We Were Cowboys: (A Memoir of a Physician’s Surgical Training)

By J.F. Lee

The American cowboy speaks of a bygone era when these Old West icons represented personal initiative, diligence, and industry. Coincidentally, surgical students of the fifties and sixties were in many ways similar to the American cowboy as they diagnosed and treated conditions and diseases they had never before seen such as gonorrhea, gunshot, and stab wounds.

In a fascinating memoir filled with entertaining personal anecdotes, Dr. John Lee details his passage from a middle-class Irish Chicago neighborhood into the frenzied, pre-Institutional Review Board days of physicians’ training as determined students pursued their dreams, driven by personal initiative and, at times, grueling study habits. During a period when young surgeons enjoyed freedoms that helped define an era in medicine, Dr. Lee shares a rare glimpse into his daily routine as he built bonds with fellow students, found humor amid challenges, and cared for a variety of patients, all while riding the ups and downs of life as a surgical cowboy.

We Were Cowboys shares the true story of a medical intern’s experiences as he endured the rigors of surgical training in the mid-twentieth century.

• Language: English
• Publisher: AuthorHouse
• Release date: Jun 10, 2019
• ISBN: 9781728310756

J.F. Lee

John Lee is Chicago born and educated. He trained in vascular surgery at Henry Ford Hospital, was the first fellowship trained surgeon on Florida’s west coast, and worked as a locum tenens, traveling to hospitals nationwide until an auto accident ended his career. Dr. Lee is the father of nine and author of scientific papers, a memoir, and several short stories. He resides in Sarasota, Florida.

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© 2019 J.F. Lee. All rights reserved.

No part of this book may be reproduced, stored in a retrieval system, or transmitted by any means without the written permission of the author.

Published by AuthorHouse  06/07/2019

ISBN: 978-1-7283-1076-3 (sc)

ISBN: 978-1-7283-1077-0 (hc)

ISBN: 978-1-7283-1075-6 (e)

Library of Congress Control Number: 2019905918

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Because of the dynamic nature of the Internet, any web addresses or links contained in this book may have changed since publication and may no longer be valid. The views expressed in this work are solely those of the author and do not necessarily reflect the views of the publisher, and the publisher hereby disclaims any responsibility for them.

CONTENTS

Preface Or Prologue

Introduction

Chapter 1

Chapter 2

Chapter 3

Chapter 4

Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Chapter 10

Chapter 11

Chapter 12

Chapter 13

Chapter 14

Chapter 15

Chapter 16

Chapter 17

Chapter 18

Chapter 19

Chapter 20

Chapter 21

Chapter 22

And Finally, A Postscript

To Anne

PREFACE OR PROLOGUE

I dislike prefaces, introductions, and prologues, but here I am, writing a prologue followed by an introduction, which I sense is absolutely necessary for an understanding of We Were Cowboys, particularly if one is outside the loop with which we are concerned here. Almost sixty years ago I graduated from high school; it seems like yesterday. At that time, I had decided upon a career path and that my future was in medicine as a physician or surgeon. That meant college, med school, internship, fellowship, residency, and possibly a two-year stint in the military. I was looking at fourteen to sixteen years before I would be able to make a living wage! Furthermore, this was the apex of a man’s life in mid-twentieth century America!

The tendency here is to live life for the light at the end of the tunnel. I felt I could not do that and consequently sat back to enjoy the journey. In the chapters that follow, major experiences in that journey are detailed, occasionally even at my expense and chagrin.

In the introduction that follows I have attempted to explain many of the activities and define some of those peculiar words and procedures we use. I’ll provide definitions, as the need arises, for words in the text that were previously overlooked and left undefined.

I find it difficult to believe the journey started sixty years ago, as I don’t feel a day over thirty ’til I stare into a mirror and see an old man staring back. I am reminded of six years ago, when I grew a beard, expecting to look like General Robert E. Lee, only to look again in the mirror and see Gabby Hayes! The beard was gone before I left the room.

I have presented portions of this manuscript to my creative writing class and received encouragement, yet they also expressed concern that these episodes may have been shared by their own personal physicians. The reader is reminded that these episodes, for the most part, occurred over a half century ago, under close supervision of the individuals involved by panels of professors and that dismissal was not uncommon. We all are still committed to HIPAA policies and the privacy and reverence to our patients. We have not abandoned the oath.

If my text does not state this directly, it will become apparent that we considered ourselves slaves or indentured servants, working eighty- to one-hundred-hour workweeks and performing after-hour lab studies and taking necessary imaging studies. This, in addition to the history and physical, the admitting notes and orders, and even the 2:30 a.m. rigid proctosigmoidoscopy, robbed the senior student or intern of much-needed sleep. Transport services after midnight frequently became the jurisdiction of the intern.

Then, in the eighties and nineties, everything changed in postgraduate medical education. In response to an aroused public after a series of deaths, maimings, and serious injuries suffered by patients at the hands of overworked and exhausted house staff, workweeks and call schedules were altered. Harassment decreased, and I have it on good authority that surgeons threw fewer instruments in the operating rooms.

All of the above provided a system of checks and balances that prevented most of the events discussed here from recurring regularly in training programs. Institutional Review Boards (IRBs) were established in hospitals to oversee experimental evaluation of innovative therapies and procedures with careful attention directed at controls and timely, regular post-therapeutic visits, with reports generated on a sometimes daily, sometimes weekly, and sometimes monthly basis. The reader will note the many tales that would have been eliminated in the text that follows, had these IRBs functioned a half century ago.

These stories all involve a general surgery program at a major university center. Fifty years ago, these were prestigious programs, where students vied for admission. Now, with increased government oversight, early burnout of the general surgeon population (often in their fifties), and that constant concern regarding the malpractice brouhaha, general surgery has been stripped of much of its appeal to the young medical graduate.

For those concerned regarding the intensity of the surgeon’s commitment, what follows might be called a sound bite of me during a typical carotid endarterectomy:

As I approach the room in which we have scheduled the procedure, I note that the drapes (that is, the towels and sheets covering the patient, with the exception of the anticipated wound site) have been inappropriately applied. Nobody sits in the theater chewing Junior Mints or Gummy Bears. I pull up my mask and walk into the room.

"You know I get tired of this. Take it all down and re-prep her. I want exposure from just below the clavicle to the angle of the jaw. No towel clips or staples."

"Bu-bu-bu-but—"

No buts; just do it.

I step from the room and begin to scrub, watching all the while through the window into the room. After I walk into the room and gown and glove, I look around and announce, Perfect. Glancing at the anesthesiologist, I ask, How’s she doing?

Great, but she needs some stimulation from you. (Translation: Put the knife to her neck.)

Again, it is quiet as I proceed with the operation and carefully isolate and sling the common, internal, and external carotids.

How’s her pulse?

No change.

I walk over and check the back table, which looks well prepared. I stop and check her Mayo stand and then look at the scrub nurse. Which clamps do I want and in what order? She responds appropriately, and I say, Good! Then let’s go.

I carefully clamp each vessel.

Any change in the EEG? I ask.

No.

I’ll take the knife, then the arteriotomy scissors.

From here, I proceed with the operation. There is no place for any other distractions.

INTRODUCTION

Anne was driving home with Muffy’s three children, and the discussion turned to the attention deficit disorder of the little seven-year-old, Kate. Her brother carefully described her response to sugar. It ain’t pretty, Grandma. This represents our lives some fifty years after my cowboy days in surgery—nearly forty children, grandchildren, and, yes, great-grandchildren between us and a life calmer in many ways as we try to age gracefully. ADD did not exist in that bygone era, and we just climbed up on our horses and rode away.

Today I brought our eleven-year-old English bulldog to the local Paw Park. Maxine is living in injury time, as described in soccer, or in other words, she is living well beyond her life expectancy. At the Paw Park, she ignores most dogs younger than she and appears to be hopelessly in love with a ten-year-old basset friend, who has had his testes removed and thus drags only his penis on the ground while Maxine usually has her teats sweeping along the ground. Canine geriatrics! Is it really any different from ours?

I wonder now if am no longer the cowboy of fifty years ago, when young surgeons enjoyed such freedoms that helped define that era in medicine. Now in my declining years, my multiple disabilities prohibit my presence in the operating room, while most of my colleagues have been reined in by the federal government and proceed more like Dusty and Lefty through their elder years. I refer here to the university training programs like that at the University of Chicago, and I refer to the early and mid-twentieth century. This was when we went from open-drop ether to muscle relaxants and noncombustible and nonexplosive gases. We tackled immunosuppression and transplants, and the field of vascular surgery was founded and grew.

When I was a resident in surgery, George Halas, owner of the Chicago Bears football team, went to England to get a hip replacement. The procedure was not allowed here in the United States. Thus it was that when I presented to Sister Gladys, the administrator of St. Anthony’s Hospital in St. Petersburg, the only other surgeon presenting his credentials was a young man from the Midwest who was trained in hip replacement, which had just been sanctioned here in the States.

Now, a procedure such as this is totally elective; nothing urgent about it as well. Surgeons prefer and often require a specially equipped room, with air flow carefully controlled and numerous other adjustments specifically directed at prevention of infection. The surgeon wears an outfit that looks like an astronaut. So at St. Anthony’s Hospital, we began to do hip replacement procedures. The surgeon was excellent. He had superb judgment and fine—what I call crisp—technique, but he was slow.

Because these cases are so purely elective, he usually received a 7:30 or 8:00 a.m. starting time, often with a pile of other cases following him. He might schedule the operation for two or three hours, but four hours later, he was still going strong, while surgeons waiting to use his room were backing up and becoming increasingly impatient, while standing around in the surgeons lounge or hanging out at the surgical control office. These doctors all had patients waiting to be seen at the office, operations at other hospitals, or maybe a one o’clock tee time.

One of the surgeons could be exceptionally rude and would call in on the intercom to ask if there was something he could do to help him finish the case—a real no-no. This particular surgeon did this continually, usually on Wednesdays, when he had a 12:45 tee. Allow me to return to this situation, but we will continue with the slow hip replacement, which on one day in particular dragged on and on …

The nurse running the board, or schedule, was Sue Hamilton, a very savvy young woman married to a colorectal specialist. A group of surgeons was harassing her, trying to get operative time, and our doctor could not speed up. Suddenly, she walked into the operating room and over to the clock on the wall. She took the clock off the wall, and in its place, she hung a calendar!

Back to our friend Dr. Joe. BurnsI had a close friend, almost like a brother, Alex Stratadoukis (may he rest in peace). Alex and I trained together at the University of Chicago, and he was two or three years my junior. He was born in Alexandria and spent most of his life there, with the exception of four years when he was in Athens. He trained as a plastic surgeon under professors of plastic surgery with excellent reputations. When a person was introduced to him, he clicked his heels and bowed. In other words, he was a student of etiquette and proper protocol. So Alex was livid when Dr. Joe Burns actually entered Alex’s operating room without an invitation and asked what he could do to speed up the case.

Wait in the surgeons’ lounge, Alex said, and I will call you.

Alex finished the case, and after putting his patient on the gurney, he called into the lounge, If Dr. Joe is there, tell him we need him in room 7.

When Joe walked into room 7, Alex handed him a mop, pointed to the pail on the floor, and left the room.

It was long ago when I entered practice, but in those times, I gave the chemotherapy to my patients and made decisions with regard to infectious diseases, as these specialties were still in the incubator. We saw the tail end of rheumatic heart disease, thanks to penicillin and improved early diagnostic techniques. Rheumatic heart disease certainly wasn’t pretty, but that and pediatric cardiac surgery for congenital anomalies is what we cut our teeth on. Our diagnostics lacked the definition they enjoy today; consequently, we dealt with only the most complicated cases, and each of those children required imaginative repairs, corrections, or reconstructions. Oncologic surgery was in its infancy, and the general surgery residencies in the university programs were beginning to realize that sophisticated techniques and procedures would be needed to achieve the improved results demanded by a frightened populace.

But again, it wasn’t pretty, Grandma, as initially, surgeons performed more and more disfiguring, radical, and aggressive operations. I actually scrubbed as a second assistant to a president of the American Board of Surgery, who performed a Whipple procedure for a man bleeding from a known metastatic focus of melanoma in the duodenum. The Whipple operation consists of the removal of the duodenum, the common bile duct, the head of the pancreas, and the gallbladder, with a mortality approaching 30 percent. If done by the inexperienced surgeon, mortality can certainly skyrocket, and morbidity is significant.

As medical students, interns, and residents, we discussed super radical mastectomies, which included a standard radical mastectomy with an internal mammary node dissection (removal of the lymph nodes on the inside of the chest wall with the overlying portion of rib cage) and a radical neck dissection, which included all the nodes on that side of the neck. This is at great variance with our approach today.

Again, the consequences were not pretty, but we faced them daily. Often, we left patients horribly disfigured and totally unaided by these procedures. How or in what way we were able to advance the art of surgery remains a mystery, but somehow that was accomplished, and now we can all expect expertise of the highest level in most venues here in the United States.

Before embarking on the tales in this book, a brief description of internship and residency in the mid-twentieth century will foster understanding for individuals who are outside of medicine. When I graduated from medical school, several internship and residency positions were available from which graduates could choose. The first choice was either a straight internship or a rotating internship. Straight internships were limited to one discipline, such as surgery or medicine, while the rotating internship involved all disciplines, with exposure to medicine, surgery, and pediatrics. Most people were required to make a decision regarding their lifetime career path at the end of internship.

In my day, a five-year residency was required to be eligible for the surgical boards. It was during this time that career preparation was accomplished. The longest residencies were in the surgical specialties. Technical proficiency was assessed yearly and, in most programs, took second place to moral proficiency. As an example, surgeons were expected to always be available and affable, while ability was considered a distant third.

Surgery training programs varied heavily as well. The premier programs were those affiliated with major universities, such as the University of Michigan in Ann Arbor, Johns Hopkins, Stanford, and so forth. Some programs at private hospitals were loosely affiliated with universities, such as St. Francis Hospital in Evanston, Illinois, which eased the life of the attending surgeons or internists, as the house staff performed most of the scut (routine or menial) work. Compensation reflected the desirability of each program. As an example, the compensation at St. Francis Hospital was $7,200 for the year in 1967, while at the University of Chicago, it was $1,700. House staff was more responsible in university hospitals, while at the private hospitals, interns and residents were forced to defer to the attending surgeon or internist and often merely transcribe the orders of the attending.

I can best describe the division of labor in the residency at the University of Chicago, where I performed my internship and residency. I suspect it is a rather typical example of a university training program. No moonlighting was allowed and was considered grounds for dismissal. We were on call every third night on most services, although occasionally we were required to be on call every other night, and when there were a plethora of interns to take call, it could be every fourth night. The intern was to accomplish the history and physical examination—this is an in-depth study of the history of the patient, plus an extensive physical examination. A history and physical was to be on the chart within twenty-four hours of admission. The intern ordered all the tests and often performed the tests himself. The intern was to arrange the x-rays, and often the intern transported the patient to x-ray and back. The intern was to write the orders; if anyone else wrote them, they required the cosignature of the intern.

If an operation was performed, the house staff member performing the operation was required to dictate the operative note. Discharge summaries were the province of the residents. There were designated rooms within the hospital where house staff could sleep when on call. Uniforms and laboratory coats distinguished the interns from the residents.

In the latter days of my medical school career and the early years of internship and residency, intravenous solutions came in glass bottles. The bottles contained standard IV solutions, such as 5 percent glucose, normal saline solution (0.9 percent sodium chloride), and lactated Ringer’s solution. If the patient required potassium supplements, these had to be added, as did vitamins, antibiotics, and any other special requirements. All this had to be done by the doctor—code for intern. Thus, I would review labs each evening before leaving and then write the IV orders for the following day. The next morning on my rounds, I expected that the nurses at each nursing station would have the bottles arranged for each of my patients with any required solutions, which I then mixed.

Ah, rounds. Cook County Hospital gets the award for most uncomfortable rounds, particularly on male medicine. Female medicine was similar. First of all, we were medical students and knew little. Second, we were sleep-deprived, and this was true for several reasons. Cook County Hospital was one of the largest hospitals in the world, and consequently, their accommodations were rather unusual. The interns’ and residents’ quarters were located in a building known as Karl Meyer Hall. Karl Meyer was a fixture at Cook County and an established surgeon of great renown, but when I was there, it was well past the end of his career.

Every evening at ten o’clock, coffee, toast, and assorted snacks were served, which may sound great, but ward demands were such that we rarely found the time to traipse over to Karl Meyer Hall to partake in this minor repast. Next, came the visit to the on-call sleeping quarters. Here we found the real treat. This was a large room built like a hall, with numerous cots arranged in a series of decreasing-sized circles around a central telephone on a simple table. The first people there got to sleep farthest from the phone, while the last to arrive had the pleasure of answering the phone and continuously calling out the names of people he knew not, with only dim lighting. Remember that five schools sent medical students to Cook County Hospital, and we all slept—or tried to, that is.

At the University of Chicago Hospitals and Clinics, (Billings Hospital). The situation was different. There were three double rooms in the house-staff quarters, which were located in northwest section of the sixth floor, and here we also had lounges, televisions, and gaming tables. Entry was limited, and there was easy access from the OR, which was on the south side of the sixth floor. Cardiac surgery and ICU call had a double room just outside the surgical intensive care unit and adjacent to the thoracic-cardiovascular floor, and here the resident on general-surgery call would sleep.

Last, Wyler Children’s Hospital had a small suite where we took call on