Travels (3 page)

Pretty soon everyone in the anatomy lab was talking out loud, repeating mnemonics to help them remember.

“S 2, 3, 4, keeps your rectum off the floor.” That told you where the nerves to the levator-ani muscle originate, in the second, third, and fourth sacral segments.

“Saint George Street.” For the order of muscles inserting around the knee.

“The Zebra Bit My Cock.” For the branches of the facial nerve: temporal, zygomatic, buccal, mandibular, cervical.

My lab partner developed a new one: “TE, TE, ON, OM.” Two eyes, two ears, one nose, one mouth.

They quizzed us constantly, calling us “Doctor” even though we were first-year students. One instructor came in and threw up an X-ray of a skull. I’d never seen one before. A skull X-ray is incredibly complex.

“All right, Dr. Crichton, what would you say this is?”

He pointed to a whitish area on the film. It was near the face, and horizontal.

“The hard palate?”

“No, that’s down here.” He pointed to another horizontal line, a little below.

I tried again, and suddenly it came to me: “The inferior border of the orbit.”

“Right.”

It was a great feeling.

Then he said, “How about this?” A small, hook-shaped thing near the middle of the skull.

That was easy. “The sella turcica.”

“Containing?”

“The pituitary.”

“What is just lateral to it?”

“The cavernous sinus.”

“Containing?”

I rattled it off: “The curving internal carotid artery, and the ocular nerves, three, four, and six, and two branches of the trigeminal nerve, the ophthalmic and the maxillary.”

“And this dark space, just below?”

“The sphenoid sinus.”

“And why is it dark?”

“Because it contains air.”

“Right. Now then, Dr. Martin …” And he turned to another member of the group.

I thought, I’m getting it. I’m finally beginning to get it. I was excited. But at the same time, the pressure was building. Every day, building.

The jokes got worse. One guy wrote “Al’s Body Shop” on the back of his anatomy lab coat. And the cadavers began getting names: The Jolly Green Giant, The Thin Man, King Kong.

Ours had a name, too: Lady Brett.

After two months, on a day when the instructors were out of the room, several people played football with a liver. “He’s going out, he’s deep in the end zone, the ball is in the air … and … touchdown!” The liver flew through the air.

A few students pretended to be horrified, but nobody really was. We had by now dissected the legs, and the feet had been unwrapped; we had dissected the arms, the hands, and abdomen. We could see that this was a human body, a dead person laid out on the table before us. We were continuously reminded of what we were doing—we could see the form clearly. There was no way to get the necessary distance, to detach, except to be outrageous and disrespectful. There was no way to survive except to laugh.

There were certain jobs in the dissection that nobody wanted to do. Nobody wanted to cut the pelvis in half. Nobody wanted to dissect the face. Nobody wanted to inflate the eyeballs with a syringe. We portioned out these jobs, argued over them.

I managed to avoid each of these jobs.

“Okay, Crichton, but then you have to section the head.”

“Okay.”

“You remember, now.…”

“Yeah, yeah, I’ll remember.”

The head was in the future. I’d worry about it when I got there.

* * *

But the day finally came. They handed me the hacksaw. I realized I had made a terrible bargain. I had waited, and now I was stuck with the most overt mutilation of all, to divide the head along the midsagittal plane, to cut it in half like a melon so we could see inside, inspect the cavities, the sinuses, the passages, the vessels.

The eyes were inflated, staring at me as I cut. We had dissected the muscles around the eyes, so I couldn’t close them. I just had to go through with it, and try to do it correctly.

Somewhere inside me, there was a kind of click, a shutting off, a refusal to acknowledge, in ordinary human terms, what I was doing. After that click, I was all right. I cut well. Mine was the best section in the class. People came around to admire the job I had done, because I had stayed exactly in the midline and all the sinuses were beautifully revealed.

I later learned that this shutting-off click was essential to becoming a doctor. You could not function if you were overwhelmed by what was happening. In fact, I was all too easily overwhelmed. I tended to faint—when I saw accident victims in the emergency ward, during surgery, or while drawing blood. I had to find a way to guard against what I felt.

And still later I learned that the best doctors found a middle position where they were neither overwhelmed by their feelings nor estranged from them. That was the most difficult position of all, and the precise balance—neither too detached nor too caring—was something few learned.

At the time I resented the fact that our education seemed to be as much about emotions as about the factual content of what we were learning. This emotional aspect seemed more like hazing, like a professional initiation, than education. It was a long time before I understood that how a doctor behaved was at least as important as what he knew. And certainly I did not suspect that my complaints about medicine would eventually focus almost entirely on the emotional attitudes of the practitioners, and not their scientific knowledge.

A Good Story
 

The first part of a student’s clinical work involves interviewing patients with various diseases. The resident on the floor says, “Go see Mr. Jones in room five, he has a good story”—meaning that Mr. Jones can give a clear history for a specific disease. Off you go to find Mr. Jones, take his history, and diagnose his illness.

For a student beginning work in a hospital, there is considerable tension in interviewing patients. You’re trying to act professional, as if you know what you’re doing. You’re trying to make the diagnosis. You’re trying not to forget all the things you’re supposed to ask, all the things you’re supposed to check, including incidental findings. Because you don’t want to come back to the resident and say, “Mr. Jones has a peptic ulcer,” only to have the resident say, “That’s true. But what about his eyes?”

“His eyes?”

“Yes.”

“His eyes, hmmm …”

“Did you check his eyes?”

“Uh … sure. Yes.”

“Notice anything about them?”

“No …”

“You didn’t notice his left eye is glass?”

“Oh. That.”

To avoid these embarrassments, and to make the job easier, all students quickly learned certain interviewing tricks. The first trick was to get someone to tell you the diagnosis, so you wouldn’t have to figure it out for yourself. Knowing the diagnosis took a lot of the pressure off an interview. If you were especially lucky, the resident himself would let it slip: “Go see Mr. Jones in room five; he has a good story of peptic ulcer.”

Or you could throw yourself on the mercy of the nurses:

“Where’s Mr. Jones?”

“Peptic ulcer? Room five.”

Then there might be relatives in the room when you arrived. They were always worth a try. “Hello, Mrs. Jones. How are you today?”

“Fine, Doctor. I was just talking with my husband about his new ulcer diet when he goes home.”

And, finally, the patients generally knew their diagnoses, and they might mention it, particularly if you walked in, sat down, and said heartily, “Well, how’re you feeling today, Mr. Jones?”

“Much better today.”

“What have the doctors told you about your illness?”

“Just that it’s a peptic ulcer.”

But even if the patients didn’t know their diagnoses, in a teaching hospital they had all been interviewed so many times before that you could tell how you were doing by watching their responses. If you were on the right track, they’d sigh and say, “Everybody asks me about pain after meals,” or “Everybody asks me about the color of my stools.” But if you were off track, they’d complain, “Why are you asking me this? Nobody else has asked this.” So you often had the sense of following a well-worn path.

But even if you figured out the diagnosis, there was always an exciting uncertainty about interviewing patients. You never knew what would happen. One day the resident said, “Go see Mrs. Willis, room eight; she has a good story of hyperthyroidism.”

I walked down the hallway, thinking, Hyperthyroidism, hyperthyroidism, what do I know about hyperthyroidism?

Mrs. Willis was a thin thirty-nine-year-old woman, sitting up in bed, chain-smoking. Her eyes were bulging. She was edgy and appeared unhappy. Her dark tan highlighted the many slashing scars on her arms and face, presumably the result of a bad automobile accident.

I introduced myself and started to talk to her, focusing on thyroid questions. The thyroid regulates general body metabolism and it affects skin, hair, voice, temperature, weight, energy, and mood. Mrs. Willis gave me all the right answers. She couldn’t gain weight no matter how much
she ate. She was always hot and slept with the covers off. She had noticed that her hair was brittle. Yes, yes, yes, everybody had asked her these things. She was quick and impatient in her responses. She often seemed on the verge of tears.

I asked her about her suntan. She told me she had been staying with her sister in Alabama. It was all right because her sister’s apartment was air-conditioned. She had been with her sister in Alabama for three months. Now she was back in Boston.

Why was she in the hospital?

“For my thyroid, it’s too high.”

What had brought her to the hospital?

A shrug. “I came and they said I had to stay. Because of my thyroid.”

“How did you get the scars on your arms?”

“Those’re cuts.”

“Cuts?”

“From a knife, most of them. This one here’s glass.”

The scars seemed to be of different ages, some recent, some older.

“Yes. This one is about five years old, the others are newer.”

“How did they happen?”

“My husband.”

“Your husband?” I proceeded cautiously. She seemed close to tears now.

“He cuts me. When he’s, you know, drinking.”

“How long has this been going on, Mrs. Willis?”

“I told you: five years.”

“Is that why you went to your sister’s?”

“She says I should call the police.”

“And have you?”

“Once. They didn’t do anything. They came and told him to stop it, is all. He was
mad
after that.”

And she burst into great sobs, her whole body shaking, tears streaming down her face.

I was confused. Emotional lability is characteristic of hyperthyroidism; patients frequently burst into tears. But this woman appeared to have been seriously abused by her husband. I talked to her some more. She had initially come to the hospital because of her wounds. The doctors had admitted her for hyperthyroidism, but that was clearly an excuse to get her away from her violent husband. She was safe enough in the hospital, but what would happen once she was discharged?

“Has anybody talked to you about your husband? A social worker or anybody like that?”

“No.”

“Do you want somebody to talk to about your husband?”

“Yes.”

I said I would arrange it, and I left, filled with outrage.

In those days, physical abuse within a family was not really acknowledged. Everyone pretended that wives and children weren’t beaten. There were no laws, no government agencies, no homes, no mechanisms at all to assist these people. I felt strongly the injustice of this situation, and this woman’s dangerous isolation—sitting alone in a hospital bed, waiting to be sent home to her husband, who would stab her again.

Nobody was doing anything about it. The doctors might be treating her thyroid, but nobody was dealing with the real, life-threatening problems she faced.

I went back to the resident.

“Listen, did you see Mrs. Willis’s wounds?”

“Yes.”

“Those are knife wounds.”

“Yes. Some of them.” He seemed calm.

“Well, here we are treating her hyperthyroidism and it seems to me she has a much bigger problem.”

“All we can treat is her hyperthyroidism,” the resident said.

“I think we can do more. We can take steps to keep her away from her husband.”

“What husband?”

“Mrs. Willis’s husband.”

“She doesn’t have a husband. What did she tell you?”

I told him the story.

“Listen,” he said, “Mrs. Willis was transferred here from a private sanatorium in Alabama. Her family is well-to-do, but her husband divorced her years ago. She’s been in and out of institutions for a decade. All those cuts are self-inflicted.”

“Oh.”

The resident said, “Did you ask her whether she’d ever been in any mental institutions?”

“No.”

“Well. You should have asked. She’s not that crazy. She’ll tell you, if you ask.”

Another time, the resident said, “Go see Mr. Benson; he has a good story of duodenal ulcer.”

I went to see Mr. Benson, first stopping at the foot of his bed to read his chart. This was another trick. The bedside chart contained only nurses’ notes on fluid intake, things like that, but it could still be helpful. Also, it made you look professional if you came in and read the chart first.