Mimosa 14, pages 38-41. "Tales of Adventure and Medical Life, Part IX" by Sharon Farber

We leap forward once again, back to contemporary fandom and another installment of what's become our most popular continuing feature -- Sharon Farber's Medical Adventures series. We're happy to report that Sharon was a Nebula Awards finalist this year, for a story that was derived in part from one of her Mimosa articles. And there's more to come yet...

'Tales of Adventure and Medical Life, Part IX'
by Sharon Farber; title illo by Teddy Harvia

Nice people get bad diseases.

That is one of the primary superstitions of medical students and housestaff, and often debated by them. Do nice people really suffer more, or is just that the doctor cares? But it seems true: if a drunk stumbles off a curb he'll spring back up, but a kindly granny will get a blood clot in the brain and die. The scuzbucket who smokes three packs a day and stole your stereo is fine; the dedicated teacher who started his pack-a-day habit in the Army will get lung cancer for sure.

The problem with nice people is that you like them. And if you care too much for someone, you lose your clinical judgement -- you hesitate, you equivocate, you worry too much, you pretend there's no problem. That's why doctors aren't supposed to take care of family members.

One of my medical school roommates had a patient who was young, attractive yet modest, intelligent, an upstanding member of society. He never failed to be polite, even when suffering. He commiserated with the housestaff when they seemed fatigued, thanked them for their concern, and insisted they help themselves to the candy and fruit. He was NICE.

So when his tests came back negative, the doctors knew that had to be wrong. He was so nice, he had to have something bad. Really bad. Probably disfiguring and terminal. So they ordered more tests, and when those were fine too, they didn't give up. They ordered still more arcane studies, looking for even more obscure diseases... Finally the attending caught on, and said, "Look, the guy's fine," and sent him home before they suggested exploratory surgery.

Of course, there are many levels of clinical detachment.

Recently, the Lynchi were kind enough to show me a letter of comment that called me "a callous quack." Now, I certainly take exception with quack. If I were promising to cure your cancer with spinal manipulation, then I'd be a quack. Callous though -- well, yeah. Readers of previous installments will have realized that, without a fair modicum of callousness (self-preservation, if you will), a doctor in training will wind up either ineffectual or an alcoholic. To paraphrase that medical school bible, The House of God by Samuel Shem, "Remember that the patient has the disease."

Think about it -- do you really want a doctor who, upon witnessing disaster, says, "Oh, this is too awful, I'm going to go vomit and then cry. And I'm so upset, I think I'll take the rest of the day off." No, I suspect you'd prefer the cold clinician who will gently push aside the shrieking relatives and then do something.

I have stories where I saw tragedy and suffering, and it affected me. But do you really want to read stuff like this:

The young man's chest wound has burst open and he's covered with pus and blood; the odor is enough to knock you flat. He's screaming. I'm running beside the stretcher as we try to get him to the surgeons, holding his hand and saying, "You're going to be fine." The medical student on surgery is a classmate. "See?" I tell the patient. "This is my friend. He's going to take good care of you." He should have done fine. Before I even have a chance to get back to my ward, they announce a code, and I know that he's died.

Loads o' laughs, eh? Or how about:

The bald, emaciated little boy in pajamas, an IV attached to his arm, sits proudly in his huge black Knight Rider toy car. He's back in the hospital to check on the progress of his soon-to-be-terminal brain tumor. Two equally tiny children, also with pajamas and IVs, stand in front of the car, pretending to check under the hood. It is unbelievably cute and unbelievably tragic. I go into the staffing room so I can wipe my eyes.

These stories aren't callous but they also aren't especially entertaining. And I'm being paid here to be entertaining.

Hey waittaminute -- I'm not being paid here!

# # # #

The last couple episodes have been about people who fake diseases, usually to manipulate family or the medical system. But not all fakers are faking. I learned this important lesson in my fourth year of medical school, on my emergency room rotation. I didn't learn a heck of a lot in the ER, but it was 8 to 5 and no week-end or night call -- in other words, heaven. I spent most of the off time moonlighting in Labor and Delivery at a suburban hospital.

The main problem with the rotation was the pair of surgical interns who alternated 24-hour shifts. The male intern thought I should see a patient, jump to a conclusion, and then support it with tests. The woman thought I should gather all the data before deciding on the diagnosis. I had to alter my mindset 180° every day, something that's not particularly easy for a student, especially one who's been up all night with pregnant women. My main memory of the rotation is of the intern du jour yelling at me for doing things the way the other intern preferred.

I did learn to suture after the fashion, but as people went to surgery clinic for follow-up care, I only once saw the fruits of my labor. A workman I'd sewed up my first day returned to the ER with a new injury six weeks later. Seeing me walk by, he held up the arm I'd repaired and shouted, "Hey Doc! Looks great!" I was intensely relieved. I'd been a bit worried that my patients were all having their wounds fly open once they got home.

One day a neurology resident I knew came down to the ER to consult on a teenager who claimed to be completely paralyzed. I wandered over to watch the exam. Her muscle tone and reflexes seemed okay and she wasn't lying in the floppy manner one would expect with extreme weakness. (Or death. I sometimes don't realize when someone on TV is supposed to have passed on to the Great Beyond, as they clearly retain tone. Or are still breathing. It really helps when someone says, "He's dead, Jim.")

The girl didn't look paralyzed. But she still refused to move.

"Raise your arm," the neurologist said.

She whimpered. "I can't."

So he lifted her arm and let it drop. It fell back onto her chest, but not as quickly as a paralyzed arm should have. Very suspicious. My friend looked at me and raised an eyebrow. Then he lifted her arm, suspended it over the gurney railing, and dropped it. Thunk! He did it again. The arm struck metal again.

The third time, she pulled her supposedly dead arm away. My friend nodded sagely, the fakery confirmed. She was bundled into a wheelchair -- still refusing to walk -- and taken to a suburban psychiatry ward.

A couple of weeks later I left the ER to become the student on the neuro consult service. Before we began, the attending said, "I'd like to read you this letter from a local neurologist. 'Dear Doctor, please remind your residents that the diagnosis for Guillain-Barré exists.'"

It seemed that the girl had been suffering from early acute demyelinating neuropathy, a sudden rapid weakness that often follows an immunization or viral infection. She had become progressively weaker while on the psych ward, and wound up on a ventilator.

Now, had she come into the ER saying, "I feel funny, kind of weak. I'm having trouble walking and it's getting worse," the proper diagnosis would have been suspected immediately. Instead, perhaps worrying that doctors would not be impressed by minor weakness, she exaggerated. And since you obviously can't detect a subtle weakness in someone faking total paralysis, she was misdiagnosed and nearly died.

I've kept this paranoia-inducing lesson in my mind ever since; it's caused me to give the benefit of the doubt to many people with clearly functional (fake, psychogenic) problems for longer than most neurologists would. Sometimes you can find a real problem underneath all the functional overlay (i.e., bullshit). Sometimes you just have to sit back and watch and wait.

It's just not a good idea to exaggerate to your doctor. You'll either have all your problems disbelieved or, what may be worse, believed.

A fellow medical student with unfortunate histrionic tendencies forgot this principle. She went to the ER with a migraine. She should have told the doctor: "It's one of my usual headaches, but it isn't responding to medicine; I need a shot." But no, she had to say, "It's the worst headache of my life." Now, at the Barnes ER the phrase worst headache of my life was properly interpreted as meaning I may have a subarachnoid hemorrhage. I want a lumbar puncture. So she got a spinal tap she didn't really need or enjoy. She blamed me for it, too, because neurologists invented the spinal tap, and I was planning to be a neurologist.

(Lumbar punctures are called LPs. I knew I'd been a doctor too long when I heard the radio announcement 'Win a free LP or cassette', and found myself wondering why the hell anyone would want to win a spinal tap.)

Cases in the ER were usually either boring, sad, annoying, or gruesome. They could also be messy. Nowadays, people wear goggles, gowns, and gloves just to draw blood; in those pre-AIDS days, blood was considered a relatively clean bodily fluid. If it got all over your hands, hair, clothes, shoes, eyes...well, that was an inconvenience, or maybe a fashion statement.

The ER was in the distant corner of the hospital. The only way to get anywhere was down the busy main corridor in front of the cafeteria. I have vivid memories of pushing bloody accident victims past unfortunate visitors who had just enjoyed lunch. Then there was the time we got a woman with a gunshot wound in her breastbone. Every time I compressed her chest, blood oozed out onto my hands and I'd start to slide off. She was so young that the surgery resident got a little desperate -- he sliced into her chest and began open heart massage. I last saw her being rolled off to surgery -- down the corridor in front of the cafeteria, the surgeon's hand inside her. No wonder, when they remodeled, they added a back route out of the ER.

I mostly kept a low profile. The other student was busy chasing after the guy who was later to win the Nursing Service Award, for the intern who slept with the most nurses. My main goals were to get out in time to go moonlight, and to avoid annoying the surgeons. I wasn't out for a rep.

There were three trauma beds in a row by the ambulance entrance. One day a schizophrenic man came in after swallowing half a bottle of aspirin. We wanted him to take an emetic and vomit up the pills. He sat on the middle trauma bed, crossed his arms, and refused.

"You know," said the medicine resident, "you can drink this now, or you can get your stomach pumped."

The patient just grinned.

"Get the nasogastric tube," ordered the doctor, hoping the threat would be enough. Then all hell broke loose -- two cardiac arrests rolled in simultaneously.

The resident shoved the ipecac into my hand. "Get it down him, or put down an NG," he snapped, and went to one of the codes.

There I was, surrounded by chaos. Bed number one was occupied by a dead man, a dozen shouting nurses, doctors, and medics crowded around him doing CPR, putting in lines and tubes, and giving drugs. The same in Bed 3. And Bed 2 has me and a guy who was refusing to swallow ipecac.

"Take this!" I shouted. It was too noisy to communicate any other way.

He shook his head.

I tried reason. "If you don't, you'll wind up dead, or on a machine with a bunch of tubes. That's real uncomfortable." I waved the cup invitingly.

He grinned with lips tight. I think he was enjoying it.

I tried threats. "Drink it, or I'll shove this tube down your nose." Yeah, sure. Like I could pump his stomach without five orderlies to hold him down -- all the orderlies were at the codes. Where I would much rather have been, the drama of life and death being a bit more exciting than too much aspirin.

I tried begging. The patient showed me clenched teeth.

I was getting desperate. The codes would end eventually, and the resident would be furious if I hadn't done anything. Not to mention the fact that this guy was in danger every minute the aspirin stayed in his stomach.

So I held the cup in front of him and shouted, "Open the hangar door, here comes the airplane!"

His mouth dropped open in utter astonishment, and I threw the ipecac in... And suddenly realized that everything had gone silent. The two codes had stopped, completely. Everyone who seconds before had been busily resuscitating the dead were now paused to stare at me, aghast, unable to believe what they had heard.

But hey, it worked!

All illustrations by Teddy Harvia