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

Was it for Love or Money?

The last eighteen years of my life in the United States were spent shepherding the development and growth of the Aliquippa Hospital cardiac care unit (CCU).  Preventing deaths of cardiac patients was an almost daily occurrence for me and my staff.  Those were heady days as one medical advance followed quickly on the heels of another, and consequently, death rate from heart attacks fell from thirty to fifteen percent.  If I wasn’t involved with each individual incident, at least those I had trained were.

 For the many hours of service to the unit, I received no financial remuneration, not a nickel; at least not until the final five years when I did receive a token stipend.  I won’t deny though that as the reputation of the CCU sprouted, so did the size of my cardiology practice and my income. 

Since Aliquippa Hospital had no interns or residents, almost nightly a CCU nurse woke me with a question about either one of my patients or that of another doctor.  Three or four nights a week a visit to the hospital was necessary, which made my living a few hundred yards down the road an advantage.  From time to time my visit would entail a time-consuming insertion of an intravenous cardiac pacemaker wire or a catheter into a pulmonary artery to aid the treatment of shock.  These visits were medically fulfilling while frequently yielding significant fees.  Many times I asked myself, “Am I getting out of bed for the money?”  And if it was for a non-paying patient, “Was this one just to ease my conscience?”  I usually answered myself; “I’m doing it for the love of my work.”  But I had to admit that the money and the adulation of the nursing staff didn’t hurt.  There was no way to pass judgment on my motivation, that is, until I got to Israel.

During the first four months of my aliyah (move to Israel), I was totally dissociated from medicine.  My time was consumed with the study of Hebrew. The memory of the previous eighteen years of frequent night visits to the hospital remained pleasurable but finally I experienced the joy of uninterrupted sleep – and obviously I wasn’t being paid for that night’s sleep.  For the ensuing four months I worked an eight-hour day as a senior hospital resident upgrading my skills in nuclear medicine. Subsequently I was appointed Director of Nuclear Medicine at Wolfson Hospital.  The department consisted of one nuclear camera, one technician named Shula, and me.  It was my task to build the department into both an active ancillary service and a teaching facility.  I encouraged the appropriate requesting of nighttime emergency scans; their performance fell to Shula and me.  In time, since I had to be present to interpret the nuclear scan, I excused Shula from helping me.  I also routinely arrived at the hospital each morning an hour and a half before Shula in order either to carry out quality control measures or to begin a time-consuming patient study, all in order that the day’s work would flow smoothly.

And now to my point.  I received a fixed salary with no extras for additional effort.  More than that, after six months passed, I received tenure; my job was guaranteed at least another five years, when I would be sixty-five.  I could have sat back and done very little, even wander into work at ten in the morning and leave at three.  Nor would I have been the first to take concurrent private jobs to earn more than my hospital salary.  Even though I didn’t need to prove myself or answer to anyone, I never took advantage of any of these perks.  And for all my extra work hours and the emergency night calls I received not an extra penny.   A few colleagues praised me.  Others called me a friar, a Yiddish word meaning, “sucker.” 

Again I ask, “In Aliquippa did I get out of bed at night for the money?”  My continued zealousness in Israel indicates, “No.”  And yet as I try to exonerate myself, I have to admit that in Israel, whatever I did, including moving here and taking emergency calls, was predicated on a strong Zionist urge to help build my new homeland.  So I’m hardly off the money-motivation hook yet.

Was I so conditioned by the capitalistic reward-for-work ethic so that even after the reward was taken out of the equation, the work habit persisted?  If so, does that mean that Israeli doctors raised in a socialistic society extend themselves less and justify it because of their poorly compensated and under-appreciated workday?  I have no statistics.  I can only assume that there is no difference between us as to character and that the answer to the last question is, “No.”  My daughter, Raina, who witnessed my medical style while growing up in America but received all her medical training in Jerusalem, validates that assumption as a tireless, underpaid Specialist in Family Medicine. 

In both my Aliquippa and Wolfson Hospital offices, I hung photographs of my esteemed Boston mentors.  Was I afraid that some evil spirit would emanate from them if I didn’t perform nobly?  And I remember two of my Beth Israel Hospital teachers who spent countless unpaid hours with me and other fellows during evening and nights.  We were the children they never had.  

In the last analysis let me be unscientific.  I shall beat my breast no more.  I conclude that I was and remain primarily motivated by the love of my profession.

Don't Put Off Till Tomorrow...

Those were exciting weeks as I anticipated the opening day of my medical office.  It was to be August 1, 1956, eleven years and ten months from the day I entered Harvard Medical School and approximately ten years since I first laid a hand on a patient.  So much preparation in those years, acquiring knowledge, developing skills, molding attitudes toward patient care, and drawing up schematics of the form my medical practice would assume.

Taking a cue from my brother Jerry’s General Practice before he went off to fight in WW II, I rented office space above my Aunt Sarah’s jewelry store on the main street in Aliquippa.  Adapting it to my physical needs required no structural changes.  At the entrance was a combination secretarial office-waiting room, which led into both a consultation-examining room and a room accommodating an x-ray machine.  A closet became an x-ray developing room and a bathroom. Sharing the waiting room with an adjoining lawyer's office reduced my costs.

I had spent the month of July ordering office furniture and medical and secretarial supplies including calling cards and personalized stationary.  One dilemma arose when it came to deciding on a desk chair.  The corporation president’s chair was too ostentatious and expensive; I settled for the vice-president’s model, also too expensive.  (I remembered the advice of a highly successful accountant who was under my care at Lahey Clinic.  We were discussing my bleak financial situation as I approached entering private practice.  “Don’t borrow a small amount of money from the bank; you’ll just stay awake at night worrying how to pay it back.  Borrow a large sum.  You’ll sleep better knowing that you’ll have to pace yourself over a long haul rather than repaying the loan quickly.”  To wit, the lavish chair.)

The most costly item was the x-ray machine.  Though I was a specialist in Internal Medicine, my training included one year of gastroenterology during which I became proficient in performing x-ray examinations of the gastro-intestinal (GI) tract.  One of my favorite teachers, the chief of radiology at the Beth Israel Hospital in Boston, showed his disapproval by ordering me out of his fluoroscopy room when he realized that I, as an Internist, would be performing GI x-ray procedures.  I rationalized my plans on the basis of the absence at that time of a hospital and a radiologist in my town.  At the outset of my practice a few physicians became acquainted with me by sending patients just for an x-ray.  The fact that Blue Cross Medical Insurance paid handsomely for x-ray procedures years before compensating a doctor for his consultation was of more than subliminal importance in those early hungry days. Oh, yes, my in-laws paid for the x-ray machine -- my request as a substitute for their furnishing our home.

Lastly was the need to find an office assistant I could afford, a woman who could be a nurse, a lab and x-ray technician, and a secretary.  A newspaper ad produced several candidates, one of whom, Pauline, stood out above the rest.  A licensed practical nurse, she had done office work for her husband.  She also had a pleasant personality.

For several days prior to the announced opening date as printed by our local newspaper Pauline and I organized schedules of painters and plumbers, electricians, and instrument technicians.  Pauline practiced drawing blood from me and together we performed the basic blood counts and screening chemical tests.  I also taught Pauline urine tests; this time it was her specimen.  She also performed an electrocardiogram on me and on the lawyer in the adjoining office.  All that was lacking was a special switch to activate the x-ray machine, which was promised for the 31^st of July.

It was Pauline who answered the phone on the morning of the 31^st.  “Good morning.  Dr. Chamovitz’s office.”  It was a woman calling.

“I would appreciate it if the doctor could see me today.”

“Just a moment.”  Placing her palm over the phone’s mouthpiece, Pauline relayed the request.

 I picked up the phone.  “This is Dr. Chamovitz.  Can I help you?”

“Why, yes.  Yesterday morning I awoke with one side of my face flat and I believe it’s paralyzed.” 

“How has your health been otherwise?”

“Fine. But I’m really worried.  Can you see me today?”

“Truthfully, we need today to make last minute preparations but I’ll see you first thing in the morning.  I’m sure you’ll be okay.”  I assumed she had Bell’s palsy for which there was no treatment anyway.  (As I write forty-five years later my attitude appears lackadaisical; were it today, she would have had an immediate Computerized Tomogram of her brain to rule out a stroke.)

I could hear the disappointment in her voice as I turned her back to Pauline.  I gave it no more thought except to whisper a “Eureka!  My first patient.”

The following morning Pauline and I donned our new, dazzling white professional garb, I, a long lab coat, she, a nurse’s uniform.  At the appointed hour Pauline ushered in Mrs. Georgia Lewis, a thirty-nine-year-old housewife dressed in “church-going” clothes.

I noted the faint sagging of the right side of her face as she sat in one of the two salmon-colored leather office chairs opposite my desk.  A faint smile further exaggerated an asymmetry of her face.  I posed my opening question.  “Why are you smiling?”  I anticipated compliments for my office décor or comments regarding my being so young to be a specialist.  (After a few years I no longer heard that latter compliment.)

“Doctor, you won’t believe it but when I looked into the mirror this morning, I could see that my face was much improved.  What do you think of that?”

I should have been delighted.  “You fool,” I said to myself.  “Look at what a hero you would have been if you had seen Georgia yesterday!”  Still I tried to reap some glory out of the situation.  “Over the phone I suspected that your diagnosis would be Bell’s palsy, most often a self-limiting disease that requires no treatment. That’s why I had no qualms about delaying your examination one day and why I tried to reassure you that you would be okay.”

Georgia took the bait.  “It’s true that I felt more relaxed after I spoke with you.  Could it be that’s why I improved?”

I wasn’t a total scoundrel.  “The truth is that we don’t know everything about this illness except that it’s probably caused by a virus but why it subsides quickly in some and very slowly in others, we have no idea.”  With tongue in cheek I added, “Who knows what a positive attitude will do?”  I was shameless.

Without much enthusiasm I proceeded with a history and physical examination and had Pauline perform the screening lab work.  I asked Georgia to report to me in a week and with that phone call our relationship came to an end. 

Well, not quite.  I called her on our “first anniversary” to note the occasion and to inquire as to her health.  “I’m fine and you’re such a marvelous doctor!”  Again, shame on me.

If I Could Only Have A Hotdog

Clashing wills with a patient generally calls for a medical divorce.  It would be appropriate for a physician to say, “It’s time I remove myself from your care and turn you over to another doctor.”  In truth in all my years of practice this never happened.   Once it should have but the patient was my cousin’s wife, Fern.  I loved her; there was just no way I could abandon her.

Fern was only two years older than I but, having started raising a family eleven years before me, she had played a senior role in my eyes.  Our lives interlocked in many spheres.  She became one of my wife Marcia’s best friends.  Every year the two spent many hours each day for three months fine-tuning Broadway musicals that Marcia had adapted to Hadassah themes.  For years the three of us sang in the synagogue choir.  We laughed together a lot and at low points we comforted one another.

My cousin Milton, Fern’s husband, was one of the most competent public figures I had ever known.  In addition to being a superb optometrist, he was the editor of the prestigious national optometric journal and simultaneously president of our synagogue, Hopewell Jointure School Board, and the Beaver County Community College.  It was not unusual for him to have three meetings in one day and chair them all with aplomb.  I obviously admired Milt greatly, which allows me at this late date to be candid about the disagreement I will describe.  Besides, he’s no longer around to take umbrage.

Being the physician to family members is fraught with potential problems, not the least of which, because of wishful thinking, is the possibility of overlooking significant illnesses.  (I can confess to missing my own wife’s pneumonia though I had enough sense to ask a colleague to examine her; he, in turn, made the diagnosis and put her on the right tract.)

Therefore it was with some trepidation that I started my study of dear Fern when she presented with back pain.  From her story I early suspected that it was not the common garden variety of musculo-skeletal disease. Testing by means of ultrasound of her abdomen raised the possibility of a tumor of the pancreas.

With Fern and Milt’s consent, I referred her to the Presbyterian Hospital in Pittsburgh under the care of my gastroenterologist brother, Bob.  Within days a surgeon performed an abdominal exploratory operation; the diagnosis was inoperable cancer of the pancreas.  This carried a death sentence.  Occasionally radiation therapy was used but it really had little to offer.  The same was true for the early chemotherapeutic drugs.  Fern would die within a year.

Bob accompanied the surgeon to the family waiting room and nodded in agreement as the surgeon spoke to Milt.  “I’m sorry.  I have nothing to offer your wife.  No one does.”

Without a moment’s hesitation Milt took control.  “In that case, Bob, can you get me a key and show me the way to the hospital’s medical library?”

Milt spent the next four hours researching every entry related to pancreatic cancer.  Without any input from Bob or me, Milt made his decision.  He called a “scientist” doing immunological research on cancer therapy in the Bahamas.  Two weeks later he and Fern were on a plane in search of the “Holy Grail.”  At least that’s how I perceived Milt’s gesture.  Although I did not approve this turn of events – I wasn’t even certain that the scientist was legitimate – I did not fault Milt; decades later “immunological research” has become credible and is beginning to impact on patient care.  I trusted that, at least, Fern would enjoy the tropics.  

When Fern’s condition slowly deteriorated, Milt brought her home.  He thereupon embarked on a variety of therapies scorned by conventional cancer specialists but nevertheless pursued by what would now be called “alternative medicine”. Their treatment consisted of injections of worthless Laetrile, high colonic irrigations, and a very low-protein diet.  Fern went along with Milt’s frantic efforts to prevent the inevitable.  Understanding my cousin’s need to do something, not to stand idly by while his wife was dying, I reluctantly went along with these charades.  Sad to say, Milt was contemptuous of all offers for counseling that might have helped him adjust to the somber reality of Fern’s impending death.

I was appalled by Fern’s appearance when I last visited her at home.  Her voice was weak as she lay in what would soon be her deathbed.  She was deeply jaundiced from blockage of her bile ducts and she was literally just skin and bones.  Fortunately she was free of pain.  With a whimsical smile she half pleaded with me, “David, if only I could have a hot dog.”  I resisted going out to buy her one, knowing that Milt was clinging desperately to the low-protein diet.  I had such an urge to crawl in bed with Fern just to hold and comfort her – and myself.

Three days later Fern lapsed into a coma.  Milt finally relented, restraining himself from starting high calorie intravenous infusions.  Fern was dead in two more days.  Poor Fern.  How she had yearned for mutual consolation with Milt, something Milt couldn’t handle.  And lastly, she had been denied the opportunity to say goodbye.

I have often wondered if I had sought a replacement for myself, a physician less emotionally involved, would the situation have been different?  Could Milt have been brought to appreciate Fern’s need for support with her dying process rather than being bypassed as he fought her disease?   My lame excuse was that I was certain that none of my colleagues could have thwarted Milt’s steamroller approach any better than I.  Thirty years later I find that stance untenable.

Cigarettes or Me

Gloria lay in bed in the surgery ward recuperating from removal of a lung tumor which to everyone’s surprise was not malignant.  A plastic tube in her stomach exited through her nose draining yellow liquid into a plastic bag under the bed.  In addition over her nose and mouth was a transparent mask delivering oxygen.  Gloria’s husband, Philip, sat at her bedside, tears in his eyes, for endless hours following the operation.  In the ensuing days he remained there except for quick visits home for a shower and a change of clothing even after the surgeon reassured him that Gloria was out of danger.    Having witnessed Philip’s quiet crying both before and after Gloria’s surgery and the outburst of sobbing when I told him that the tumor was benign, I could only empathize with his terror from the possibility of losing his cherished wife. 

Gloria was tiny with wavy, blond hair, Phil, tall with thick, gray hair.  She was my patient; both were my personal friends.  Despite all my admonitions, she smoked two to three packs of cigarettes a day.  I pleaded with her, appealing to her zest for life and to the needs of her four children.  Even with a deep cough and worsening shortness of breath, the threat of severe emphysema had no impact, even less so, the high risk of lung cancer.  She remained recalcitrant.  She mulishly refused all suggestions for joining support groups that might help break her addiction.

It was the second day after her surgery.  The stomach tube was to be removed.  That morning I put my hand on Phil’s shoulder.  “Tell me, Dear Friend, what can I do for you?”

“Do you have time to talk now?”

“Certainly,” I replied and led him to a vacant patient room.  Philip closed the door behind him.  

“First, tell me,” he started, “how much worse will Gloria’s breathing be after having had part of a lung removed?”

“That’s an easy one.  Probably not at all.  We just took out a small lump of tissue, which hadn’t contributed to her lung function anyway.”

“Okay, Dave, since this tumor was benign, does that say something about a lower risk of developing lung cancer in the future?”  Both questions validated my assessment of Phil as a perspicacious scientist – he was a research biochemist.

“I’m almost certain the answer is, ‘No,’ but I must admit I’ve never considered the question.  And certainly if Gloria asks me that question, I’ll be less equivocal and say that cigarettes caused the first tumor and that the next one could well be cancer.  Philip hesitated to speak.  “What’s your next question?”

“I don’t know how to say this but sometime in the next few days, certainly before Gloria is discharged, I intend to deliver an ultimatum about her smoking.  It will include a threat.  I need you only to tell me when she’ll be strong enough to handle it.  And I would feel better if you are there at the time, if necessary, to pick up the pieces.”

On day six after surgery I told Philip that he could fire away at his pleasure.  Already after only eight days of a nicotine-free existence plus cool mist inhalation and chest percussion to facilitate expectoration, Gloria was less short of breath.  At an agreed time for meeting Philip in her room I sat inconspicuously off to the side.  Without a moment’s delay – as if gazing at her would cause him to back down – Philip lashed out, “Babe, I’m telling you in all seriousness.  You either give up cigarettes now or I’m leaving you.  I refuse to sit around and watch you kill yourself!” 

This time the tears were only in Gloria’s eyes.  “Please, Phil, Dear, don’t do this to me.  I was a smoker when you married me and you didn’t raise any objection then.” 

“Well, thirty years later we know better and maybe I love you more now than I did then.”

“I’ll switch to the least harmful brands and I’ll cut down.  You’ll see.  That will be enough.”

“No.  There is nothing to negotiate.  It’s cigarettes or me!”

“But…”

“No buts.  I’m leaving for the day.  Dave is here if you need him but frankly, I don’t think anyone can help you.  I’ll be back tomorrow for your decision.  When you are ready to be discharged, I’ll be here to take you home but if you decide in favor of smoking, my clothes will already be out of the house.  For the time being you can count on me for financial support but that’s it.”  And out he walked.

If ever I had witnessed an example of tough love, this was it.  And in my head as I waited for Gloria to ask for my help, a calypso song Marcia and I had heard on our honeymoon was repeating itself in my head; Never interfere with man or wife – when they’re fighting –.  Oh, just offer sympathy.

Gloria, without looking at me, waved me out of the room.  Had she attempted to involve me, it might have been another example of a physician failure from having our families so intimately involved.  She was weeping as I departed.

I visited Gloria at suppertime.  She was sitting in a chair picking at the food on her tray.  Her wastebasket was overflowing with soggy Kleenex.  “I don’t have a choice, do I, Dave?”

“How can I possibly advise you when it would devistate Marcia and me if you and Phil split up?  With that off my chest, yes, you do have a choice.  In either direction I will remain your doctor though I can’t tell you how many times, like Philip, I’ve wanted to threaten to abandon patients who would not give up smoking.  Maybe I should have but none loved me as much as you love Phil.”

I paused.  “But I promise you I’ll involve whatever physician and lay experts who can help you overcome your nicotine addiction.”  Gloria’s sobbing was now audible.  Again she dismissed me.

She met Phil at the door the following morning.  She hugged him and with her head buried into his chest, she wailed, “Don’t leave me, Phil.  I’ll try.  Honestly I will.  But stay with me while I try.  You’ll be proud of me.  Please don’t leave me.”  All the nurses in the unit heard every word.  There were few dry eyes, mine included.

“Okay, Babe.  You’ve got a deal.  We’re a couple and I do believe we’ll remain a couple.  I know you can do it.”

The two lovebirds left the hospital smiling, handing out trinkets to all the personnel.  I visited Gloria at home two days later.  To everyone’s amazement she had no craving for a smoke and her breathing was appreciably improved.  I wish I could say that it was smooth sailing thereafter.  Hardly.

That night I was called to the hospital Emergency Room.  Gloria had arrived by ambulance.  Philip was in hysterics.  Gloria had awakened complaining of severe chest pain.  She gasped for breath.  Phil called 911.  After six or seven minutes the ambulance attendants arrived and administered oxygen.  Gloria’s breathing eased minimally.  In the hospital emergency room an electrocardiogram showed no evidence of a heart attack but suggested blood clots in the lungs.  An emergency radioisotope lung scan confirmed the diagnosis.  Anticoagulant treatment was started.  

Philip confronted me.  “What could have happened?  She was doing so well.  She was great.”

“All I can say, Phil, is that pulmonary emboli is one of the dreaded complications of any major operation.  The longer the surgery and the longer the period of inactivity, the greater the risk of developing blood clots in the legs which break lose and end up in the lungs.”  I didn’t add that it also occurs more often among smokers; Phil already had enough reasons for hating the weed.

Gloria’s course was stormy.  After a second episode of new clots in her lungs, she underwent an operation on the large vein in her abdomen to block further clots from traveling to her lungs.  It took another three weeks until she could be discharged and a further two months until her breathing and stamina were normal.  If Philip’s threat wasn’t enough reason to continue off cigarettes, certainly the assault on her life was.

Gloria lived another twenty-six years filling her life with good deeds for many community organizations as well as caring for her numerous grandchildren, including at age seventy-eight, taking a teenaged grandson on the Space Mountain roller coaster at Disney World; the trip was her reward for his giving up cigarettes.  A year before her own demise she buried Phil, the love of her life and the giver of her own extended stay on this earth.