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.