at that time was clueless about what it would really take to upgrade to a level two. And not really in a position to do much about it. Did that matter? You'll see.

Hospital politics: the infamous memo. Part one.

In an earlier post, I made reference to a memo I once distributed to the medical staff which was so inflammatory it disappeared from every doctor's mailbox before most ever caught wind of it. Although there might have been suspicions, I don't think it was ever known who did it. I'm ready to let the cat out of the bag. It might take a couple of posts to explain the whole scenario. Done well, it ought to shed light on many aspects of what has been wrong in medical practice in recent years. Done poorly, it could bore you to death. But first, a disclaimer:

Let me say in all sincerity that this occurred some time ago, when medical relationships were at their nadir in our town. And the hospital in question has turned things around in remarkable fashion, so much so that it's as if I'm talking about another place. So understand this: although it's all true, without question, categorically, undeniably it is not a reflection of the current situation. Politics have improved, and the quality of hospital care and commitment to it are exemplary and award-winning. The hospital is now one of the best there is. Really.

Once upon a time, when hospitals were not under the sort of financial pressure that exists today, they could focus on their mission (providing care to the sick, in case anyone's forgotten) without much concern about the competition. And doctors, maybe a little too fat in their wallets, worried more about their patients than about their financial survival. But as those who pay for medical care (governments, health insurers and, to a lesser extent, consumers) began -- rightly -- to seek ways to control costs, they -- wrongly -- focused only on payments to hospitals and doctors. Squeezing pretty much all of the blood out of the turnip, they went -- in the opinion of me and many others -- well beyond what was reasonable, and set medical finances upon its collective ear. And whereas I'm among the first to admit that there was a time when many doctors were overpaid, and that hospitals should have long ago looked more closely at efficiencies in the delivery of care, the result has been chaotic and frustrating, and damaging. Among other things, it has set doctor upon doctor, hospital upon hospital, and every combination within: collegiality has been replaced by competitiveness and divisiveness. Our community has been a microcosm of all that, a laboratory study of how it works.

Guy wakes up one morning and hears a voice in his head: "Sell your house, your business, take your money, and go to Las Vegas." He ignores it. Next day, he hears it again, and again, until he hears it pretty much all the time. He decides he must believe it; sells his house, his business, takes the money and goes to Las Vegas. On arrival at the airport, the voice tells him "Go to Caesar's Palace." He goes. Entering the lobby, he hears the voice tell him "Go to the roulette wheel." He goes. "Take your money," the voice says, "and put it all on red 36." He does. The wheel spins, the ball stops on black 15. The voice says, "Shit."

The above had nothing to do with anything; I just thought things were getting a little heavy.

There's been a huge political divide in our medical community, between the docs in a large clinic (including me), and everyone else. Things got a lot worse about the time I arrived in town, just before which the clinic had opened a satellite office in a nearby town, and had signed an exclusive contract with one of the local health insurance companies. So I'd walk down the hospital hallways, smiling happily at the docs I'd see, oblivious to it all, young and optimistic; and they'd literally turn away without speaking. Unless they were in the clinic, in which case they probably wondered why I wasn't in the office cranking out patients. The other guys figured we were aiming to take over the town, running them all out of business. That was not the case, of course, and it never happened. Even though the clinic is nearly ten times as large as when I joined, the town nicely accommodates everyone. But it wasn't so clear, then. A major effect of payment reduction has been to cause everyone in healthcare to focus on their bottom line, to behave in ways they never thought they'd have to: competing for dollars, forming alliances, signing contracts they don't like. Up to a point, it wasn't entirely undeserved. But it's turned docs away from what they loved in the first place, which was providing care, and it's made them love it less. That's, I suppose, fodder for a whole other series of posts. But maybe not: it's too depressing.

Meanwhile, the hospitals were in trouble. There were two for many years, one private, one public. Having lived together in a measure of peace earlier, as reimbursement decreased each felt the need to grab patients from the other. Duplication of services, generally not a great idea when there are fewer patients than beds, actually increased as each hospital strove to attract clients. (Yeah, they started calling them "clients." What BS. It's like I told my son when he was tiny and asked if he could call me Sid. "Everyone in the world can call me Sid," I said. "You're the only one who can call me Dad." Likewise, everyone is someone's client. Only doctors and nurses have patients.) Long, longer and longest story short, the public hospital (the better one, in my opinion) started to fail and despite such draconian measures as firing all the senior nurses and relying more and more on less expensive locums nurses, eventually it sold out to the private hospital, and they merged. There followed a very dark time, and sadness descended upon the medical community, most especially the nurses. Though many of the public hospital nurses were retained, everyone had to get used to new people, new systems, and to try to forget the old days, when there were enough nurses to provide what they knew was excellent care. At some point, administration literally told the nurses to shut up and stop with the suggestions, or find another job.

The level of care unquestionably descended. The surgical floor at the old public hospital had been, not long ago, the best I'd ever known. Highly experienced, highly dedicated nurses with a team approach, were assigned to that floor and nowhere else. I love having confidence that my patients will be getting top-notch care, and that when something goes awry, the nurses will find it and understand it right away. That all slipped away, as the few remaining nurses were surrounded by a different crew every day; in fact, it became the mantra that all nurses should be able to work anywhere. Specialization was rationalized away, because it was cheaper to believe it didn't matter. Doctors were getting extremely frustrated; some of us began to consider admitting our patients, inconveniently, to hospitals in neighboring communities.

So what would you think they'd do, as morale fell, quality suffered, and word began to grow in the community that maybe you should think about going elsewhere when you got sick? Trade in the pig for a quarterhorse? Focus like a laser on improving care? Nope: think again. You put lipstick on the pig. Stay tuned.

Breast Cancer Women

Something you may not know, and won't get by looking at most renditions of them, is that the legendary Amazon warrior women are said to have cut off their breasts. One, more accurately. In order to shoot their arrows with their bows, the left breast (assuming right-handedness) was removed. (The linked article above has it wrong, I think.) Pantomime it on yourself: the left breast would be in the way, particularly if bare-breasted, as they were, so it is said. And here's the kicker: it's in the name. Amazon. A (for absent); Mazon (same root as mastectomy: referring to the breast.) Of course, none of this is confirmable, but it is an accurate account of the legend. And so I told it to Gloria and her husband, competitive archers.

Women are tougher than men, no doubt in my mind, having operated on both more than a few times. The fact emerged first in medical school, when a fellow (male) student fainted dead away as we heard a lecture on blood types. A lecture, not even a lab! And about types; not even the gooey stuff itself! The prof was unsurprised: "Happens all the time," he said. "Always the men. Ladies live with blood. It's no big deal to them." Bunch 'a wimps, we.

Don't get me wrong: I'm well aware how devastating the idea of cancer can be, and how mutilating many operations are -- mentally as well as physically. And yet it's been a source of inspiration over the years to witness how well most women are able to adjust to mastectomy: with bravery, with calm, with humor. I learned many years ago, when inspecting a surgical wound, not to say "beautiful," no matter the operative type. And yet I've heard lots of patients, when they looked at their mastectomy scar, say "gee, that's not as bad as I expected." And many, for various reasons, chose not to have reconstruction later, when they'd initially figured they would.

This is not a treatise on the benignancy of mastectomy, nor a suggestion that women who have a hard time with it are somehow deficient. I'm just saying -- because it's been a source of amazement to me -- that for some women, it turns out to be ok. More ok than they'd expected it to be. On the day of her surgery, I pulled back the covers on one lady to discover that she'd crocheted a quite impressive nipple/areola in brown and pink yarn and placed it on her chest; delighting in my surprise.

So, back to Gloria. A very athletic woman, tall and muscular, she and her husband sat in my office hearing the results of her biopsy. In addition to all the usual fears, they were concerned about their archery careers. They competed at a very high level, and had tournaments coming up. How soon, they wanted to know, would she be able to pull a bow? That was as high on their list as any other issue, and I was glad to hear it: desire to get back into life is important, whatever the operation. I hadn't known about this avocation of theirs, and it gave me my one and only chance to tell the Amazon story. And yes, it was her left breast, and she was right-handed. She loved it.

There was no question in her mind which option to choose: it was mastectomy for her, and she recovered like the athlete she was, proudly arching (or whatever they call it) and telling the legend to her competitors in short order. As I recall, her husband got her some sort of Xena paraphernalia to wear, as well. Sometimes, things have a way of working out.

[Addendum, 5/2014: I was sent this link to some very inspirational quote by celebrities who've dealt with breast cancer.]

Tagged

Jordan tagged me (by email, the sneak!). Since I ignored a previous tag, and since he did it so personally, I guess I must respond to this one. And now, intellinurse2b has, ever so nicely, asked the same:

1) Are you happy/satisfied with your blog’s content and look?
Not entirely. I wanted to have a particular picture be the title part of the blog. I see that some blogger people have figured that out. I haven't. I switched from wordpress (where I easily did it) to blogger -- which seems to be the opposite direction of most -- because I thought a couple of other things were easier. Too late, now. Fact is, details aside, I'm amazed that anyone provides the service to do this, for free!

2) Does your family know about your blog?
Most of them. One, maybe, would rather not know. Lots do, and enjoy reading it. My wife has 8 siblings. We're close. They say nice things.

3) Do you feel embarrassed to let your friends know about your blog? Do you consider it a private thing?
I've let people know about it. If I had a lot of friends, I might not be blogging. (Said with wry smile, visible on close inspection.) I just told my oldest friend, Dougie, (since we were about three years old) about it and he was quite complimentary(Stlll call him Dougie. He's an old fart like me, astronomer, bearded, professorial but highly energetic.)

4)Did blogging cause positive changes in your thoughts?
I've always felt that any form of writing is good for the thought process. I think you don't really know what you think until you can write it down. Writing crystallizes thought, and gives it shape. It's a good thing in any form.

5) Do you only open the blogs of those who comment on your blog or do you love to go and discover more by yourself?
Certainly those of commenters. And the commenters on theirs. And on theirs. And their blogrolls. It's never ending. Somebody make me stop!

6) What does a visitor counter mean to you? Do you like having one on your blog?
I have that map thingy. I love seeing the parts of the planet from which people visit. I think it's very cool. I don't get info more specific than that. And I think I may become obsessed over the daily numbers. Why down on a particular day? What did I do wrong?

7) Did you try to imagine your fellow bloggers and give them real pictures?
Here's a deal: I won't try to imagine you if you don't try to imagine me.

8) Admit it. Do you think there is any real benefit in blogging?
Quite honestly, I think some of my posts have been useful to other people, based on comments. So that's good. Of course, it's a very self-indulgent activity; it may be that the rest is just rationalization.

9) Do you think that blogger’s society is isolated from the real world or interaction with events?
Since blogging covers the whole spectrum (and maybe more of the spectrum than there actually is) I'd say it's a better reflection of what's real than reality itself. Yeah, that's it.

10) Does criticism annoy you or do you feel it’s a normal thing?
Blogically speaking, can't say yet. In life, criticism causes great sorrow; which is why being a surgeon wasn't an entirely perfect choice.

11) Do you fear some political blogs and avoid them?
There are several I visit regularly. I'm of two minds on their value: to the extent that they are echo-chambers, I think they just worsen the already horrible polarization of politics in the US. To the extent that they do what the MSM aren't doing (ie raising questions and pursuing answers), they are a good thing.

12) Were you shocked by the arrest of some bloggers?
I plead ignorance.

13) What do you think will happen to your blog after you die?
I'm close enough, age-wise, that this is probably a pretty good preview.

14) What song do you like to hear? What song would you like to link to on your blog?
I love music, of nearly all types. I just found a great online customizable radio station and I'm listening to it now. Jazz at the moment. Might switch to blues. On the other hand, I don't think I can pick a single song. I guess I'm a gourmand.

15) The next “victims”?
I think I need to be around longer before I can tag someone else.

PS: here's something amusing. As usual, I google image searched for an appropriate photo. One of the first that came up for "tag you're it" is the one I used, which happens to be my home-town minor league baseball team. In the background, on the fence, is an ad for the clinic in which I used to work for many many years (The Everett Clinic). Large world?

Breast Cancer: family matters

There's only been one person I wanted to kill in my office, and it wasn't my patient, so it shouldn't count against me. It was her husband. I was talking to her about her newly-diagnosed breast cancer. She was about forty; smartly attired, blond hair trimmed short, she looked younger than her age, and seemed more worried than frightened. Eye contact was furtive, but she was paying close attention. Pretty and prim, businesslike, she listened with care, but seemed distracted. And a contrast with her husband, an open-collar, sports-car sort of guy.

Karen's cancer had been found early, on a routine mammogram, and was highly favorable. I explained the situation in detail, including the likely good outcome no matter what treatment she chose. I told her she needn't lose her breast, that lumpectomy and radiation would have a very high cure rate, equal to mastectomy. But she worried: her breasts were unusually lumpy, and she'd had a couple of biopsies in the past, always scared to death until the reports came back. Knowing herself, she thought it would terrify her to leave the breast in place. Every lump, every sensation would throw her into a panic. She wanted it off.

It was not what her husband wanted to hear. "This is just what my first wife did," he told me. "She died of ovarian cancer. And now Karen is pulling the same shit on me." Wow. What do you say to a thing like that? But he was just warming up. He turned to Karen and said, "I'm telling you right now. If you have a mastectomy, I'm never going to touch you again." When she showed up for her surgery, she was alone.

Mary's husband was the opposite. He'd been with her at every visit, right there at her side the whole way. Young and pretty, she'd had a mastectomy, too, because of multiple tumors within the same breast. At the three-month followup, when she was in the midst of her chemotherapy, they told me she'd gotten a different wig for each day of the week. "I look forward to Thursdays," he said. "That's when she's a redhead."

Breast Cancer: scary tales

Here is a truism by which I've always stood in my breast practice: an excellent way to investigate a palpable (feelable) breast lump is "fine needle aspiration." In fact, I'm a bit of a fanatic about it: I think gazillions of dollars are wasted by unnecessary breast ultrasounds for lumps, and by more extensive biopsies than -- in many cases -- are needed. I'm happy to say I was a bit of a burr under the saddle to many a radiologist, and some primary care docs as well, as I tried to spread the word. (In one particularly enthusiastic moment, during a joint conference between surgeons and radiologists to address such issues, I dis-ingratiated myself by saying, "When all you have is a hammer, everything starts to look like a nail.") I tried -- ultimately unsuccessfully, I'll sadly admit -- to convince primary docs that when they could feel a lump, the first stop ought to be at the surgeon's, not the radiologist's store.

A breast lump is either solid or liquid. For the most part, that's all an ultrasound can tell you for sure. At considerably less than half the price, a surgical consult with needle aspirate will give you that, and much much more. Poke a fine needle (size of one used to draw blood) into a lump: if it's liquid it's nearly always a harmless cyst, in which case the needle withdraws yellow clear fluid, proving the diagnosis and making the cyst go away, usually permanently. Same info as the ultrasound, along with therapy. If the lump is solid, the needle can remove a tiny sample, which, properly spread on a slide and given to a pathologist skilled in such things, can be very accurately assessed. When a lump is cancer, the needle sample either shows cancer, or some cells that are highly suspicious. And when the sample shows entirely innocent cells, and when the lump in question is clinically innocent (as judged by a competent examiner), the chance of missing cancer is extremely low, in which case followup without further biopsy is often a satisfactory option. Few things -- medically speaking -- bug me more than seeing a woman who's had an ultrasound that shows a cyst, referred for treatment. Had it been the other way around, the ultrasound would have never been needed. Even worse is a woman who had a palpable lump, sent first to radiology and getting a mammogram followed by an xray guided (stereotactic) biopsy. Huge waste of time and money. (I may post about diagnostic issues again and get back to this. For now, suffice it to say that stereotactic biopsy is an excellent tool for a NON-palpable lump. And, along similar lines, I'd say this: a mammogram is to find things we can't feel. When a lump is feelable, it makes more sense to me to see the surgeon first: for example, if it's a cyst, and I drain it, what's the good of having taken a picture? It'll be gone on the next one!..... It could take several posts -- or a hellaciously long one, to cover this well.)

So here's the drill: if I saw a lump, I'd generally poke a needle in it. Takes literally about five seconds, hardly hurts. If I'd get clear yellow fluid, and if the lump went away completely, I'd tell the woman with total confidence that it was a simple cyst, explain exactly what that means, arrange followup, and flush the fluid. (It used to be routine to send the fluid to the lab. But several studies confirmed what I'd come to believe: if clear yellow, and associated with a disappeared lump, the tests never showed a thing. So tossing it away became the marching order.) If the lump was solid, I'd sample it with the needle, make a slide, and send or carry it to the pathologist. And when I was sure it was cancer, the sample virtually always showed it. I'm efficient as hell, with a woman's time, and money. But I got two surprises in one week, and they were close to disastrous.

When I saw the referral came from a family doc who always used someone else, I thought this was gonna be something strange, and indeed it was. She'd done a needle aspirate (good for her!) on a young woman with a lump, had gotten clear yellow fluid, observed the disappearance of the lump, but sent the fluid to the lab. And had gotten back the diagnosis: cancer. I was stunned, and deeply disturbed. It was against everything I believed: I'd tossed tens of hundreds of fluid sample into the trash. How could this be? I called the lab, I talked to the lab doc. Was there any chance of an error, a mixup of labels, anything to explain it? There was not. I asked them to double check. They did; there was not. When I examined the woman, the site of the needle poke wasn't visible, and there were no lumps. The doc couldn't say with precision where the lump had been. The mammogram was normal as could be (she was young enough -- early thirties -- that mammograms aren't all that useful, anyway.) Just to make it all more interesting, she was an attorney in the DA's office. To say it was disquieting is to understate by a factor of a pants-full. The woman evidently had cancer, despite the diagnosis being counter to a fundamental principle of my practice. In fact, I already had reason to question my whole approach: I'd just done a needle aspirate on a little old lady who I was absolutely convinced had cancer, and it had come back totally innocent. I must have missed the lump by a mile: me, who made a crusade about the method. Not even my fellow surgeons used it as much as I did. I'd had to do a more expensive, more invasive open biopsy on the lady to confirm the diagnosis of cancer...

Getting goose-bumps yet? It all became clear, about a day or two after I operated on the young attorney. I'd removed the entire quadrant of the breast in which the "cyst" had been, and had done a small lymph-node sampling under her arm. The good news is that because the breast (properly managed, if I may say so) can end up with very satisfactory contour after a pretty large lumpectomy, she got a nice cosmetic result, other than a fine scar. The pathology report, which showed absolutely nothing out of the ordinary, came about the same time I got a phone call: they'd pursued it further and discovered a lab mixup: the slide made from the cyst fluid, and the slide I'd made from the little old lady had been confused by the lab. They even acknowledged that mine had -- as always -- arrived from my office properly labeled and marked and that the error was entirely theirs. Without being asked, the lab doc sent a letter to my patient explaining exactly what had happened, and that I'd twice asked them to double-check. She was surprisingly gracious. And my little old lady, who indeed had cancer, did well despite having undergone an unnecessary open biopsy before her definitive treatment.

And here's the thing: these aren't even the worst stories. I once did a biopsy on a lymph node under the arm of a woman in her seventies. Metastatic breast cancer, was the report. No ifs, ands, or buts. The mammogram, the physical exam were normal. It's uncommon but not entirely rare, and the concensus is that the treatment is mastectomy on the affected side, with around a 60% incidence of finding the cancer in the removed tissues. I was in the recovery room writing post-op orders, having done just that, when I got a call from the pathologist. "Hey Sid, this is Dave. Just got the report from the university. Remember that lymph node? They said it was melanoma. Guess it's lucky we waited, huh?" "WAITED!!!! WHAT THE F--- ARE YOU TALKING ABOUT???? I just took her breast off!!" "Jesus," Dave said. What happened is, they have a weekly cancer pathology conference, at which -- after the final and unequivocal report had been sent out -- another pathologist (he's the one to whom I always carried my breast aspirates -- the best I've ever seen. He was out of town during the week of the first two cases...) had said he thought it might be melanoma. They'd decided to send the slides for consultation, but hadn't bothered to let me know... I said "Dave, you are coming with me when I talk to the lady." Dave said..... well, I don't remember what he said. But he came.

What's the lesson here? Damned if I know. I was inspired to write this after reading the latest post at Urostream. If good news isn't always good news, and bad news isn't always bad, I guess you have to hope to hell you have a team that talks to each other.

Blue baby blue

We got a call last night, from our best friends remaining from my training time in San Francisco. "We've had a tragedy in our family," L said. Immediately my wife, Judy, thought of their newborn grandchild, a few weeks old. But it was A, their first born son, who died suddenly, in his thirties.

We'd known him since birth, when he arrived in the world blue and scrawny, suffering from transposition of the great vessels, among the most complex and disastrous of the potentially survivable congenital heart conditions. Then, his life was saved by a daring procedure, creating a hole between the two upper chambers of the heart: in itself a dangerous condition, but necessary in this case to get blood from his lungs to his body, which otherwise would have run in two separate circles -- one back and forth between heart and lungs, the other from heart to body, exhausting its oxygen without replenishment. A had been a sad little baby, squeaky and blue as his baby blanket, lips purple; not growing much, squatting to breathe as such kiddies typically do.

Forced to languish until he'd gotten big enough, he went with his parents at about two years of age to Birmingham, where there was a surgeon who'd had the greatest success on the planet in fixing these kids. Amazingly, the head of heart surgery at UCSF had the audacity to express hurt that J and L hadn't had him do the surgery: he who'd done exactly two, and they'd both died. (Readers of my book would have plenty of reason to side with J and L in their decision.)

The operation is ingenious, and complex -- and now has been replaced by better methods, done right at birth. But it worked. It's hard to give a word picture: imagine (understand that I'm no mechanic) taking the exhaust manifold off your car, and laying in a series of baffles to redirect the exhaust from one set of pistons to the exhaust pipes of another, and then replacing the cover over the baffle. In the case of this operation, a window of tissue is cut away from the sac around the heart (the pericardium) and used as the baffle. And in A's case, it worked great.

A took off, as they say, like a weed. Making up for lost time, and in the pink, he grew and thrived. In grade school, he was a regular on a local TV station, giving kid editorials. On one, ahead of his time, he demonstrated how much sugar there was in breakfast cereal by pouring milk over a bowl of Snickers Bars. When Judy was pregnant, and J and L kept asking us what the name would be, A suggested "Freshwater." He loved the Tintin books, and in one, the captain had referred to 'freshwater swabs." Freshwater Schwab. For many years, whenever we'd talk with a member of that family, they'd ask "how's Freshwater?" Eventually, A moved to New York City, where he became somewhat of an icon amongst a particular niche of the music scene, a favorite DJ for a certain crowd, and writing reviews of music clubs in the Village Voice. He worked for a while for a record producer, one that made vinyl records for the super-audiophile.

But he was his own man, and despite his parents' urging, refused to see a cardiologist after he left home. L tried every way she knew; even more ardently when a recent report came out on sudden death among people who'd had his operation years ago. They saw him through his toughest times, helped him to live a normal life without fear, and he did.

J and L are scheduled to be here in a couple of weeks: he's to give a special lecture at the medical school, and is the guest of honor at a fancy dinner. I guess it's too big a deal to cancel. So we'll be seeing them soon.

Breast cancer: some basics

Based on comments, I'd say readers of this blog are pretty sophisticated; so at the risk of boring some, and before flying off in various directions on the topic, let me establish a few basic breast cancer bits.

First, the most basic of all: what is cancer? Most all of the tissues in your body have a cycle of life and death, as cells die off and are replaced by new ones. This is especially true of surface cells, like skin and those that form inner linings: glands, guts, various tubes. Different cells have particular rates of division and reproduction, timed exactly to replace those that die off: dandruff is proof of the process, if you need any. For a few reasons, a cell may mutate in such a way that it loses the control of the replication rate, dividing more rapidly than needed to replace its cousins. The cells formed in that division process have the same misinformation, and the process continues, producing a cluster of cells: a tumor. If that tumor grows slowly and stays where it started, we call it "benign." If it grows more rapidly, and especially if it develops the ability to invade through local barriers and into blood and lymph vessels, by which process it can spread elsewhere, we call it "malignant" -- cancer (or "carcinoma.") Cancer carries the name of its organ of origin, no matter where it ends up: breast cancer means cancer that started in the breast. If it spreads to the liver, it's still breast cancer, not liver cancer. In the breast, there are two main cell origins: the ducts through which milk flows (from which arises the most common form: ductal cancer), and the glands (lobules) that produce milk (from which arises lobular cancer.) Behavior of the two is slightly different, but the treatment is essentially the same (lobular may grow a little more slowly, but has a greater tendency to occur in both breasts.) There are a couple of rare types; and there's the whole issue of cancer in its most early -- and theoretically 100% curable -- form, ductal carcinoma in-situ. (DCIS -- an entire treatise in itself. Maybe, at some point...)

The goals of breast cancer treatment, from a surgeon's point of view, are two. The first is to eradicate the cancer from the breast, and the second is to get information about how far it might have spread from the breast, mainly by removing some regional lymph nodes for analysis. Many changes have occurred in the achievement of each of those goals.

If a breast has a cancer in it, there's a significant chance some cancer cells exist elsewhere within that breast. If the only treatment were to remove the cancerous lump, many women would in fact be cured; but at least thirty or forty percent would have recurrence. Since there's no way to determine with certainty when a woman might be in the first category, the entire breast must receive treatment. (I've seen many a frail and very elderly woman for whom I felt it best simply to remove the lump -- often in my office under local anesthesia -- perhaps adding hormone treatments (more later on that subject), and following along, expecting another of life's end-games to play out before the cancer ever would. But those are very individual cases.) As I said in the previous post, until around thirty years ago, breast treatment meant removal, usually by radical mastectomy. Over time that most radical operation was modified (known now as the "modified radical mastectomy"), still involving removing the entire breast but leaving enough skin to close the incision, and leaving the muscles on the chest wall. It's significantly less disfiguring and disabling, but still is complete removal of the breast.

The other option is to remove the cancerous lump with a rim of healthy tissue around it, and to treat the remaining breast with radiation. As both surgical and radiation techniques have evolved, the cosmetic results are usually excellent (as opposed to my description in the previous post), and the local control (meaning absence of local recurrence) approaches (but does not quite match) that of mastectomy. There are a few situations that mitigate toward choosing mastectomy (multiple or very large tumors, mainly) but for most women, how the breast is treated is a matter of personal choice. Some readers might be surprised to learn that many women prefer breast removal to breast preservation. And like many other emotionally charged issues, the choice has become complicated by factors beyond such simple matters as cure and personal comfort.

"If your surgeon tells you you need to have your breast removed, find another surgeon," says the woman who's the subject of my previous post. Said, more properly. No longer says. Took her a little longer to get it. What's wrong with that recommendation is that, first, there are a couple of situations for which there really is no option but removal of the breast. I'll get to them eventually. Second, some women simply don't want the stress of worrying about what's going on in that remaining breast. Many women have had lots of lumps and lots of biopsies before developing cancer. Surgery and radiation can cause lumps and mammographic abnormalities which change over time and which may require biopsies to be sure what's going on. Some women simply don't care that much about that aspect of their appearance (I've always thought, paradoxically, that that was the most liberated view of all -- the opposite of the "women's movement" argument). Or they elect peace of mind over concern about some aspect of appearance. It can be a strange thing: when a woman chooses mastectomy, there's an assumption on the part of some folks that either her surgeon is an idiot or a pig, or that she's in some way falling short of her obligations to.... to whom, exactly? It complicates things, sometimes.

It's another paradox: much as it's a step forward in healthcare that people are taking more and more charge of their medical decisions (the days of the god-like doc telling a patient what will happen and expecting no questions are happily and long gone) there are times when choice ain't all it's cracked up to be: when faced with a deadly disease, many people want someone to take charge and tell them what to do. It's a copout, in my opinion, when a doc basically tells a person, well we could do A, B, C, or D. Let me know when you make up your mind.... I think it's a doc's obligation fully to inform, lay out the pros and cons of the various options, but also to state an opinion of which is the better choice, if that doc has such an opinion. For breast cancer, I'd get asked for my opinion very often; and in most cases I'd honestly say I thought the options were equal and that it really came down to which the person felt, at her core, would make her most comfortable. When there were specific reasons why I thought mastectomy was safer, I'd say so. And when I thought there were reasons why lumpectomy and radiation might produce a less than satisfactory cosmetic result, I'd say so; likewise, when I thought post treatment surveillance would be an issue. I ended up doing a fair number of mastectomies: whether that reflected an unconscious bias on my part, I can't say with certainty. Twenty years ago, when the data were young and the radiation treatments were less reproducible, I'd have to say yes. In recent times, I don't think so. I know I had no problem with women choosing preservation in the vast majority of cases. But if it were me, or my wife -- and as a male person I happen to be among those that deeply loves the female form, visually and tactilely -- I'd start with the idea mastectomy (for its lowest chance of local recurrence, for avoiding the hassles of radiation, for simplicity of followup) and work back from there. For a small tumor with favorable parameters (guess that's another thing we need to get around to, eventually) it would probably seem like overkill. That's just for the record, since this is a personal blog. It in no way means women who choose otherwise are making a poor choice; not one bit, whatsoever. And my wife would make up her own damn mind, thank you very much.

We still haven't talked about lymph node testing. That's next, among other things.

Breast Cancer; prologue

Driving to the hospital on a Saturday morning several years ago, I was listening to NPR, which happened to be airing a discussion about breast cancer. One of the panelists was a woman surgeon with whom I was vaguely familiar; in fact, it's possible she sewed me up once. While training in San Francisco, in an incident well-documented in a certain book I'll not specifically hype (just this once) I suffered an intra-operative cut to my finger, which necessitated a trip to the ER for stitches. At the time, some surgical residents training at Beth Israel in Boston spent time at our trauma center for the unique experience (their boss had trained at UCSF; plus it's well-known there're no training programs in Boston that compare with mine....) I've forgotten the name of woman who sewed me up (and did a fine job), but I know it was one of those residents. And I know that the NPR panelist had done time in that capacity while I was there. I'd been grateful for the repair work. What I heard on the radio pissed me off royally.

"The only reason mastectomy was invented," she proclaimed, "is that men like to mutilate women." I managed to maintain control of my vehicle while screaming at the radio. "You shameless bitch," I shouted. "If you really believe that, you're too stupid to be a surgeon. And if you don't, you're a unprincipled self-promoting whore. Ever hear of penectomy? Know how debilitating prostatectomy can be? The reason mastectomy was invented was that at the time, it was the only thing that had ever cured breast cancer. The reason we do those gross things is that gross is all we have. We're still Neanderthals. You unrepentant hack." Or something subtle like that. I heard her and her shtick several times in several venues over the next couple of years. It made her famous, and probably rich. To her credit, I'll acknowledge she used her fame and fortune to produce an excellent book on breast disease, and eventually dropped the man-hating drivel. I'd Love to tell you her name.

When it comes to cancer treatment, we are indeed Neanderthal, compared to the ideal, and to how it'll surely be in a few decades. It's because of two most major failings: first, we have no way of knowing, for a given individual, how much is enough to cure a cancer (and the converse: we can't tell which tumors aren't going to be cured -- even when they fall into a favorable catergory -- no matter what treatment we apply.) Second: we don't have the proverbial magic bullet -- a therapy that will kill every single cancer cell, and spare everything else. With rare exceptions, non-surgical treatments -- drug therapy and radiation therapy -- can't distinguish between healthy and deadly cells. They work in proportion to the rate of cell division; and cancer cells divide more rapidly than normal ones. But that's why they cause side effects: they kill good cells along with the bad. Just in smaller numbers. And surgery -- like radiation -- only goes where it's aimed, and we have no way of being accurate enough only to remove malignant cells while leaving everything else behind.

We have good data about responses of large numbers of people. But there's a spectrum, of course; which means that we can't avoid the fact that we will over-treat some people, giving them side effects they didn't need (or remove too much or too little), and will under treat others. Some would have been cured had we done less than protocols require: some will die no matter how favorable their situation appears. Before radical mastectomy was invented, by William Halstead in 1889, women who got breast cancer pretty much all died.

Simply stated, the idea of surgical treatment of any cancer, when aiming for cure (as opposed just to biopsy or palliation), is to remove the entire tumor with a rim of healthy tissue around it, allowing enough room to include possible locally migrating cells. And it also means taking adjacent lymph nodes from the region likely to include those to which the tumor might also have spread; hoping, of course, that the surgery is being done before spread has already happened beyond the limits of the operative field. In the time of William Halstead, there weren't mammograms, women didn't do self-exam, and decorum meant that a gentleman (doctor) didn't touch a woman's breasts for routine checkups. So by the time attention was actually given to a breast cancer, it was likely to be huge.

The fact is that radical mastectomy was the first procedure to come along that actually cured breast cancer. It was a huge deal: enormously disfiguring, and significantly debilitating. I'm old enough that I watched a few being done, and even did some. I always found it horrendous. One of the surgeons who taught me had a specially-made, highly polished oak plank with which he levered the patient's torso off the operating table, still asleep at the end of the operation, in order to wrap her round and round with compressive bandages, tightly tethering her arm to her chest in the process. After the wrap -- which by immobilizing the arm ensured a long hard rehab -- we'd lower the woman back down and slide the board out of the bandages. Later, we'd begin daily dressing changes and re-wraps, after inspecting the skin graft for viability and likely avoiding the stunned eyes of the patient. Yes. Skin graft. The operation entailed removing the entire breast along with all its skin, and the two pectoral muscles; and extensive removal of the lymph nodes under the arm. The edges of the wound were too widely separated to re-approximate, so a skin graft was fashioned from somewhere to cover the ribs, which were exposed from the dissection. The effect was indeed mutilating, and the loss of the pectoral muscles, along with the lymph node dissection ensured that the arm was weakened and swollen. But until around the 1970s, the only alternative was death. Rather than some sort of perverse vendetta against women, it was done because at the time of its invention, nothing but radical mastectomy had ever worked on the gross tumors that were typical at the time.

Big changes were occurring by the time I was learning my craft, inspired in large measure by the realization that breast cancers were being discovered smaller and earlier every decade. In France (of course, it would be France) preservation of the breast using radiation treatments was being tried. I saw a woman who'd been among the early subjects: her breast had been cooked hard and brown, and was like a piece of wood on her chest: as different from the other as a rock from a pillow. But she was happy with it -- compared to the alternative, it seemed a fair trade. Surgically, mastectomy was being modified to a less radical form: more skin was left, so it could be closed without a graft. And one or both of the pectoral muscles were being left in place: cosmetically it still left a flat chest, but it was a human one, with contour and function, as opposed to bare ribs. Lymphedema (swelling of the arm) was much less common (but hardly eradicated), as lymph had channels in those retained muscles through which to flow from the arm. With no chain of patients, no long experience with treatment failures, I could be open-minded. But my mentors were of the prior era; for years, they'd seen it as it had been. Big tumors. Local recurrence. One and only one way to treat it. Is it a wonder that they'd be skeptical? Or, more correctly, worried about doing lesser operations when the data were young: when the price of failure was losing someone who might have been saved by the "old ways?" In my transitional time, in my arrival on the scene as things were changing, I could see it their way, without malice. That lady on NPR, she was of my time. Why couldn't she see it, too? Why cast it in such venal terms? But heck with her. It's a complicated and interesting subject. Let's talk some more, later.

Interlude

While gathering thoughts on my planned series on breast cancer, allow me a brief interlude. I had reason recently to recall something of interest:

My wife is the oldest of nine kids, and all her siblings live within shouting distance. As a result, I've been to many a graduation of many a niece or nephew. Always I find myself not particularly looking forward to them, and always they turn out to contain pleasant surprises. Since it involved graduation from U Dub (as we like to call it), a huge university, I was particularly not happy about going to see my niece graduate, a couple of years ago, with her degree in marine biology. To my great relief, her group had their own ceremony, in a friendly little auditorium. And the speaker turned out to be Jonathan Raban, a British writer now living here, who's written novels and non-fiction about the sea. In his buttery British voice, ennobled by the accent of the erudite, he gave a wonderful talk on mankind's relation to the sea, as manifested in literature; beginning with the myth of Narcissus falling in love with his reflection, and ending with (natch) Moby Dick, he delivered an enrapturing talk. I spoke with him afterward, which only added to the joy of the day.

More recently, we watched a nephew graduate from high school. The speaker was the district superintendent who, we all knew, had only recently recovered from life-threatening illness. He spoke candidly about it, in gripping prose, to a silent and barely breathing audience, telling us what he remembered, and what he'd been told. Suffering a perforated colon from diverticulitis (a condition with which, as a general surgeon, I'm all too familiar) he'd gone on to multisystem failure, was on a ventilator in intensive care for weeks, had been given last rites, and his family had been advised to collect anyone who'd want to arrive for their final goodbyes. He told us of vague memories of conversations around him, about sensing and trying to make peace with his imminent death. And he closed with this (more or less): "I've been through something I hope none of you will have to endure. I've seen life in its frailty and death in its inevitability. I've learned things about myself, and about life itself, and I'm in a unique position now -- for which I'm eternally grateful -- to pass a lesson on to a group of wonderful eighteen year olds as they approach adulthood. This I tell you from a perspective most will never have. If there's one thing I would have you know -- one thing I hope with all my heart that you'll carry with you through your lives -- it's this......... EAT LOTS OF FIBER! Good luck, and congratulations."

Book report

Well, for anyone who's interested, the reading actually went pretty well, in that several (well, around a dozen) people showed up to my reading. And they all bought books, which tells me they liked what they heard. If I say so myself, I like performing (high school: Sir Joseph Porter, KCB in "HMS Pinafore; Judd Fry in "Oklahoma." College: Conrad Birdie in "Bye Bye Birdie.") and make it pretty entertaining. If it'd been advertised, one can only imagine an impressive bunch of sales. Oh well.

More importantly for this blog: I'm back home now, and after a day at work tomorrow, I plan to begin posting on a subject I've planned for some time: breast cancer. Numerically speaking, breast problems made for the largest part of my practice. There's a lot I have to say about it, I think. So stay tuned.

Beach bust?

I'm doing a reading of my book tonight at the Cannon Beach Gallery. It's been on the books, as it were, for a couple of months. Beach time: they never got around to running announcements in the paper or putting up any of the thirty posters I had the publisher send them. Can't say I blame them: the weather's been beautiful, the beach beckons at any time of day or night. Who'd want to take the time to arrange things, much less show up on a Saturday night of vacation? I'm thinking I'll be talking to pictures on the wall. Which reminds me of one of the more bizarre evenings I've spent: on a trip to Death Valley, having heard about her somewhere, we stopped at a small auditorium in the middle of nowhere, desert on all sides for miles, heat shimmering even toward night. There, a woman named Marta Beckett danced her ballet every night, to music played on an old phonograph on the front of the stage, and with an audience of kings and queens and their subjects, sitting in fancy balconies, painted on the walls. That night, Judy and I were the only breathing visitors, except Marta's husband, who'd painted the walls and lifted the arm of the phonograph onto the record. That's love. Judy'll be there tonight, absorbing some of the echos.

Heartfelt

Still at Cannon Beach, we've been driving into Portland frequently to visit my mom and my aunt. Yesterday my aunt told me a story I hadn't heard before, and it moved us all to tears.

She has a friend who had a heart transplant, nine years ago. He'd been an Olympic-class athlete, and now, with his new heart, he's again able to climb mountains, run marathons. In fact, he's participating this weekend in the annual and insane run from Mt. Hood to the Oregon Coast. A team event. But still...

Before his transplant, he'd come very close to the end. My aunt describes the two months he was hospitalized, awaiting a heart: she visited regularly and saw more machines and hoses than she imagined possible (I infer he was hooked to a ventricular assist device). All the while, the man maintained humor and optimism. When the heart arrived, it had come from a young college student, killed in an auto accident. It was a perfect match in all senses of the term.

My aunt's friend came to know the mother of his heart donor. They've become extremely close, and visit with one another regularly. He, my aunt says, is a big guy, six feet five or six. The mother is tiny, less than five feet. The three of them -- my aunt, the man, the mother of his heart -- spend time together frequently. My aunt says that when they meet, the mother -- whose ear is chest high to the man -- always leans to him, wraps her arms around him, ear to his chest, to hear the sounds of her son's heart, beating inside the man and giving him life.

Giants of the Jungle

In a previous post, I mentioned stopping on my way to Vietnam, to participate in jungle survival school, in the Philippines. I want to tell you more about it, even though it's not at all surgical.

Before heading off to the great war, I'd spent three months in San Antonio learning to be a doctor for fliers, at flight surgeons' school. Much of it was fun and interesting: I learned about the physiology of flight, about baro-trauma, about particular afflictions that affect one's ability to operate aircraft. Playing soldier, I learned to fire an M-16, went up in an altitude chamber (note: gas expands at altitude. Colon gas.) I found out what hypoxia (low oxygen levels in the blood) feels like; how you can be completely gorked out from lack of oxygen and believe you are functioning just fine. Showing how tough we were (or ought to have been) we went into chambers filled with tear gas wearing gas masks, and were made to take them off. Then, while choking and coughing and nearly blind, we rammed toothpaste-like tubes with needles at the end into our thighs, squeezing saline (in lieu of atropine) to practice saving ourselves. Over half the guys couldn't do it: push in a needle through dirty pants, no alcohol wipes? No way! Pussies. I was the only one headed to Vietnam: I had no problem. Later, we used parachute trainers, and fired and rode ejection seats up a Disneyland-like tower.

I got onto a Pan Am (note to young readers: it used to be an airline) plane at Travis AFB, dressed in my starchy khaki uniform replete with shiny silver bars on my collar. Cheery stewardesses smiled us all the way to Clark AFB, where I disembarked a couple of weeks before Christmas, onto a steamy-hot tarmac, trying to look like I knew what I was doing. After waiting in several lines, showing my orders to several people who actually did seem to know what they were doing, I found my way to a bed, with plans to begin survival school the next day. Went to the officers' club, where I heard a guy sing "I be home for Chreeesmiss..." After a mostly sleepless night and a ride in a beat-up bus with GIs of various services and rank, I stood in a group of men at the edge of dense tropical jungle. Within three days and two nights out there, we were to learn everything needed to forage and hide, escape and evade an enemy -- not to mention snakes and big bugs. Divided into groups of eight, we headed off in different directions, each with two instructors: an Air Force trainer, and a Negrito genius.

Legendary for the help they gave the Marines during WW II, the Negritos are a pygmy race who populate many of the Philippine Islands. Their chief, we were told, is the only person on the planet not in the US military who is officially entitled to wear the uniform of an Army general. After spending two nights in the jungle with one of their tribe, I have no difficulty whatever believing the several stories I heard of their military prowess. To wit: it's said that during a terribly bloody battle in which Marines where trying to take a strategic hill, they were pinned down for days and taking huge casualties inflicted by machine gunners dug into foxholes further up the hill. At some point the Marine leader was surprised by the arrival of a Negrito leader who offered the help of his men.

The Marine, skeptical but desperate, probably said something like, what the hell, do whatever you want. Next morning the Marines awoke to silence. They crept up the hill, encountering no resistance, eventually making it up to those foxholes, in which they found the enemy gunners, decapitated. On another occasion, a base commander was approached by a Negrito leader who offered to take over security: the base had had a huge problem with thievery and other crimes. The commander wasn't interested, but finally agreed to a challenge: if your men can keep my men off the base tonight, and away from the flight line, I'll forget it, the Negrito man offered. But if we manage to get there, you agree to hire us. Deal, said the commander. He doubled security that night. They heard a few noises, fired off a couple of shots, and kept the base quiet. Next morning the commander and the Negrito leader met. "Guess you lose," said the commander. "Not so fast. Check the shoes of your guards. Every one has a mark on it. Go down to the flight line. Each plane has an X painted on the side." And it was so. And I believe it.

I believe it because I watched my guide, four feet tall and so at one with the jungle that he practically disappeared into it before my eyes, produce fire and water like magic. I saw how he knew where to find food, how to move through the underbrush without leaving a trace; knew which plants stopped bleeding or cured headaches. With a homemade knife and a length of bamboo he produced fire in less than two minutes: slitting off a thick piece of bamboo and then a thin one, he made a bow and string. Another rod of bamboo was carved off and place in the bow in such a way that it spun like a drill as the bow sawed back and forth. The end of the rod was poked onto the remaining bamboo, on the surface of which the guide had carved up a bunch of curls, still attached, like the pubic hair of the Jolly Green Midget. Rowing the bow and spinning the rod, puffing breath onto the curls, he made smoke appear and then fire, in seconds. None of us came close to making a serviceable bow, let alone fire. Later, he showed us how to recognize a particular palm; how to lop it off about a foot above ground, and scoop out the center. Next morning, a gallon of fresh and filtered water filled the bowl. He dug taro root, chopped it up, put it and some water into a section of bamboo from which he'd cut off a trap door and re-attached it after filling the hole. Buried under the fire, it cooked into a (marginally) palatable meal.

Rustling sounds in the jungle kept me awake most of the night. Rats, we were told, were everywhere and had been known to gnaw on fingers. Who knows what else was out there?

Next morning was instruction in E and E (escape and evasion). Find a leafy branch to use as a broom, back your way into underbrush, sweeping away your tracks as you do so. Cover yourself with vines. Negrito kids were hired to find us: we had special dog tags that we had to give them when discovered, and they turned them in to exchange for food and candy. Eventually everyone in my group was found (we were told the kids never failed) but I was the last one. That, despite the humiliation of backing my way into underbrush, sweeping away my tracks like a pro, backing deeper and deeper until I'd showed my camouflaged ass, like a hippo in reverse, to a bunch of instructors smoking and chewing the fat by their jeeps on the road on the other side of the brush. Oops. See ya later.

There were no failing grades. They showed you stuff, you took it in and hoped you'd never use it for real. We were given radios and taught to guide a helicopter to our position in heavy jungle, unable to see it but hearing the sound. Talked them to our position, had them lower a "tree penetrator" (a cable with a heavy bullet-shaped device at the end.) Flaps folded down from it to make a sort of seat you slid under your thighs, then rode the thing up and out of the jungle into the chopper. Scary, but somehow reassuring when I managed to do the whole drill, scrambling into the pounding machine high above the trees.

On the final day, we learned what was known or surmised about POW camps. We saw devices. We read a letter that a prisoner had managed to get to his wife despite the censors: it said, "If he paints the house, tell old Roger to use real enamel." Not knowing anyone named Roger, she'd turned it over to the military, who recognized an acronym. Do you? Tales were told, pictures were shown. I guess the point was to make sure we took seriously the idea of avoiding getting caught. Pretty grim. Suffice it to say, I think surviving that environment isn't a matter of what you're taught: it's about who you are. I'm glad I didn't have to find out.

Dirty Sex and Soldiers

There. That ought to get a few new viewers. And here's a warning: grossness follows.

Medically speaking, my time in Thailand was boring. There were no attacks, no casualties of the sort I'd seen in Vietnam. Since guys weren't scared all the time, there was much less of the depression and jitters amongst the troops. We did get an occasional cobra bite, which could be exciting. The flying I did was also not as much fun: in Vietnam I mostly flew with a squadron of spy planes, low and slow. There were creepy guys in the back doing things I didn't have clearance to know about; but the flying was uninteresting to the pilots, so they were glad to turn the controls over to me. "Roger, rollout one-five-zero," I'd say, as I followed directions from the back. "Roger, climb to flight level eight thousand." Cool hardly describes what I was. Us pilots: shit-hot as we liked to say.

In Thailand, I flew on tankers. Converted Boeing 707s, flying gas tanks, militarily known as a KC-135. I did occasionally get to fly the things, but they were more complicated than the old Gooney Birds of Danang, and I was just kidding myself. Aware of the potential consequences of a gas tank with wings meeting a missile with fangs, I tried to sign on to missions well into the south.

Wrong information got me all the way to Haiphong harbor by Hanoi once, and when I heard the copilot call out "Bandits approaching 6 O'clock," I reached for my survival vest. (That's a story in itself: it contained such things as a hacksaw in a rubber casing, for insertion into one's rectum. It had a beautiful silk cloth with an American flag and a paragraph in sixteen local languages, saying "I am an American citizen. Misfortune has befallen me. ["misfortune." "befallen." Who wrote that stuff?] My government will reward you if you take me to safety." A six-shot .38 pistol was included. Those hot shot pilots, they added a bandoleer containing a couple hundred rounds. Me, I figured if I went down, I'd only need one.)

Once, I got to control the fuel nozzle. From the back of the plane protrudes a long maneuverable hose. It has little wings on it, and by manipulating controls you can make it move up, down, left, right. Lying on your belly, facing backwards and looking out a small window, wearing headphones so you knew when to expect them, your eyes would pop as a group of F-4 fighter planes would swing into view, in formation, just yards from the back of the tanker. One by one they'd fly into position, close enough that you could easily see the pilot, like he was across the dinner table from you. And you'd manipulate the nozzle -- sort of a team effort: you'd move it around a bit as the fighter jock nudged his way into it, and the nozzle would find its way into a receptacle on the nose of the plane. Then we'd fly together like dragonflies do, while I transferred fuel to the fighter.

The one time I did it, the pilot smiled at me (nice blue eyes) and held up a photograph. It showed a particular sex act that one might associate with the feat we'd just accomplished. Prodigious equipment.

Which gets me to the meat, as it were, of the post. Routine in most ways, my medical experience in Thailand was an occasional lesson in tropical medicine; in particular, venereal diseases of which I'd only heard most vaguely in medical school: syphillis, lymphogranuloma venereum, chancroid, and, of course the clap (gonorrhea.) We did see some malaria and plague. But today we're talking crotch. And hygiene, or the lack thereof.

"Hey doc, you treated me a month ago for the clap, and now it's back," he said. "So what do you have," I asked the airman, "the drip, or the burning, or what?" (Those of you who read my book have heard this one.) "The drip," he says. "OK, let's have a look." So he drops his pants to reveal a green stain of pus on his underwear, the size of a salad plate. "Wow," I say. "That's some drip!" "Yeah," he grin/grimaces. "And that's just since Thursday." It was Tuesday.

"Congratulations. You've got the clap," I tell another. "Why the hell don't you guys wear a rubber like I warned you?" I ask. (I'd descended into lecturing all newcomers about VD.) "I did, Doc. I really did." "Did you use it every time?" I ask. "Damn right, doc. Second time I just turned it inside out and used it again." And of course, every day ad nauseum I heard, "Shit doc, you wouldn't take a shower with a raincoat on, would ya?"

There was a persisting rumor about "The Black Clap," a variety so virulent and so resistant to treatment that anyone who got it was spirited away to an island off the coast, never to be heard of again. "Is it true, doc?" "Nah," I'd say. "I've been to the island, and you got nothing to worry about."

For some reason, it fell to the Flight Surgeon's office to control the spread of VD; that included, among other things, making inspections of all the bars and their "staff." Once a week we'd make the rounds, nurses doing pelvic exams and testing for gonorrhea. To whom that ever made sense I was never made aware. I was not among them. We were, of course, offered various incentives to certify the ladies. Despite our efforts -- pathetic as they were -- the attack rate for the GIs who partook was around 90% if they didn't use condoms, and still above 30% if they did: not surprising, given the above examples...

So I did a little experiment with my staff of medics, who were not inclined toward abstinence. I gave them little tubes of neomycin ointment. "You didn't hear it from me," I said as I passed the little saviors out. "But you might want to see what happens if you take a leak and then squirt some of this up your urethra right after sex." "Doc, you're a genius," I heard more than once. In around seventy-five "exposures," there wasn't a single case of the clap. Of course I was loathe to write it up, and never did. And, in retrospect, I was damn lucky none got a contact reaction to the stuff: such things are not unheard of, and in the urethra, one can only imagine what might happen. So don't try it yourself, and don't tell anyone what I did.

Shrinking from duty?

I know I have at least one psychiatrist reader who passes by these parts. So Dr W, this is for you:

As I mentioned a post or two ago, when I was in Vietnam, part of my job was that of a humdrum office doc, when we weren't being rocketed or, rarely, shot at. While humdrum, being in Rocket City wasn't exactly your normal existence, and it was not infrequent that a GI came to see me with the complaint, "Doc, I can't take it anymore."

For most of these poor guys, there really wasn't a hell of a lot to do: sympathy, the occasional specific suggestion, once in a while a kick in the pants. Except in rare circumstances, there was no choice but to send them back to duty. On one or two occasions, I'd give a guy a break, and bed him down in our small inpatient facility for a day or two.

There were lots of backaches, headaches, sore this or that which begged a duty excuse (and I must say that during the time I had to lift my right arm to the desk using my left arm, I got fewer requests for duty excuses); once again, for most it was some sort of analgesic a pat on the back, and return to work. (There was in our pharmacopeia a great drug, called Parafon Forte. I don't know if it's still around or not. It was supposed to be an analgesic, touted in particular for back pain. It was my distinct impression that it was no more effective than aspirin, maybe less. But it was HUGE! And HEXAGONAL! And GREEN! Give a guy a horse-pill like that, and he just knew it was a killer drug; gonna work like a charm. I'd write for a few and add "NO REFILL" in big letters on the prescription. I wasn't above snake oil when it was called for.)

So it happened that among the ebb and flow of unhappy guys in various states of depression, I encountered one who was borderline de-compensating. I decided I needed help, and tried to contact a military psychiatrist in Saigon. It took about three days of calling, leaving messages, radioing, and cursing. Finally I caught up to the man. "Look," he said. "I'm the only military shrink in all of Southeast Asia. I can't deal with guys who are depressed or neurotic, or I'd be swamped. If he's not out-and-out psychotic, you're just gonna have to figure it out yourself." Click.

Well, I thought, I suppose that's reasonable. Poor guy must be overwhelmed, alone as he is; although it did occur to me that Saigon was pretty plush duty. I'd been there. It's a beautiful city, with canals, classic Asian architecture, and at that time was perfectly safe and quiet. Buzzing with commerce, women in traditional garb, men zipping around on scooters, smells of food, noisy markets. No rockets, no sappers (individual sneak attackers -- we had a few). And between drinks and girlfriends, GIs assigned to Saigon picked up the same combat pay that the rest of us did. But heck, he was alone in theater. Whacha gonna do?

I can't recall what exactly I did, but somehow or other I managed my patient and got him back to duty. Time passed. GIs trooped in and out of my office, rockets landed at night, life went on. And then one day I was made aware of a man who'd had a bona fide psychotic episode, and who remained fully delusional and unfit for duty. I gave him a bed and a guard, and began the frustrating process of tracking down the Shrink of Saigon. Messages left, calls placed and re-placed, swear-words issued profusely.

And after another three days or so, during which I worried that I had no idea how to manage the man beyond restraints and a few drugs, the doc got back to me. I described the situation. "Well," he said. "That man is psychotic. Nothing I can do for him here. Send him back to the States."

Beach to beach, cont'd

I figured out right away what had happened: a rocket had, by pure chance, hit my barracks -- slammed into the revetment protecting the bottom floor of the two-story building. It turns out there was far less damage than you'd conclude from the crash and the subsequent chaotic yelling. My mental inventory made note of a pretty painful shoulder, and some blood dripping into my right eye. Dripping, not flowing: I was ok. I got up and out, checked the hall and, seeing no obvious carnage, headed downstairs. The building was dark, and it was nighttime outside. In front of the door lay a guy familiar to me but unknown by name. He was rocking slowly and moaning. "Get a flashlight!" I said to an onlooker. "Get an ambulance here!" I said to another. Meantime, I could see blood on the man's shirt, by his left shoulder. Tearing open his shirt by the neck, I saw that part of his shoulder was missing; when the flashlight arrived, it was apparent that it was bleeding pretty briskly. I took off my shirt and shoved it into the wound, applying firm pressure. That was it. Nothing more I could do until the ambulance showed up, which it did in a few more minutes. I rode with the man to the clinic, helped unload him and get him inside. After clamping and ligating a couple of vessels, and exchanging my shirt for some disinfectant-soaked gauze, I wrapped the shoulder as tightly as possible while a medic got a couple of IVs in. Meanwhile, someone was calling for a chopper. A quick check-over revealed a few more shrapnel wounds, on his buttock and belly. Given our lack of facilities, and his stability at this point, I just documented what I found for the docs at the evac hospital and sent him on his way.

There were a few other casualties; wounds needing cleansing and suturing, taking up a couple of hours. Finally, as the dust was fully settled, I began to pay attention to the fact that my own shoulder hurt like hell. Broken clavicle, as it turned out. Poor timing, given that in a few days I was scheduled for a week's leave in Hong Kong, with my wife scheduled to meet me there. Well, where there's a will, as they say, there's a way...

I called the Army hospital next day to find out how the man was doing. The news shocked me: he'd died in surgery to repair internal abdominal injuries from the shrapnel. I wasn't able to track down the surgeon; the nurse with whom I spoke didn't know the whole story. Even now, I can't imagine what it could have been, given how stable he'd been while at our base. As I said in the previous post, I had it better than most in Vietnam, and didn't handle many major injuries, at least not initially (I was in charge of the medevac flights to Japan, and saw lots of injured in that role, but they'd been stabilized enough to make the flight.) So that man's death bothered me a lot; and again when I saw his name on the subsequent casualty list. And today, miles and years away, I can't remember his name at all.

I only had one GI die in front of me, and I can't remember his name either. It was toward the end of my tour of duty. Because the US was bugging out, we'd had to leave Danang in rather a hurry, as the North Vietnamese made their way relentlessly south, though our base and not long thereafter, to Saigon. We ended up in Thailand, at a hastily re-opened air base in a little town called Takhli, the downtown of which went from one or two bars to fifty literally overnight. With that, of course, came rampant venereal disease. We'd arrived at the base before much in the way of equipment (can you believe it? The military sending undersupplied soldiers to a place?) so we set up shop using cots for exam tables, empty boxes for chairs and desks. We had plenty of penicillin, a few other drugs, virtually no machinery. So when a poor soul developed anaphylaxis (severe allergic reaction, prominent in which is airway constriction), we (and he) were up a creek. We did have a laryngoscope (for passing a breathing tube into the airway) and I managed to intubate his trachea and start squeezing oxygen into him, but it was increasingly difficult as his bronchioles (the smallest airway branches) shut down one by one. Ten by ten. Thousand by thousand. Epinephrine was given to open the airways; at some point I stabbed it directly into his heart (like in Pulp Fiction). But he clearly wasn't responding. We had no heart monitor, no defibrillator, but it became obvious that he was heading toward cardiac arrest. I looked around the empty and echoing room, and in desperation grabbed a lamp and ripped out the electrical cord. Not being much of an electrophysiologist, thinking maybe it would give his heart a jolt, I peeled the wires, plugged in the plug, and touched the raw ends to opposite sides of his left chest. Made his pectoral muscle jump, not much else. And then it was over. How, I wondered as I looked at him lying there, his underwear showing the green stain of his gonorrheal discharge, would we inform his family back in the world?

At this point, I feel I should say something: I think my beach-blogging isn't up to whatever standards I might have had, blogging from home. I don't want to wear out my wifi welcome by taking the time to provide links to words or ideas; so I'm saving the "deeper" posts for later. My war stories aren't as glamorous as some, but I have a few more that might be instructive. Hope you'll understand. And keep coming back anyway; it'll get better, at least in my view, after I return home.

Beach to beach

Beach blogging is harder than I thought: prying surgical stories out of my surf-soaked brain ain't easy. Here comes the best I could do, taking a circuitous route from the sands of the Oregon coast to the gentle breakers of China Beach, in Danang, Vietnam, and then beyond. A major difference between Cannon Beach and China Beach is that at the moment there aren't helicopters patrolling the beach, gunners dangling their feet out the doors, making it safe for us to swim. Plus this water is way too cold to attract me. And there are no Army nurses peeling off their camos to get to their bikinis. Attention span shortened as it is by the lure of walking on the beach, I might have to tell these stories bit by bit.

I got drafted during Vietnam war, at the end of my surgical internship. After three months in San Antonio learning to be a flight surgeon, and a brief stop in the Philippines to take a course in jungle survival and escape and evasion, I found myself in Danang, near the northern end of South Vietnam, just below the ironically named Demilitarized Zone. Danang was otherwise known as Rocket City, and it wasn't because it was where rockets were made or fired. It was where they landed, pretty much every night.

I was at the Air Force base. The big army hospital was across town; may as well have been across a canyon, because driving there was unsafe. We choppered the injured or the really sick to the hospital. On our side of the chasm, we had a clinic with a few inpatient beds. Compared to the grunts, I had it pretty easy. I never slogged through a jungle or slept in a foxhole. I never fired a gun except in training. Arcing up toward me on many a night flight as we took off and landed on surveillance missions, I often saw tracer bullets come close but none made a dent. The rockets, well, they tended to make life a little uncertain, and constantly reminded us that we weren't in Kansas. Like the ones you've been hearing about in the Middle East, they really weren't aimed precisely. In fact, it was said they often were launched from makeshift bamboo cradles. (Typically, in our daily security briefing, we'd be told how many to expect that night: eight, a dozen, sixteen. They saw them being assembled; couldn't go into the villages where they were without permission of the village chief, who'd be killed by the Viet Cong if he gave it. "Friendly villages" they'd been designated.) But they always landed somewhere on base, in clusters. You could hear the whoompf somewhere in the distance, and then several more, one at a time, a few seconds apart, seeming to walk their way closer and closer. The nearby landings were more of a crack -- like close lightning -- than a whoompf. Injuries were random. We thought the rockets were mostly aimed at the flight line, toward the planes. As opposed to the rest of the doctors and nurses, who lived in the center of the base, I lived with the pilots, alongside the airstrip, so we got more than our share. We counted on and took comfort in the odds: lots of acreage, only a few rockets.

As a flight surgeon I was required to log a certain amount of flying time, which is why I was on those missions I mentioned (more in another post?). Otherwise, during the day I was mostly office-bound. "Doc, I can't take it any more" was a common complaint. So were drug problems: detoxing guys who found the practically pure heroin over there more than they'd been used to. Saw a few cases of bubonic plague, believe it or not. (Rats. Plenty of them.) Syphilis. Cerebral malaria, hepatitis, granuloma inguinale. I also gave intake lectures to the newly arrived about snake bites. Cobras, I'd tell them, contrary to popular belief, can't lunge very far; only one third of their total length. 'Course some of them are eighteen feet long...

Being closest to the clinic, when the nighttime rockets began landing, I had to run a few hundred yards to the clinic, ready to receive victims. My sleep pattern was not unlike that of my internship: somnus interruptus. As I ran, ridiculously useless helmet flittering around my head, somewhat more functional flak jacket on my torso, I'd usually see Cobra helicopters firing into the jungle. Sixty rounds a second, many of them tracers, making like a spotlight. Who the hell am I and what am I doing here, I'd think. But I kept running.

On one occasion, I saw four guys nearly stuporous with barely receding fear: a rocket had crashed through the ceiling of their hootch, pronging through the card table at which they were playing poker, drilling itself into the floor without exploding. Guess they all held winning hands that time. And I think they needed a laundry more than they needed me. On another night a rocket hit my barracks, and that one didn't misfire. I was asleep at the time, and wound up in a heap on the floor. I awoke to yelling and screaming....