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.”