When I woke up on July 1, 1986, I was an orthopedic surgeon. It was official. I had a new name tag with my picture, my name, and there is bold letters it said: Tulane Orthopedic Surgery. I had gone to bed a general surgery intern, and overnight transformed into an orthopedic surgeon. I had wanted to be an orthopedic surgeon for a long time. In high school, I was thinking about going to medical school. Did I really want to go to school that long? Did I really want to work those crazy hours? I got a summer job as a hospital orderly cleaning operating rooms and was able to observe surgery. The orthopedic surgery was amazing, there were saws, drills, screws, plates, new knees, and new hips. If it was broken, you fixed it. If it was worn out, you replaced it. Most doctors just manage diseases, they don’t see the disease and fix it. They prescribe medicine for hypertension, or medicine for your thyroid. I liked the idea of seeing and fixing the problem. Some people say orthopedics is just bone carpentry, but I liked the visual and hands on treatment. I was sold, I knew orthopedics was for me. So after four years of college, four years of medical school, and a one year general surgery internship it was finally time to start orthopedics. It was a long nine years to get to this point, but I had made it. During those nine years, I had only spent four months doing orthopedics. Even though my new name tag said I was an orthopedic surgeon, I had a long way to go.
The internship in general surgery at Charity had been long and at times grueling. In residency programs, like life, crap rolls down hill. An intern was on the bottom, and got all the worst jobs. My internship was over 30 years ago, most of it is a blur –long hours and little sleep, but there are some things that I will never forget. Early on in the internship, I learned to close the skin and tie a surgeon’s knot. I learned to manage sick and injured patients. Towards the end of the year, I even took out a few appendixes and gall bladders from skin to skin with my fourth year resident watching my every move. But there was a lot of scut work. Scut was the term used to describe the very unglamorous duties given to the intern. The State of Louisiana was not ever very generous in the funding of Charity Hospital. With the budget restraints, there were minimal ancillary care workers at Charity. The interns made up for the lack of staff.
There was one CT scanner at Charity. It was busy twenty four hours a day. The CT scanner technician might page the intern at four in the morning. You had to stop whatever you were doing and get your patient to the CT scanner. There was no one else to transport the patient. That was the intern’s job and if you didn’t get the patient to the CT scanner in a timely fashion, your patient was put back at the end of the line. Also, there were no respiratory therapists at Charity. Amazing, a hospital as big and busy as Charity and no respiratory therapy. It was common for patients to get atelectasis after surgery and general anesthesia. This was fluid buildup in the lungs that would clear up with coughing and deep breathing. If it was allowed to stay in the lungs, it would lead to pneumonia and serious problems, especially for someone trying to get over a major surgery. Every day, the nurses and house staff would remind patients to cough and deep breath. Many patients did not want to do this, because it would hurt their abdominal incision. As an intern at Charity, you learned quickly that a red rubber nasogastric tube made a great respiratory therapist. For the patients that just wouldn’t cough enough, just putting the tube down their nostril and down the back of their throat would start some serious coughing. It sounds mean, but it was done to save their life. I will never forget a second year general surgery resident that kept a red rubber NG tube in his white coat pocket. He would tell the patient the importance of coughing and deep breathing and use it on a patient. The patients were on wards, so there was no privacy, and all the other patients could hear and see the patient getting the NG tube treatment. He would then walk up and down the center aisle of the ward swinging the red rubber catheter like a cowboy swings a rope. In a second, everyone on the ward was coughing and deep breathing. After getting the entire ward to cough and clear their lungs, he would put the NG tube back in his coat pocket. He said it was the same NG tube from his internship. Surely he put a new clean one in his coat pocket each day. Occasionally, a patient was resistant to the red rubber NG tube treatment. They would continue to get atelectasis despite your best efforts with the NG tube. The first time that happen to me as an intern, the third year resident said to use a “tickle tube.” I had heard of NG tubes from medical school, but had no idea about a tickle tube. As per the Charity way, he would show me one and then I would do the next one. For a tickle tube, the resident numbed up the skin on the neck and then placed an angiocatheter into the patient’s neck between the cartilage rings of the airway. An angiocatheter is normally used to start ivs, but now it was being used to inject some sterile saline into the patient’s windpipe below the epiglottis. The sterile saline would irritate the lungs and the patient had no choice, but to cough for the next half hour or so. It was very effective, with most patient’s chest x-rays clearing up in a day or two.
There were several outpatient clinics at Charity. This is where patients were either seen in follow up for their recent hospitalization or for the care of non urgent problems. The interns would man the clinics with some upper level residents and see countless patients. If you were not in surgery, or dealing with a patient in the hospital, you were assigned clinic duty. There are a few clinics that I will never forget.
Pus Clinic was an experience (yes it was called Pus Clinic). As interns, our job was mostly to changing Unna boots on patients with venous stasis ulcers. This was a medicated gauze that was wrapped around the legs from the knees down to the feet to try to encourage healing of leg ulcers caused by poor circulation. Where did all these people come from? Did everyone in New Orleans have bad circulation? We would change hundreds of Unna boots each week in clinic. I had never seen maggots on human flesh. Maggots are just the larval stage of flies that eat decaying tissue. You would find maggots under about half the Unna boots you changed at vascular clinic. Once you cleaned the maggots off, the ulcer was very clean. The maggots only ate dead tissue, at least that is what we were told.
I can still remember a conversation I had with a man while changing his Unna boot. He asked a question, “Hey doc, they tell me I gots the high blood, the low blood, and the sweet blood – all at the same time. How can my blood do all dat?” This man had the all too common Charity trifecta. I explained the high blood meant he had hypertension. It was important for him to take his blood pressure medicine to prevent a stroke or heart attack. The low blood meant he had anemia. I explained this meant he had not enough red blood cells in his blood. This could be from blood loss, chronic diseases, or poor nutrition. Finally, the sweet blood was diabetes. His blood sugar was too high. He needed to take his diabetic medicine and eat right to keep his sugar under control to help his ulcers on his legs heal. He just shook his head and said something about all that being too complicated. Charity patients in general, were not very good at preventive care and were notoriously noncompliant with medications. Most could not afford medicine and did not really understand the importance of the medicine. They would just come to Charity when there was a problem they could see or feel, like these leg ulcers. Taking care of high blood pressure that had no symptoms seemed like a waste of time and money. Unfortunately, the hypertension would eventually catch up with them, and they would come to Charity when they had a stroke or heart attack or kidney failure.
The other clinic that I will never be able to forget was Procto Clinic. There was a weekly clinic a Charity where every patient was there for a proctoscopic exam. This is basically a lighted tube used to examine the lower 8 inches of the rectum. Now, I was compassionate for the patients, anyone keeping an appointment to have a stranger look up your butt must be having real problems. The most common problems were rectal cancer, hemorrhoids, and infected rectal fissures, that was nic named “butt puss” at Charity. My first day at Procto Clinic, the upper level resident let me watch him do one. That was it, I was ready and started doing procto exams. The rule at Charity was “see one, do one, teach one.” I never taught anyone how to use a proctoscope. For me it was more “see one and do a few hundred.” This was another hurdle to get over to make it to orthopedics, at least that’s how I looked at it. There are some things that can never be unseen, Procto Clinic is one of them.
But it was July 1, 1986. I was now an orthopedic surgery resident. I was no longer on the bottom rung of the medical training ladder. There would be dozens of new interns starting and they were below me. They would be asking me the dumb questions I was asking a year ago. And at the age of 25, I was finally going to learn about what I wanted to be when I grew up. And my new orthopedic name tag meant I was no longer qualified to use a proctoscope. July 1, 1986 was a great day, and I walked into Charity with a big smile on my face.