I waited for a while with Cindy, in the pre-op holding area, and then went back into Greg Rauscher's room to see how the case was going. Greg was still struggling to close that leak in the vena cava and the patient's blood pressure kept rising and falling as he placed the sutures, until at one point, completely exasperated, he threw a vascular clamp half-way across the room where it hit the wall and clanged onto the floor. It left a deep purple mark on the green tile wall, as if someone had smashed a bunch of grapes against it. At moments like these, an intern knows enough to say nothing, breathe softly and simply become invisible. After a few more tense minutes I backed quietly out of the room  and returned to the holding area. Cindy was visibly more uncomfortable and her fever had spiked to 102 degrees. I made a few calls.
"So am I gonna lay up here all night?" she said.
"I'm trying to find an available surgeon. Rauscher's occupied and the on-call attending has a bowel obstruction going in Room 3 with the fourth-year resident. I just put in a call to Kottmeir but he hasn't answered yet.
"The pediatric surgeon?"
"Yep. He's next on the call list. You're not that far from puberty, anyway."
"You're funny," Cindy said.
I was actually getting a little worried. The cases going on now were life or death, for sure. But still, I didn't want Cindy to end up with a perforated appendix, a long hospitalization and an open wound - and the longer we waited, that became more of a probability.
Finally Peter Kottmeir called back. "Jesus, I'm in my summer place in Long Beach," he said (well, it was the summer). "It'll take me at least an hour to get there. You start if there's no one else available. You've done appendectomies?"
"Well, not...."
"Come on now. It's a simple operation for God's sake. Just start. I'll be there. Where is the chief?"
"He's in with a knife wound."
"But he's there?"
"Yes."
"Okay then. If something happens just get him."
"But this a nursing student......"
And he was gone. Just like that.

"Okay," I said to Cindy. "Dr. Kottmeir is on his way as we speak. One of the best surgeons in this place, as you know. So you got lucky after all."
"A goddam baby doctor," she shook her head.  I unlocked the gurney, grabbed her chart and started rolling her down to Room 4, which was set up and ready to go. "Aren't we waiting for him?" Cindy said.
"Don't worry. He'll be here in a jiff."

Now, I want to say that Peter Kottmeir arrived just as Cindy went to sleep. Or that he arrived in time to make the first incision, or separate the oblique muscles, or cut open the peritoneum, feel around for the appendix and flip it up into the surgical field, or tie off the inflamed appendix and snip it out and watch it plop into the steel basin. But he didn't. Instead, it was me and Sherman, a black surgical tech with twenty years under his belt, and a shock of gray hair barely contained beneath a psychedelic surgical cap, who ended up removing Cindy's appendix. Needless to say, I was terrified from beginning to end. Thank God-almighty for Sherman, who could have done an appendectomy with his foot and blindfolded, and who started out by asking me where McBurney's point was (look it up!), where I would make the incision, what I would do if the appendix was normal and what seemed like a thousand other questions, and then took me through every step of the procedure down to the ritual dabbing of the remaining appendiceal stump with some betadine.

(Sometimes I think back on my time at Kings County and find it hard to believe that interns and residents were doing cases like this and much bigger ones than this, basically unsupervised. But somehow we managed to get through them and everything turned out OK. At least that's how I remember it. I think it was because people like Sherman were around to make sure of it. I don't think this still happens, but I'm glad I had the experiences I did and I know it made me a better and more confident surgeon in the long run.)

Just as the dressing was placed and I had peeled my gloves off, and given Sherman a big hug for saving me (and Cindy), Peter Kottmeir poked his head into the room. "You Palumbo?" he said.
"Yes, sir."
"Everything OK?"
"I believe so."
"See?" he said. "It's an easy operation. Good job." 
I came to understand, after a while, that "good job" simply meant the patient was still alive when you were finished. It had nothing to do with the actual 'quality' of the job you had done.

"Everything OK with that appendix?" Greg Rauscher asked me a few hours later. He was obviously exhausted and in the dumps after he failed to save that young guy with the torn vena cava.
"All OK," I said.
"Good job," he said.

  We all remember our first time. The jitters, the tentativeness, the churning stomach, the excitement of anticipation....our first appendectomy! Mine came early in that sub-intern year at Kings County.
One night, around 11pm, I was scrubbed in on a knife-wound case with my chief resident Greg Rauscher, a good-looking, mild-mannered, cocky guy who was headed for a plastic surgery fellowship the following year. Greg always had time to teach, no matter what was going on, and he let me scrub in routinely on these big cases, mostly because I was always hanging around, but also because I was another pair of hands and legs when he needed them. I do credit him with getting me interested in plastic surgery at an early stage, and with demonstrating to me how important teaching the residents who were coming up after you was.
Nothing fazed Greg, that I remember, and it was comforting to be around someone who showed no fear when a terrible motor vehicle accident, or stabbing, or multiple gunshot wound victim was brought in. You need to be cocky, I think, to be a good trauma surgeon. Even if you're not exactly sure about what to do in that first instant when the patient arrives and the EMT is shouting data into your face, you can never let anyone else become aware of even the slightest indecision on your part. You're the general at that moment, and the troops need to be led, even if, rarely, it might be in the wrong direction.
Greg still runs a very successful plastic surgery practice in NJ and I see him once in a while at the plastic surgery meetings in New York.
Anyway, someone had called up to the OR from the emergence room while we were huddled over this young man with the knife wound. There was a woman in the ER with signs of appendicitis. Her lab-work was pending but the ER doc was pretty sure this was the real thing. They needed someone from surgery to take a look.
Greg, at that point, was up to his elbows in blood which was oozing out in a steady untamed stream from the patient's nicked vena cava. He was attempting to place sutures into the vena cava's fragile side wall before it disappeared beneath the liver, a feat which is as precarious and difficult as it sounds.  Without looking up, he mumbled, "Steve, go take a look." So I scrubbed out and left.

"Jesus Christ, you MUST be kidding," the woman said when I walked into the exam room. Of all people, an ex-girlfriend from college who was now in her last year of nursing school at Downstate, was propped up on one arm on the gurney.
"Just the welcome I had hoped for."
"No really, you're not going to lay one hand on me."
"Sorry, Cindy (I changed her name to protect her medical history, among other things) you don't have much choice at this hour of the night."
There are moments, we've all had them, when Karma and Coincidence conspire to make things, shall we say, a little more interesting than they might have been. Seriously, how unlikely was this? How sweet for me! I hadn't seen Cindy in over four years. I knew she was in nursing school at Downstate, but our paths had just never crossed there. Until now.
Cindy had been working the night shift in the ICU at the County, felt pain in her lower right abdomen, got nauseous, and assumed the worst. Instead of heading across the street to the University Hospital, she just thought she might as well head right down to the Kings County ER to be checked out. And then I show up.
"So let's make this as professional as possible," I said. "Lay back and let me take a look."
"Do you even know what you're doing? I need a real MD. Where's the resident? This is just too ridiculous."
Some of her snarkiness, I was sure, had to do with my failing to come up with Rod Stewart tickets at Madison Square Garden in September of 1972, at a time when I was in love with her, but she was in love with Rod Stewart. But I also realized that Cindy most likely had no recollection of that episode, and that my own memory was surely clouded by the fact that she had dumped me around the same time that those tickets became an issue, moved on and was now dating a guy who would become her future husband.
"You are DEFINITELY not operating on me,"  she offered.
"Of course not," I said. "How could you even think that? I'm a sub-intern. The fourth or fifth year resident will do it. And that's assuming something needs to be done. Can I just take a look and see?"
She slumped back onto her back, lifted her gown and put both her arms behind her head in a huff.
"Take a feel," she said.
Suppressing the urge to laugh, or even smile, was unbearable. I put on the most serious countenance I could muster, warmed my hands like my physical diagnosis instructor Saul Grossberg had told me "always" to do, and began to poke around Cindy's belly. It was softer, and smoother and more perfect than I had remembered, but then I thought, I really had never run my hands like that down by her pelvis before. I had gotten to second base maybe, but definitely no further, when the "ticket incident" impeded any further progress.
"What are you doing?" she shouted.
"Examining you."
"Well, yeah, I can see that!"
"Oh for God's sake. Let's be adults about this," I said. "Does this hurt?" She shook her head. "Here?"   "No."
Finally, when I got to the right lower quadrant, she winced and jerked back. "Hm, that's pretty significant," I nodded. "And your white count is 13,000." After taking a history and confirming her periods were normal, which is a rather delicate conversation to have with an ex, and after the gynecology resident examined her and told me she didn't think Cindy had an ovarian cyst that had ruptured, or a tubal pregnancy, we all agreed (including Cindy) that her appendix needed to come out. Now these were the days before sonography or laparoscopy (let alone CT scans) were widely available, and it would be a long while before they were  available to the poor patients at Kings County Hospital, for sure. So appendectomies, and other emergency surgeries were routinely performed on a good exam, some basic blood work, and the hope that you were right. So up to the OR I brought her, where, I assumed, she would be operated on by the first available qualified surgical resident, even Greg Rauscher if she was lucky enough to catch him when he was done with the knife wound.

TO BE CONTINUED

          On July 1, 1976, I began my sub-internship in surgery at Downstate Medical Center in Brooklyn, NY.  Forty years ago exactly. (July 1st, by the way, is the date on which all new hospital interns begin, and residents move up a grade in their training. It's a date you probably don't want to get sick on; at least seriously sick. Or injured.)   I was 24, eager, and completely terrified.
      Because I was still officially a medical student (4th year), they arranged for me to start out at the Brooklyn VA Hospital in Bay Ridge (which coincidentally, was the area where I was born and raised.) It was one of Downstate's training hospitals, along with Methodist, Brookdale and the famous Kings County Hospital. I had volunteered at the very same VA  when I was in high school, mainly on the lookout for candy-stripers, but also sorting and filing medical records in the days before computers became a normal part of business and real people roamed the records rooms, filing, retrieving and misplacing the vital information of our veterans. I think they sent me to the VA because that was the least busy of all the hospitals in our network and I assume they thought I could do the least damage there.
   My chief resident at the time was Howard Golden, in his fifth and final year of training, cranky and tired and as done with it all as he could be, ready to go out into the real world and make some money. He told me he had put me on call that first night, which I figured was akin to putting the busboy in charge of the kitchen for the night. Or giving your ten year-old the keys to the car. Nothing good could ever come of it. But surprisingly, on my own, by eleven pm, I had made rounds, done the new admissions, inserted two urinary catheters, and finished reviewing charts for the next day's cases.
    Around midnight, though, one of the surgical unit nurses paged me (remember, no cell phones back then!) and told me that a patient needed venous access; that his IV line had pulled out and he was already an hour behind on his dose of intravenous antibiotic. No problem. I had put dozens of IV lines in before. But when I got to Terrence's room (I forget Terrence's last name) I realized that he had no obvious veins available, and the line that had pulled out was what we called a "cut-down", an intravenous line that is put in surgically by "cutting down" through the skin and finding a suitable vein in the subcutaneous tissues that will support an IV for a week or more. (Nowadays these are called PICC lines and are put in by specialized nurses or MDs under sonographic guidance). In other words, Terrence needed a little operation by the bedside - something I had never done before.
     Terrence was all too understanding when I told him this was my first cut-down. "Just do it," he said. "You'll be fine."  A little something about Terrence that I learned from his chart: he was twenty-eight, a Vietnam Veteran with a heroin problem that he was constantly battling and a below-the-knee stump where the rest of his right leg used to be. Every now and then, from the stress and pressure of an ill-fitting prosthesis, he would end up at the VA with a whopping staph infection in the stump, which would then have to be drained and packed. Eventually it would close and he would get to go home with another ill-fitting fake leg after a few weeks of inpatient IV antibiotics. He had red hair and a red beard. Not much of a talker. Nice-looking. I think he had a girlfriend, but maybe that was his sister who came up once in a while to visit.  It didn't look like he wanted to talk much and I was happy enough to accommodate. 
       I knew where to find the vein, and I knew how the procedure was supposed to go. I prepped his right arm, numbed up a 2 inch square area below his right elbow, and made the incision. Soon enough I found what I thought was a suitable, plump, blue vein. But when I tried to insert the catheter, the vein tore wide open and I had to tie it off. (I'm sure a few drops of my sweat had already contaminated the wound, but that was the least of my concerns just then.) After two more botched attempts, and as the vein supply was rapidly dwindling under my attack, I asked the nurse to call Howie Golden to come in.
"Givin' up, eh?" Terrence smirked after she had left.
"Nope," I said. "I just need someone who knows what the hell they're doing. And so do you."
"You're doing fine, pal. You'd make a good medic, too. The guy that did this to me," he pointed to the stump, "Jesus, he did it right out there in the field, crappy instruments and all, hardly any anesthesia. He stayed with me the whole time we were under fire. Suoi Bong Trang,"  (I wrote the name down later on).  "I'll never forget that fucking place," he said. "We were building a road. A really important one for us. When the bombing started and seemed like it was never gonna stop. I was one of the lucky ones. I'm still here. Because of that amazing doc." He shook his head. "I lost a lot of my brothers that day, man."  And then, "So do what you need to do, doc. You're doin' just fine."
      I gulped. I tried just to focus on his arm and not to look at Terrence since I was about to shed some serious tears into his wound.  Here I was, just a few years older than Terrence was on the day he lost his leg. What did I have to complain about. Ever again?
     Howie finally staggered in, grumbled something, looked at the wound, and sighed. "Try the other arm," he said.
     "I think you should...."
      "No, no. Try the other arm," he said again, almost whispering. "That OK with you Terrence?" he asked.
      "Sure thing, doc," Terrence nodded his head.
      And for the next hour, with Howie looking over my shoulder, talking me through a half-dozen aborted attempts without once raising his voice or taking over, and Terrence staring up stoically to the ceiling, I finally managed to locate a vein, pass the iv catheter into it, tie in the line and close the incision.
       "Good job," Howie carped before heading home. "Good job," Terrence said.

       I think about that night all the time. About Terrence. And Howie. I think between the two of them they taught me a lot on the very first day of my internship and I'm forever grateful for it. How never to give up. How to respect every patient. How to teach someone without making them feel inept. How every patient has a story, and most of the time, it's so much more than your own.

       Three days later, on July 4, 1976, on the fifteenth floor of the hospital (16 was the psych ward), I watched the Tall Ships come sailing through the Narrows, under the Verrazano Bridge, with Howie Golden, Terrence and a few dozen other staff and patients, cheering through the big picture windows along the Shore Road. Me, Howie and Terrence, each one the grandchild of immigrants. We were all celebrating the 200th anniversary of the country's Independence, with ring side seats that only the VA Hospital, situated on a peak near Fort Hamilton, could offer. I remember that Terrence was smoking Camel cigarettes, which you could do in hospitals back then, especially VA hospitals. His IV was still in and working well. He looked over and gave me a thumbs up.
It was a glorious, warm, sunny day.