Articles published in medical journals
By Reza Ghadimi

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Published in JOPA 2013 - Of ether, re-usable needles, and rusted instruments

 Way back in the middle of last century, a doctor friend of my father came over for dinner one summer night.  In the tradition of the old days, they sat around talking about family, kids, politics and weather - we had no TV back then.  Heck we had no electricity.  I was a peewee fourteen year old boy who knew everything and was going to become a brain surgeon.  Don’t ask me why, but I suppose that the brain being in the head and the head being on top f the body, well that was as good a place to start as any. 
So when the good doctor asked my father - they never talked to you directly - what he was going to have mestudy, my father answered that I was interested in becoming a doctor.  Then the good doctor turned to me and asked; “Is that a fact?”
I sat up straight and put on a silly grin. “Yes sir!” was my confident answer.
It so happened that our doctor friend was one of a few physicians who was part owner of a private hospital in our town.
“Well if that is the case,” he said, “we better get you started.  Since you are on summer break, why don’t you come over to the hospital tomorrow and we’ll see if we can get you a summer job.  What do you think about that?” I wasn’t expecting that, but was elated with the offer and said so.  They went back to talking and I suddenly felt that I was not connected to the ground anymore.
I could hardly wait for tomorrow to arrive.  In the hospital, my father’s friend met me for a pep talk and instruction.  “Medicine is an art,” he said “it is an art of listening, feeling, looking, and finally examining.  Your grandmother is a master of this art.  I will never be as good a doctor as she is!”  He continued, “you don’t know this, even she doesn’t know this, but I have referred patients to her.” he said with a smile and then laughed heartily to my shocked expression (my grandmother was a sort of medicine woman who had an immense knowledge of folk remedies - more on her in another time.)  A voice behind me, broke into my surprise.  I turned to see a rather large middle aged lady in nurse uniform. I was introduced to this cantankerous woman with a mustache and wild wavy hair.  “This is Lady Mary (not her real name), she is the Chief Nurse here.”  My benefactor whispered to me to follow her and listen to what she has to say.  “She too is a master in the art of medicine!” he said and left us.
She was told to find me a job that would teach me something about medicine.  She gave me one of those “if looks could kill” glances and grumbled her disapproval.  She then grabbed me by the arm and with a most ominous hush voice said that “the people around here are too busy to teach a little kid like you” she continued, “so you better not interfere with other workers and make them get behind in their work.” I was overwhelmed by her demeanor and overpowering posture and thought that maybe I shouldn’t be there and planned to beg my benefactor’s forgiveness and ask to be let go. But I never got the chance. 
She lead me to the basement and down a long dark hallway to a hot steamy room.  The name on the door said; “Instrument Room.”  Several women were hard at work in that room and briefly looked up as we entered.  I was shoved behind a rusty steel topped table with a large sink in the middle of it and somebody pointed to a basket full of strange looking tweezers, pliers and gadgets, and told me to start washing them.  Before I had a chance to say anything or even introduce myself, I was soaked up to my elbows in a strange smelling soapy water.  In the corner of the room a huge drum with pipes attached to it, sat hissing and belching like an old steam locomotive.  I learned that it was an autoclave and used to sterilize the instruments I washed.
Over the next couple of weeks, I was scolded numerous times about not getting all the blood, puss, and dead tissue out from within the teeth of those awful looking things and learned that they were “surgical instruments” each having a different name.
In fear of old hairy face, I scrubbed, rinsed and cleaned those instruments till they shined. Cleaning the core of the needles were particularly challenging.  God knows how many times I stabbed myself with them.  It is a miracle that I did not get hepatitis. My hands were wrinkled beyond recognition and they ached at night - gloves were not used back then either.  Still I could not please old Medusa.
One day, by chance I was passing a patient’s room and saw Lady Mary tending to a young woman.  I was shocked to see the tenderness and compassion with which she cared for that patient.  Her manner was almost ministerial.  I could not believe that kindness from someone who ran the place with an iron fist.
I kept washing, cleaning and sterilizing instruments but could not see what this had to do with me learning about medicine.  So I went to confession to my doctor friend and told him that I didn’t like washing instruments.
“Who does?” He said, “it’s a disgusting job cleaning all those germs, blood and crap from those instruments. But you want to be a brain surgeon, don’t you?” He asked.  “So first you have to learn all these instruments you are going to use.  There is no better way to learn about them than washing, cleaning, and sterilizing them.  After all, you don’t expect me to wash them, do you?” he continued. “Because I did my instrument washing when I was fourteen years old.”
So it came to pass that I learned about needles, hemostats, syringes, curettes, ring forceps, curved and long kelly and many other instruments.  The bossy nurse kept at me.  Her fiery looks bore into my very soul and I learned quickly to follow orders.  In fear of facing her wrath, I was all attention.  Still I made all the usual mistakes and listened to many smirks of laughter behind my back.  But in spite of everything that fearsome nurse mothered me to the understanding of a world of caring for sick and injured.
Then one day my doctor benefactor called me into the operating room and asked, “do you think that by now you know all those instruments?” I looked around at all the tables, lights and people in sterile attire and said, “Who, me?”
The Moment of Truth had arrived.  Real shakes.
A real patient lay on the table.  My benefactor - now instructor - guided me to the sink in the corner of the room and said to observe and follow his proper washing and scrubbing technic.  With great trepidation I mirrored every move of his.  When he was satisfied that I was clean, we walked onto a special matt to discharge all electricity from our body.
“We can’t have any sparks in the OR,” he explained.  “The ether is explosive.” 
I nodded, as though I understood, not having a clue what he was talking about.  “What is explosive?”
My head was spinning, my ears were having trouble adjusting to the sounds of hissing tubes, gyrating (ambo) bags and other noises, a strange smell filled the room.
“If you feel dizzy let somebody know.  It maybe the ether.”
I was guided by a man in scrubs (the scrub nurse) to the back side of a table full of instruments, neatly placed in rows.  The scrub nurse put a gown on me and lightly tied my hands behind my back.  “Don’t touch anything.  If you feel dizzy, you can pull your arms out from behind your back and sit down.” I felt like sitting down, just then.  Oh God, what if I faint and fall on the table, what if that thing explodes and I am killed , oh God, what if ....  But nothing happened.
Soon the patient was asleep, the anesthesiologist kept a cloth mask over his face and occasionally dripped ether over it.  A strong noisy fan blew fresh air into the room, adding to the confusing racket.  I never saw any of the procedure, itself.  But every time the surgeon asked for an instrument, the scrub nurse looked at me and I was to point to it verbally and he handed it to the doctor.  Halfway through the surgery, I started to feel confident and relaxed.  I knew all the instruments.  Hey, I can do this!  I felt proud, this is easier than I thought.  NOT!!!
Twenty minutes later - which felt like twenty hours - the appendectomy was over.  The surgeon removed something from a small incision in the patient’s abdomen and placed it into a basin held by the assistant and closed the little hole.  All was over.  But not for me.  Over the next few days I told my heroic experience to family and friends over and over again.  Every time, I repeated the story it got more dazzling.  Before long my brothers and sisters were spreading the word around the neighborhood that I did the surgery and saved a man’s life.
Back at the hospital, I continued to observe and work in the OR.  Before long, I was passing instruments which lead to collaboration with other assistants and finally assisting.  Over the next three years, I assisted on many surgical cases and learned much about health and illness, until one day I left home for America.
Now, fifty years later, my experiences include; practice in seven countries on three continents, a military service in the United States Air Force Medical Corp during the Vietnam war,  work in rural as well as urban settings, teaching and serving on many medical boards and committees.
We have come a long way from the days of ether for anesthesia, re-usable syringes and needles, and rusted instruments.  I have seen many changes, yet we are still struggling to bring needed healthcare to many people of our country and the world.
Though we have eradicated some diseases, new ones have emerged and population increase, longevity, environmental changes, economic disparity and new mobility of our people have all added to new challenges.Mankind has survived wars, epidemics and natural disasters.  Despite of it all, our population is seven billion and growing. 
Today medicine has become more technical than an art.  Patients fill their history and make their appointments on line.  Smart phones and computers take their vital signs and relay it to their electronic records.  Medical softwear identify possible medications conflict and suggest differential diagnosis. Internet, robotics, nano-technology and wireless communication are helping us be in many places at once and treat patients near and far.  Providers spend little to no time with the patients and depend on these technical information to diagnose and treat patients.  Good or bad, here we are.  Yet we have a long way to go to what medicine should be in the twenty first century.  Still the experiences of today will be the memories of tomorrow.  What tales of the past will these new doctors tell, fifty years from now, I wonder.  Hmmm?


Published in JOPA in 2014 - When you assist, assist fully!

     “I like it when you help me, Reza” Al Rosen use to say “you don’t talk a lot and you don’t suck a lot.”
Al Rosen was a legendary doctor and an avid skier in Taos, NM.  An all around country doctor and surgeon, he practiced the old way.  He made house calls, held patient’s hand when he talked to them and knew everyone by their first name.  He first came to Taos in the late 1930s. Over the years, along with Doctors Pond and DeVeaux, they became the corner stone of medicine in Taos and Northern New Mexico.  Although Al Rosen was not a board certified surgeon of any kind, he did most of the surgical cases and obstetrics in Taos in those days.  Before I arrived in Northern New Mexico in the early 1970s, no other PA had assisted him.  Many young residents from UNM School of Medicine rotated through Taos and often helped Dr. Rosen in surgery.
I met Dr. Rosen soon after arriving in the area and when he learned of my surgical and orthopaedic background, he asked me to assist him. My knowledge of traction setup also helped keep more patients from being transferred away from home. Shortly after however, Steve Halmstad PA joined his practice and became his primary surgical assistant.  But because of my orthopaedic surgical experience, I continued to help him on many such cases that were not referred out. Steve Halmstad was a  great PA and a good friend.  A graduate of the Medex program and an Ex Special Forces Medics.  Steve died in 2001 from cancer.  I miss him - even today.

Picture
Overhead traction setup per Army/Air Force Manual circa 1960s. This setup is still being used in many parts of the world.

   Al’s surgical room was always quiet.  He did not like anyone to play the radio or music or talk loud in his operating suite.  “The auditory nerve is not anesthetized!” he used to say. “Un-necessary noises can cause subconscious anxiety and the patient will dislike the surgical experience.  By keeping quiet and paying attention to our work, the surgery will have a more positive and rewarding outcome.”
Al Rosen was of the opinion that most of the younger doctors who assisted him wanted to constantly do something, thus they ended up hindering rather than helping him. “They pull the wound toward themselves so that they can see better” Al used to say “and in the zeal of doing something they constantly use the suction tube, even when there is nothing to suck and block my view.  I have to almost fight them to do the surgery.”
On the ski slopes of Taos Mountain however, Al was a daredevil.  Flying down black diamond runs and around hairpin turns, made him a different kind of a legend.  Hard to believe that such a mild mannered doctor was such a risk taker.  He was such a regular presence on the ski slopes that they named one of the black diamond runs after him.  “Al’s run” challenges many expert skiers, even today.  In his later years, he was often seen skiing down the slopes wearing an oxygen tank and mask.  Al Rosen died in October of 1982 but his legacy lives on.  I learned a lot from Al Rosen and others like him.
When I first entered the operating room at the ripe age of fourteen, I was shaking with excitement and fear. Excitement for entering such a sacred realm and fear of screwing something up.  I was given the job by Dr. Azïm, a friend of my father who was a part owner of a private hospital in our town.  (See my article; “Of powder plaster, overhead traction, and broomstick prosthesis in the October 2013 issue of this publication.)  He became my benefactor and like Al Rosen, his devotion to his work, strong regard for his patients and love of teaching was the greatest gift I received during the early days of my medical career.  He often told me, “it is harder to assist than to do the surgery because the assistant must think twice.  First he must realize what the surgeon is doing and then act accordingly to help him accomplish it.”
“Don’t watch me,” he would start “watch my hand, watch where I put the instrument, the needle, the suture. What is the purpose of my action and what can you do to improve it’s outcome.”
So it was that I got introduced to Dr. Azïm’s assistant; Ibrahïm.   He was a burley, kind looking middle aged and stoutly religious gentleman who had been working with Dr. Azïm ever since he opened his private hospital.  Ibrahïm was - for all practical purposes illiterate.  He read very poorly and could not write to save his life.  But he knew and could identify every part of the intestine and abdominal tissue and fissure.  Over the years he had watched intently his operating surgeon’s every move and had seen his share of successes and failures.  Watching the two of them was a treat, as though only one brain moved those four hands in concert.  Ibrahïm started every procedure with a prayer - quietly, under his breath, he would pray for the safety of the patient and his/her rapid recovery.  Not once did I hear him pray for himself, or the surgeon.  Always for the patient so that he or she could return to the family waiting for them, healed and recovered.  I learned so much from him that helped me cope with many challenges of ever day medicine through the rest of my career.  “The human body is sacred,” he use to say “the very breath of God has given it life, treat it with reverence and respect and it will repay you by healing well.”
Years later and halfway around the world, I had an opportunity to be involved in the FDA clinical trials of the Osteonics (cement-less) porous coated press-fit stem hip implants.  I moved to Lubbock, Texas in the late 80s to assist with the process by helping an Osteonics recruited orthopaedic surgeon there.  While living and working there, I got to work with several orthopaedic surgeons. I came to know and highly respect one particular physician (not the one in the trials.)  He was a doctor from India named; Gurdev Gill.  He used very few instruments to do his surgeries, was very fast and accurate and had remarkable results.
He was of the philosophy that instruments injured the tissue and one should be cognizant of their use - a strange thing to hear from an orthopaedic surgeon who cut bone and tissue and replaced them with metal and plastic.  Yet there it was.  His patients recovered faster and better than many other surgeons I worked with.
In that job, I also was trained and acted as a salesman for Osteonics, thus got a good understanding of the mentality of the world of medical device sales and business.
One reward of assisting many doctors is that you appreciate the difference between good surgeons and the others.  This can teach you a lot of medicine.  The process of assisting many surgeons with different ideology and technics could make the job of a PA assistant difficult.  But different approaches to a problem is a powerful learning tool.  The PA’s knowledge of the different approaches becomes very helpful when problems arise and can make the PA a valuable member of the surgical team. However, the job of the PA is not and should not be just assisting the surgeon in the procedure.  First and far most, the PA must be mindful of the patient’s well-being.  A good assistant should familiarize him/ herself with the patient’s health status like allergies, medications, other medical and social issues, etc.  It is the responsibility of the assistant to make sure that the patient has been prepped and readied for the surgery properly.
I was once called to replace an assistant who did not show for a case.  The surgical procedure was of a laminectomy on an elderly lady.  I got there a bit late and hastily scrubbed and entered the OR.  I had assisted that particular surgeon before and knew him to be a competent spinal surgeon.  When I joined him, he had already made the incision and was placing the microscope over the incision site to proceed with the laminectomy.  I, dutifully joined him and we proceeded with the surgery.  When the laminae was exposed, it did not look particularly injured but I said nothing since many such tissues do not necessarily look damaged.  We were at the right level but still something bothered me throughout the procedure.  The surgery went well and we closed the wound and the patient was awoken.  As she was being rolled out of the room, the surgeon stopped everyone and made some expletive comments that we had operated on the wrong side.  The patient was rolled back in, put back under anesthesia and we proceeded to remove the injured lamina on the other side.  Although the surgery was successful, the surgeon accepted all responsibility and the patient was gracious enough not press any charges, I felt that somehow I neglected my duty and let the patient and the surgeon down.  Had I taken a moment to note the procedure for which I was assisting as I was scrubbing for it, I could have noticed the error.  Since then, I make it a point to always familiarize myself with the case I am about to assist on.  Especially if I am in an unfamiliar, unusual, unscheduled, or unknown situation.
I strongly feel that the PA should be completely familiar with the case he or she is about to assist in.  Especially if he/ she is helping a surgeon in a different practice.  That includes making sure the lab work is done, the patient has been cleared by the medical team, and that the anesthesiologist is fully aware of the patient’s condition - good or otherwise. 
A particular gripe of mine is the freedom given to orthopaedic salesmen who are allowed or even invited into the surgical suites.  As I mentioned above I actually worked as an Orthopaedic salesman for a while and have a first hand knowledge of their mind set. I have seen some of these sales people go in and out of the surgical suites at will, flirt with people in the room, even hand instruments and move around the surgical room freely.  It is true that many of them are previous scrub techs, nurses or even PAs or doctors. But at their present position they are salesmen and may not be mindful of their doings.  If the surgeon is lax or unaware of these people’s activities, it is the responsibility of the assisting PA to bring it to his or her attention.
If you are like me and assist many surgeons, I strongly recommend that you keep an assistant’s version of an op-report.  If for whatever reason, a particular case goes sour and problems arise.  You maybe called to testify in front of the hospital board, Medical Board, malpractice board or jury.  You would look very professional and blameless if you show up prepared with clear and concise documents.  When a case runs into trouble, it may not go to a hearing or a trial for months or even years after the day of incident.  Not much credit is placed on testimonies given from memory.  By having your own report, you can best help your case, the surgeon’s and the patient’s.
I have served on the “Medical Board” and “Medical Review Commission” of my state for many years.  I have served as a hearing officer, expert witness, judge and jury on many such cases.  The plaintiff lawyers do not care or often even allow circumstantial evidence contributing to the outcome.  As far as they are concerned the surgeon is responsible for everything that happens in that room - end of story!
Over the years I have had many student precepts.  I try to impart this knowledge that was taught to me over the years. To my students I say; “when you assist, assist fully and be cognizant of the patient’s well-being.  Be gentle to the tissue you are working on, especially if the doctor you are assisting is rough in his work.”  “Be kind to the tissue and the tissue will be kind to you and heal well.”
Also be aware of your work environment and do not hesitate to point out conflicts, discrepancies or problems, even if you make others uncomfortable.  This is especially hard when those you reprimand are your friends.  But do not ever forget that your primary role as an assistant is the well-being of the patient not your co-workers.
Be good to your patients and they will like you.  People who like you won’t sue you!


Published in JOPA 2014 - Perceptions and expectations

A few years ago, on a cold January morning, a man walked unto the L’Enfant Plaza subway platform in Washington DC, carrying a violin case. He opened the case and placed it on the ground in front of him, took a violin out and started playing. Hundreds of people past by.  Some glanced over at him, some listened while waiting for their train.  A few dropped coins and money into the open case without even looking at him.  He played for about an about forty minutes and then left.  He had collected about 30 dollars in coins.
    Three nights previous to that morning, the same man had played the same exact piece of music on the same exact violin to a sold out audience at Boston’s Stately Symphony Hall.  Admission tickets were around $150.00 
    When serving in the United States Air Force, the hospital I worked in required all doctors and medical personnel working in specialty clinics to cover the ER on rotation in evenings and weekends.  Dr. V. was a recently arrived physician of African American race and was working on one particular night with me.  The ER was quiet and we were watching TV in the back room.  Outside a civilian janitor was buffing the floor of the waiting area.  Our doctor was restless.  Suddenly he got up, took his white coat off and went outside and asked the janitor to let him buff the floor - to burn some of his excess energy.  The janitor gladly obliged. 
    A few minutes later a Caucasian lady - wife of a serviceman - arrived, seeking emergency care.  Not seeing anyone at the desk, asked our doctor/ janitor as to where everyone was.  Dr. V. called for someone to come and get her checked in. Being the corpsman on duty, I took her back to the exam room, got her H & P, vital signs, gave her a gown and informed her that the doctor would be with her shortly.  Outside, I told our doctor that she was ready and went back to reading my book and watching TV.  Our doctor passed the buffer back to the janitor, put his white coat on and went to see the patient.  Well you guessed it, moments later the patient exited the room yelling and screaming that her husband was a Major and that she was going to have everyone court marshaled for playing games with her. 
    About a few months after the above incident - as a member of the United State Air Force’s Air Transportable Hospital (ATH - Air Force equivalent of the Army’s MASH unit), we were sent to Jordan following the Jordanian Civil War of 1970, to care for the injured (we were sent as Red Cross Volunteers - our military did not want to be directly involved in another country’s civil war). For the first month, I was the only member of the team with orthopaedic surgical experience who also spoke a little Arabic.  There was an OB-GYN doctor (our CO), two family practice docs, an Ophthalmologist, and one general surgeon on our team. Prior to this deployment, we never went anywhere so I guess the Air Force didn’t see any reason to have ER and trauma personnel on ATH. It being war, many of the injured required orthopaedic surgical intervention.  So we sent an urgent request for an orthopaedic surgeon and in the meanwhile I assisted in all surgical cases of orthopaedic nature.  To the non-English speaking patient population and Jordanian medical personnel helping us, I became known as Doctor Reza.  Though I repeatedly informed everyone that I was not a doctor, since I was being consulted on all orthopaedic problems and scrubbing on their surgical procedures, their perception was otherwise.  And though I was an enlisted person, my team-mates felt that if it eased the injured’s mental health, let it be.  After a while, Gary C, an orthopaedic surgeon from my own out arrived. But by then the native population expected my presence on all orthopaedic cases.  Although, even our newly arrived surgeon found the situation humerus, at times it did create problems as patients demanded that I do the surgery.  We solved the problem by me showing up on most cases till the patient was put to sleep.  Then I left and attended to my own work.  By the way that particular assignment earned me the Air Force’s Commendation Medal. 
    I pride myself in always dressing professionally when I see patients.  I wear a tie, white coat and try to present myself accordingly.  I sincerely believe that I am not only presenting myself to my patients but the entire medical profession.  As a PA, I feel that I need to try even harder in order to show the true professionalism of our relatively new profession. I am proud to say that most of my PA colleagues too, are professionally attired and well groomed. 
    Since I am telling war and PA stories, one day, while working at an urgent-care, the physician working with me was a particularly egotistical obese female with manners of ... well not becoming a professional.  She wore a cheap dress without a white coat.  An elderly female patient was being taken to the exam room by the nurse.  As she past us, she gave us all a piercing evaluating look.  She seemed particularly ill and thus our doctor went in to see her.  Soon however, she returned, upset and cursing.  “Reza, she wants to see a real doctor.  I told her that I was the only real doctor working here.  But she insists that I am lying to her and that the doctor was the man outside in the white coat with a tie - me.” 
    As a PA, we deal with many levels of people in our profession.  Both in our patient population and our work environment.  Some of the biggest resentments, I have faced as a PA, have been from other PAs and medical personnel.  When one of them seeks medical care, often they ask to see an MD and not a PA.  In the patient population, the most resistance comes from patients from the lower class of our society and from those of foreign origin.  The problem here, as I see it is our name.  ‘Assistant’ by definition requires someone for us to assist.  Thus giving us a second class status, even before we enter the exam room.  Many times, I have finished with a patient - done my exam, started the treatment and even given them a prescription and expecting them to leave and they just sit there.  “Is there anything else, you need?” I ask. 
    “Well when is the doctor going to come and see me?”  Is a standard question.
    Patients who have been treated by PAs however, usually appreciate the experience well. In busy practices many patients feel that they get better attention from PAs and I have to say Nurse Practitioners as well. Back in the eighties, I was the sole provider at a small clinic in the resort town of Red River, NM. It is a ski resort with an average population of 500 year round, back then. But during the winter and summer, the population explodes to many thousands. My orthopaedic experience got me the job, since my practice was more like an urgent-care or ER, as 99% of my patients returned to their respective towns after receiving their initial care. They took with them a positive experience and that gained me a reputation at the clinics these people went to for follow up. 
    So it was that when a friend of mine at an orthopaedic clinic in a busy metropolitan city needed some time off, he asked me to go cover for him. There was a secondary reason for this invitation however. My reputation had raised the curiosity of the physicians in that clinic so they wanted to check me out and perhaps recruit me to join their practice. Since it was during off season for me, I gladly accepted it. Once there however, the very busy practice and the rushed way of patient care became a turn off for me very quickly. 
    A particular incident killed the deal for good. One clinic rule was that all new PAs were to present new injuries and fractures to the on-call physician before casting and discharging the patient (no problem there.) On one very busy morning I saw a young patient with a nondisplaced distal radius fracture. I informed the family that I was new and thus had to get my doctor’s OK before proceeding. They understood and after I informed the doc I was working with, we waited. The attending for that morning (a relatively young doctor who didn’t know anything about me) had arrived late and was very busy seeing his own patients and so took a long time to get to me. But finally after multiple requests, he dashed into my room, walked to the viewing box, took a quick look at the x-rays, walked to the patient and made a cursory exam of the wrist and told me, “put him in a short arm cast and let me see him back in 6 weeks.” and without talking to the patient or the family left the room. Now my routine is to re-check the cast in two weeks and change it since once the swelling subsides, many casts loosen and also in the heat of that southwestern city, many children’s cast become rancid with sweat and dirt. So I ran after him and asked whether we should re-check the cast in two weeks? He gave me an annoying look over his shoulder and snapped back that six weeks would be fine and if he had any problems he could just return and be seen in the walk-in clinic, and again rushed away from me. So I cried after him; “the family lives too far and the patient is a girl not a boy!”  
    A great football player - whose name I have unfortunately forgotten, was once asked; “why do you always play with such zeal, passion, and enthusiasm?” Pointing to the thousands of people in the stands, he replied; “Football is THE great American game.  These people have paid a lot of money to see a great game.  But more importantly, there may be just one person in this entire crowd who is here for the first time and expects to see a great American game.  I play for that person and want to make sure that that one person sees the game he or she expects.” 
    In our profession, we see thousands of ill and injured people.  They expect us to be professional and caring people.  Among the many we see daily, there maybe - by chance - a patient who is seeing a healthcare provider for the first time.  He or she expects full attention from us - regardless whether the problem is a hangnail or cardiac arrest - and we must give that person our full attention.  Anything less not only degrades us individually but the profession as a whole.  In today’s computerized healthcare system, personal care is being all but forgotten.  We are expected to see patients in rapid succession and generate a good revenue for the bean counters. Yet it is our reputation that is on the line.  If we get sued, it is us who faces the judge and jury.  The hospital administrator is not going to court with us.  So it behooves us to be vigilant in providing care to our patients and to assure that their perceptions and expectations are answered and met.  It’s what makes a PA even more valuable to a particular practice. . I hope I am not being pedantic, but I have done this for a very long time and still have most of my original teeth in my head. As my mentor and long time friend of more than forty years; doctor George E. Omer (chief orthopaedic and professor emirate at UNM HSC) use to say; "Listen to me, I have done this for more than fifty years and I have never been sued!" 
    Oh yes, the man who played the violin in the story at the beginning of this article was Joshua Bell, one of the world’s renown violinists of our time and the violin he played on was a three and half million dollar Stradivarius, handmade in 1713. His performance at the subway station in DC was part of a study arranged by The Washington Post. By the way, the DC people never let him forget that inattention, so on September 30 of 2014, he returned to DC in the main hall of Union Station. This time he played for a large and engaged audience. Bell says he performs best when all the pressure is on. “When hundreds of people are paying hundreds of dollars to hear him play music that is hundreds of years old. It warrants perfection.” That is what I feel about performing medicine. The person trusting you with his medical problem needs to see the hundred years of accumulated knowledge of medicine passed on to you by your educators to play magic in treating him or her. That happens by you showing a little concern about his or her problem. When you rush in and rush out without even noticing whether the patient is male or female, … well you can see how that could vex people!


Published in JOPA 2016 - Communication is a two way street

   One of my favorite drawings of M,C. Escher reveals a two dimensional repeating pattern of interlocking reptiles.  From the lower part of the picture, one of the creatures detaches itself from the flat world of the paper and creeps upward into the three-dimensional world of the table, and climbs onto one of the artist’s tools on the table - triumphant.
Escher was a philosopher who marveled at the possibility of the duality of the world, and of life itself.  He believed that there is an opposite to everything and every situation.  That while one person may live in total chaos and gloom another can live in the same world and under the same situation and circumstances but totally content and happy. 
The duality of our world often intertwines in ways that we cannot foresee or expect. In no profession is this more true than medicine for often we, the providers, are better off than those we treat.  Into this “for profit” world of healthcare, many have come to capitalize.  So it is that most people are caught in the ironic situation of being cared for by those who cannot fathom their predicament or understand it. These encounters can be scary and chaotic and become even more of a dilemma, when the clash is between cultures.  It is therefore imperative that we realize our position and communicate best with those under our care.
New Mexico where I have lived for the past forty five years, is Indian country and many of the people we treat are Native Americans.  Not understanding their culture can result in misinterpretation of their needs and their mis-comprehension of our intent.
One of the first things I learned when I began work with them was that their culture teaches them the value of tolerance and respect of others in ways different from ours.  Especially if the others are elders, leaders, or professionals.  One such value requires them to not interrupt others’ speech and conversation.  Often they wait to answer after you have finished talking to be assured that you are finished.  It also facilitates their understanding of what was said.  This pause is confusing to many of our fast talking, rushed providers and is often perceived as lack of communication or disagreement. 
They also value our conversation as significant enough to see no reason to acknowledge or recognize it by thanking us.  Often after we are done, they just leave without saying anything.  This too confuses many of us and we perceive it as a sign of dissatisfaction.  Yet it usually is far from the case.  Hence it behooves us to learn and follow the ways of our patients.
I love our Native people, as their traditions and outlook on life resemble much of what I was taught in my upbringing.  One of the many jobs I have held as a PA, required me to travel to under-served areas of our state and provide care for children of the indigent.  Several of these clinics were on Reservations.  On one particular visit, my patient was an adorable boy of three who was there for problems with his feet.  For my exam, I needed him to disrobe.  He did this but refused to take his shoes off.  His mother talked to him in their native tongue but to no avail.  She finally informed me that there was a hole in one of his socks and he was ashamed to show it to me.  I laughed heartily and sheepishly took my own shoe off and showed him a hole in my sock.  He beamed gloriously and we became good friends to the delight of his mother.

I was visiting a PA colleague who is a Native American on the Navajo reservation and she asked if I could go with her to see her aunt who had injured her leg.  She lived about thirty miles deeper in the reservation.  We drove her Land Cruiser off the pavement about 3 miles past her home and headed into the high country of the Navajo world on a dirt road.  About twenty miles down that road, we turned off unto a primitive road and headed deeper into the hills.  Finally we reached her aunt’s house at the end of what was now more like a trail than a road.  Her aunt lived in a one room adobe dwelling with no electricity or running water - common in many dwellings of the large reservations of the American Southwest even in today’s highly technological world.  Her leg was swollen and discolored but she was still walking on it with the help of a self-made cane.  Even through the edema, I could feel the incongruity of the bone.  A fracture of the fibula above the lateral malleolus was clearly evident.
“There is an obvious fracture here, I think we should take her back with us and get an x-ray of her leg.”  My friend smiled and told me that she will not come with us but still translated.  To make the long story short, all our reasoning and rationalizing was for naught.  She had a herd of sheep and goats to care for and would not leave them.  Despite the fact that we promised to return her home the same day.  I started to insist but my friend stopped me and said; “you are not listening to her, she won’t go!”
There were good pulses, sensory and motor functions were intact.  So we applied the leg brace my friend had so thoughtfully brought with her and showed her how to apply it properly.  She patiently listened and even practiced it a couple of times.  Then carefully folded the brace and set it aside.
On the way back, my friend told me that her aunt had not been off the reservation for many years.  “She lost her husband a while back and had been living by herself, isolated and happy.  Local people and the Navajo Police check on her once in a while and take one or two of her sheep or goats to sell when needed.  With the proceed, they buy provisions and bring it back to her on the next visit.  She does just fine without electricity and indoor plumbing.  Computers, internet and even cell phones are completely alien to her.”  I smiled and told her of my grandmother and similar other people I know.  We both shook our heads with dismay but agreed that people like her keep our traditions alive and are the foundation of our old cultures - we did not use the word ‘primitive cultures’ - even in twenty-first century America.
  One of the best surgeons I have had the privilege to work with is George Harrington, pediatric orthopaedic surgeon who is a retired army veteran and joined our practice in Albuquerque for a few years before moving to Las Cruces, NM, where he practices now.  Dr Harrington is a tall, towering gentleman of Comanche race.  His upbringing gives him a special perspective that is very helpful in treating children with special needs.  He is uniquely qualified to deal with challenging pediatric orthopaedic problems.  Although Albuquerque is home to Carrie Tingly Hospital - one of the top Pediatric Orthopaedic Hospitals in the country, Dr.  Harrington’s expertise stood out.
On one special occasion, we were caring for a young man of about fourteen with Blount’s Disease that gave him uneven leg length.  This type of problem often requires multiple surgical procedures to straighten and lengthen the shorter leg.  Joseph (not his real name), was a big African American young man who like all teens of his age wanted to play sports and be with his friends.  His severe tibia vara however prevented this and thus made him unhappy and indulged him to eat which added to his weight and in turn his problem.  When he first came to us, he had a low view of doctors.  He already had several operations of his leg and was not at all looking forward to more surgeries, casts, and immobilization.  Dr, Harrington’s calm, reassuring and professional attitude however, soothed Joseph’s concerns and over the next few years that we cared for him, he continued his treatment with us but with the zeal of a person with a new view and positive prospects in life.  I don’t know that we did anything different in his surgical care than other doctors he had seen, but how we related to him and his family made an immense difference in his accepting of his fate.
Children are not the only ones who need help facing their tragedies.  Many adults too need our assistance. When I was in the Air Force, a military lawyer from the Judge Advocate office, broke his leg while playing soccer.  It was the beginning of the season and understandably, he was upset.  While I was putting a cast on his leg, I noticed that he was at the verge of crying and made a comment that “now I have to stand on the sidelines hiding my cast while watching the game.”
He was leaning back on the gurney and not looking at me or my work.  When I finished his cast, I built a replica of the ‘scale of justice’ out of plaster over his cast.  Then I showed it to him and said; “Now you don’t have to hide your cast.”
His face changed from sadness to hilarious laughter.
Later, he returned grateful and wrote a letter to my commanding officer on how I changed a terrible time to a tolerable one for him, and thanked me for it.
  When I served on the NM Medical Board, the most single common complaint of the patients was the way they were treated by their providers and how little communication there was between them.  Communication is a two-way street and need not be complicated.  A simple show of concern and patience in dealing with people is usually all it takes.
  Making sure that we understand our patient’s problem and convey our instruction to their satisfaction is the key.  This does not require any degree of literary acumen, just a clear conveyance of information.
The PA School I attended, was in the US Public Health Hospital in Staten Island, New York.  It was during the Viet Nam war and a shortage of doctors necessitated hiring foreign trained physicians for public health jobs.  The hospital was the key healthcare facility for merchant marine sailors from around the world who happened to get sick or injured while traveling through US waters.  It was not unusual to have a foreign patient - who knew little English - be treated by a foreign doctor with equally limited knowledge of our language.  Some of the interactions were truly comical and yet of concern since it had to do with the care of people.  Still most of the care was good and it was heartwarming to see the diligent effort of our foreign colleagues in dealing with the challenges.  To this day, I remember a page from a patient’s chart describing the history of an incident written by a Chinese physician.  It went something like this;
“Man sat on toilet.  Wife come home not know man sat on toilet.  Wife open door hit man in eye.  Man have bump in eye.  First small bump now big bump.”
On first read, it may show bad English and vocabulary.  But it clearly and distinctly describes the incident. Shakespeare couldn’t describe it better!
  No matter what our profession, we all strive to be the best and achieve stardom in our work.  I don’t know what ‘reaching the summit of a profession’ may mean to different people.  It maybe having a corner office on the top floor of the Mount Sinai Hospital overlooking Fifth Avenue and earning a seven figure income or having a tenure at USC Medial School.  Equally satisfying though is a little boy with a hole in his sock, laughing happily.  For the end result is the position we all find ourselves when all is said and done.  The plaques and awards put away, the bulging bank accounts passed on to our inheritors and we, needing the care of those we looked down on and now have taken over our corner office.  Just like the lizard in Escher’s drawing, crawling out of the flat picture, climbing over the zoology textbook, unto the (polygon) paperweight ball and sending a snort of smoke in satisfaction and triumph.  To quote Escher himself; “Reaching the pinnacle of its existence.  Yet after its victory, it finds itself returning to its flat, static, home on the paper to close the circle of life.”  So it is for us that no matter how successful we are in life and what pinnacles we reach, it is the smiles and satisfactions of our patients that will make us remember the good days.