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It Takes a Team

First published in the Hektoen International Medical Journal. Hektoen International Journal is published by the Hektoen Institute of Medicine.

To view the story online visit the Article Here.

I saw two bright colored Polaroids: One pictured Rudolph, a burly coal miner with a white bandage about his left ankle. The second was a close-up showing a four-inch long festering ulcer overlying his Achilles tendon. Its crater floor appeared necrotic, slimy, and green. The margins looked chronically inflamed and rolled inwards. The lower edge was thicker and suspicious of an early squamous cell cancer—a classic Marjolin’s ulcer. As an oncology surgeon, I had only seen a similar photo in a textbook. I was certain of the diagnosis, although I had never treated one.

Tom and Dorothea, my next-door neighbors, casually showed me the photos during a gathering of distraught parents with teenagers approaching driving age. They congregated at our home on a gray Saturday afternoon, November 25, 1990, to petition our town of Manlius, a Syracuse community, for a traffic light at the top of our street. Another sixteen year old had died in a crash at its intersection on Thanksgiving.

“Is this something you could operate on?” asked Tom.

“Yes,” I said with assuredly, as if answering an academic question. “Where did you get the photos? And who is the person?”

Tom and Dorothea had visited Poland the previous summer, accompanied by Rudolph’s nephew, Jan, one of Tom’s students at Utica College in Upstate New York. Their visit coincided with the tumultuous sociopolitical upheaval. The anti-communist Solidarity movement, the Soviet-bloc’s first independent trade union, ended communist rule and saw its co-founder, labor activist Lech Walesa, form the nascent Solidarity government. Accompanied by Jan, the American couple traveled to Jaworzno, an industrial city of about 90,000, south of Warsaw in the Silesian Highlands where they met Rudolph. Jan had asked them if his uncle could be cured in America.

Tom continued, “One morning in 1965, Rudolph was riding his old motor cycle to the mine. Bumping over railroad tracks it overturned, pinning his left leg beneath him. The battery’s acid spilled onto his ankle, burning his skin, eating it away and creating a painful ulcer.” During the first few years his frequent wading in polluted water during his twelve-hour mining shifts constantly irritated it, preventing the wound from healing. When his political activity as a Solidarity union leader elevated him to a desk job at the mine, he had access to the best medical care Poland could offer—the ulcer still did not heal. Why had all the salves, creams, and medical attention not healed it? The situation could be more complicated than I understood.

“Would you be willing to operate on Rudolph if we brought him to Syracuse?”

Continue reading It Takes a Team

The Colors of Pride

First published in the Hektoen International Medical Journal. Hektoen International Journal is published by the Hektoen Institute of Medicine.

To view the story online visit the Article Here.

* * *

In August 1978 we moved to Los Angeles. The van had barely left when Zan padded across our cul-de-sac, shirtless in knee-length shorts, concealing a bulging large mass he called “my benign sliding inguinal hernia.” At sixty-five, he was a tall, stocky man with a crop of wavy white hair.

In fragmented pieces, revealed casually and interspersed with daily political news, Zan gradually painted his life as a gentleman farmer in Orange County. In a moment of bravado he said, “I’ve had it for so many years and it hasn’t bothered me, it’ll probably be all right, Doc.” After a swig of his beer, he added, “If you’re willing to fix it I’ll let you do it someday. I don’t trust doctors, but you’re different.”

Eventually Zan made an appointment.  His hernia reached his left knee. Elsa, my resident, had not seen anything like it—I had, in India. He lay back. I successfully reduced it.

“An operation will fix your problem.”

“It doesn’t show,” he argued. “Why fix it?”

“If you aren’t willing to fix it under controlled conditions, will you be willing when it’s strangulated and a life-threatening emergency?”

His operation was my first of the day. Backing my car out of our driveway, I failed to note signs of inactivity across the street, riveted by news that Iranian Revolutionary Guards had stormed our embassy and taken fifty-two hostages.

My usual surgical team, including my scrub nurse, and the operating room (OR) were ready.  We hung around in our blues, expecting Zan at any moment. We continued to wait.  I grew frustrated, believing Zan would turn up, then incensed at being let down.Still smarting, by 9:30 I called for my next case. My team disbanded and a different nursing team turned over the OR while Mr. Nazari was wheeled in. A new scrub technician what was unknown to me at the time kept irritating me by asking numerous questions about what instruments and sutures I was going to use. It was more efficient and safer to work with my familiar team.

Continue reading The Colors of Pride

The LeRoy Catastrophe: A story of death, determination, and the importance of nutrition in medicine.

“To this day, I wonder whether his death certificate truly reflected the cause of death: ‘physician-induced’ malnutrition.”  – from The LeRoy catastrophe

Below is the abstract of this article as published by The Columbia Medical Review. It can be viewed in full here. The Review has recently launched a place for thought leaders to convene and develop action-oriented agendas to combat contemporary and anticipated social issues in medicine.

Abstract

In August 1976, a young man named LeRoy fell from a ledge, fracturing his femur. Major internal bleeding was suspected. During a laparotomy, the trauma team ensured that all internal organs were intact and the orthopedic team set his fracture. Thirty days later, LeRoy died. He had eaten little; each day he only received three liters of glucose, the equivalent of 510 calories, intravenously. The glucose was insufficient to meet his nutritional needs, and he lost over 20% of his body weight during his hospital stay. The cause of death was due to “physician-induced” malnutrition. Meanwhile, a paper around the same time documented that the prevalence of malnutrition in Boston hospitals was 44% and that malnutrition itself was a predictor of higher complication and death rates.

Continue reading The LeRoy Catastrophe: A story of death, determination, and the importance of nutrition in medicine.