44 Years on the Frontline of Medicine

By Dan Andrews MD

The tales here are rendered with great detail, covering years when the medical community saw many changes in treatment and tools. Some of the stories are grim, occasionally ending in death, sometimes due to a medical error. But there are plenty of light moments, too, and Andrews manages a candid, matter-of-fact tone that aptly fits each tale; he is sympathetic without being sentimental, humorous without being silly. He also does a fine job of revealing the behind-the scenes personalities and practices in a medical facility, while offering a perspective that patients dont often experience. Andrews does a solid job of weaving the narrative thread in an engaging voice that invites the reader to curl up for a good read. In short, 44 Years on the Front Line of Medicine is likely to please a wide audience.
-BlueInk Review

• Language: English
• Publisher: Xlibris US
• Release date: May 23, 2014
• ISBN: 9781499015386

Dan Andrews MD

I graduated from Eastern Washington State University and from the University of Washington, School of Medicine. Boarded by the American Board of Family Medicine, I was a fellow of the American Academy of Family Practice. I have been in solo, group, and emergency room practice and have practiced primary care in a university setting. I was the president of a medical corporation, the president of a county medical society, and the chief of staff of a small hospital. I was on the adjunct faculty for the University of California at Davis teaching nurse practitioners, and I have taught medical students for the University of California both at San Francisco and Los Angeles. I also taught both medical students and residents at the university where I worked for the eighteen years before retirement.

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Copyright © 2014 by Dan Andrews MD.

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Rev. date: 06/09/2014

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Contents

Introduction

Medical School

Guatemala

The Final Year

Internship

Residency

Air Force

Solo Practice

Group Practice

The ER Years

The University

Reflections

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Introduction

I’ve wanted to be a doctor for as long as I can remember. My mother claims it started when I was two or three and she had a major surgery. I did vary between wanting to practice medicine and wanting to do medical research but no further than that. My schooling varied quite a lot when I was young, ranging from public schools in small towns to the Agnes Russell Center, which was an experimental school associated with Columbia University in New York where my father got his doctorate in music education. I also spent one year in the school used for teacher training at the small college where my father taught.

The school in New York was very different because they were very liberal. We called the teachers by their first names and would plan each morning what we were going to do that day. I suspect that’s part of the reason I can’t spell. We never wanted to study spelling.

We did, however, have the resources of the university behind us, so when we wanted to study nutrition, we had lab rats and were supplied with food mixes to our specifications. Because our schedule was tied to the university’s and not to the public schools’, we would be off when they were in session. One time my friends and I wanted to go to a movie on our day off, but the theater wouldn’t let us in because the public schools were in session. We finally found a foreign film theater that would let us in, and they really gave us an education as well.

New York was the first place I really came in contact with hard-core racial prejudice. Even the building we lived in (which was owned by Columbia) had all-black maintenance men and the only black family in the building was in the basement apartment, a fact that meant nothing to me but which they had not failed to notice and which one of their boys commented on.

I also got my first job there carrying a paper route for a couple of blind ladies who owned a news stand on Amsterdam Avenue. I got paid a whole dollar a week for delivering about ten to twelve papers a day. Not much work until the Sunday Times showed up. Since my route passed the edge of Spanish Harlem, it was a little bit dangerous (something I made a point of never telling my mother). I was held up three times by kids with knives and was very careful not to carry any money or candy with me. Even though I was always pudgy, I learned to run fast especially when the other guy had a knife.

By the time I got to junior high, I was back in the public schools in our town in eastern Washington. I maintained my keen interest in science and had some problems with it. In the seventh grade, we had a science teacher who simply didn’t know his subject so I decided it was my duty to correct him. The man must have been a saint because I would have killed a little snot who acted that way. The science teacher in the eighth grade knew his material but was very strange in other ways, including being a neat freak. He had us keep these huge notebooks, and since my handwriting was as bad then as now, he wanted to flunk me in science. Since I had never missed a question on any exam including bonus questions, I felt this was very unfair. My parents and the principal finally convinced him this was unacceptable and I got my A.

When I got to high school, I started a science club, and since it was my idea, I got to be the first president. Several of my friends and I also organized a debate club, which got us out of class for trips. When I was a junior, I was involved in setting up the junior-senior prom and developed the idea of a fountain in the middle of the gym. We put a couple of washtubs of hot water in the fountain and added dry ice at regular intervals, which resulted in a mist over the dance floor. Unfortunately, it also got the gym floor wet, which didn’t make the janitor and principal very happy with me. My interest in medicine never left me, to the point that I signed up for two years of Latin, thinking it would help me later. Not only was it a horrible experience, it wasn’t much help either.

I’d always wanted to earn my own money, so in junior high, I had a paper route carrying eighty to eighty-five papers daily, rain or snow. The system was such that the paper took no risk. The carrier had to pay for the papers and collect the money. If someone didn’t pay, that was too bad; the paper didn’t help. Sometimes you’d have to return to the same house three or four times in order to collect. By the time I turned sixteen, I had a job at a local filling station back when you pumped the gas and washed the windshield and checked the oil. I got a whole dollar an hour, and in the three to four years I worked there, I never got a raise even though I eventually was responsible for hiring and firing the night shift.

By the time I was a senior in high school, I started going to the college where my dad taught. We had what was called advanced placement courses, but at that time, it meant we went to the campus and took honors courses with the college students. I managed to finish a year of math and a year and a quarter of English by the time I graduated from high school. Because I knew I would be going to medical school (arrogant, huh?), I decided to get through college as quickly as possible and live at home, since we lived in that town, so as to save as much money as possible. As soon as I graduated from high school, I went on to a full load at the college in summer school. I majored in biology and had minors in math and chemistry. I also joined the college debate squad and soon was elected captain. After the first year our coach quit and we had to find a facility advisor. I found a professor who said he didn’t know anything about debate but was willing to sponsor us, so I became the coach for that year. I also gave up my job at the filling station in favor of a job as the biology department’s laboratory assistant.

College went fairly smoothly as I went year round in hopes of finishing in two years, but by my last summer, I decided to take the summer off and work. I also had taken the Med CAT test (I never even knew there was such a thing until the head of biology asked if I had signed up but I must have done OK). Subsequently, I was given the chance to interview at all three medical schools I had applied to. The medical school I finally chose had interviews that were the roughest, and I learned later they were designed that way to see how you reacted to pressure. There were eight applicants in each interview group, and we had four interviews, each lasting about twenty minutes with twenty minutes between each interview. Less than half the total applicants were even asked to interview. My first interview was with the chief of medicine (very famous but known to the house staff as Dr. Malignant). I found his office, and since it was Saturday, there was no one at the secretary’s desk, so I timidly knocked on the door of the inner office. He was sitting in a high-backed chair facing the window and away from the door. He apparently had my transcript and spun around with his finger pointing at me and said, Andrews, why do you want to go into medicine instead of music where you belong? (I had taken several music courses in college.) The interview went downhill from there. I learned at the end that half the interview group had left without completing the whole process.

Fortunately, I was accepted at all three schools where I’d applied, but my ultimate choice was considered as good as any school in the country, so I decided to go there.

That winter I took a light schedule because I was close to having enough credits to graduate anyway. The summer before med school, I helped my dad build a summer cabin at a lake north of Spokane, and having already received my book list, I started studying my books for the fall. I made arrangements to live in the Phi Chi House (a medical fraternity). This was very cheap lodging and included meals. Come fall I thought I was ready to go and was very enthused. Boy, did I get that knocked out of me in a hurry.

This book is largely made up of memories. I didn’t keep notes or charts, so if memory is a little self-serving, please keep in mind that we all remember the good things better than the bad and see ourselves in the best light possible. I have tried to be honest, but I’m only human too. Many of the people discussed are still alive, and I have avoided the names of people and places, although anyone who really wanted to could, I’m sure, figure most of them out. If I’ve wronged someone, it wasn’t intentional, and I will apologize ahead of time. I’m reasonably sure no one will be able to figure out who the patients are and their privacy will be protected. I’ve changed some of the circumstances and locations to prevent any loss of privacy.

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Medical School

The first day of med school we were assembled to hear the dean discuss what was expected of us. We were to wear black slacks and white shirts. He then looked hard at one of the guys from Phi Chi who had arrived with a full beard and said, "We have always been proud of our student’s clean-cut appearance." Needless to say, the beard was gone by that afternoon. We were shown around the school, including the gross anatomy lab where there were twenty complete bodies for the eighty students and numerous partially dissected body parts for demonstration. This experience was somewhat of a shock. A couple of people fainted, and even though I had dissected cats, fetal pigs, and various other animals, including searching through the entire contents of a cow’s gut to find parasites for the biology department, real people were different, and I got very light-headed for a while.

The courses were arranged so that the first year we studied the normal such as human anatomy, physiology, histology, biochemistry, and normal psychology. The second year would be spent in abnormals such as pathology, abnormal psychology, pharmacology, bacteriology, and so on. We were required to take the full set of classes, which amounted to twenty credits or so of graduate-level classes. Other graduate students were only allowed to take twelve. We also had a small number of electives, which you could add if you wanted more.

After the day of orientation, we jumped right into the fire on the second day. We started with the anatomy lecture. I was feeling pretty good because I’d read the first 100 pages of the book and thought I would be ahead, but the professor opened the lecture by saying he knew we’d all been studying the book so we would be held responsible for the first 150 pages on the exam, but he was going to start his lectures on page 151. I’d been in class only a few minutes and was already 50 pages behind. That was just a taste of what was coming.

We finished our morning classes and were scheduled for gross anatomy lab for the afternoon. In the lab we were assigned to a cadaver—two students on a side. Our first assignment was to skin the chest and get the muscles so they could be seen. This included removing fairly large quantities of yellow fat. When we got done, we went home with the smell of formaldehyde clinging to us like a special medical student perfume.

Dinner that night at the Phi Chi House was a tradition we freshmen weren’t aware of until they served us large plates of corned beef with yellow fat clinging to it. Many of the freshmen had to get up and skip dinner while the upper classmen laughed and hooted. That was the only instance of initiation I remember ever happening there, but it was effective and probably was the only incident of skipping a meal in my medical career.

My lab partner was Jan, one of the women in the class and indeed on the other side of our cadaver was Mary, another of the four women in the class. These slots were decided by alphabetical order and we worked together through most of medical school. There were only four women in the class because the state legislature limited the female slots to 5 percent of the class. Their reasoning was twofold: (1) women averaged a 50 percent dropout rate (indeed two of our ladies were gone by the end of the second year), and (2) women tended to get pregnant and drop out of full-time medicine and the legislators wanted physicians who would practice full time. Today about 50 percent of medical students are female and such limitations would be thrown out as unconstitutional. It is still true, however, that many female physicians don’t work full time.

Anatomy lab soon became routine to the point students would go there on their lunch hour to catch up and eat with one hand and dissect with the other. We did have some levity because we had in the class a ventriloquist who had studied under Edgar Bergen (he of Charley McCarthy fame) and occasionally would have one of the cadavers say something. We also had one wag who was working at night when he heard the janitor coming and went to an empty table and covered himself with one of the blue plastic tarps we covered the bodies with to keep them from drying out. When the janitor came in to clean, he just sat up. We had to clean the lab after that.

Physiology lab was also of interest. We had to do experiments, some of which involved white rats. After the experiment, we had to sacrifice the animal using a small guillotine designed for the purpose. It was fast but we all hated it. One experiment required human blood samples from a finger stick. I volunteered to provide the sample. The instructor suggested we take it from the side of the finger so it wouldn’t bother us as we worked. Jan took the lancet and prepped my finger. She then proceeded to rip part of my cuticle off. Naturally I complained about the pain and asked why she did this. She admitted she’d closed her eyes as she poked me. After that we used her blood.

As a group, medical students are an interesting bunch. The guys in our class had varied backgrounds such as an electrical engineer, an optometrist, and a night club performer. The guy in the room next to mine at Phi Chi graduated from Harvard with a degree in English. He had his own drummer all the way. One time he went skiing even though he didn’t know how. He told me he took the lift to the top and just pointed his skis straight downhill and screamed at people to get out of the way because he didn’t know how to turn. He also hitchhiked home on the freeway across the mountains. Both ways he got picked up by the highway patrol but talked them into taking him where he wanted to go rather than giving him a ticket. He had an old car that had windshield wipers that only went one way. He rigged a string from the wiper to the wing window, and when the wiper went across the windshield, he would pull it back using the string. That car eventually killed him when he got drunk after finals and wouldn’t let anybody drive him home. He crossed the centerline on a bridge and hit five cars head on. He was in the ER for several hours before one of the Phi Chi guys recognized him.

We experienced a very high mortality for a group of young men. In addition to my friend above, the class ahead of ours had a student hang himself from a pipe in the locker room during finals. A senior student committed the most hostile suicide I’ve seen. He had been in a fight with his girlfriend. She left to go to work. He took some strychnine and lay down behind the door. Strychnine works by blocking all the inhibitory circuits in the brain so lying quietly on the floor in a quiet room, he was just fine until the girlfriend came home and opened the door throwing him into terminal convulsions. We lost one guy trying to get home for Thanksgiving. He’d been up all night in OB and then tried to drive home. He apparently fell asleep on the freeway and didn’t make it.

As we worked our way through the year, sleep was a precious and rare commodity. I became a heavy coffee drinker to keep going. I was so stressed the whole first two years my pulse never got below a hundred. We tried to have a party one night each weekend, but that was about the total for recreation.

Phi Chi House was a beautiful half-timbered house located on the boat canal from an inland lake to the sea directly across from the medical school. Inside was not so beautiful. My first room was in the basement where we had a chronically backed up and nonworking toilet. We were afraid to try to get it fixed because we suspected it emptied into the boat canal out back, and if the city found out, we’d have major repairs for which we had no money.

My bed was like sleeping in a hammock; it sagged so far. It was somewhat difficult climbing out. Also in the basement was the liquor vault where the house’s store of hard liquor was stored. There was a large lock on the door for which only the house manager had the key. One of the largest bottles was a giant vodka bottle, which held mostly lab alcohol and was the basis of the punch we sometimes made for the parties. Those of us in the basement also got to share with some large black rats. The student in the room next to mine woke one night to hear the throw rug next to his bed moving. When he turned on a light, he found it was being dragged by a huge rat.

The house sat next to a city park, which was on a kind of point out into the bay, and beyond that was the city yacht club where there were many boats, some of them million-dollar corporate yachts with million-dollar girls sunning themselves on the decks. We considered that as medical students we were very eligible bachelors, but the security at the club didn’t seem to see it that way so all we could do was watch. That sometimes got worse on Sunday afternoons when we had a ton of material to study and the yachts were going through the canal passing just twenty or thirty feet from where we were working. This really made concentration difficult.

One night at 2:00 or 3:00 a.m. when I still had work to do and was falling asleep, I took my small fishing rod out to the boat canal intending to cast a few times and see if that would wake me up. I had seen locals fishing for bass off the bank in the park. On the second cast, I felt a tremendous strike and the line started streaming off my reel. Fortunately I had more line than the canal was wide. I fought the fish for about forty-five minutes, slowly winching him in and then he’d run across the canal again. When he was finally tired I started yelling for help from the guys in the house, and they came out and helped land this monster. It turned out to be a twenty-one-pound King Salmon migrating from the sea. I cleaned the fish and put him in the refrigerator. He eventually made dinner for the whole house. While I was doing that, I discovered some of my housemates, being good physiologists, had the fish’s heart in a glass of salt water at the strength of saline and had gotten it to start beating. They kept it going as long as possible. By that time I was wide awake and able to finish my studying, which was what started the whole episode.

There was a tradition of presenting an unknown slide to one of the professors in histology who, it was claimed, couldn’t be stumped. This professor wasn’t into deodorant so most of us avoided him when possible, but a group of students made up a slide using some ground up chicken’s beak and presented it to him on the last day of class. He studied it under the microscope and said in his thick German accent that the only thing he could think of was ground up chicken’s beak, thereby keeping his perfect record intact.

Exam time was total panic time the first two years in medical school. The grading was on a curve, but in the anatomy lab final, for example, 100 percent was an A, 99 percent was a B, and if you didn’t get at least 97 percent, you failed. Nobody in our class failed but a couple of anatomy grad students did. The stress resulted in a lot of misadventures. One student looked into a microscope in the histology lab and vomited all over the scope when he realized he hadn’t seen that slide before. One guy got so stressed he couldn’t urinate and had to be taken to the ER to be catheterized. One student disappeared for three days and was finally found after sitting in a downtown all-night theater for three days. He had to drop out for a year but was told he could come back the next year, which he did, but eventually he dropped out altogether. We even had one student admitted for observation for chest pain.

The second semester I ran into my nemesis, neuroanatomy. I did everything I could think of to learn the various tracts in the brain including diagramming them in all planes in colored pencil, but they wouldn’t stick. Fortunately the class was called a conjoint class with neurophysiology. By combining the grades, I eked out a C in spite of failing the anatomy section. I never wanted to be a neurosurgeon anyway, but it was disappointing that I spent at least twice the time on neuroanatomy as anything else. I guess I don’t see in three dimensions very well and that has never changed.

That semester our anatomy professor became ill and had to take a leave. He was replaced by a little Italian professor with a very big ego. Needless to say, the students didn’t like him and his attitude didn’t help. He was in the habit of coming in before class and drawing the skeletal anatomy of whatever region he was talking about on the blackboard. One day we came in and found the skeleton of a foot drawn on the blackboard but no sign of the professor. One of the students went up front and drew a sixth toe and a corresponding metatarsal on the board. When the professor arrived, he didn’t notice and began drawing the muscles and tendons on the foot in colored chalk including the sixth toe. He finally figured out something was going on when the class kept giggling and stood back from the board. He demanded to know who had done it, but he got no response from the class. In those days it was traditional for the other faculty in the department to attend each other’s lectures. Even though they’d been sitting there while the superfluous toe was added, they didn’t point out the culprit. I don’t think they liked this guy either.

The summer after the first year I landed a job as a research assistant in the public health division. I was especially interested in tropical medicine and particularly in parasitology.

I had heard this department had summer programs in that field when you got further along. My job consisted of developing tests to identify the various strains of mycoplasma, which is a specialized form of organism halfway between a virus and a bacterium. My boss was one of the world’s experts in the field and also taught a course in virology I took that summer as well.

The lab was an interesting place with all kinds of people working there. The boss had several projects going at once and mostly sat in his office and thought. He was both a chess master and a bridge master and would join the rest of us for a bridge game at lunch. Playing with him as a partner was scary because it was as if he’d seen every hand during the bidding and would make bids you never thought would work out, but they always did.

In addition to the boss there was a professional lab technician who was working with Trachoma virus. She caught an eye infection with that organism and responded readily to antibiotics, which I couldn’t understand at the time because antibiotics don’t work with viruses. Subsequently it was discovered that this organism was in fact an obligate intracellular bacterium, which today is called Chlamydia trachoma. An obligate intracellular organism cannot grow outside another living cell. We no longer even try to culture it but simply diagnose it with a DNA probe. This organism was once the number one cause of blindness in the world and is still a common sexually transmitted disease.

The woman sharing my lab was a graduate student who was studying streptococcus and growing huge quantities of bacteria in twenty-liter bottles to get enough material for the studies she was doing. One day she left early to go to a tennis date, and that afternoon we heard she was in the hospital. She later told me she had a small pimple on her arm and suddenly went into sepsis while playing. The organism was in fact Strep, which was fortunate because it was so easy to treat in those days.

We had one other full-time lab tech I only saw at lunch and I don’t remember what she was working on, but she did have great stories about her cats. She and her husband kept exotic cats, including an Ocelot and an Indian Fishing Cat, which was so big it pretty much did what it wanted because even her husband (an able-bodied seaman) couldn’t control the animal. One day she told us she was leaving because her husband had fled to Texas. He’d been diagnosed with active TB and, in Washington State, was required to remain in quarantine for at least six months while he was being treated, and he refused to do that. We never saw her again.

We had a grad student who was also a nun, and since she was very willing to discuss religion, we had long discussions while waiting for a culture medium to cook. She was the first nun I had met who didn’t wear the habit but only somewhat conservative dress. She had been something of a fast lady when young and had come to religion later in her life, which perhaps gave her a more earthy view but did not make her any less devoted. Since I had had minimal exposure to Catholics, I learned a great deal from her I had never understood.

Another very significant thing happened that summer. One of the men living at Phi Chi was getting married and we were all invited. Two of us didn’t know anybody we could take and felt uncomfortable going to the reception alone where there would be dancing. We finally hit on the idea that we’d call one of the women’s dorms and see if anybody was interested. Amazingly enough, this worked. The young woman who was coming as my date was teaching in central Washington and had come to the university for the summer to pursue a master’s degree in English. We both felt a little uncomfortable going to a wedding as a first date and stayed at the reception only for a while. My friend and I decided to take our dates to a place called the House of Banjos, which was a favorite of the college students. The floor of this place was covered in peanut shells and the only things on the menu were peanuts and beer. There was a stage high above the main floor where a banjo band played, and they had a drummer with many noise makers such as a siren and a weight he kicked off the stage, which pulled a rope attached to the hammer of a fire bell. A special event occurred when you got the waiter’s attention, usually with a five-dollar bill in your hand and pointed to your lady. Soon the band would play a fanfare and a spotlight would go on and find your lady. The waiters would surround the woman and stand her on her chair. They would then put a garter on her as high as they dared while everyone hooted and hollered. The girls took it with good spirits probably in part because we’d been filling their glasses every time they looked away. I have no idea how many pitchers of beer we went through.

Sue and I saw each other almost every night that next week, and on Saturday I cooked a steak barbeque for several of the guys and their girls on the patio of Phi Chi House overlooking the boat canal. Apparently I was the only one who knew what different cuts of steak meant, and I really had to work to get theirs tender because they all bought round steaks the cheapest cut. I had bought T-bone. By the end of the evening Sue and I agreed to get engaged. While we’d only known each other for a week we did wait a year to get married, and now, after forty-four years and six kids, we’re still together. I guess it worked out.

My second year in med school was another tough one. We embarked on our studies of abnormal such as pathology, pharmacology, bacteriology, and abnormal psychology. In addition, I became the manager of Phi Chi, which saved me $25 a month and required me to control the finances with the cooks and do what I could to improve things in the house. I also was going frequently to see Susan. I began taping the lectures so I could play the tapes when I drove since I couldn’t study my notes. It turned out that worked fine going over there, but trying to listen to a lecture in the dark coming back at the end of the weekend nearly got me killed when I found myself falling asleep. So I had to give that up on the way home.

We had two cooks at Phi Chi, both of them older ladies who were on Social Security. In those days, if you were on Social Security, you could only earn $1,500 a year in additional income. We split the job between the ladies and they each worked half time and only during the school year. Each week I would sit down with the head cook and we’d plan the menu for the coming week. We tried every way we could to keep costs down. One trick we tried was to switch to dried skim milk because the guys drank a lot of milk and it was getting to be a major expense. Unfortunately the complaints came fast and furious, but we found if we mixed the dried milk half and half with regular, we could stand it.

We had one luxury that consisted of buying a gallon jug of cheap Mountain Red wine on the nights when we had spaghetti. In retrospect, it doesn’t seem like much of a luxury, but back then it was a real treat.

My biggest accomplishment that year was getting new beds for the house. We had some money in our account, and I got a couple small donations from Phi Chi alums in the area. I used these to bargain with a hotel supply company and got pretty good beds for the house.

All medical students were broke and there were a number of ways to make extra money. The researchers had figured out that students would do practically anything for $25, which was usually the going rate. The pharmacology department tested new painkillers while I was there. They would give you $25 to put you in a thumbscrew or a metal head band and see how many screws of the tightening mechanism you could stand. They’d then give you a known painkiller, the experimental drug or a placebo and see if you could tolerate more turns of the screw. One of the things discovered was that the placebo worked about 20 percent of the time. The psych department had a famous annual drug party where you were given a psychoactive drug or a placebo and were in a room with many other people and with observers who tracked your responses. Since in those days one of the psychoactive meds used was LSD, it was more than a little dangerous. Fortunately, my parents were able to help me out so I never had to do any of those things.

The most interesting course that year was pathology. In addition to the regular lectures, on Fridays, all the pathologists in the area would participate in the bucket brigade. This consisted of each of them bring in a specimen or two that they’d had the previous week and lecturing on the disease. One fellow autopsied a pilot from a small plane crash in the southern part of the county. Purportedly he’d been buzzing the airport and failed to pull up in time to clear some trees near the end of the runway. The pathologist had brought in his heart, which had ruptured with the force of the deceleration. You could still smell alcohol when he opened the bucket. The pilot not only was