Samuel Shem - The house of God

"Oh, and by the way," said the Fat Man, poking his head in again, "I've written an order for this."

In his hand was a Los Angeles Rams football helmet.

"What's that for?" asked Potts.

"It's for Ina," Fats said, strapping it on her head. "LAW NUMBER TWO: GOMERS GO TO GROUND."

"What does that mean?" I asked.

"Fall out of bed. I know Ina from last year. She's a totally demented foxed?out gomere, and no matter how securely restrained, she'll go to ground every time. She cracked her skull twice last year, and was here for months. Till we thought of the helmet. Oh, and by the way?even though she's dehydrated, whatever you do, do not hydrate her. Her dehydration's got nothing to do with her dementia, even though the textbooks say it does. If you hydrate her, she stays demented, but she gets incredibly abusive."

Potts's head turned to watch the Fat Man go, and somehow, her left hand free, Ina slugged him again. Reflexively Potts raised his hand to hit her, and then stopped himself. The Fat Man nearly keeled over with laughter.

"Ho ho, did you see that? I love 'em, I love these gomers I do . . ." And he laughed his way out the door.

The manipulation of her head intensified Ina's screams: GO AVAY GO AVAY GO AVAY . . .

And so, leaving her tied down six ways from Sunday, the ram horns curling around her ears, we proceeded to Visit Rounds.

Being an academic House affiliated with the BMS, the House of God had a Visit for each ward team: a member of the Privates or the Slurpers, who held teaching rounds every day. Our Visit was George Donowitz, a Private who'd been pretty good in the pre-penicillin era. The patient presented was a generally healthy young man who'd been admitted for routine tests of his renal function. My BMS, Levy, presented the case, and when Donowitz grilled him about diagnoses, the BMS, straight from the library of obscure diagnoses, said "amyloidosis."

"Typical," muttered the Fat Man as we gathered around the patient's bed, "typical BMS. A BMS hears hoofbeats outside his window, the first thing he thinks of is a zebra. This guy's uremic from his recurrent childhood infections that damaged his kidneys. Besides, there's no treatment for amyloid, anyway."

"Amyloid?" asked Donowitz. "Good thought. Let me show you a bedside test for amyloid. As you know, people with the disease bruise easily, very easily indeed."

Donowitz reached down and twisted the skin on the patient's forearm. Nothing happened. Puzzled, he said something about "sometimes you have to 'do it a bit harder" and took hold of the skin, wadded it up, and gave it a tremendous twist. The patient gave a yelp, leaped up off the mattress, and began to cry with pain. Donowitz looked down and found that he'd ripped a big chunk of flesh from the guy's arm. Blood was squirting from the wound. Donowitz turned pale and didn't know what to do. Embarrassed, he took the piece of flesh and tried to put it back, patting it down as if he could make it stay in place. Finally, mumbling, "I . . . I'm so sorry," he ran out of the room. With a cool expertise the Fat Man put a gauze compression bandage on the wound. We left.

"So what did you learn?" asked Fats. "You learned that uremic skin is brittle, and that the House Privates stink. What else? What do we have to look out for in this poor bastard now?"

The BMSs ventured several zebras, and Fats told them to shut up. Potts and I went blank.

"Infection," said Chuck. "In uremia you gotta watch for infection."

"Exactly,' said Fats. "Bacteria City. We'll culture for everything. If it hadn't been for Donowitz that guy would be going home tomorrow. Now, if he lives, it'll be weeks. And if he knew about this, it would be Malpractice City."

At this thought the BMSs perked up again. The BMS now comprised a majority of minority groups, and "Social Medicine" was a hot ticket. The BMSs wanted to tell the patient so he could sue.

"It won't work," said Fats, "'cause the worse the Private, the better the bedside manner, and the higher the patient's regard. If a doctor buys the TV illusion of 'the doctor,' so does the patient. How can the patient know which are the 'Double O'Privates? No way."

" 'Double O'?" I asked.

"Licensed to kill," said Fats. "Time for lunch. We'll see from the cultures where Donowitz last stuck his finger before trying to murder that poor uremic schlump."

The Fat Man was right. Colorful and esoteric bacteria grew out of the wound, including one species that was native only to the rectum of the domestic duck. Fats got excited about this, wanting to publish "The Case of Duck's Ass Donowitz." The patient flirted with death but pulled through. He was discharged a month later, thinking it usual, even a necessary part of his successful course of treatment in the House, for the skin to have been ripped off his arm by his dear and glorious physician.

When the Fat Man went to lunch and we did not, the terror returned. Maxine asked me to write an order for aspirin for Sophie's headache, and as I started to sign my name, I realized I was responsible for any complications, and I stopped. Had I asked Sophie if she was allergic to aspirin? Nope. I did. She was not. I started to sign the order, and stopped. Aspirin causes ulcers. Did I want to have this poor LOL in NAD bleed out and die from an ulcer? I would wait for the Fat Man and ask him if it was all right. He returned.

"I've got a question for you, Fats."

"I've got an answer. I've always got an answer:"

"Is it all right to give Sophie two aspirin for her headache?"

Looking at me as if I were from another planet, Fats said, "Did you hear what you just asked me?"

"Yes."

"Roy, listen. Mothers give aspirin to babies. You give aspirin to yourself. What is this, anyway?"

"I guess I'm just afraid to sign my name to the order."

"She's indestructible. Relax. I'm sitting right here, OK?"

He put his feet up on the counter and opened The Wall Street Journal. I wrote the order for the aspirin, and feeling dumb, went to see a gorilla named Zeiss.

Forty?two, mean, with bad heart disease, Zeiss needed a new IV put in. I introduced myself, and tried. My hand shook, and in the hot room I got sweaty, and the drops of sweat plopped onto the sterile field. I missed the vein, and Zeiss yelped. The second time, I went in more slowly, and Zeiss squirmed, moaned, and cried out:

"Help, nurse! Chest pain! Get me my nitroglycerin!"

Terrific, Basch?your first cardiac patient and you are about to give him a heart attack.

"I'm having a heart attack!"

Wonderful. Call a doctor. Wait you are a doctor.

"Are you a real doctor or what? My nitros! Fast!"

I put a tablet under his tongue. He told me to get lost. Crushed, I wished I could.

Filled with great moments in medicine, the day wore on. Potts and I clustered around the Fat Man like ducklings around a mother duck. Fats sat there, feet up, reading, ostensibly into the world of stocks and bonds and commodities, and yet, like a king who knows his kingdom as well as he knows his own body, who feels the rages of a distant flood in the pulsating of his own kidneys, and the bounty of a harvest in his own full gut, he seemed to have a sense for any problem on the ward, instructing us, forewarning us, helping Potts and me. And once, only once, he moved?fast, unashamedly a hero.

A scheduled admission, named Leo, had arrived for Potts. Gaunt, white?haired, friendly, a little breathless, Leo stood at the nursing station, suitcase at his feet. Potts and I introduced ourselves and chatted with him. Potts was relieved that here at last was a patient who could talk to him, who was not deathly sick, and who would not slug him. What Potts and I didn't know was that Leo was about to attempt to die. In the midst of a chuckle at one of Potts's jokes, Leo turned blue and fell down on the floor. Potts and I stood there mute, still, frozen, unable to move. My one thought was "How embarrassing for poor Leo." Fats glanced over, leaped to his feet, yelled out "Thump him!" which we were too panicked to do and which I thought would be rather melodramatic, ran over to us, thumped Leo, breathed Leo, closed?chest?cardiac?massaged Leo, IV'd Leo, and organized with a cool virtuosity Leo's cardiac arrest and Leo's return from the world of the dead. A large crowd had arrived to assist in the arrest, and Potts and I had been pushed out of the action. I felt embarrassed and inept. Leo had been laughing at our jokes, his attempt to die was surreal, and I had denied that it existed. Fats was marvelous, his handling of the arrest a work of art.