Gut Feelings : 2013

Wednesday, July 17, 2013

If I Only Had A Heart

Robert S. Rosson, M.D.

Former Vice President Dick Cheney Has Heart Transplant- -Hartford Courant: 3/24/2012

(To the tune of “Tin Man” from the Wizard of Oz)

When a man’s a former Veep,

Starting wars on the cheap

With the gun and sword;

If I’d catch a man of terror

To get info free of error,

I’d use the water board!

When hunting with a chum

I might shoot him in the bum,

And never give a damn.

While Bushy was the Chief

I could play him like a thief

And get Saddam on the lam.

It was fun and it was nice.

Although I was just the Vice,

A conflict I could start.

War was all consumin’

Pretending I was human,

If I only had a heart.

Silence

Robert S. Rosson, M.D.

It hangs over the house like a dense curtain,

Like a thick, impenetrable fog.

It is everywhere and nowhere;

Unbroken by the Brahms from the stereo

Or the nattering noise of the TV.

It is the silence of her absence.

There is the welcome ring of the phone.

They ask “How are you doing, Dad?”

I tell of the latest dinner with friends,

Or the movie attended alone.

Then the silence returns.

I long to tell her the latest gossip,

Or the good news about the choice

Of a new music director for the Symphony.

But there is only silence.

The lonely, numbing, deafening silence.

A Visit to the Doctor

The encounter described below was told to me by a physician friend. It illustrates many of the problems plaguing today’s medical care.

I enter the doctor’s waiting room 15 minutes before my appointment. I sign in and the receptionist copies my insurance cards for the ninth time. I fill out a lengthy questionnaire designed to be entered automatically into the electronic record. I then sign the privacy form without reading it.

I sit down and unfold my New York Times. I get through most of it before I realize that 45 minutes have passed. Finally a medical assistant appears and calls out “Doctor, you may come in now”.

“It’s about time” I say, irritably.

“Oh, I’m so sorry,” she says as she guides me into a tiny examining room that would be inadequate for a monk’s cell. The room is dominated by a large computer screen on a movable bracket attached to the wall. After she checks my weight and blood pressure she leaves, assuring me the doctor would be in soon. Another half hour goes by during which I wish I had brought something else to read.

Finally the doctor enters greeting me with “Hi Bill, how’s retirement treating you?”

“Great,” I say.

He disappears behind the monitor, eliminating any chance of eye contact. I tell him I’m there because of a cough that has persisted for six weeks after a common cold. He asks some questions, all the time typing away on the keyboard.

He then examines my chest, listening with his stethoscope through my shirt and sweater. I can’t resist asking him if he can hear anything this way. He assures me that with his electronic stethoscope he can hear quite well and that my lungs are clear.

He writes a prescription for an expensive cough medicine that isn’t covered by my insurance. I decide I’ll pick up a cheap over-the-counter preparation. I ask if a chest x-ray might be a good idea. As he goes out the door he says it’s not necessary because my “lungs are clear.” I glance at my watch. Total “face” time with the doctor is 11 minutes.

When the cough persists for another two weeks I order my own chest x-ray:

RADIOLOGY REPORT. “There is a five centimeter oval mass in the right upper lobe, adjacent to the mediastinum. The appearance is consistent with a primary neoplasm of the lung.”

Published originally in YJHM January 23, 2011

The UConn Health Center: Whither or Wither?

On November 21, 2009 it was announced that the University of Connecticut had rejected a proposal by Hartford Hospital to merge with the UConn Health Center to form a first rate medical school-hospital complex. Under this plan, supported by a state-sanctioned commission, the state would build a new hospital in Farmington to be owned and operated by Hartford Hospital. The result would be a new University Hospital with campuses both in Farmington and Hartford. The Hartford Healthcare Corporation would assume financial responsibility for the new hospital except for $13 million in labor costs to be born by the state. The other community hospitals in Greater Hartford would continue to participate in the teaching and research activities of the medical school.

Now the situation will revert to that of 18 months ago; the Dempsey Hospital will remain too small to be financially profitable, and the state will continue to be responsible for an annual deficit of about $20 million. Moreover, the 32 year-old hospital is said to be in need of major renovations. No alternative plan has been proposed by UConn or the Legislature. The question is where we go from here with this unsustainable situation.

In the Hartford Courant of Sunday, December 6, 2009, Connecticut State Representatives David Baram and Timothy Larson, suggest that the VA partner with UConn as a way to solve the problem. They make no mention of the Newington VA Hospital; which already has an affiliation with the Health Center. In recent years that hospital was reduced to an outpatient facility and its inpatients transferred to the West Haven VA, which is a major affiliate of Yale Medical School. At one time a suggestion was made that the VA build a hospital on the Farmington site, but nothing came of it. While the VA does provide salaries and space for residents and faculty at many medical schools, I do not know whether it can provide operating expenses for university hospitals or funds to build new non-VA hospitals.

I would suggest, as others have, that UConn revisit the idea of the “Harvard Model.” This system is one in which the university medical school has no hospital of its own, but rather utilizes the hospitals within its geographic area for teaching students, residents and fellows, and for care of patients and research by its faculty.

In this regard I suggest the following:

The Legislature and UConn should appoint a joint commission to study this possibility. Representatives should visit Harvard Medical School to learn in detail how the system works.
UConn should engage a consultant with intimate knowledge of the Harvard Model to determine the efficacy and implementation of such a system in Greater Hartford.
Under this proposal, the John Dempsey Hospital would close its inpatient services.
The hospital would be re-fitted to include research laboratories, outpatient clinics, outpatient surgical centers, a walk-in center, and a triage emergency center. Patients needing admission could be rapidly transferred to one of the cooperating community hospitals by helicopter or ambulance.
The participating hospitals, Central Connecticut, St. Francis, and Hartford Hospitals, and others, would provide laboratory and office space and designated hospital beds to the university physicians. Consultations between the university and community physicians would work to the benefit of both groups and their patients. Each group would contribute significantly to the education of medical students, residents and fellows, who would continue to rotate among the hospitals as they do now.

Obviously many financial and administrative problems would have to be worked out before such a plan could go into effect. With, however, strong, enlightened leadership and open-minded good will among the various players, the University of Connecticut-Greater Hartford Medical Center could become the first rate system of education and medical care the citizens of Connecticut deserve. If we can become first class in basketball and football, we ought to be able to do it in medical education, research and patient care.

Note: The writer is a graduate of Harvard Medical School and Clinical Professor of Medicine at the UConn School of Medicine. The views expressed herein are strictly his own and do not necessarily reflect those of either institution or YJHM.

Published originally in YJHM December 9, 2009

Remembrances of Internship Past

As I read the recent obituary of Dr. A. Stone Freedberg (NY Times, 8/24/09), memories of my internship at Boston’s Beth Israel Hospital came flooding back. Dr. Freedberg, who died at the age of 101, had a long and distinguished career in cardiology at that institution. I recall herein some of my experiences of some 50 years ago.

In the Beginning

I reported for duty at the BI as a medical intern on July 1, 1958. An eager, freshly-minted MD, I looked forward to working every other night and weekend, for $25 a month and all I could eat. I was outfitted in a white barber’s smock, white trousers and white bucks and sent off to the medical ward under the supervision of an all-knowing, experienced first year resident. Before I could catch my breath I was doing histories and physicals on admissions sent up from the emergency room. I quickly learned that the admitting residents were to be designated as “sieves” whereas when I was in the ER, I was to be a “steel door”.

My wife, Eileen, taught second grade in Norwood, Mass. She drove to work from our Boston apartment in our battered Chevy while I took the “T” to the hospital. The physical and mental stress of internship and our marginal financial status put a tremendous strain on our year-old marriage, but at the same time strengthened our relationship. The celebration of our 52nd anniversary this summer attests to that fact.

Emphasis on Cardiology

Dr. Herrman Blumgart was Chief of Medicine at the BI. This brilliant, gentle physician was the first doctor the entering freshmen at Harvard Medical School encountered. He had made outstanding contributions to the understanding of coronary artery disease, including the finding of plaques in the coronaries of young men killed in battle in WWII. His cardiology division included, in addition to Dr. Freedberg, Dr. Louis Wolff, Dr. George Kurland, Dr. Paul Zoll, and others. The most common disease admitted to our service was acute myocardial infarction. The treatment at that time was three weeks of strict bed rest and anticoagulation. Needless to say the mortality rate was quite high. We spent a lot of time using Dr. Zoll’s invention, the cardiac defibrillator, with limited success. Later Dr. Zoll’s machine would be supplanted by the one developed by Dr. Bernard Lown at the Brigham.

A Near Death Experience

Sometime in that first year I developed axiliary furunculosis. I had a resident drain the first boil uneventfully. When Dr. Jim Feeney, the physician to the house staff, found out about it, he insisted that the next one be drained by an attending surgeon. Two days after that was done I awoke with a temperature of 103 degrees, feeling worse than I had ever experienced. My wife was almost out the door heading for work when I called her back and suggested she take me to the hospital. I was admitted with septicemia due to the nasty strain of staphylococcus then running around our hospitals. The only drugs available at that time for treatment were oral Chloromycetin and intravenous erythromycin. Each day Dr. Blumgart listened to my heart and felt for my spleen while I pretended that I didn’t know he was looking for signs of endocarditis. I was also seen by the famous infectious disease expert, Dr. Louis Weinstein, which was at once a comfort and a source of anxiety. At one point Dr. Blumgart horrified Eileen by saying “We’re just as concerned about him as you are.” At any rate I recovered and a brilliant career was not aborted.

The Thyro-Cardiac Axis

The cardiology and endocrinology sections of the department of medicine collaborated on the relationship between thyroid function and coronary disease. Dr. Freedberg explored the treatment of severe angina by inducing hypothyroidism with radioactive iodine. Dr. Kurland investigated the role of hyperthyroidism in cardiac arrhythmias. For a time I worked in his laboratory, suspending an isolated rabbit’s heart in a lactate solution and recording its beat on a smoked drum kymograph (!). I tried to induce atrial fibrillation by adding thyroid hormone to the bath. I suspect the only fibrillation I induced was in my own heart.

Role Models

The physicians I was privileged to work with, and learn from, during that year, Drs. Blumgart, Freedberg, Kurland, Milton Hamolsky, Louis Zetzel, and Herb Saver, to name but a few were a source of inspiration that influenced my entire career. They taught me that no matter the specialty we are internists first and foremost, a lesson that I fear is lost to today’s crop of super sub-specialists.

Back to the Future

I stayed at the BI for two years, during which time my daughter Julie was born. I entered that institution a medical student and left as a physician. I then served two years in the Air Force, after which I went to Yale/New Haven for my GI Fellowship under Dr. Howard Spiro. But that’s the subject of another story.

Published originally in YJHM September 2, 2009

Your Online Ethics Quiz

Welcome to Your Online Ethics Quiz. Submit your answers to The Institute for Ethics Research, insethres@morality.org.

1. Rick Pitino, prominent and successful basketball coach, admits to a one time sexual “indiscretion” six years ago. The married father of five and pro-life advocate is also said to have paid $3,000 to the woman for an alleged abortion. The President of the University of Louisville, his current employer, should:

Fire him immediately, but with a golden parachute.
Give him a raise in pay.
Keep him on as coach if his team gets to the final four.
Force him to give 100 hours of community service to Planned Parenthood.

2. The former chief financial officer of Hadassah, Sheryl Weinstein, admits in her new book to have invested heavily for the organization and for her own account with convicted fraudulent investor, Bernard Madoff. Moreover she admits to an affair with the financial wizard. She should now be forced to:

Apply for food stamps.
See Bernie regularly for conjugal visits in prison.
Perform 500 hours of community service for Hadassah.
Accept a job at A.I. G.

3. Michael Vick, recently released from prison for running a dog-fighting ring, has been signed as back-up quarterback for the Philadelphia Eagles. The Commissioner of the NFL should now:

Commend the Eagles for combating unemployment.
Permit season ticket holders to bring their dogs to Eagles’ games.
Make Vick do 200 hours of community service for the American Kennel Club.
Permit the use of pit bulls in the backfield to protect Vick from opposing linemen.

4. Sarah Palin, the recently self-deposed governor of Alaska, accused the Obama administration’s health care plan of providing for “death panels” for seniors. She should now:

Promise never to run for elective office again.
Learn that “euthanasia” is not a young persons group in China.
Apply for membership in the Hemlock Society.
Perform 150 hours of community service for the Coalition for Teen Age Abstinence.

5. Governor Mark Sanford of South Carolina has confessed to an affair with a woman in Argentina, while allegedly hiking on the Appalachian Trail. He should now:

Divert attention by flying the Confederate flag over the state capitol.
Ask President Obama to appoint him Ambassador to Argentina.
Join the Appalachian Mountain Club.
Wear an ankle bracelet with a GPS device whenever he is away from his office.

Be sure to go online next week when our quiz topic will be: “Are there any ethical challenges on Wall Street?”

Published originally in YJHM August 18, 2009

XXY

More than seven years have elapsed since I retired from liberating common duct stones and electrocuting colon polyps. Recently I have discovered that I possess a new and rare talent. I am now able to diagnose obscure medical illnesses in celebrities based only on newspaper and TV reports.

My first, and only, case so far, ("Apple's Apudoma," YJHM, January 25, 2009) involved Steve Jobs, CEO of Apple Computer, in whom I successfully diagnosed an islet cell tumor of the pancreas, metastatic to liver, He recently underwent liver transplantation, a treatment for this type of tumor for which I was an early advocate.

I turn now to the case of recently deceased popular music star, Michael Jackson. I mean no disrespect to him or his memory. I am, however, unashamedly giving him the diagnosis of Klinefelter’s Syndrome. In this disorder males have an extra X chromosome, giving them a profile of XXY rather than the normal XY. This has a feminizing effect and is characterized by a scarcity of facial and body hair, small testes, low testosterone levels and absence of sperm.

Mr. Jackson had an androgynous appearance, a high pitched voice, lack of facial hair, and was apparently infertile. His two older children were allegedly conceived with the aid of a sperm donor according to TV reports. His personality and body habitus were compatible with those described for some cases of Klinefelter’s.

The ambiguity of his gender role was dramatically illustrated by his ex-wife, Debbie Rowe, who, when asked in an interview to explain her limited role in the lives of the children stated in effect that Michael did everything: “He was both mother and father to the kids”.

Whether this diagnosis is correct will probably be known only to his personal physician and the Los Angeles coroner. It does offer an explanation for some of his strange behaviors and characteristics, which have puzzled some of us pop music aficionados.

Published originally in YJHM July 12, 2009

Medicare Sticks It to Virtual Colonoscopy

Medicare Blow to Virtual Colonoscopies: New York Times, Friday, February 13, 2009

Screening for colorectal cancer is undoubtedly a worthwhile and laudable process. At present the gold standard is optical colonoscopy, which has the advantage of permitting removal of pre-cancerous polyps. This procedure, however, requires a dedicated endoscopy unit, a skilled, highly-trained gastroenterologist or surgeon, one or two nurse assistants, expensive equipment, and the presence of an anesthesthetist (or two!) to administer the currently recommended sedation.

A relatively new and possibly more cost effective, screening tool has been developed utilizing CT technology. While this procedure, “virtual colonoscopy,” requires essentially the same unpleasant preparation as colonoscopy, it requires only one technician, a radiologist and a CT scanner in a standard radiology suite. With increasing utilization, this procedure should incur lower costs to the patient and to Medicare.

Now in its infinite wisdom the Centers for Medicare and Medicaid Services has tentatively decided not to pay for virtual colonoscopy. Each method has its strengths and weaknesses. Virtual colonoscopy sees only larger polyps and requires the patient to be referred for conventional colonoscopy for removal of the polyps. Conventional colonoscopy can find smaller polyps, but most of these do not need to be removed. Virtual colonoscopy does not carry the slight but definite risk of perforation of the colon associated with the conventional procedure. I believe this is a short-sighted and ill-conceived decision by Medicare

I would suggest a way to improve the situation and decrease the cost in which two procedures are required when polyps are found by the CT method. I would have colonoscopy units reserve a certain number of time slots the next day for patients found to have polyps by virtual colonoscopy. The patient could be kept on a clear liquid diet and not need further colon preparation. The professional and facility charges for such a “targeted” colonoscopy and the CT scan could then be reduced significantly for the combined procedures.

As Dr. Howard Spiro and I suggested in our letter to the Annals of Internal Medicine in 2003, virtual colonoscopy or other developing tests should become alternatives to optical colonoscopy as primary screening tests for colorectal cancer.

Published originally in YJHM February 17, 2009

A Boutique System of Primary care for Medicare

The shortage of primary care physicians has been well-documented in these pages and elsewhere. It is particularly acute with respect to Medicare patients. Not only are physician reimbursements low, but these patients often have complicated illnesses requiring more time than the physician has to give. Many primary care internists have closed their practices to new Medicare patients. Graduating medical students are opting for more lucrative fields such as cosmetic dermatology or plastic surgery.

Many internists have turned to a boutique or concierge system of medical practice in order to provide better care, increase income and improve physician life style. This system involves a limited panel of patients and a pre-paid retainer fee. In return the patient is guaranteed 24/7 access, adequate time for visits, and home care.

I have suggested a boutique system for Medicare patients, associated with an incentive to attract medical students into primary care. James Ocampo, a fourth-year medical student at the University of Connecticut, is currently working on this idea as a selective project. Such a plan might work as follows: Medicare would support the formation of groups to provide boutique care exclusively to Medicare patients. Groups would consist of four to ten internists complemented by nurse practitioners and physician assistants. The groups would provide ready access to care 24/7 with same day access, easy communication by telephone or e-mail, home visits, and adequate time for office visits. The optimal panel size per physician and the amount of the annual retainer per patient remain to be determined. Hospital care and prescription drug coverage are not included in this proposal.

Medicare would pay the retainer per patient plus a reasonable overhead sum to the groups. Patients would pay the usual Medicare monthly fee plus deductible, with adjustments for income level. An additional surcharge may be added for the boutique program. Patient satisfaction with access and quality of care would be measured by annual questionnaires.

As an incentive for medical students to choose internal medicine residencies and residents to join Medicare boutique groups, a program of debt forgiveness would be initiated by Medicare. Reimbursement for student debt could vary from 25 percent per year for four years to 10 percent per year for 10 years of service.

I am confident that Mr. Ocampo’s research will indicate whether this plan could provide improved access and quality of primary care for seniors at reasonable cost, and attract medical students into primary care. If such a plan appears reasonable, a grant for a pilot project funded by the government or other funding agency could be sought.

Published originally in YJHM February 1, 2009

Apple's Apudoma

The current and highly-publicized medical situation of the well-known CEO and founder of Apple Computer suggests to me the possibility of a metastatic apudoma or neuroendocrine tumor. He is said to be a four year survivor of “pancreatic cancer” who now has a “hormonal imbalance.” I have no knowledge of his actual medical diagnosis, but I am reminded of some of the most memorable patients I cared for in my career. Let me illustrate with a few anecdotes from memory.

A woman in her fifties presented with severe diarrhea, weight loss, and extreme loss of body potassium. When an extensive workup failed to reveal a cause, we resorted to diagnostic laporotomy. I went to the OR in time to see the surgeon holding up an orange-sized tumor from the tail of the pancreas. The resected specimen showed an islet cell tumor of the pancreas, possibly malignant. At about that time, in the 1960s, reports began to appear of vasoactive intestinal peptide (VIP) secreting tumors which produced this clinical syndrome. She recovered dramatically and, in spite of later spread to the liver, she lived for another twenty-five years. I stored the tumor in a freezer in the hope of a future assay for VIP or other hormones. It disappeared, however, mysteriously from the freezer (perhaps it became part of someone’s lunch), and we could never do the assay. Nevertheless it is clear that the tumor was a VIPoma, as it is now known.

A forty year-old man developed an ulcer in his lower esophagus. That unusual location led to our finding a markedly elevated serum gastrin. CT scan showed no abnormality in the pancreas. He was explored and a tiny tumor was found in the first portion of the duodenum. When it was resected the profuse drainage of acid from his stomach tube stopped immediately, as if a spigot had been turned off. He recovered uneventfully and suffered no recurrence. The pathology sections showed a typical neuroendocrine tumor which stained for gastrin -- a classic case of Zollinger-Ellison Syndrome due to a solitary benign gastrinoma.

A 55-year-old man was seen for right upper abdominal pain and abnormal liver blood tests. CT scan revealed multiple liver lesions which, upon biopsy, showed metastatic islet cell cancer. The tumor did not stain for peptide hormones, nor were there clinical symptoms of hormone secretion. The primary tumor was never located. Two years later, when he developed signs of liver failure, he underwent liver transplantation over the strenuous objections of his health insurance company. In spite of later recurrences in liver and bone, he lived productively and relatively comfortably for fifteen years after transplant. Although this was initially a non-secreting, malignant neuroendocrine tumor, the subsequent metastases secreted gastrin and caused a gastric ulcer. Liver transplantation was offered because these tumors grow slowly and do not seem to be accelerated by anti-rejection therapy. His response to liver transplantation was gratifying and provided outstanding palliation.

These cases illustrate the dramatic clinical syndromes the various hormones secreted by these tumors can produce. In addition these tumors, even when malignant, are indolent and can be compatible with long survival. They are among the most interesting, challenging, and rewarding diseases confronting the clinician. Even when the primary tumor cannot be found or removed, treatment of the hormonal syndrome, for example using proton pump inhibitors for gastrinoma, can bring about dramatic relief. Modern diagnostic tools such as CT scan, MRI, nuclear scan, and serum hormone assays are effective in making the diagnosis.

There are reports that the aforementioned CEO is being considered for liver transplantation. If true, this lends credence to my diagnostic speculation.

Published originally in YJHM January 25, 2009

MacSpit: Duke of York

Dramatis Personae

Kierek, Kelley: castle guards
Macspit: Duke of York
Kristen: a harlot
Silvia: Duchess of York
Bruno: Lord Chamberlain

SCENE: Dukedom of York

ACT I

Scene I (Outside a hunting lodge near the Duke’s castle)

Kierek: Who goes there?
Kelley: ‘Tis Kelley, come to relieve thee.
Kierek: Thou art welcome. The cold doth rattle my bones whilst I watch over our lord’s “hunting”.
Kelley: With whom doth he consort this time?
Kierek: ‘Tis the beautiful Kristen, who doth pleasure the Duke.
Kelley: Oh, it’s a mighty price to pay for such sport—but well worth it I’m told.
Kierek: That mayest be, but methinks she providest the very same services available to us in the town brothel--at little more than the cost of a pint.
Kelley: Aye, but noblemen believe the dearer the price the better the quality of the experience. But away with thee now; the Duke emergest from his tryst. (Exit Kierek.

Enter Macspit and Kristen

Macspit: Thank thee my dearest Kristen. Thou hast given me great joy. I shall forward the necessary gold to thy procurer.
Kristen: Thank thee my lord. Thou hast pleased me more than any of my other Jonathans. I pray I shall see thee again in short order. (Exeunt.

Scene II (The Duke’s castle)

Enter the Duke and Duchess

Macspit: How now my beautiful wife.
Silvia: I am well my lord now that thou drawest near. I have so missed thee from our marriage bed, source of my joy and fulfillment. How went the hunt?
Macspit: Verily, I have achieved great satisfaction therein, my love. I didst bed-- er bag a wild boar and a most lovely doe.
Silvia: Good. I shall have the servants prepare them for a banquet.
Macspit: Ah—that won’t be necessary dearest. I have already so instructed them.
Silvia: So be it then. Let us off to bed for an afternoon of ecstasy.
Macspit: Forgive me dearest. Let us delay our pleasure a bit since I am exhausted from my amorous—I mean--arduous hunt.
Silvia: So be it my lord. ‘Til then I shall dream of our next encounter. (Exit Silvia.

Enter Bruno.

Bruno: Forgive me my lord. I have a matter of great delicacy to discuss with thee.
Macspit: Go ahead dear Bruno. Thou shouldst have no fear of consulting me on any matter of state.
Bruno: Well my lord. It doth appear that rather large quantities of gold are missing from the treasury, the receipts for which are drawn personally by your lordship for what are called “personal expenses”.
Macspit: And what of it? Do I not control my estate absolutely?
Bruno: Aye my lord, but rumor has it that these same amounts have appeared in the possession of a well known procurer of exotic services, and these things are also known to the townspeople, who pay high tithes, whilst the procurer payest none.
Macspit: By the gods--I am exposed! The fair Silvia will soon know of this adventure and will surely have murderous thoughts.
Bruno: Aye my lord. Many great leaders throughout history would have been prudent to resist the temptations of the flesh.
Macspit: I pray thee dear Bruno. Order my horse saddled and provide me with two attendants and provisions for a fortnight. Do this for me post haste and secretly, so that I may go forth before I am confronted with my indiscretions. I shall see that thou art well rewarded, (be there any gold left in the treasury). And if thou canst find my son, Patter, wherever he be wenching, notify him that he shall become Duke as soon as my departure is secure.
Bruno: It shall be done as thou wishest my lord. I bid thee safe journey. (Exit Bruno.

Macspit: So I am done; depart I must. Such fate awaits who yield to Lust.

The End.

Published originally in YJHM March 26, 2008

Endocenter: A Tragedy in One Act

CAST OF CHARACTERS
(in order of appearance)

Dr. Cash, an endoscopist
Lucille, a nurse
Kevin, Barbara, patient care assistants
Mrs. Glass, an elderly patient
Bill, a nurse
I.M. Frugal, AdministratorFlorence, Nurse Manager
Joan, recovery room nurse

ACT I, SCENE I

A GI endoscopy suite in a two-story medical building in suburban Bloomfield, Indiana. Time: the present. Dr. Cash, dressed in a blue operating gown, is in the procedure room, eyes fixed on the monitor into which he has patched CNBC. Enter Lucille in surgical scrubs.

Lucille: Hi Dr. Cash! Your patient is ready.

Dr. Cash: Quiet Lucille! I have to see if the market is up or down.

Lucille: But Dr. Cash-- it’s only 7:30 in the morning; the market isn’t even open.

Dr. Cash: So what. I have to watch the Dow futures and the Asian markets. Bring in the patient.

Enter the patient, wheeled in by the two patient care assistants.

Lucille: Mrs. Glass, this is Dr. Cash. He’ll be doing your procedures.

Dr. Cash: Hello, Mrs. Glass. What brings you in today?

Mrs. Glass: I don’t see - - - - - -

Dr. Cash: Of course not, dear. We, however, can see everything with our little scopes and we’ll be doing a nice double-dip on you today.

Mrs. Glass: Can you do both at the same time? I was told you only did one - - - - - -

Dr. Cash: That’s ridiculous. We do both at the same time to save you a trip, and you only need to be sedated once. Not to worry. We’ll take care of everything. Just sign here. Have you had your history and physical done?

Mrs. Glass: No I - - - - - -

Dr. Cash: Never mind. The automated computer program will take care of it. Eh Lucille?

Lucille: But Dr. Cash!

Dr. Cash: Forget about it. Let’s get going. Give her 150 mg. of Demerol and 12 mg. of Versed.

Lucille: What?? She’ll arrest.

Dr. Cash: Arrest? Don’t be silly—just do it. We’ll start with the colon. There we are -- in the rectum. Poor prep! And there’s the cecum!

Lucille: With all due respect, Doctor, you are just in the sigmoid.

Dr. Cash: Nurse, are you questioning my judgment? It’s an S-shaped cecum! Give me a snare for this polyp.

Lucille: Doctor! That’s a suction polyp!

Dr. Cash: That’s it! Get me another nurse!

Exit Lucille in tears. Bill breezes in.

Bill: OK, Doc Cash. Just take out that “cecal polyp” and get out. The computer program will make it read just right.

Dr. Cash: That’s more like it. Let’s remove this scope and do the upper.

The patient, still sedated, is repositioned. Dr. Cash passes the upper endoscope into the stomach.

Aha! Just as I suspected. Pyloric stenosis and C.Difficile. Let’s balloon and biopsy.

Bill: Don’t you mean H. Pylori?

Dr. Cash: Whatever!

Frugal sticks his head in the door.

Frugal: Thanks for doing every procedure on everybody, Cash-man, but remember to keep expenses down. Use as little Versed as possible and slow the IV down to 5 cc. per hour.

Dr. Cash: Right, Frugie! (aside) What an idiot!!! OK get her out of here and set up the next case.

Exit Fugal. Mrs. Glass is wheeled out by Barbara and Kevin.

SCENE II

The recovery room, 6 hours later. Mrs. Glass wakes up surrounded by Florence and Joan.

Florence: There you are, dear. We thought you’d never wake up.

Joan: I’ll bring you some juice and a cookie. (aside) That damn Frugal only lets us give one cookie per patient.

Mrs. Glass: I feel awful—so gassy. What did he do to me? And where are my eye bandages?

Florence: What are you talking about?

Joan: What eye bandages?

Mrs. Glass: Isn’t this the Eye Center? I came to get my cataracts fixed!

CURTAIN

Published originally in YJHM January 14, 2008

Capital Punishment on Trial

TV ANCHORWOMAN: Welcome everyone to CourtTV. As many of you know we have been following the trial of Capital Punishment, indicted for multiple crimes including “cruel and unusual punishment.” After three months of testimony a three judge federal circuit court panel has found the defendant guilty as charged of four out of five counts, and today we take you live into the courtroom, where Chief Judge Moses Solomon is about to pronounce sentence.

The scene shifts to a courtroom where the presiding Judge has just asked the defendant to rise. The defendant is seen standing flanked by his two lawyers. He is dressed in a black suit and black shirt. His blood-red tie resembles a hangman’s knot.

THE JUDGE: Defendant Capital Punishment. After months of testimony on both sides this panel has unanimously found you guilty of the crimes of: 1) racial discrimination, 2) excessive expense, 3) execution of the innocent, and 4) cruel and unusual punishment. You were acquitted on a fifth count of lack of homicide deterrence. It is my task to hand down an appropriate sentence. Before I do let me review some of the important arguments in this case. This case did not deal with the philosophical and religious issues surrounding capital punishment. Whether the perpetrators of heinous crimes, such as rape and murder of young women and children, should be put to death or sentenced to life in prison without parole was the central issue for us to decide.

We heard many arguments from experts on both sides. We were informed that African Americans are sent to death row far more often than white defendants. The issue of the death penalty as a deterrent to homicide remains controversial. Recent studies have suggested a decline in homicide in jurisdictions where the death penalty is invoked. Although there are many critics who find fault with the methodology of these studies, the panel acquitted you on this count.

We were told that it is too expensive for taxpayers to keep prisoners incarcerated for life. On the other side it was pointed out that the numerous death row appeals result in high legal expenses to the state and long delays before execution. Furthermore, New Jersey has found that it costs more than 2 1/2 times as much to maintain inmates on death row than in the general prison population.

We heard testimony that DNA testing has resulted in the release of many death row inmates who had been wrongfully convicted. This finding has led Illinois and Maryland to declare a complete moratorium on executions in those states. Certainly our society cannot tolerate execution of innocent persons.

Recently evidence has surfaced that lethal injection, long considered the most humane method of execution, might actually cause severe pain in the helplessly paralyzed condemned inmate. This has resulted in a de facto moratorium on executions throughout the country pending a Supreme Court decision. Physicians, true to their oath and supported by major medical societies, have refused to participate in lethal injection or to investigate alternative methods of the procedure,

This Court, after due deliberation, has decided that you are guilty of four of the counts in the indictment. Most notably lethal injection, and by inference, all methods of execution were found to constitute “cruel and unusual punishment”. Therefore, the Court hereby sentences you, Capital Punishment, to be banished, immediately and permanently, from the United States. The Court is aware that the pending Supreme Court case and pending legislation in New Jersey may affect the ultimate outcome of this case on appeal.

Does the defendant have any final words for this Court?

CAPITAL PUNISHMENT: Your Honor. I obviously disagree with the verdict and sentence in this case and shall appeal. You are now depriving U.S. society of the opportunity for retribution in crimes of the most heinous nature. I must admit that life imprisonment without parole is severe and just punishment and permanently removes the offender from society. I shall, nevertheless, continue to execute in countries, such as Japan, where I am still legal, and in Iraq where I still have some unfinished business.

THE JUDGE: Court is adjourned.

TV ANCHORWOMAN: That’s it for CourtTV today. Be sure to tune in tomorrow when we cover the latest developments in the legal problems of O.J. Simpson and Barry Bonds.

Published originally in YJHM December 1, 2007

The Return of the I-Man II

Don Imus recently returned to radio and TV as I predicted on these ethereal pages. This demonstrates America’s affinity for redemption as well as the primacy of commercial advertising in our society. I now predict that one of his early guests will be President George W. Bush and that the interview will go something like this:

Imus: Welcome to the program, Mr. President

Bush: Thank you, Don. I’m pleased to be here and especially happy that you’re back on the air.

Imus: Let’s get right to it. How are things going in Iraq?

Bush: We’re making progress, the surge is working and we’re creating a peaceful, stable democracy in the Middle East.

Imus: Judging from the results of the last election, the American public doesn’t agree. Most people feel the war was a big mistake.

Bush: We must stay the course, not cut and run.

Imus: Even though violence is decreased, many Iraqis and U.S. troops are still getting killed. And the government has not met most of the goals we set for them.

Bush: In Iraq we toppled a murderous dictator and prevented him from using weapons of mass destruction against us,

Imus: Which he never had! Who are you kidding, Mr. President?

Bush: Watch it! Besides I had to finish the work my father didn’t do.

Imus: But who’s your daddy now? Rummy?

Bush: I canned him. It’s Shooter Cheney.

Imus: I thought he was convicted of lying.

Bush: That’s SCOOTER Libby! Why don’t you ask me about North Korea and their nuc-u-lar ambitions?

Imus: Why can’t you say nuc-le-ar? And you better watch out for Iran in this regard.

Bush: If the Iranians get nuc- uh - nuc-uh - atomic bombs, I’ll invade them and turn them into a peaceful, stable democracy.

Imus: Not again!

Bush: That’s enough, I-Man. Let’s change the subject.

Imus: OK. Who do you like in the current Republican race?

Bush: I favor the views of that preacher feller, but he doesn’t have a prayer. Heh, Heh.

Imus: How about the Democrats? They’ll be running either a woman or an African-American.

Bush: You don’t rate very well with either of those groups, Imus.

Imus: This is not about me! Many people fear that we’re in the midst of either a Clinton or Bush dynasty.

Bush: Don’t worry. Laura is too nice and too smart to get involved in politics and my girls aren’t interested. Jeb is a possibility but who knows?

Imus: Thank you, Mr. President. Come back again.

Bush: Thanks, Don. Ask me before next January, after which I’ll be history.

Published originally in YJHM February 14, 2008

The Return of the I-Man

It has been rumored that CBS and MSNBC are preparing to reinstate the morning simulcast of the Don Imus show. This reporter has obtained a copy of a taped segment for review by the networks before allowing live broadcasts to air. Here is the script:

(The studio is shown as before. Don Imus is behind the mike, dressed in a charcoal grey suit, a blue striped shirt with white collar and a rep tie. His hair is cut short and dyed light brown. His eyelids have been surgically tacked up in a wide open position. Across from Imus is Tiki Barber, formerly star running back with the New York Giants, now commentator on the Today Show. He is wearing a navy suit, white dress shirt and quiet plaid tie.)

(Music: The theme from Ode to Joy from Beethoven’s 9^th.)

Imus: It’s great to be back on the air. I want to introduce my new sidekick, Tiki Barber, recently retired running back for the New York Giants.

Tiki: Thank you Don. It’s great to be here. Your first guest today is Rabbi Jacob Feldstein of Temple Beth Shalom in Passaic, New Jersey.

Imus: Greetings Rabbi. It’s a pleasure to have you with us. What brings you to see us?

Rabbi: Thank you for having me, Mr. Imus. We wanted you to know that the Sisterhood of our Temple is having an art show of paintings and sculpture from Israel and we’re inviting you to come.

Imus: That’s wonderful! I don’t know if I can make it but I’ll have Tiki see that you get a check for $1000 for the Sisterhood. By the way how are things in Israel these days?

Rabbi: Bless you Mr. Imus. Things in Israel are much the same—an uneasy truce-always the potential for violence.

Imus: Well I hope you people kick some butt over there!

Tiki: Watch it I-man!

Imus: Oops, I forgot. May there be eternal peace for all in the Holy Land. Thank you Rabbi for coming in.

Tiki: Joining us now is Herman Budge, President of the Fatpeople’s Club of America.

(Enter a young man, weighing at least 250 pounds. He is wearing a white T-shirt and jeans.)

Herman: Good morning Mr. Imus.

Imus: Good morning. Tell me about the Fatpeople’s Club.

Herman: Well, we’re a group of men and women who don’t believe all this “obesity epidemic” stuff and believe you should eat what you want when you want it.

Imus: That’s marvelous! We need more people like you in this country. Otherwise McDonalds and Burger King would go broke. Keep up the good work! Who’s next, Tiki?

Tiki: Welcome Mr. Karl Rove, Assistant to President Bush.

Imus: Hello, Rovey. You’re doing a heckova job.

Rove: That what Bushie always says. I’m glad to see you’re back, I-Man.

Imus: How are things now that the Plame thing is settled? And what about the firing of those eight prosecutors?

Rove: Well, Scooter took one for the team, and now it looks as if Gonzo will have to do the same.

Imus: Now that we’ve gotten rid of Brownie and Rummy, who’s next?

Rove: Who knows? Maybe Wolfie. In any case I’ll still be around.

Imus: I’m sure you will. Thanks for coming in.

Tiki: Our next guest in a minute--after this message.

(Commercial: This program is brought to you by The Center for Civilized Discourse in America. Now that Mr. Imus has atoned for his previous sins, we welcome him back to the airways and expect him to be a poster child for dignified and respectful dialogue among all members of our society. Now back to Imus in the Morning.)

(Music: Wagner: Siegfried Theme)

Tiki: Joining us now by telephone is 11 year-old Bobby Jenkins from Seattle, Washington. He’s the winner of the National Student Science Fair.

Imus: Congratulations and welcome, Bobby. What was your project?

Bobby: I designed a method to get man safely to Mars and back.

Imus: Wow! Tell me about your mother and father.

Bobby: My mother is a school science teacher and I don’t have a father. My other mother is an engineer who works for Boeing.

Imus: Isn’t that terrific? I’d love to meet your two mommies. We’ll have to have you visit us here in New York with them.

Tiki: That‘s it for today. Be sure to tune in tomorrow morning when our guests will be the Reverends Al Sharpton and Jesse Jackson.

(Camera fades back.)

(Music: Opening theme from Beethoven’s 5^th.)

Published thoriginally in YJHM May 7, 2007

InHUMANAty

(The piece you are about to read is based on a true story. The names have been changed to protect the innocent, not the guilty.)

As I sit here in my room on the locked ward at the Institute, waiting for the attendant to bring me my anti-psychotics, I am trying to reflect on how I got here. The events of the past few months are mostly a blur but I’ll reconstruct them as best I can.

It all started very innocently. As a Medicare recipient I naturally took advantage of the Prescription Drug Plan. Like most citizens I could hardly understand the provisions of the plan but believed it would save me some money. I had no more understanding of the “donut hole” than I do of a black hole. On the advice of my pharmacist I chose Inhumana, the giant health care corporation, as my insurer for the plan.

I’m just an ordinary guy – a 68 year old retired accountant named Roger Robertson. My wife and I live on a modest pension and Social Security. I take standard medications for stable coronary disease, high blood pressure and elevated cholesterol.

For the first year there was no problem. Then I made the mistake of trying to upgrade my plan from “Standard” to “Enhanced”. For a higher premium I thought that I would take advantage of greater benefits. That’s when the trouble started. I called in my intentions in November of 2006 as I was instructed. I was told the upgrade would be accomplished. Months went by and every time I filled my prescriptions I was told I was still on the Standard Plan and had to pay the deductible and the higher co-pays. I had heated arguments with my pharmacist who said the whole problem was with Inhumana. I called Inhumana “Customer Service” (clearly a misnomer) at least five times and sent several e-mails, each time being told that the appropriate changes would be made and that I would be reimbursed for my overcharges.

These are some of the conversations with Customer Service in response to my requests:

11/20/06; Sonia: “Yes sir, we’ll take care of it for you.”

1/12/07; Thomas: “It wasn’t processed properly the first time. I’ll straighten it out and send it on to Underwriting.”

1/29/07; Tara: “It hasn’t gone through yet. I’ll make sure it’s done”

2/19/07; John: “It wasn’t put through correctly. I spoke to my supervisor who told me to enter it into the computer myself and it will be effective tomorrow.”

3/9/07; Carlos: It hasn’t gone through yet. I’ll see that it gets taken care of right away.”

By the end of March of 2007 I could take it no longer. I wrote to Medicare and my congressman. I threatened to engage a lawyer. I tried unsuccessfully to call the CEO of the company. All I got back was an e-mail from Nichol at Inhumana who said she understood my frustration but could not make any changes. The e-mail contained the following message:

“P.U.S.H. - PRAY UNTIL SOMETHING HAPPENS"

At this point something snapped. I overturned my desk scattering papers and computer components everywhere. I tore at my clothing. My wife found me sitting cross-legged on the floor in my underwear singing The Battle Hymn of the Republic.

That was two weeks ago. I’m better now. My therapist says I can go home soon. She says she’ll give me prescriptions for two anti-psychotics when I leave. She says I have to get them filled right away…………..

Published originally in YJHM April 19, 2007

The Raving

(With apologies to Edgar Allan Poe)

Once upon a midnight dreary, while I suffered weak and weary

Over a doublet of knee construction,

As I moaned, insomniac and bloating

Distended, groaning, intestines floating,

“’Tis some ileus, I conjured, or gut obstruction--

Merely gas and nothing more!”

Ah, distinctly I recall, my knees were the sorest of them all.

As each dying cartilage wrought its pain upon its host,

Eagerly I wished the morrow; vainly I had sought to borrow

From Cox II surcease of sorrow. Sorrow for the last served ball

And for the joy of forehand strokes now lost--

To play tennis nevermore!

Now here’s the surgeon of the bone, with his saw and knife to hone:

“’Tis no wonder that you moan and groan;

X-rays and MR’s do not lie,

It’s clear to me you’re bone on bone.

With metal and plastic I’ll smooth the bone--

To the OR—Say no more!”

Back from the OR I arrive; knees restored, I’m still alive.

Pain controlled, but what I fear

Is immobility and helplessness. “ Oh dear!

What have I done? What was I thinking?”

“Wait you’ll see; you’ll rejoice your thinking.”--

Quoth the surgeon, “Evermore!”

Presently my legs grow stronger, painful and weak no longer.

I enroll in rehab – a form of torture;

Flex and extend, stretch and bend!

The surgeon is ecstatic, his work a perfect score.

“Aren’t you pleased? Would you repeat it once more?”--

Quoth the patient, “Nevermore!”

(Ed. Note. The author is currently recovering from bilateral total knee
arthroplasties. He is pleased with the result and no longer hates his
orthopaedist.)

Published originally in YJHM February 4, 2006

Pages

Wednesday, July 17, 2013