Probably won't resuscitate (by Danny Chamovitz)

“By all means resuscitate! … implies a splendid life, one not always delightful, but clearly fascinating and fulfilling. A life that, given the essential ingredient of an alert mind, I would want prolonged even at the expense of broken ribs and skin burns from heroic resuscitation.” This is how my father David Chamovitz describes his choice for the title of his autobiography.

Unfortunately, as I write this, the ingredient of an alert mind no longer holds for him. As he lies in the hospital, recovering from pneumonia, his mind has escaped to conversations with his brothers Irv, Allen and Jerry, all long dead. At 88, he is suffering from dementia likely brought on my numerous mini-strokes. Over the past year his cognitive abilities have rapidly declined as he has also lost physical control of walking.

However throughout this, we have been immensely blessed as he has maintained his loving demeanor. And even now, as most of his day is spent lost in yesteryear, he has brief moments of surprising clarity, as when each of his five grandchildren visited him over the past few days. For each he managed to open his eyes, recognize, and give a loving sentence, specific for each one, only to then retreat to conversations with those no longer among us, or to admonitions to let him go home.

“To go home”. Therein lies the rub.

Is he asking to go back to his apartment, to his bed, to Marcia? Or is he asking to go home in the biblical sense? “To go home” is the idiom that my father would often use for his patients, perhaps to make death easier for their loved ones.

Indeed over the past several weeks, as his rapid decline became clear even to him, my father more than once questioned the need to keep living. The pain of his decline, and the panic it induced in him, led him to clearly tell me, about one month ago, that the joy of life, the joy of being around family, did not make his suffering worthwhile anymore. That he had come to terms with the fact that he was not going to improve, and that while he no longer felt a need to live. That daily life was too difficult.

This was the last completely coherent conversation I had with him.

So now as we contemplate our next steps, my sister Raina and I struggle with postponing the looming loss of a parent. On the other hand, my father was clear in his wish – prolong his life only if he has an alert mind. I think love for a parent mandates that we honor this wish.

Epilogue: My father passed away peacefully on January 6, 2014, with my mother and his wonderful care-taker Theodora at his side. Five days earlier we succeeded in honoring his wish and had him released from the hospital to palliative care at home. Among his final words: "likewise" in response to me telling him "I love you", "Shut up!" in response to repeated requests to open his mouth to take medicine, "Hi sweetheart", to my sister the morning before he died.

Tell Me I Didn't Put it There

E

ven after forty-five years, memories of Simon continue to haunt me.  He was a simple man, so it seemed from the initial medical history.  A high school graduate, he opted out of college for earning a living as a salesman in one clothing store after another.  In an era of few working wives the family income was supplemented by his wife’s clerical job. 

Simon had no special interests or skills.  He was not a joiner. Having had no ritual training, he even avoided synagogue life, which further alienated him from potential friends.  He lumbered through his ten-hour workday, arriving home with no more energy than to eat supper, read a newspaper, and listen to the radio news.  (Television had yet to be commonplace.)  Conversation with his wife was sparse and usually concerned money.  He had little to say to his three children.   

 Yet, Simon was a likable soul.  Customers appreciated his gentlemanly behavior: he offered advice without pushing to make a sale.  In my office he was genuinely courteous.  He was embarrassed to admit that he had agreed to come to me only after a mutual friend had reassured him that I would charge a minimum fee.

He a big man who overflowed the sides of my office chair.  His clothes were crumpled, his thinning gray hair was combed but unruly.  Hesitatingly, he offered his reason for coming to me.  “I’ve been bleeding when I go to the toilet. It happens when I move my bowels … for three weeks.” 

He was pale; otherwise his physical examination was normal.  I hoped I would find bleeding hemorrhoids; no such luck.  The next day I performed a proctoscopy, which showed no abnormalities.  Had I missed something?            

At that point Simon asked if he might have cancer.  “What makes you think so?” I asked.

“Well, my father died of it at forty-seven (Simon was sixty-one). My brother died at fifty-five; we never knew his diagnosis but he lost a lot of weight and was in pain for months before he died.  I don’t think I could go through that.”

As he spoke each word I could sense my training being challenged.  My medical mentors, always peering over my shoulder, waited for me to stumble.  If Simon had cancer, would I be able to lie to him?  Of course I must for that was what I was taught only ten years before (in 1946).  Simon wasn’t one of the exceptions listed on the blackboard such as a wealthy corporation executive with an estate to protect.  I temporized.  “It could be colitis or polyps.  Maybe tomorrow’s X-ray of your colon will give the answer.”  He was not cheered but then again, I don’t think I ever saw him smile.

I gave Simon instructions for “cleaning” his bowel in preparation for the X-ray.  I called his wife, Rose to tell her that “the diagnosis might be cancer and if so …”.

Rose interrupted me.  “You mustn’t tell him.  It would kill him.  He’s been talking about nothing else since he finally admitted to me why he was seeing you.  He says he knows he’s going to die like his father and his brother.”  She began to cry. 

“Okay.  We’ll see.  Maybe you should come in with him.  We can talk after I finish the barium enema.”

What I didn’t tell either of them was that, as a resident though I had performed over a hundred X-ray examinations of the bowel, Simon’s would be the first in my new office. I saw no reason to mention my apprehension about the technical aspects of the procedure.  I didn't want to disturb my image as an infallible Harvard specialist.

The next morning my nurse, Pauline, had everything ready.  Simon lay on the X-ray table. A two-liter bag of chalky barium suspended three feet above the table was connected via a tube inserted into Simon's rectum.  I motioned to Pauline.  “Let’s begin.”

  Pauline released the tubing clamp.  As I turned on the fluoroscope to watch the barium enter the rectum, I was chagrined to see barium spreading on the table.  “Stop,” I said to Pauline.  She snapped on the lights. 

“Oops.  The enema tip came out.  Simon, I’ll reinsert it deeper.  Sorry.”  I  couldn’t be sure but I think Pauline was blushing. 

With the lights out again, we resumed.  Barium was entering freely.  All was normal in the rectum and deeper into the sigmoid until “Oh my God!” resounded in my head.  “Look here,” I whispered to Pauline.  The X-ray motor drowned out my voice.  There was a huge mass, which allowed only trickles of barium to advance beyond it.  I took a few X-rays to show to a surgeon.  “Finished,” I said to Pauline and Simon. 

  I returned to my consultation room and sat in my expensive, high-backed chair.  “Look at me.  What a great doctor I am!”  But almost simultaneously I thought, “Oh, my God!  Poor Simon.  Until I found the tumor, it didn’t exist.  Tell me I didn’t put it there!”  Irrational?  I don’t even have to ask.  I guess it was a form of denial; I didn’t want Simon to have cancer and I dreaded handling all that was bound to follow. 

After Simon had dressed, I invited him and Rose into my consultation room.  They could tell from my expression that the news was not good.  “Bad and good,” I started.  “Good in the sense that we’ve localized the problem and good in the sense that there is a large polyp inside the sigmoid."  I drew them a picture to show its location.  "That’s where the bleeding is coming from.  Bad in the sense that you need to have it removed, Simon, to stop the bleeding.”  I didn’t think it was necessary to add the threat of bowel obstruction if he were to procrastinate. 

“Then, it’s not cancer.”  Rose made it a positive statement.

I lied.  “It doesn’t look like cancer but to be honest, only the pathologist will be able to tell us for sure.  If it turns out to be cancer, I'm sure that the surgeon will be able to remove it all.  You’re not your father, Simon.”  He fought back tears.  “You have reason to cry, Simon, but more reason to be optimistic.”  (See the chapter “Down with doubletalk to cancer patients” in my memoir, “By All Means, Resuscitate.”)

Simon wasn’t convinced nor was he wrong.  Within the week he was operated on.  The bowel cancer had spread to his liver.  The huge mass was removed but only to prevent the hideous complication of obstruction.  Since I had nothing good to offer Simon (those were the days before chemotherapy), I told him that he had a "benign (noncancerous) adenoma" and that it had been totally removed.  (With Rose I was truthful.)  Simon felt better after receiving two units of blood but this didn't last long.  His condition rapidly deteriorated as the flesh fell away from his body. 

Simon never returned to work and he never asked questions even as his skin became yellow from progressive liver failure.  He had very little pain.  Oddly, though he had no medical insurance he never expressed concern for the hospital bills that Rose would have to contend with after he was gone.  Two months following surgery and after a three-day coma, Simon died at home.

  So I didn’t kill him, but in my mind he didn’t have cancer till I found it.  That's an ironic way of looking at what happened in Simon's medical story. I was proud of myself for having suspected and proven his true diagnosis but, then again, how could I feel gratified if I was the one who brought out a verdict of death?

Taking Roy for a Swim

Danny: The following is taken from my late father's autobiography "BY ALL MEANS RESUSCITATE!". I'm posting it here in honor of Martin Luther King Day. Our children, who think it wonderfully normal to have an African American President, need to know history, and some of the brave (or stupid) things that many people, including my father, did to try to change the world. The term "African American" was not part of my father's generation lexicon, and I've left his original wordings.

My hometown, Aliquippa, should have been a true example of the melting pot which characterized the American dream. Though numerous ethnic groups settled the town, the Jones and Laughlin Steel Corporation (J&L) which enticed them from Europe and from the USA’s deep south, segregated them by nationality and color by selling each group houses on the various hills. The inhabitants did come together somewhat as mill workers: mid-Europeans were laborers while office and foreman jobs generally were assigned to Anglo-Saxons. Mixing of cultures was more complete in the public schools though a small number of students went to Catholic schools. By 1956, when I returned with my family to live in Aliquippa, most neighborhoods had become integrated except for the continued exclusion of Blacks. It took well more than a decade for that particular wall to come down.

From the days of my childhood to the year of my return to Aliquippa, three public swimming pools existed in the town. The largest was in Plan 12, a predominantly Anglo-Saxon neighborhood, serving several other Plans within a mile or two – for me, about a mile. There was a second pool across the railroad tracks in West Aliquippa, which housed predominantly Poles and Italians. The third pool in Plan 11 Extension, was exclusively for Blacks. The latter were not to be found in the other two pools, at least not until the seventies. There was also a small private pool for more affluent residents of Hillcrest.

Private neighborhood pools were becoming fashionable in the fifties. Soon after we moved into our house on Hospital Drive in 1958, my neighbor, Ed Nanasi, and I approached the DiMattias, builders of all the houses in the neighborhood, to request a parcel of ground for the purpose of building a pool. They made the gift on condition that the pool be named for their son, Daniel, who was killed in an accident not long before. We promised; the honor was ours.

Ed and I invited neighbors to my house one evening. From this meeting grew an organization with elected officers and committees. Membership grew to include first-and-second-generation Italians, Poles, Ukranians, Greeks, Serbians, Croatians, Germans, and Irish – all Caucasian. There were also Jews, Roman and Eastern Orthodox Catholics, and Protestants. Knowledge of democratic process was well-known since many of those involved were active in the steelworkers’ and teachers’ unions. At one meeting I had my comeuppance after making what I thought was a suggestion to streamline our proceedings. A coarse-looking steelworker shouted, “I don’t know who you are, but you’re out of order;” he was correct.

The organizational details escape my memory except for several significant incidents. Mother’s Day in 1960 was never to be forgotten. Volunteers assembled to construct the pool clubhouse. The foundation had been laid; it was now a bricklaying job. There were Ed, a paint chemist, and I, a Harvard internist, making cement (mud) – my only relatives who did this were delivered from Egypt by Moses – carrying it in hods to five professional bricklayers.

We had considerable difficulty keeping up with the demands of “More mud! Get a move on!” After about forty-five minutes of me being pilloried with expletives, one of the bricklayers, an elderly, old-school Italian gentleman, discovered that I was “Dr. Chamovitz.” His embarrassment, his mortification (no pun intended), were touching. To him I was the Professor Doctor equal to a priest in stature. It took a while for me to reassure him that I loved the anonymity and the sharing of this venture, like homesteaders of bygone days raising a neighbor’s barn on the wild prairie. After this dramatic interlude, construction progressed, though at a slower pace out of respect for the doctor.

Marcia served on the bylaws committee. As to membership she suggested the phrase, “regardless of race, creed, or color.” Resistance was heated. “Why bother with ‘color’ since no Blacks live in our area?” was the response.  Residing within walking distance of the pool was a substitute precondition. Marcia kept pushing but to no avail. The committee decided, “We’ll handle the matter when a problem arises.” Marcia was not reassured.

When Roy Hart and family, a Black family with two sons, moved within a stone’s throw of the pool, they applied for membership. Their application was summarily rejected. The father Roy was a steelworker as were most of the pool members. “You know he was accused of using J&L telephones for personal calls,” hardly a capital offense among speeding ticket fixers, numbers writers, and God knows what else. It seemed to Marcia and me that our dream of neighborliness was being vandalized.

These were the dreadful years of the sixties when Detroit was burning from race riots. During an annual Brotherhood meeting I rose to confront the political leaders and clergy who were spewing forth platitudes that had characterized so many fatuous showpiece gatherings.

The following day I was confronted by phone by a Black steelworker, James Downing. “Did you mean what you said last night or are you just another smooth talking White liberal?” That was the moment “to put up or shut up.” I could hear Dad saying, “Just be a good doctor,” as James and I planned our first interracial meeting. It was to be held in my living room. “You bring six Whites and I’ll bring six Blacks.”

One of my six was Eric Garing, my high-school teacher of American Civics. To me he was the epitome of morality, a preacher of excellence in scholarship and justice in human behavior. All that had been twenty years earlier. He was dumbfounded at the opening meeting when he heard angry Blacks attacking the City Council, the schools, and white society in general. His naiveté reminded me of my own childhood acceptance of Negroes sitting upstairs in the theater balcony. Mr. Garing’s reaction paralleled that of visitors to the Holocaust Museum in Washington. They shake their heads from side-to-side in disbelief and say, “I didn’t know.” He was humiliated by these same Blacks who had been his admiring students or so I had assumed.

The most enlightened member of my group was Father Phil Schaffer, a young pastor of the Episcopalian Church. Shortly after we began our deliberations, Father Phil was inspired to remove his clerical garb and go to live for two weeks in a Chicago slum. The experience for him was earth-shattering; he now had a new calling. And for these efforts his congregation ran him out of town. “We want a minister who will devote himself to religion,” was their excuse. I wish I could say I never heard such a remark in a synagogue.

I don’t recall that our group accomplished anything of significance other than meeting alternately in White-and-Black homes. Many Whites had never been in a Black home, let alone been to Plan 11 or Plan 11 Extension, a mix of low-to-middle-class homes bordering the town’s garbage dump. If Blacks had been in a White home, it would have been only with mop and pail in hand. But one of our group’s Blacks was Roy Hart who, as previously mentioned, had moved into a house near the pool.

One morning without any advanced planning, without consulting either the American Civil Liberties Union (ACLU) or any other civil rights group, I called Roy to ask if he felt like taking a swim. Without hesitation he accepted an invitation to be my guest at the Daniel DiMattia Swimming Pool.

Accompanied by Marcia and Danny and attired in bathing suits, Roy and I drove to the pool, walked through the gate, and within minutes, were in the water. Little did I realize that for us it was hot water. But why should that be? Wasn’t I Dr. Chamovitz, physician to many of the members? Wasn’t I one of the pool’s founding fathers? How vindicated I felt not seeing any bather jump out of the water. Nor did any mother haul her child from infested waters. Surely my action would be universally approved.

Hardly! It and we were universally denounced.

That afternoon with only Amy at home, I was visited by three members of the pool board. Poor Amy, sitting on the stairs outside the living room, heard them threaten me “If you ever to do this again, ...” The threat to do what was open-ended. I dared not ask.

When they left, Amy rushed into my arms sobbing, “Daddy, can’t you do something?” Like call the police? How could I explain to my daughter that most of the police were friends and relatives of my attackers? I was paralyzed with the shock, the embarrassment at my naiveté about how far my patients’ goodwill would carry me. It really was sheer arrogance that I hadn’t done my homework to prepare a plan of action, or to consult with the ACLU, for example.

That same afternoon the pool board canceled all guest privileges. Soon after, they were restored, though to blood relatives only.

Almost everyone was scornful in varying degrees of my blatant move to integrate the pool. Marvin Neft, a member of our Jewish congregation, called to offer endorsement. Only Steve Plodinec, an older Serbian friend and businessman, called, saying, “Call me if there’s trouble.”

I remember having visions of burning crosses in the yard. Poor Amy must have suffered even worse fantasies. Raina remembers only being proud of her parents. We had anonymous threatening phone calls but there were no dirty tricks. We did feel isolated from our neighbors. For months I could not escape the feeling that my family and I were in physical jeopardy.

A few days after the event my sister-in-law Irma was having her hair trimmed in Sewickley by a former Aliquippian. He asked Irma if she had heard what her brother-in-law had done. “Yes,” she knew.

He continued. “Can you imagine the kind of Negro he took to the pool, a real shady character?”

Irma replied, with tongue in cheek, “He tried inviting Ralph Bunche, (a famous American United Nations diplomat and Nobel Peace Prize laureate) but he was busy.”

The hairdresser asked, “Who’s Ralph Bunche?”

Did we accomplish anything worthwhile? One teenager, a stranger to us, related some years later that she got into an argument with her parents when she expressed admiration of us. Did we liberate her? Are Roy Hart’s sons less prone to be racists because of one white family’s courage? Did we delay integration that might have come from more considered action? The Plan 12 pool did become integrated several years later when economics forced the closure of the pool on Plan 11. By this time there were a number of neighborhood pools that presumably siphoned off a significant number of politically strong opponents of integration.

Our standing at the Pool had hardly been enhanced by a poolside discussion regarding intermarriage with Marcia participating. This was prompted by the elopement of our baby-sitter, Donna. She had run off with a local Black after prolonged and futile attempts to have her family accept him. Her father was a devoted cardiac patient of mine, an Italian immigrant whose self-image was already marred by a congenital clubfoot. Marcia posited that a shared philosophy of life was more important as a basic ingredient to a happy marriage than was matching skin color. A Catholic worrying about his soul burning in hell would find little solace from a Jewish spouse for whom the concept had no meaning. Similarly, a couple harboring strong but opposing political opinions might tangle over them. Marcia’s conclusion: “Better for a white Jew to marry a black Jew than a white Christian.” So much for intellectual pursuit of the good life. Word went around town that the Chamovitzes were “nigger lovers” and Christian haters.

I did have the shallow satisfaction of confronting my neighbors at a dinner in 1980 when I received the Aliquippa Chamber of Commerce Brotherhood Award. Dad had been the recipient in 1960. (Dad’s fourth-grade English bested many of the college-educated speakers on the program.) He and I were the only Jewish Brotherhood awardees since its inception in 1958.

After introducing my family and giving the perfunctory “Thank Yous,” I lashed out: “And where were you when I needed you, when I ran for Democratic delegate in the Presidential year meant to bring down Richard Nixon (I came in ninth in a field of twelve aspirants beating one Governor Wallace and my two fellow Senator McGovern candidates) and where were you when Roy Hart and my family went for a swim in the Daniel DiMattia Pool?” By then Roy was a county detective; I had him stand up. Dad used to quote a Harry Truman supporter who shouted, “Give ‘em hell, Harry!” That’s what I was doing, but for whose benefit? Surprisingly the award wasn’t rescinded. Only Racheal, Marcia, and Danny acknowledged my remarks.

Soon after, we resigned from the pool, but only after Danny stopped using it. We are still awaiting the refund of our building assessment fee as mandated in the bylaws. In January 2000 I wrote a letter to Roy to remind him of that epical moment in our lives. In return I received a video cassette, a promotional message advocating Roy’s candidacy for the United States Congress. He presented the image of an elder statesman. I doubt that it would have helped his case for membership in the DiMattia Pool.

Better than Money

One of the delightful aspects of adopting a new life in Israel was the move from a fee-for-service payment system to a fixed salaried one, delightful even though entailing a drastic reduction in my income. It was like returning to the days of my medical training when hospitals paid minimal salaries while providing years filled with rich doctor-patient encounters, unencumbered by that ugly word, money.

Whatever the reasons, I was uncomfortable having a patient put money directly into my hands or even discussing fees. I avoided these whenever I could by referring the patient to my secretary. Did I feel guilty thinking I was rewarded enough just by being allowed to provide my services? Or was it my worry that maybe my fee was too high or maybe that I had misjudged the patient’s ability to pay. Or maybe I was tapping into the ill-conceived notion that just talking with a patient didn’t merit a fee. One surgical colleague didn’t charge a patient for his consultation unless it was followed by an operation. He rationalized, obviously incorrectly in my opinion, “If I didn’t operate, I didn’t do anything for the patient.” Matters were greatly alleviated for both the patient and me, when insurance carriers, Blue Shield and Medicare, began paying most of my fees. The following patient put me to the test.

Roland Jasper at age 53 had an attractive, debonair flair as he offered a firm handshake across my desk. “A born salesman,” I thought. In answer to my opening question, “What can I do for you,” he replied, “Not much. It’s just that I’m going across the country to promote and sell encyclopedias to families and schools. It’s very profitable but also very exhausting work. Though I’m feeling fine, I wanted a general checkup to make sure.” At the conclusion of my study, which included routine lab work, a chest x-ray, and an electrocardiogram, I suggested that because of borderline high blood pressure he should lose ten pounds, go easy on salt, and, by all means, quit cigarettes. The multitude of oral medications now popular for hypertension was not in vogue at that time. He agreed to try to comply – he didn’t display much enthusiasm – and said, “See you when I get back in a couple of months.”

On the way out, he stopped at my secretary’s desk and gave her ten dollars as the initial payment on his $110 bill. For the remainder he gave her a post-dated check, cashable two weeks later.

At the appropriate interval the check was deposited. Lo and behold, the following day the bank manager called to inform me that the check had bounced “for insufficient funds.” He continued, “Let me tell you, David, this Jasper guy is a con artist. He’s passed bad checks all over town. I even lent him a few hundred dollars on the basis of his previous year’s tax return, which I later discovered was a fake. Welcome to the club.”

Approximately six months later Roland, without an appointment, popped his head past my office door saying he had palpitations and a severe headache. “Please, can you help me?” The patient I was examining was startled by this rude intrusion. I excused myself to her and went into the waiting room.

“Yes, but on condition that you pay up your old bill and put down another fifty dollars toward your next bill.” I didn’t like myself, sounding so mercenary, but I wasn’t going to let him take advantage of me a second time.

“I can give you fifty dollars now and another fifty tomorrow. The rest, I really can’t say.” That bit of honesty was a step forward.

Something about his expression told me “Con man or not, I believe him and besides, this time he looks sick.” I said, “OK. Hold on for about ten minutes until I finish up with my last patient.” As I turned around I noticed him handing a fifty-dollar bill to my secretary. I mused, “I bet it’s counterfeit.”

As Roland sat on my examining table, I was tempted to begin by discussing his morals. His fearful facial expression dissuaded me from that. Instead I took his blood pressure. 230/130! I checked it repeatedly, in the other arm as well, without noting any significant difference. Among other findings were warm, moist skin and a heart rate of 125/minute. I said to myself, “So what if I’m conned out of a couple hundred dollars! This case is my meat.”

I immediately thought of a severely overactive thyroid, causing “thyroid storm.” Untreated, this can be quickly fatal. Against this was the absence of either a goiter or protruding eyes.

My second choice was an adrenal tumor called “pheochromocytoma.” (The adrenal glands sit on top of the kidneys.) I listened with my stethoscope over his kidney regions and sure enough, there it was: a murmur suggesting the tumor’s increased blood flow. I didn’t have time to congratulate myself for in the next few moments Roland began gasping for breath. Liquid in his lungs was audible without a stethoscope. Sitting him up helped somewhat as did an oxygen mask. I gave him an intravenous injection of a strong, rapidly acting diuretic. Roland was considerably improved by the time the ambulance came to take him to the hospital.

Within two more days urine chemical testing and computerized tomography confirmed the diagnosis. Conservative medical treatment resolved Roland’s symptoms but cure would come only from surgical removal of the tumor. For that I wanted him to be in a medical center for the operation requires a team of experienced, highly qualified surgeons, anesthesiologists, and specialists in hypertension. I had already learned that Roland had hospital insurance but like me, his doctors would have to enjoy the medical experience for monetary remuneration would exist on paper only.

The surgery was successfully performed in a Pittsburgh hospital. Other than the discharge letter from the operating surgeon I lost all track of Roland. Statements of money owed to me were returned, “addressee unknown.” We gave up. Seeking the aid of a collection agency long ago in other trials had lost its appeal for me; it was an angry, fruitless gesture. Satisfaction from a quick diagnosis and cure of a rare disease were to be my reward.

It was five years later that the man with an attractive, debonair flair walked into the office. Roland told my secretary that he just wanted to say, “Hello.” She escorted him into my office. We shook hands and, without any greeting, he handed me a brown paper heavy bag. “Look inside,” he ordered. To my chagrin there were a several handfuls of silver dollar coins. “This is a first payment,” he said. “Believe me (I didn’t) there will be more.” Then, departing, he called back over his shoulder, “And thanks, Doc.”

After the door had closed, I took one of the coins and bit it. Though it stood the test – I wouldn’t have been surprised if it had been chocolate – I thought I should do the same for the whole collection. In today’s competition of “one upmanship” both Roland and I were “one-up,” he for recovering his health at a bargain price and I for having a story to tell my grandchildren.

Just Try to Change a Surgeon

Though doctors' medical licenses generally indicate permission carte blanche from governing medical societies to practice both medicine and surgery; it is generally accepted that surgical procedures will be of a limited nature; it is given to the individual staffs to mandate which procedures and under what conditions an individual doctor may perform an operation. A surgeon may not just walk in to an operating room and perform an appendectomy, e.g.,without his credentials having been been closely scrutinized by a committee of his peers.

Hammering out these rules caused many hard feelings especially when turf battles were involved. A surgeon may say, "I've been taking out tonsils or appendicies before you were born. Why must I stop now?" The answer is easy: he need not stop. He must just prove his qualifications..

I remember one particular surgeon who was irate when the head OR nurse stopped him at the operating room door and refused him admission. Our staff president asked our pathologist along with a significant committee to review the surgeon's previous 10 appendectomies. Tho' each case was diagnosed by the admission surgeon to be an "acute appendicitis," in actuality only one showed evidence of infection.  It was further made clear that the surgeon did not understand the disease as he blatantly wrote in the chart, "Schedule for appendectomy in 2 weeks when I return from my vacation"; surely at least one of the appendicies would have ruptured during that 2 week period if the diagnosis were correct. The reviewing committee decided to require the admitting surgeon to obtain a consultation on every new case of suspected appendicitis. Result? He gracefully stopped treating patients with abdominal pain.

Problems concerning surgical privileges generated much hostility and were a bane of contention in the opening months of the Aliquippa hospital. To the credit of the Aliquippa surgeons and to those general practitioners who for many years had included minor surgery as their domain, Final decisions were, eventually assigned to, board certified surgeons. The very loose rules acceptable for years to the older staff at Beaver County's three hospitals were summarily overturned by Aliquippa's Staff and soon adopted almost overnight in the three other county hospitals. It was not only a significant advance in medical care but also the prevention of potential malpractice suits.

It took longer to eliminate "ghost " surgery. A "surgeon" would be gowned as he said "hello" to his patient at which point another surgeon unbekownst to the patient would walk in and perform the operation. The referring surgeon would collect a major portion of the fee.

“You’ll make no friends serving on the Quality Control Committee,” my brother, Jerry, cautioned me.  It was to be the first of its kind at the Aliquippa Hospital.  At Jerry’s hospital tempers raged during their first attempts at quality control; a couple of meetings ended as members stormed out.

My reaction?  “What!  A Harvard man shirking the responsibility of teaching colleagues and protecting patients?”  “It’s not arrogance,” I mused.  “Rather a solemn obligation to my profession.”  Whatever my noble or immodest motivations, I let myself be maneuvered even to the committee’s chairmanship.  Jerry wished me, “Happy hunting.”

In truth at our first meeting I successfully sidestepped one land mine after another, maintaining a full complement of friends.  It could just as easily have gone otherwise.
 
At first glance a layman or a physician-reviewer might not fault the first patient record to be reviewed.  On the patient’s history page Larry, the orthopedic surgeon, had written: “This forty-five year old male came to the E.R. with a fractured femur.”  End of history.  Then on the physical examination page: “There is marked swelling and deformation of the region of the upper right thigh.  Heart and lungs, normal.”  On the pages meant for progress reports Larry wrote: “Performed closed reduction of femoral fx under gen’l anesthesia.  Cast applied.”  And lastly, three days later: “Patient walking on crutches.  Home.”  The chart furthered included the minimum blood tests required for giving a general anesthetic.  Completely impersonal, not once did Larry indicate that the patient’s name was Carl.
 
“No problem here,” said a member of the committee.
   
“Not so fast,” said another member.  “It just so happens that I’ve been Carl’s family doctor off and on and I know for a fact that he’s quite a heavy drinker.  The history makes no record of this and I see the surgery took place four hours after admission to the E.R., time enough to obtain liver function tests.  None were done.”
     
The first physician, who thought the chart passable, minimized the criticism.  “Carl got through the surgery well enough.  What’s the problem?”
          “C’mon.  Though you’re right, we’re not here to whitewash our colleagues.  The surgery was successful but if the history of alcoholism had been elicited and if liver function tests had been performed, a different anesthetic might have been indicated.  And you know what else?  Mention is made in the nurse’s notes that Carl fractured his leg when he ‘fell down the stairs at home.’  No written comment by Larry.  Listen.  I know this guy’s son.  He’s a violent kid who’s always fighting with his Dad.”
       
“So, you’re saying that the chart is lacking in liver function tests and information as to how the fracture occurred,” I summarized.
   
“I’m saying that as much as I like Larry, apart from making the right diagnosis, he did the work of a carpenter.  I hate to make an example of him but I got out the hospital record of two years ago when I admitted Carl for pneumonia.  Look at what I wrote on the discharge summary: ‘1. Pneumococcal pneumonia.  2. Chronic alcoholism.  3. Aortic stenosis, possibly from rheumatic heart disease.’  Did Larry ask the record room for old records?  Of course, not.  ‘Heart and lungs, normal’, my arse.  Any second year medical student would have heard Carl’s heart murmur.”
     
I added fuel to the fire.  “I doubt that Larry had ever sat down with Carl to ask about work-related financial concerns – nor did he call for a social service consult.  Furthermore I would have given him a gold star if he had verbalized the known myth in patients’ minds that equates a fractured leg with impotency.  So, what are your recommendations?” I asked, looking at each member of the committee.
     
Larry’s critic spoke up.   “Well, I agree that the outcome was satisfactory.  But I think Larry fulfilled only half of his responsibilities.  No disciplinary action is indicated but I believe that the minutes of this review should be given to him.  He’ll be mad as hell.  Put him on the committee next year.”
     
With a unanimous vote we did approve a recommendation that charts of all previous hospitalizations be provided the attending physician as expeditiously as possible.
   
That’s not the end of the story.  After receiving our report, Larry asked to be invited to the next meeting of our committee.  More accurately, he asked for an immediate opportunity to face his critics.  We accommodated him.
   
“What do you guys want from me?  You all trust me with your orthopedic patients.  Dave, I operated on your cousin’s knee and Jim, you let me operate on your wife’s back.”
   
I called a halt.  “Hold it.  No one has challenged your surgical competence.”
   
“Well, at least, thanks for that.  Okay.  Let’s go point by point.  Carl’s alcoholism.  Listen, he eats three meals a day and is as strong as a bull.  The anesthesia was brief, no more than fifteen minutes.  I set the fracture and took an x-ray to see if all was in place and finish.  There wouldn’t have been any ill effects even if he had alcoholic cirrhosis.  You may not know it but the anesthesiologist hasn’t had a great deal of experience with the new less liver-toxic agent.  And if Carl wants to announce that’s he’s a member of AA, that’s his privilege.  Why should I write it in the chart for busybody eyes?  It’s nobody’s business.”
   
The orthopod certainly had a point about privileged information.  We all had struggled with this dilemma.  I remember wanting one particular patient’s history to be complete; I felt smug substituting “sexual identification problem” for “homosexual,” hardly much of a ruse these days.  In an effort to direct others involved in the patient’s care I had divulged privileged information.
     
As chairman of the committee I took the liberty of concluding at the point: “I find little or no fault with your reasoning.  If no one disagrees, let’s move on.”   One hand went up.
     
“Okay.  So I missed the heart murmur.  As I said, Carl is as strong as a bull.  If he could run up three flights of stairs, I couldn’t care less if he has a heart valve problem.  It’s true that if he had had an open wound, I would have known better to prescribe antibiotic therapy to prevent endocarditis.  In that situation I might well have been negligent.  So what do you guys want?  That I have an expensive medical consult on all my cases?”
     
A committee member took me, a medical consultant, off the hook.  “No, you have a good track record for using consultants.  But if you had taken the time to review the discharge summary of the previous admission, you would have been a lot farther ahead.”
   
“No disagreement there and I do like your recommendation that old records be made available with all due haste.  You guys earned your keep with that one.”  (He was being sarcastic since he knew we received no compensation for the committee’s work.)  “As to how Carl broke his leg, I took him at his word that he tripped on the stairs.  If his son pushed him, that’s between them.”  The reader must remember this was in the 1970s before doctors accepted the responsibility for preventing violence in the home.  None of us in the room was sensitive enough to take up the gauntlet.
       
“Lastly.  ‘Sexual impotence?’  You got to be kidding!  No patient is ever going to admit he’s worried about that.”
     
Again, none of us was equipped to give a lesson in the psychodynamics of trauma.  All I could do was to say, “Well, maybe once in awhile you might just ask.”  And I did add the well-known adage that “the patient knows how he feels but not what he’s got; the doctor knows what he’s got but doesn’t know how he feels.”
 
“So now the committee will recommend routine psychiatric consultation on all my fracture cases?
 
I closed the meeting thusly.  “I’m in line to be Staff President next year.  You can make that question your first agenda item as the new chairman of the Quality Control Committee.”
 
Years ago I took a course on “Psychiatry for Internists.”   It was given by a friend, Bob Plesset; I enjoyed it thoroughly.  After the last session, I thanked Bob and added that it would be wonderful if he could repeat the course, but for an audience of surgeons.  He replied, “Listen, Dave.  If I have emotional problems, I’ll go see my internist and if he can’t help, I’ll go to a psychiatrist.  But if I have a surgical problem, I want to be operated on, not by someone who will waste precious anesthesia time by deliberating on all the implications of what he’s doing, but rather by the best man for the job, an out and out bastard.”
 
Maybe we should have left Larry alone.  If Dr. Plesset were right, we would have achieved nothing by trying to change him.  Who knows?  If successful, we may have created an impotent surgeon.

Are You Really My Brother?

It was Hanukah 1984 and we had been living in Israel for three months in a one room apartment in what is called an "Absorption Center", a residential facility for new immigrants. Arieh Dulcin, the Chairman of the Jewish Agency, was addressing us new Israelis.  My Hebrew comprehension was poor but with the help of Marcia and others around me, I understood that something momentous was unfolding in Israel.  “Top secret,” was Dulcin’s description and yet he continued to speak of “Ethiopians” and “mass aliyah” (immigration to Israel).  Dulcin was probably not the first to leak this story.  In the next few days we read in the newspaper that over 7,500 Ethiopian Jews had arrived in Israel during the previous few weeks.  Many had walked hundreds of miles across desert terrain with little more than the clothes on their back.  They crossed the Ethiopian border into Sudan before completing the next leg of their journey by airplane.   Sadly, “Operation Moses” was aborted by the Ethiopian government when their complicity with this exodus was made public; they feared the wrath of the Arab world.

In May 1991 another 15,000 flew from Addis Ababa to Ben Gurion Airport, planeload after planeload arriving within a period of thirty-six hours.  Two more new Israelis arrived than took off, babies born in flight.  Israelis were proud to be able to demonstrate that all Jews are brothers independent of color and culture.  They flocked to the temporary housing centers bringing clothes, blankets, kitchenware, food, and toys.  This is not to say that many problems of absorption didn’t arise soon thereafter but those initial days were indeed intoxicating.

The woman named Miryam who walked into my office one morning in 1992 had been twenty-seven years old in 1984 when her family gathered in a small village near Addis Ababa.  Accompanied by her mother, her husband, and four children and a number of relatives and friends – a total of fifty people – she set out on a 350 mile-walk to the Sudanese border; it took eight weeks.  On the way they experienced the atrocities and hardships inflicted on similar groups: robbery, rape, looting of their meager household goods and jewelry, hunger, sickness, including malaria and tuberculosis, and even death.  Her mother died, as did her baby after two days of a raging fever.  They buried them in shallow graves.  The somewhat obese, stately patient who now faced me, had regained the thirty pounds she had lost during the trek.

Miryam was primitive in appearence, dressed in a brightly multicolored dress with a woven,  rope tied belt.  Her skin was light brown, her hair black with strands of white.  Most striking and distracting were the numerous linear, blue tattoos over her face, across her forehead and along her cheeks.  I was most unsettled by the tattoo under her lower lip; it was a Christian cross.

Accompanying Miryam was an American Israeli social worker, Beatrice.  Before I could begin my consultation I had to have the mystery of the cross resolved.  In English I asked Beatrice about it.  The answer disheartened me.  It was to ward off potential rapists who would not molest a Christian.

The three of us shook hands, the American with a firm grasp, Miryam with a few limp fingers.  Her referral letter indicated that she was one month after surgery for thyroid cancer.  I was being requested to use radioactive iodine to eradicate any cancer cells the surgeon’s knife may have missed.  I asked the relevant questions to establish a full picture of her health and family situation.  Miryam was soft spoken.  We constructed our Hebrew sentences slowly; her vocabulary was broader than mine. 

At age thirty-four she now had five children, two of whom required special schooling.  Her husband, older by twenty years, was working as a gardener on the hospital grounds.  I had to be certain that she wasn’t pregnant and to make clear to her that she mustn’t become pregnant for the ensuing six months.  This was to prevent radiation to a fetus from the radioactive iodine, which could totally destroy a fetus’s thyroid.  She nodded unconvincingly that she understood.  I was somewhat relieved to learn that a normal menstrual period had begun the previous day.

At that point I indicated that I wanted to examine her briefly in reference to the thyroid status.   She made the typical sabra gesture with the waving of her five vertically extended fingers, meaning, “Wait a minute.”  She leaned over to Beatrice, appearing to be asking a question.  I couldn’t make out the words but Beatrice flashed a constrained smile.

“What does she want?” I asked.

“She wants me to find out if you’re Jewish.”

Then I too, smiled but my unspoken reactions varied from “Such chutzpah (impertinence)!” to “What a historical moment!”  How much more significant was Miryam’s inquiry in light of the trauma inflicted on the Ethiopian Jewish community by Israel’s religion ministry.  Despite ample oral confirmation of their Jewish ancestry, individual Ethiopians were being required to undergo mikva (ritual immersion) to establish themselves as legitimate Jews.  There were instances of suicide by young couples who were being forced to undergo this conversion procedure, humiliating to them, before being granted a marriage permit.  A sit-down demonstration was held on Yom Kippur 1985 opposite Hachal Shlomo Synagogue, the seat of rabbinic power in Jerusalem.  This was near the synagogue where Marcia and I were praying; we visited the protestors to express our support.  The Rabbinical Authority would not relent. 

“Are you really my brother?” I answered in the affirmative and authenticated by Beatrice satisfied Miryam.  Our relationship over the following years was warm and trusting.  Between her shyness and my reticence to invade her privacy, I developed only a superficial understanding of her life with one exception.

Two years after her first treatment, Beatrice required a second dose of radioactive iodine.  Again came the discussion regarding avoiding pregnancy.  Miryam now had a sixth child, one year old.  I learned that Miryam could not tolerate birth control pills and wouldn’t use a diaphragm.  An intrauterine coil had caused profuse bleeding.  Her husband, who would not accompany Miryam to my office, had refused to use a condom, to try the rhythm system, or to consider “withdrawal.”  Tube tying, whether for husband or wife, was repugnant to her husband.  I was stymied.  That left only abstinence.  Since there was no urgency to make a decision (her cancer was extremely slow growing), I suggested, “Go home and think about it.”

Miryam came back two days later requesting a note from me to be addressed to her husband, ordering him to abstain from sexual relations with her!  Possibly I should have consulted an expert in Ethiopian culture for I was thinking as an American who wanted to die only of old age and not at the hands of an irate husband.  I declined the request and concluded with, “We’ll go ahead with the treatment.  Do the best you can to avoid becoming pregnant.” 

Successful she was as was the therapy.  She remained well, with one more child, during the next four years prior to my retirement.

We met one more time two years later when I was visiting my former department.  There was a difference in her appearance, which I couldn’t at first define, that is, until Miryam, smiling, pointed to her chin.  The cross was gone with only a faint stain remaining.  Miryam’s absorption into Israel was now complete.  We indeed were family.

Sicker Than I Thought

It never occurred to me when I sat at Rose’s bedside that she would be any different than the scores of patients I had treated with radioactive iodine for an overactive thyroid.  And as with the others, it wasn’t long before her tremulousness, typical of the disease, also infected me; I felt my body trembling in rhythm with hers. 

It was 1950.  I had accepted a fellowship in radioactive iodine research at the Beth Israel Hospital in Boston without even knowing what radioactive iodine was.  Few academicians anticipated that this isotope would herald the field of nuclear medicine.  That it would play such a significant role in my life was hardly in my mind; I initially thought of the job merely as a stepping-stone to an appointment as a Resident in Internal Medicine.  In fact it was to lead me to my wife and to a successful move to Israel.  But that’s another story.

Rose K., age thirty-five, looking fifty-five, was a mother of three children; the youngest was five years old.  Her husband, age forty, hadn’t been employed for several years because of unexplained bleeding in his extremities – more on this in a moment.  They lived in a three-room apartment in a public housing project, subsisting on welfare checks and food stamps.  One child had a seizure disorder, another, asthma.  Rose had little reason to smile.  On the contrary, she was haggard, appearing malnourished with cracked lips and a vitamin-deficient, smooth, red tongue.  Her gaunt cheeks sagged, as did the skin of her arms, indications of a recent twenty-pound weight loss.  Her skin was warm and her pulse, fast.  All of these signs were typical of patients with hyperthyroidism, an overactive thyroid.  But why didn’t she have protuberant eyes and an enlarged thyroid gland, other findings typical of this disease?  I would soon learn the answer.

At this point it was obvious that I would have another candidate to add to my growing research study dealing with the use of radioactive iodine in the treatment of hyperthyroidism.  A few more and a pioneer publication could be expected, maybe even a presentation at a national medical meeting.  This sequence didn’t unfold quite as I imagined it would.

I explained to Rose the nature of the radioactive iodine test to be performed the next morning.  It would measure the function of her thyroid gland, information essential for arriving at a proper treatment dose of radioactive iodine.  I even anticipated this treatment by explaining that radiation from the dose I would give her would gradually shrink her gland over six to twelve weeks and, thereby, reduce its function.  Most patients would be cured by the end of that period.

The following morning Rose was brought to my lab in a wheel chair – her muscles too weakened to permit walking.  I gave her a drink of a small dose of radioactive iodine.  The following morning she returned for measurement of the amount of radioactive iodine collected by her thyroid gland.  In normal patients the answer would be 15-30%.  In a patient with an overactive gland it would be 35-80%.  Imagine my dismay when Rose’s measurement was 1%.  First I blamed my technique.  Had I given her water instead of radioactive iodine?  The presence of a significant amount of radioactive iodine in a urine sample discounted that possibility.  Next I blamed the equipment.  I checked the electrical connections on our homemade, primitive set-up.  Finally a successful check of a known quantity of radioactive material proved that I had to look elsewhere for the answer.

After Rose returned to her room, someone suggested that she might have been taking diet pills and just neglected to tell us.  In that era diet pills contained thyroid extract in quantities sufficient not only to block thyroid function (and reduce the entrance of iodine into the gland) but also to cause adverse effects on the body, which simulate the findings of an overactive thyroid. We called the unit and had the intern ask the patient if she was taking diet pills.  The intern spoke with me.  “Rose appeared irate and emphatically denied this.” 

I thereupon requested the nurse to send Rose back to the lab for “retesting.”  During the time that she was with me – I feigned a change in technique for measuring her thyroid activity – the nurses inspected Rose’s bedside table and locker.  Lo and behold, two bottles filled with thyroid pills were found!  The nurse phoned with this startling finding.  The mystery of hyperthyroidism associated with low iodine uptake was solved, as was the absence of protruding eyes and an enlarged thyroid gland.  A dose as little as four tablets a day would mimic hyperthyroidism.

I took Rose into a private office and confronted her.  “Rose, tell me about the bottles of thyroid pills in your belongings.”

At first she looked at me with scorn.  I suppose it was when she realized that I cared about her, that she broke down, sobbing, “I want to die.”  In the ensuing hour her tale unfolded.  More than depressed, she was angry – angry at life but more specifically, at her husband.  “He’s never held down a job.  He just sits around all day listening to the radio or studying a racing form.  Of course, that is, when he’s not in the hospital.”

“Why,” I asked, “does he need to be in the hospital?”

“‘Need to be in the hospital?’  That’s funny.  He’ll kill me if I tell you.  Oh, what the hell!  I told you that he has bleeding in his arms and legs.  Your blood department has been struggling to diagnose a rare bleeding disease.  Well, there is none.  He just bangs his legs against the toilet bowl and his arms against the sink until they are black and blue.  He loves being fussed over by the doctors and nurses.”

“But, Rose, what’s this got to do with your taking thyroid pills?”  She had admitted to taking fifteen to twenty a day, a dose that, if continued, would eventually kill her.  She knew it.  I suggested that, “there are faster ways of killing yourself.”

“That’s the point.  I wanted to make my husband suffer as he watched me dying, not that he could care much once I’m gone.”  I was now getting over my head into psychiatric waters that called for the involvement of a psychiatrist; this I arranged for both Rose and her husband.  (The latter’s hematologists on first hearing of the self-inflicted lesions wanted to kill him for wasting their precious time and resources.)

Putting a name thyrotoxicosis factitia on Rose’s condition didn’t help except as the title of her case report that was published in a medical journal a year after our first encounter.  Rose was checked in the thyroid clinic ten months after stopping thyroid pills; her gland function was normal. 

It is a sad commentary that neither my memory nor the article gives any indication of the family’s psychiatric follow-up.  It’s not conceivable that I cared only about getting my name in the medical literature.  Or is it?

A Doctor in the Family

This chapter could be titled mea culpa or the Hebrew parallel, “al het,” asking forgiveness “for the sin ... .”   Though not sealed in any oath equivalent to that of Hippocrates, an admonition not to treat one’s own family is nearly as binding.  And yet, many times there were extenuating circumstances, which placed me in a compromising role I could not avoid.

Take for example my treating my wife, Marcia, for “the flu.”  In the fall of 1954, we were living in Boston while I began a two-year fellowship in internal medicine at Lahey Clinic. Marcia developed symptoms typical of an upper respiratory infection: low-grade fever, sore throat, coryza, and a non-productive cough.  I listened to her lungs with a stethoscope and heard no abnormal sounds.

The following day when her temperature rose and her cough became productive, I threw in the towel and called a seasoned internist-colleague.  Within a couple of hours he examined Marcia and heard moist crackles – rales – in one of her lungs.  “I believe Marcia has pneumonia, Dave.  Let’s take her to the hospital for a chest x-ray.”  And, of course, the diagnosis was confirmed; Marcia was hospitalized and quickly recovered on penicillin therapy.

It is possible that the “rales” may have developed between the time of my exam and my friend’s.  More likely, thinking wishfully, I tuned them out.  And therein lies the inescapable truism: as physician to one’s family, the doctor’s judgment is faulty.  He will go to the extremes of denial, wishing away any abnormal findings. Accordingly this relationship is to be avoided whenever possible as will be re-enforced by other examples that follow.

I was one of three internists who treated heart patients in Aliquippa.  The other two are now dead so I can freely claim that I was the most experienced and up-to-date with newly developed techniques.  It therefore seemed logical to me to be my mother’s doctor when she developed heart trouble.  The relationship worked well for several years until one day in 1971 when my mother was 84 years old.  Over the telephone I could hear that she was in severe congestive heart failure.  I called an ambulance; we arrived at Mom’s house almost simultaneously.  We sat her up in the ambulance stretcher; this gave some relief.  As soon as she was in a hospital bed, I began the then state-of-the-art therapy.  First order of treatment was to put an oxygen mask on her.  I then applied tourniquets to her legs and arms, which lowered the work of her heart by reducing the circulating blood volume (not to worry, the tourniquets were removed at set intervals so that no extremity went without circulation for too long). This should have worked.  A nurse administered an injection of morphine to try to relax my mother’s frantic breathing efforts.  I then gave an intra-muscular injection of a mercurial diuretic again to reduce the fluid, which was backed up in her lungs.  Lastly, I injected intravenous aminophylline to relieve bronchospasm.  I won’t say I was proud of myself but I was self-consciously aware of the nurses watching me take control of the situation with such dispatch.

The only problem was that nothing I did seemed to improve my mother’s dire condition.  I was at a loss for something more to do for my mother who would soon die.  A “code blue” announcement went forth over the loudspeaker system, which would bring more help.  I don’t know who was inspired to initiate the call but within minutes in rushed Dr. Horto, our Turkish anesthesiologist.  He assessed the situation in less than a minute and within another, without asking my permission, inserted a tube through my mother’s mouth into her trachea.  Immediately he began pumping oxygen under considerable pressure.  This would force fluid from the breathing spaces in her lungs into the blood stream, making room for exchange of oxygen and carbon dioxide.  Within two to three minutes my mother’s breathing was easier and much less bubbly.  Her previously blue nail beds began to pink up, indicating improved oxygenation of her tissues.  (If my mother had been fully aware, removing her meticulously applied fingernail polish to expose the underlying innate color would have angered her.)  Within five minutes of Dr. Horto’s treatment, Mom opened her eyes and smiled at me.  Because of the tube, she couldn’t talk but it was evident that she was out of trouble.  Within ten days she was fully mobile and was discharged home.

Where had I failed?  It was obvious that I couldn’t bring myself to carry out the most significant therapeutic measure on my own mother; it was just too invasive.  Mom lived reasonably active another three years until her heart failure returned, that time not to be reversed.  Within hours she was dead.  As she was dying I spoke with my brother, Jerry, a superb physician, who asked, “Are you ready to let go?”

I replied with a choked, “Yes.”  I would not have been three years earlier.

The issues are clear.  With my wife, wishful thinking blunted my diagnostic acumen.  With my mother aggressive action on my part was unthinkable, too disrespectful, too unfilial.  My role as a physician was subverted.

At least I did act appropriately, albeit harshly, when Mom at age 82 caused a traffic accident in which her car was nearly totaled; she got out of the car and, adjusting her hairpiece, asked a passerby to call her son.  It was painful for me to take the driver’s license away from my mother but I gritted my teeth and did it. (Ff turnabout is fair play, my children did this to me last month!) She was less accepting when two years later, I took control of her checkbook.

My daughter Amy was not always easy to read.  As I look back on her short life, I have to admit that I, we – Marcia and I – more than once questioned her judgment as when at age six, she shouted that a suitcase had just fallen off our car luggage rack; 100 miles later she was vindicated.  So when she rather casually claimed a broken leg from what I witnessed as a rather gentle fall while skiing, I had her sit while the rest of the family finished our ski afternoon.  To placate her when we arrived home, I took her into the x-ray room of my office and x-rayed her leg.  I couldn’t believe the result: a long spiral fracture of the tibia.  I was in no way exonerated when both the ER nurse and, subsequently, the orthopedic surgeon asked, “Which leg?”  Fortunately no harm came to Amy by the several hour delay in my making the diagnosis, not even significant pain.  Both of these incidents did give her leverage in subsequent disagreements with me.

A judgment error for which I probably will never forgive myself also concerned Amy.  It was the morning after we had retrieved her from Hampshire College in Amherst, Massachusetts.  Afflicted with manic depression, Amy had made superficial cuts on her wrists.  She called us from the infirmary to say that she felt like jumping out of a window.  Marcia was at her bedside within hours while I arrived some time later by car.  Immediately on our return home we made an appointment for the following morning with a psychiatrist in Pittsburgh, thirty miles away.  That morning Amy was acting strangely; that was the only description I could apply.  As we got into the car, she was acting somnolent and “acting” was what we thought was the explanation.  I wavered between going directly to my hospital one minute away and proceeding on to Pittsburgh, an hour away.  I elected the latter.

By the time we got to the psychiatrist, Amy was in a deep slumber.  He ordered us to proceed directly to a nearby hospital where remnants of sleeping capsules were aspirated from her stomach.  Amy lay in a coma for two days during which time I didn’t budge from her unit; I had to be there when she awoke or if further complications were to develop.  She did eventually recover; I didn’t.  It is obvious that my judgment was terribly impaired.  How could I think it was just another of Amy’s tricks?  Or was I afraid to confront the staff of my hospital  – where I was "infallible" – with the reality of my mentally sick daughter? 

The most recent incident of questionable professional conduct occurred in reference to Marcia’s resolve to donate a kidney to her niece.  The final decision regarding her acceptability and ultimately the surgery were in the hands of a team in New York.  She received instructions for arranging a preliminary battery of tests here in Israel.  In addition, forms for a complete history and physical examination were to be completed by a doctor. Marcia had no family doctor and certainly no one could document as complete a history and as expeditiously as I.  I therefore undertook the responsibility.  I assiduously performed each examination as objectively as possible. It took concerted effort to fight the desire not to find any abnormality. Certainly I could not overlook any finding that might jeopardize Marcia’s life should she undergo the nephrectomy.  The only important finding was borderline high blood pressure. I was not concerned but reported it accurately.

When the surgeon who was responsible for Marcia approached her, it was obvious that he was riled up over something. Immediately Marcia saw him as an adversary who would prevent her from saving her niece’s life.  “We never use a sixty-six-year-old donor unless it’s for her own child. And does your husband not know how unethical it was for him to do your history and physical?” Marcia listed my professional qualifications, all irrelevant.

By the time the surgeon took Marcia’s blood pressure, she was in a rage and her blood pressure proved it. “Your husband lied! Your blood pressure is not 160/80.  It’s 200/100!”

 “Do you think my husband wants me to die?  Let someone else take my blood pressure in another hour.” She was terrified of further antagonizing him, lest he disqualify her as a donor.

Well, the surgeon was not entirely wrong about my completing Marcia’s examination.  But not only did he not seek an explanation, he didn’t suggest having a colleague redo the exam.  Eventually she went through the surgery and with no untoward effects, her niece was restored to good health, and a year later the surgeon was looking for a new job.

Every once in awhile when I’m berating myself, I wander back in my mind to 1967 to our family trip to Israel.  We were at a swimming pool in Eilat when Danny, age four, cut his forehead.  The cut was about one centimeter wide but deep.  We rushed him to a local clinic where the nurse indicated that no doctor would be available for another hour.  Hearing that I was a doctor, without checking my credentials, she handed me a sterile suturing kit.  With the help of a local anesthetic I deftly applied two sutures.  I was pleased with my handy work but much more so when Danny said, “Gee, Dad, you’re a great doctor.”

The Art of Dying

I cringe when I hear, “He died such a nice death!”  This description is an oxymoron since I never think of death as being nice.  Modifying the expression to “dying nicely,” that’s another matter.  This implies patient equanimity after a full and long life, freedom from pain and other distressing symptoms, the energy to put one’s affairs in order, a support system of family and friends, and time to say goodbye.

I remember well the description of the death scene surrounding a national officer of a Jewish organization.  I had witnessed his statesman-like qualities as he chaired board meetings and exasperating plenary sessions of conventions.  I also had an opportunity to get to know him personally on a tour of Israel.  When his inevitable death approached, he spent his days in bed at home, bringing order to his personal affairs and involvement in numerous civic and charitable organizations.  He cheerfully greeted numerous well-wishers, consoling them as much as being consoled by their visits.  He did not exhort God to change the evil decree.  From all that I heard, he was as much a mensch while dying as he was while living.

Without a statistical survey to corroborate my observations, I would say that the process of dying seldom matches what I’ve just described.  In defense of others whose deathbed scenes weren’t so peaceful, my friend’s mental functions continued intact and his symptoms were kept under control without clouding his intellect.  This contrasts shaprly with a patient of mine, a seventy-three-year old merchant, who was terrified of dying.  He wouldn’t close his eyes for fear of not waking up and refused sedatives for the same reason.  He railed against God for punishing him with an agonizing illness.  He refused psychiatric counseling and was disdainful of his rabbi, even refusing to allow him in his hospital room.  He struggled to his last breath, all of which added to the suffering of his wife and children.

And being a cleric did not sustain another terminal cancer patient.  Pain from prostate cancer, which had spread to all his bones, was controlled with minimal dulling of his senses.  It was ironic that this fifty-two-year old priest would be asking me, “Why would God punish me?  I’ve sacrificed my life to his service and this is my reward?”  Ill equipped to enter a theological dialogue, I resisted the platitudinous reference to Job and God testing his faith.  I did give him an opportunity to ventilate and I expressed my admiration of his contribution to our community.  This fell short of relieving his religious turmoil. 

Or the Protestant minister who during an Easter sermon had said, “I can’t wait to get to heaven and sit at the feet of my Lord Jesus Christ.”  Seventeen years later at age seventy-six, when he was suffering the ravages of untreatable lung cancer, it became time to test his declaration.  He failed abysmally for he, too, was terrified of closing his eyes.  I requested the patient’s wife to seek the help of her husband’s pastoral superior but, like me, he also was at a loss to bring solace to his colleague.

Then there are the innumerable patients who are seldom awake as the large doses of morphine that are needed to relieve their agony, dull their ability to communicate.  Relief of pain dominates the entire process of dying.  Hopefully, conflicts were resolved and goodbyes, tendered before this stage was reached.

Neither patients nor their doctors have any control over the myriad scenarios by which the dying process presents itself.  Nor does the patient’s psychological makeup always determine how he will react to his particular scenario.

Clara, a fifty-four-year-old schoolteacher, normally cheerful and stoical, lay dying of inoperable widespread cancer, which had caused intestinal obstruction.  Chemotherapy had failed months before.  A plastic tube entered her nose on its way to the small intestine.  There were intravenous needles in each arm, both covered with hemorrhages under the skin from failed IV’s and numerous attempts to draw blood for laboratory tests and, of course, there was a catheter into her bladder.  This was not a scene one would call conducive to equanimity.  She and I had already talked about relieving her intestinal obstruction symptoms by performing a hazardous ileostomy so that the nasal tube could be removed, permitting her to eat.  Clara declined this, asking that I let her die.  “Please take out all these dreadful tubes and let it end.”  I told her that without the nasal tube she would be in terrible pain and would soon be vomiting feces; without the catheter, she would develop painful urinary retention.  On the other hand without the intravenous solutions she would starve to death, usually a painless process, taking about ten days.  As though a judge were offering her death either by the electric chair, by a lethal injection, or by hanging, she made her choice.  “Stop the IVs.”  The idea was intolerable to the family and to the nurses who saw their role as nurturers.  Finally, accepting the patient’s decision, everyone consented to abide by her wishes.  Clara required little more than frequent mouth care.  She became more relaxed knowing that her travail would soon be over.  She had more patience for discussions with her husband and children.  The onset of coma was gradual; she died in her sleep from ventricular fibrillation.  An order “Do not resuscitate,” previously signed by the patient, was honored.

Terminally ill patients, particularly those who have witnessed the death of a family member, fear uncontrolled pain.  But equally frightening is the prospect of suffocation.  Medical ethicists debate whether or not intubation (placing a plastic tube into the trachea to allow easy passage of oxygen) falls in the category of “invasive” procedures for the patient who has declared that nothing invasive be undertaken to keep him alive.  In the case of John T. who was dying of emphysema, it was doubtful that intubation would have done more than relieve the exhaustion from the work required to move air in and out of his lungs.  Watching a patient struggle for every breath is a most unpleasant experience; for the patient it is a nightmare.  John had smoked two to three packs of cigarettes daily for forty-five of his sixty-five years.  A six-month attempt at reversing the disease by ceasing smoking at age sixty-three came too late; his disease was irreversible.  For a year he had managed to leave the house carrying a canister of oxygen but in the last six months he didn’t have the strength to get out of bed.   

John’s wife and children couldn’t get past their anger for his self-inflicted premature departure from their lives.  No one shed a tear in his presence.  Meaningful communication hadn’t taken place for months.  When it came time to consider helping John’s breathing with an endotrachial or a tracheotomy tube (in his neck), no one in his family could discuss the matter dispassionately.  John, between strained breaths, expressed a desire to die quickly and as soon as possible.  And yet when he and I sat alone to discuss this wish, he hardly mentioned his fear of suffocating.  “I can’t face my family day in, day out.  No one talks to me.  My kids hardly ever visit me.  You would think that they would understand cigarette addiction and not treat me like a pariah.  Everybody would be better off if I were out of the picture.”  I felt I earned my degree that day when I arranged a consultation with a family psychotherapist.  After three home visits not only had a relaxed rapport developed between John and his family, but even his breathing improved by a few, but significant, percentage points.  Six months later John lapsed into coma and died nicely at home surrounded by family.

Cousin Saul, age sixty-three, a brilliant physician, fell into an altogether different category of incurable illnesses shared by so many patients with a stroke or Alzheimer’s disease.  Saul’s stroke was massive resulting in paraplegia and expressive aphasia.  Though totally aware of his surroundings, in no manner could he communicate with the hospital staff or with family.  When my brother Jerry flew from Pittsburgh to California to visit Saul, he couldn’t wait to leave the room for all Saul did was cry silently from the frustration of not being able to speak.  Jerry compared Saul’s plight to that of a trapped animal.  He wished that he were able to place a pillow over our cousin’s face and end his agony.  In such situations all a patient’s preparations to face death soberly and with dignity fail under siege by forces beyond his control.  We onlookers breathe a sigh of relief when the patient’s eyes are finally closed forever.  “Thank God, his dying is over.”

Too seldom are Hollywood scripts adhered to.  There are exceptions; these add beauty to our lives.  Take Janet M., a close family friend.  Wasting away from the ravages of breast cancer, she designed her own home hospice situation before the word had become a functioning concept.  Janet lay in her bed giving solace to her husband and children.  She was able to handle with humor her admonition to her husband to look for a second wife.

And dear friend Beecie.  She said to my wife, Marcia, “I think it’s time to get my portrait painted.”  She was referring to the joke concerning a woman, who after her portrait was finished, asked the artist to add conspicuous items of precious jewelry, earrings, a necklace, and even a tiara.

“But why, if you don’t have any,” asked the puzzled artist. 

She answered, “I want to drive my husband’s next wife crazy looking for them.”  Beecie didn’t mean it.

Then there was Mary M., age forty-five, who astounded her physicians by persisting free of symptoms despite widespread bone metastases.  At the time of my frequent examinations we actually joked about my helplessness (and that of my consultants) to influence the inevitable shortening of her life.  Not deeply religious, she verbalized her curiosity about the afterworld she was certain existed.  Speaking to Marcia, she said, “Keep your eyes and ears open.  I’ll find a way to stay in touch with you.  I’ll want to know about the books you’re reading.”

My Aunt Rose deserves honorable mention as an example of a strong life force carrying her through what would have been insurmountable difficulties for the average person.  She suffered from blood flow problems to her legs which would lead to their eventual amputation. In her eighties she underwent by-pass surgery to improve the circulation in her legs, delaying amputation by three years.  When gangrene developed in her toes, she accepted amputation of the foot and when this failed, amputation of her leg above the knee.  She was zealous with her exercise program; within a few months Aunt Rose was walking with a prosthesis and a walker.  She rarely missed a family function or a Friday evening synagogue service.  It was only in the last week of her life six years after the first amputation, that she became delirious as a result of gangrene of the remaining leg.  She died within days after a second amputation, six months short of her ninetieth birthday.

Without entering the debate on assisted suicide, I can categorically state that the most pleasant dying scene I have ever witnessed was Sara’s (described in detail in Down with doubletalk to cancer patients in my memoir, By All Means, Resuscitate).  With no further treatment available for her rapidly advancing cancer, she lay in her own bed enveloped in loving care that only family and hospice could provide.  Pain therapy was minimally effective but fortunately did nothing to dull her mind.  Already having problems with swallowing and breathing, she knew that suffocation was around the corner.  Paralysis in one arm would soon extend to all four limbs.  She discussed every imaginable subject with her family.  With me she reviewed her life story, her aspirations, and her satisfaction with the end-of-life plans she had designed.  She joked with us all.  No one cried, not even at the moment Sara swallowed the life-ending capsules; I had said goodbye an hour before, reluctantly following legal advice not to accompany Sara to life’s exit.

The expression “dignified death” troubles me.  In many instances it is the family’s dignity, which is offended by the death scene.  The patient may be beyond concern for his appearance or the foul smells of his uncontrolled excretions; we, his family, are.  So we make frequent diaper changes, bathe him and give mouth care, change his bed sheets and pajamas, and comb his hair.  Or if unable to provide homecare, we choose the nursing home with the least offensive ammonia odor.  Since we are compelled to give all respect to the body after a person dies, how much more so do we demonstrate this respect while the patient remains alive.

End of life decisions frequently are thrust upon us on an untimely basis.  Heroic resuscitative maneuvers on a terminal patient are instituted by well-intentioned emergency room personnel before completely assessing the patient’s situation and before any discussion with family.  The urgency of the moment does not allow time for perusing prior charts; the “Do not resuscitate” order lies in limbo.  But a red line has been crossed.  Discontinuing life supports is more complicated than arranging not to begin them.  The former may require a court order if doctors aren’t in agreement with the family.  And at this point it is not the patient’s dignity, which is in jeopardy, rather the family’s.  Conflicts arise among them over the decision to “pull the plug.”  “For whose sake are we doing it?  What’s your hurry?  Are you impatient to end the dying process?  Are you concerned about wasting our inheritance?”

I was afflicted with these ruminations when my brother Jerry suffered a massive stroke after coronary by-pass surgery.  MRI showed that a large, vital section of his brain was destroyed.  It was almost certain that he would never awake from his coma and if he did, the best we could expect would be an existence like that which Cousin Saul achieved; Jerry had stated categorically to me that he would never want that kind of life.  The doctors agreed that supports should be withdrawn.  The only question was, “When?”  It was only day two of this final illness.  Jerry’s son asked that it not be on his own birthday, which would be day three.  What about my plane reservations taking me back to Israel, which allowed only enough time for burial and the prescribed days of mourning?  Or Jerry’s wife Irma’s wish to keep Jerry with her as long as possible.  All of us tried to be objective when we made the decision to detach Jerry from the respirator.  I, for one, didn’t feel dignified in the process.  Many years later my discomfort remains.

So, we all, patient, family, and physician, work to lessen the tragedy of death. The patient tries to resign himself to the inevitability of his demise and to put his financial and emotional affairs in order.  His family is obliged to share the patient’s reaction to death, to be able to discuss their sorrow on losing him while not resisting his acceptance of dying.  Lastly, the physician must broaden his role of healer to caregiver until the patient’s last breath.  This requires learning to let go, listening to the patient’s fears and desires, being receptive to follow whatever path the patient requests within limits of the law, and on rare occasions extending these limits.  Each participant can then be said to have acted with nobility and. dignity