Salt Mining at the VA
By Patrick Neustatter
It was a bright and brassy autumnal Friday afternoon in 1982 as I drove with Peter, a bear of a guy crammed behind the wheel of his Toyota Tercel, through the back roads of eastern Long Island, headed for the Veterans Administration hospital.
We were family medicine residents making our way from the mother ship of University Hospital at State University of New York at Stony Brook to do a month’s rotation under the auspices of the internal medicine department at the VA, which other residents had described as the salt mines.
“Do you really think this will be as bad as everyone makes out?” I asked.
Peter, always taciturn, just gave me a doleful look.
The road wound up a driveway that skirted putting greens and pleasant shaded grassy areas with benches until we came up on the hospital. It looked like a country club, with the Stars and Stripes flapping in the wind atop a flagpole.
A fatuous picture of Ronald Reagan met us in the foyer, while a harried receptionist behind a wooden counter embossed with a massive carved seal of the Department of Veterans Affairs was on the phone arranging a prayer vigil. She pointed: “Through the doors and look for the internal medicine office on the left.”
As we pushed through the set of double doors, I got a horrible déjà vu from the smell of antiseptic, shit, and hospital food. It transported me to my years as a junior hospital doctor in England, my homeland, where I had lived most of my life until a rather significant jaunt had brought me to the United States.
I had graduated from medical school in London 13 years before, and I was now 37, significantly older than most of the residents I was working with. I had done a variety of medical jobs but had also had a spotty work record, having taken considerable time off to drive the hippie trail to India, followed by short-term jobs in Canada, and most dramatic, as a flying doctor in Australia.
Now I was back at the bottom of the shit heap—a second year-resident in family medicine trying to get a license to practice in the U.S. because of an impulsive decision made in a state of moderate intoxication six months earlier.
On this rotation, I found myself thrown in with a crew of younger, seriously competitive, seriously nerdy internal medicine residents at the VA hospital—all overflowing with information about the latest clinical trial results, tests, treatments, and research, but from what I could tell devoid of wisdom or understanding that sick humans are sometimes a bit more than broken machines.
Peter and I found the office, where a disheveled guy in a short, white, dentist-style jacket, yarmulke precariously attached to his thinning black hair, rummaged through teetering piles of papers and charts.
This was Ron Goldman, senior resident of the internal medicine department. He was on the phone, telling someone “No, no, no, get that spinal tap done today! You remember what a shit fit Bernstein had when we didn’t have the CT results that time?”
After hanging up and a perfunctory greeting, he told us, “I hope you packed your toothbrushes. You’re on for the weekend.” I recognized it right away as the hazing approach I had encountered in England, newbies put on call the first night of any new job—to get them broken in, or broken down.
Dr. Goldman told us he was our backup, but the unspoken message was clear: It had better be something pretty serious if you call me. He presented us with a wad of index cards, summaries of what we needed to know about each patient. These had been filled out by the departing residents, who were lucky enough to have finished this dreaded rotation and probably weren’t too concerned about how well these cards, with incomprehensible hieroglyphs and numbers, communicated information.
Like the smell when we walked in, this was more déjà vu, reminding me of the indentured servitude I had experienced in England as a junior hospital doctor, living in a cell-like room with no time or energy for any kind of outside life, all in a backbiting hierarchy touted as an educational experience. But any complaints we had were greeted with: “I did it, so you can too.”
My attempts to decipher the index cards were soon interrupted by a page from the ER. I hurried over and found myself in a seething mass of human misery, so flooded with patients that gurneys were parked along the walls, each inadequately screened by a flimsy curtain. In one a heavily jaundiced man was vomiting blood into a bucket. In another, a homeless guy brought in by his girlfriend was being undressed by two nurses in biohazard suits.
I stood frozen for a moment at the nurses’ station, not sure why I had been paged, when a senior doctor with a bullet-shaped head and a buzz cut—and a coat that read “Michael Izikowski MD Emergency Medicine”—demanded to know what I wanted.
I told him I was the new family practice resident assigned to the internal medicine team and this was my first night on call. He responded by rolling his eyes, telling me everybody called him “Dr. Mike” because they couldn’t pronounce his last name, and leading me to a gurney holding a guy in his mid-60s, disheveled and sweaty, wearing an old Hawaiian shirt, several days’ stubble, and a hat like Bob Denver wore on Gilligan’s Island. He smelled of beer and vomit and looked to be sleeping peacefully, though I noted he was taking rapid, deep breaths.
“He’s diabetic,” Dr. Mike said in his rapid-fire voice. “Hasn’t had his insulin for several days, has a blood sugar somewhere in the five hundreds, has been on a bender, is also complaining of abdominal pain and has an elevated amylase. He looks to me like he’s in DKA, and probably got pancreatitis again from drinking—but that can be your call.” He thrust the man’s chart into my reluctant hands, then went away, leaving me to it.
I panicked but calmed myself, or tried to, by scrolling through the chart with lab results, previous admissions, and Dr. Mike’s cryptic notes. The patient’s blood sugar was way up, just as Dr. Mike had said, and his electrolytes were all over the place. He was acidotic and had an elevated amylase consistent with a recurrence of pancreatitis, which I presumed was the cause of his abdominal pain and meant I could rule out the threat of a burst appendix.
I tried to remember what I could about diabetic ketoacidosis—DKA—a Pandora’s box of complex and arcane biochemical abnormalities that lecturers in preclinical seminars in medical school would always talk about. They took great delight in tormenting us with questions about bicarbonate levels, acid/base abnormalities, what happens to the blood gases, why patients have Kussmaul breathing, how ketones are generated, etc. But that wasn’t much help for knowing how I was going to fix this guy’s DKA.
This was clearly above my pay grade, and my immediate inclination was to call the senior resident, the aforementioned Dr. Ron Goldman, despite his unspoken but clear directive that he not be bothered.
Fearing Gilligan going down the tubes more than the wrath of Ron I called the operator and asked her to page him. Goldman called back, displeased. I heard a TV in the background.
“You have to set up an insulin drip,” he snapped. “It’s all in the Washington Manual.”
I knew was he was referring to but so far hadn’t seen one at the VA—t he resident’s bible, a dense, springbound paperback of medical therapeutics that’s a standard part of the detritus of books, printouts, index cards, calculators, medical journals, and half-eaten sandwiches stuffed in the bulging pockets of anxious, time-pressured residents.
“I presume you have a copy,” Goldman told me, hanging up before I could answer.
I didn’t.
I had seen it. Heard people talking about it. But having just started and not been impressed with its necessity, I had not yet bought a copy. I paged Peter to see if he had one, and took the opportunity to piss and moan about Ron.
“He wasn’t exactly falling over himself to be helpful,” I complained. “It didn’t sound like he was busy. I think the TV was on. He was probably watching football.”
“No. Not the type,” Peter said. “More likely he was home reading medical journals.”
I tried to make sense of the complex instructions in Peter’s copy. Tried to follow the instructions on setting up an insulin drip—enough to bring Gilligan’s blood glucose down but not so low as to put him in a hypoglycemic coma with the possibility of brain damage. And enough saline to rehydrate him but not push him into heart failure.
By the time I wrote my admission note and orders and packed Gilligan off to the ICU, a slew of other patients in the ER waited for my attention.
Chest pains. An old soldier who’d blacked out and appeared to be on the verge of the DTs. A retired sapper whose main complaint was that his emphysema was so bad he couldn’t smoke. Gilligan woke up as his blood sugar came down. A savvy nurse on the ICU called me to suggest we back off a little on the insulin drip.
Peter and I passed like zombies among the ICU, the wards, and the ER. One particularly egregious duty was making trips to the sluice on the medical ward, to examine urine and blood slides on our patients for ourselves—despite the samples having also been sent off to the lab. Never mind that we could have been getting some desperately needed sleep.
At 7:30 Saturday morning we assembled with the other internal medicine residents for rounds with the dreaded Dr. Bernstein.
Standing at the back, trying to make sense of the index cards of all the patients I had inherited along with those I had admitted, I asked Peter if he’d had any downtime.
“I lay down,” he told me. “But I was way too wired to sleep.”
We dragged through rounds, each resident presenting their own patients, Bernstein peppering us with questions about diagnosis, treatment, prognosis—with a lot of derision if we didn’t know the answers. It was like being in medical school, except here at the VA we stood in the hallways outside the patients’ rooms rather than around their beds.
The only good thing about being so brain-dead was that I was too tired to take offense at the open criticism and Bernstein thinking I was Australian, even when he chided me for referring to an electrocardiogram as an ECG, which is what we call it in England, instead of an EKG, which for some reasons is what they say here in America. I didn’t quite have the chutzpah to shoot back with, “So how do you spell cardiac?”
Somehow Peter and I survived until Monday morning, when we were off-call again, but still had to drive back to out home hospital and spend the afternoon in the family practice outpatient clinic, burned out but still trying to pay attention to the persnickety preceptors wanting us to “ask open-ended questions” and “show empathy.”
Finally, after an awful drive in heavy traffic on the East Jericho Turnpike, I arrived in Huntington Station at the house my American wife and I had rented. I was toast. A burned-out husk of a husband who could manage nothing more than to drink a beer and fall asleep on the couch. Not the romantic cohabitation newlyweds are meant to enjoy.
All for the greater good. And if I lived through the process and actually got a medical license, I would soon be let loose on the American public.
The Doctor. Back in the Day.
***
Patrick Neustatter M.D. was born and educated in England, where he held medical jobs in and around London including a stint as an editor for Medical News. He also practiced medicine in Canada, Zimbabwe, and Australia—and, for a short time, worked as a flying doctor in the Australian Outback. After extensive travel in Asia and Africa, he moved to the United States with his first wife, completing his residency in New York before settling in Fredericksburg, where he was a family physician with the Pratt Medical Center for 24 years. Since retiring in 2010, he has served as medical director of the Moss Free Clinic while continuing to write monthly medical and health columns for The Free Lance-Star and Front Porch Magazine. He is the author of Managing Your Doctor, the Smart Patient’s Guide to Getting Effective, Affordable Healthcare and maintains the website Managing Your Doctor to promote the idea that patients should be empowered and in charge of their own healthcare. He has two grown daughters, Tegan and Alexis, and lives on 30 mostly wooded acres in Caroline County with his wife, Paula.
