I spent the night in a dreary Hampton Inn where every trip on the elevator was heavily laced with the acrid fumes of recently smoked marijuana. By the morning I couldn’t wait to get to the rented physician’s office where I would examine the worst cases NYC could ever offer me. I was ready for the misdiagnosed, the mistreated, and even the rare subset of patient that was fabricating their symptoms. But what I wasn’t ready for was a broken heart.

Her name was Jacqueline and she was extremely fit in a way that clothing couldn’t hide. She was lean and moved in a supple way that argued for a lifetime of exercise and hard work. She was a dancer for the famed NYCB, New York City Ballet. Today she was all of those things and she was angry. We were moving as quickly as possible but the vagaries of traffic in Queens meant very few of my clients were on time. It didn’t help that the scheduling company had placed thirty patients on my schedule so I was invariably behind. Some of those appointments would take 15 minutes and others took almost an hour. Patient complexity was no one’s problem but my own. So Jacqueline had waited two hours and she was angry. The nature of an IME exam is that it is involuntary and forced with a physician you didn’t choose and whom most patients believed worked for the insurance company. Well technically we did, but any allegiance to our paycheck was overridden by the sheer joy of getting it right, of solving the Gordian Knot of Workers Compensation cases that fail to progress.

“I am sorry for the delay. I am the only one here and I am moving as fast as possible,” I said. She calmed down after expressing her displeasure.

“What body part did you hurt?” I said.

“It’s my neck. Everyone says it’s my neck. The pain shoots into both arms and shoulders. But nothing works. It’s been three years and I am no better. “

The mechanism of injury involved a ballet move where she was lifting another ballerina overhead with both arms extended. Her colleague’s entire body weight was balanced on her out stretched arms. She had immediate sharp pain in both arms.

“How do you know it’s your neck for certain?”

“My MRI shows a disc herniation.”

We started a thorough physical exam. Her cervical spine exam was completely normal with full motion and no evidence for nerve compression. I proceeded to examine both shoulders as she was having difficulty reaching overhead.

“Why are we examining my shoulders? I already told you it’s my neck.”

I froze for a second and asked if anyone had done a thorough physical exam. In three years no one had touched her. Her shoulders were never examined even though she had shoulder complaints. Physicians who had never asked her to change into a gown sat in the room with her reading from an MRI report that reported a mild disc herniation. Never mind that 50% of cervical disc herniation are mild, insignificant, and benign.

Her exam confirmed clinical signs of bilateral shoulder instability with a positive Apprehension and O’Brien’s sign. The shoulder exam aggravated her neck pain and confirmed that the pain was originating in the shoulder and radiating into her neck with trapezius spasms aggravating her perception of neck pain. After confirming her diagnosis I explained that she did not have a neck injury, but a bilateral shoulder injury.

“I don’t believe you.”

“Well after three years of being told it was your neck, I would have doubts too. Let me show you something. If I can relieve your pain by manipulating your shoulder, promise me you will at least look into the possibility that I am right.”

She agreed to let me try. I asked her to let the right shoulder go limp and hang at her side. I applied anterior pressure on the ball of her shoulder and, after a moment of resistance, felt it slide back into the socket with an audible click. She winced and I asked her to reassess her pain scale which had been a 10/10 a moment before. She looked, concerned, and after a minute her jaw dropped open.

“It … it’s almost gone. It’s a 2/10.”

“ I told you so.” I then proceeded to replicate the findings in the opposite shoulder. she had a similar response and again looked incredulous.

“ What do I have?”

“You have bilateral labral tears, consistent with your lifting injury.” I explained that there was a cartilage structure that stabilized and deepened her socket that was torn, allowing the ball of her shoulder to escape out the front. The displacement stressed her trap which was in spasm and made her feel like she had neck pain. Further, I advised her that this was a classic constellation of symptoms and was not a difficult diagnosis. She looked at me with doubt as I explained that neck and shoulder injuries often mimic each other.

“Why should I believe that all of my doctors are wrong?”

I shrugged and said, “They have not had much success in three years right?”

But she was invested in her diagnosis. She had seen orthopedic surgeons, chiropractors, neurologists and therapists who had all don e the bare minimum of reading her MRI report without examining her. I told her tests can be misleading without a guiding hand and careful physical exam.

“I don’t believe you! You are just working for the insurance company!”

“ I am. But if I had those motives I would have said there is nothing wrong with you instead of trying to correct your diagnosis to a problem that can be fixed.”

She stormed out at the end of our exam and I went on with my day. Thirty minutes later the secretary advised me that she was back and was actively sobbing in the waiting room. Now I was concerned and I pulled her into a private room with a witness.

“What is wrong?”

“Do you understand that I am 30?”

“ No I don’t understand.”

She explained that she realized that I might be right and the reason she was opposed to the idea was that she had lost the last three years of her ballet career to this injury. That she was about to age out of a very physical sport and the misdiagnosis had cost her almost all of the remaining time that she could remain in the ballet company. The pain in her voice was overwhelming. She had come back to tell me that she thought I was right and that her career was over. She needed to tell someone who would listen.

“What should I do now?”

“ I can’t tell you what to do but I left recommendations in my report. See a sports medicine orthopaedic surgeon. Get an MRI of both shoulders. Try to rehab the shoulders or if necessary fix them.”

She cried some more and after an awkward silences she said what I had hoped to hear:

“Thank You.”

I think of her often. Of my colleagues who failed her. It hurt me that so many experienced and knowledgeable professionals had let her down. And that nothing could reverse the passage of time. Medicine is not just a repetitive act of parroting someone else’s diagnosis. Critical thinking is not something that happens without care and intention. I wonder if she ever followed up and got the right tests and the correct treatment. I never saw her again but I hoped that she was no longer the Patient Who Couldn’t Dance.

Chandrasekhar had a famous uncle, C.V. Raman, who discovered that light passing through a material scattered in a specific patterns which changes a portion of its wavelength and frequency. The Raman Effect led to Raman Spectroscopy which is used in modern labs to identify chemical structures by their molecular fingerprint. It was 1930 when CV Raman was awarded the Nobel Prize in Physics. Meanwhile his 19 year old nephew had earned a prestigious scholarship at Trinity College to pursue his PhD.

He boarded the SS Pilsna, a steamship, to take the 18 day voyage to England. It was routine for the English travelers to avoid Indians in a very special form of Colonial racism that was not only repugnant, but severely isolating and lonely for the young man. During the trip, Chandrasekhar passed the time filling a notebook with calculations that would turn the world of astrophysics upside down. He calculated that as mass increased inside a star, there was a limit in size beyond which stars will collapse into a neutron star or black hole. For a star to remain stable, its internal pressure must balance its inward gravitational pull. Chandrasekhar used the equation of hydrostatic equilibrium:

The Gravitational Pressure increases disproportionately as the solar mass increases to the hydrostatic pressure of the atoms. As one reaches the Chandrasekhar Limit, 1.44 Solar Masses, gravitational pressure takes over. Stars of this size and greater collapse into neutron stars or black holes. The same equation predicts a limit to the size of a star that can become a white dwarf. This 19 year-old’s musing into a notebook to pass time during a long sea voyage had discovered the origin of neutron stars and black holes from a physics perspective. It wasn’t until 1983 that Chandrasekar along with his advisor from Trinity College, Ralph Fowler, received the Nobel prize together.

This was the staggering intellect, waiting for myself and my attending when we walked into his room after he had sustained a fall with a substantial orthopedic injury in 1992. It is enough that the injury was Surgical and that he survived the surgery without incident. What is the value in this experience is that he worked throughout the fracture care and deliberately refused pain medication so he could keep a clear head. His bed was constantly flexed, so he could type away on his laptop. Books were scattered on his bed and around the side tables he had brought in to hold his texts.

I walked into the room to explain his treatment plan. He could barely veil his annoyance that I had interrupted him.

“What do you need?” He said.

“I need to explain next steps,” I responded.

“Talk to my wife. I have three more books to finish.”

And so it went. He recovered fully and went on to complete some more of his textbooks. As a form of gratitude, he invited myself and my attending to his home for a formal meal. We accepted with a great deal of gratitude. But what occurred to me was that the Chandrasekar limit was not just an Astrophysical guideline. It was the limit between an Indian immigrant’s intellect, and colonial racism. If he had not been socially isolated, it could be argued that Chandrasekhar might not have achieved the peaks of intellectual prowess. If the astronomer Eddington had not so aggressively obstructed his theories, Chandrasekhar might not have been so committed to his work. He was a product of his time and the evils of the Colonial British Empire. It was a wound to my soul that this Indian immigrant had suffered so much and now was being taken care of by another Indian immigrant, myself. Because in all of those years since 1930, we have changed the accoutrements of racism but it still lives and breathes every day in the United States, rearing its head as a convenient explanation for why some groups excel, and others do not. Have we reached the Chandrasekhar Limit for improvement in our society? I hope not.

George E. Block and I met at the University of Chicago in 1989 in my internship year. He was a colorectal surgeon who had reshaped the field and rebuilt surgical techniques from the ground up. His methods sharply reduced complications and he was a detailed researcher with over 140 publications. He was world famous and had been a visiting professor at over 100 institutions. He was my attending in the third rotation of the year and everyone warned me that he was not to be crossed. He spoke in a deep cigar-laced voice that commanded attention. He only spoke when there was reason to be heard, and it was in your best interest to listen. He was all of those things to others but not to me. He was my friend George, the cattleman.

George was bald and had a unique feature where his right eye appeared cocked and a half inch lower than his left eye. I’ll never know if that was from injury or something else. He served in the Korean War and won the Bronze Star. He was thick and muscular and his presence was felt whenever he entered a room. He was gruff and cantankerous but still managed to corral the respect of his colleagues. George was king of all he surveyed and if he wanted he could have worn the crown. But he had already served as president of the medical staff, chairman of Surgery for decades, and had headed nearly every Surgical society. Others took the titles, but everyone knew George was the emperor. His Surgical service was infamous for being highlighted in the book Forgive and Remember. He was infamous for his no nonsense criticisms during morbidity and mortality conference where everyone displayed their mistakes for public condemnation. George was firm but critical and he never shirked his duty to take a resident down a notch. Or an Attending.

So it was with some trepidation when our first surgery together was an open hernia repair, the kind we do mostly laparoscopically now. My chief resident was a fifth year resident and he was shocked when George told him to go and write orders. He was going to do the procedure with me. Except I had never done one and I was shaking in my boots. We proceeded with the incision after anesthesia and prep. Step by step, George instructed me on the dissection, passage of sutures, and careful closure. I was left handed and all of the tools were right handed. He could see I was struggling with the needle holder which didn’t want to work in the way I needed. It took us three hours for a procedure that should have taken 45 minutes, but that is the nature of a teaching institution. After the case, George approached me and said, “Meet me in my office.” He turned to my chief resident and dismissed him to the floor and rounds on the patient census. My chief was obviously miffed since it was my job to do the tedious work of floor rounds.

Here it is. I am getting fired. I was clumsy in the case and it wasn’t good enough. His office was a floor below the operating room. It was an expansive office with a giant cherry desk. The wall were covered in accolades, degrees, publications and awards. He instructed me to sit down opposite to him and pulled multiple needle holders out of his desk. He spent the next two hours working with me on the altered mechanics required for a left-handed surgeon to manipulate a right -handed needle holder. He was kind and patient. He watched me struggle until I didn’t anymore. By the end he was smiling and I was too, from ear to ear.

In the middle of my rotation I was on call and an obese African American woman named Joyce came in with horrible abdominal pain in the left lower quadrant. She was breathing rapidly and was severely acidotic. We did our workup and it was determined she had a sigmoid Volvulus, a torsion of intestine on its vascular pedicle cutting off blood flow. It was fatal if not fixed and we were in the Operating Room for 6 hours that night. George came in at 2 am and scrubbed in even though he could have left the case to my chief. He lived in Joliet an hour away and must have gotten in the car as soon as he was notified. We saved Joyce that night and she spent the next several weeks in the ICU. Her obesity led to fluid retention and poor pulmonary toilet. She couldn’t clear secretions and soon had a pneumonia. I was determined to clear her lungs and performed nasotracheal suction four times a day. When the respiratory techs weren’t available, I flipped her with the nurses help and did a pulmonary massage that the techs had taught me. She always had a smile for me even though I was going to make her miserable for the next hour. It was my first lesson in commitment, from George showing up at 2 am to my daily ritual of nasotracheal suction multiple times daily. Together we saved Joyce and I realized that committed effort can overcome almost anything.

I left his service but I didn’t leave his sight. Every time George saw me rounding with my orthopedic team, he stepped in and told my attending, “You have the best here. And any time you don’t want him I will take him on my service.” My chairman, Dr Simon, thought he was joking. But , George and I, we knew it was no joke.

George was an avid breeder of Angus cattle. In 1993 he won a national title as the Breeder of the Year. He loved raising cattle as much as he loved surgery. It was rumored that George never took his salary at U of Chicago except for a symbolic dollar. He did it because he loved to teach and he loved caring for patients. One late evening he was attacked in the parking garage by an alleged mugger. George beat the mugger to a pulp and carried him into the ER himself. His spleen was ruptured and George took him upstairs to the operating room to remove his spleen. And saved him. George was all of these things. Compassionate to a fault. A chain smoker of cigars. A cattleman.

It was 1994 and I was finishing my residency. A month after I left George had a massive heart attack after three separate bypasses. He didn’t survive and I heard secondhand. I promised myself that I would write down our story someday so everyone else could know what George had been to me. It was ironic that George had been born and raised in Joliet, the site of my first practice. Everywhere I went someone knew him. Some years later, I was at a brunch with some friends and out of the blue one of the attendees I didn’t know asked, “Did you know George Block?”

I answered, “I do. He was a great teacher. And my friend. I just wish I could have spoken to him before he passed.” It turned out that the gentleman knew the Blocks and had his wife’s phone number. Together we called Mary and I spent the next hour relaying my stories of George to his spouse. She thanked me profusely and said that she was so happy that we connected. And as we hung up the phone, I had come full circle. It was a wound to my soul that I could not see him before he died. But speaking to his wife was the next best thing. George was my friend, and my posthumous memorial to him was important to deliver. I can see him now with a cigar clenched in the corner of his mouth, teaching, educating, and reminding all of us how we can be the best at what we do. George had many things to be proud of, but he loved his cattle the most. And so I remember my friend, the cattleman.

The titled movie featured John Cleese and was released in 1988. Ironically our “fish” was a CV surgeon whose last name was Karp. He spent every other day in the operating room, trying heroically to save the sickest of the sick. His mortality rate was high but these were the patients every other hospital had turned down, so they were already dead if Karp didn’t make the effort to save them. I think our fears clouded our perceptions as I think about it now, but in our minds he was a thunderstorm and we were immobile trees waiting for a lightning strike.

Then it happened. He started appearing at random times. Nurses were flustered. Interns pulled out their hair. Medical students wept because they could sense the disorder and pain we all felt and were certain they were next to feel the wrath of Wanda. We named him Wanda as a codeword to speed our reconnaissance. We recruited the secretary in the operating room with a bag of Hershey kisses to notify us when Wanda walked past her on the way to CVICU. The third floor surgery suites were a good quarter mile from the ICU and when we got the call from the Surgical Secretary, she whispered “Wanda” into the phone.

We all stopped to listen as every person whispered Wanda in revolving ripples from the phone spreading across the ICU. Nurses scrambled to double check their paperwork, interns were awoken from the shabby cot in the call room, and medical students were positioned in the hallway between the ICU and the OR.

The medical students were beneath Wanda’s notice, insects that came and went. As luck would have it, halfway down the hallway from the OR to the ICU was a lonely phone on the wall in this era with no cell phones and belt pagers. We positioned our medical student on that phone as soon as the first Wanda call came in over the phone. We had ten minutes tops to get our sh*t in order. Once the medical student phoned in the second Wanda call it meant that Karp was bearing down on the ICU like an impending typhoon and he was two minutes away.

Papers flew, people tripped, the sun was nearly eclipsed and God forbid that we were unprepared. I did well enough on the first two weeks of the rotation that I received an invite to assist in the operating room. I had done very few surgical cases up to this point and I had never cracked a chest to look at a beating heart. I was there mostly to hold retractors and I was trying my best not to drip the pouring sweat on my forehead into the wound. I was doing well and at closure, Wanda handed me a suture to close skin. I threw about three stitches, quite happy with myself when the last knot tightened too early and I couldn’t push it down to the skin.

“Komanduri, that’s a loop not a knot,” Karp said. It was the first and last time he spoke to me as he repossessed the needle holder and forceps from my grasp. I had been tried in the court of Wanda and had been found wanting. Wanda banished me back to the CVICU and I never saw the OR again for the next two months.

But Wanda and I had an understanding. I understood the complex CV pressure measurements that we followed and I was good at correcting problems as they arose. Surprisingly, no one died on my call nights which was like dodging all the pies at a carnival pie throwing contest.

But was he so terrible? His assignment was to save the worst of the worst from horrible heart disease that was mostly self inflicted in an era where we had very few drugs and smoking was rampant. I believe he encouraged the aura that he would not tolerate anything less than perfection because nothing less would do. And although his existence was grotesque, people died if he had not existed as a bulwark against mediocrity. And for the next thirty years, as I closed wounds, I heard his words pushing me to accept nothing less than perfection.

“Komanduri, that’s a loop not a knot.”

You were right Wanda. You expected perfection in an imperfect world and the physicians you trained expected the impossible of themselves. As we left your service with the goal of perfection, we had no idea of how to forgive ourselves or others the failures that are part of life. And so it is with medical training where the grotesque mold us in their image, and we carry that burden for decades to come. I have since learned to forgive myself and others through a great deal of introspection and self healing. But it was a wound to my soul that never quite healed. To this day I can hear his words in the cold whispery voice he had and I wince at the possibility that I am still chasing perfection.

The name of the story, Marching Amputations, refers to a phenomenon in vascular patients whose blood vessels in their lower limbs had long since lost their elasticity and patency. First a foot would turn bright red in a false flush of splendor, just before the flesh began to ulcerste and rot. The smell of putrefaction is sickly sweet just before it plunges your stomach into a rolller coaster of heaving and not uncommonly vomiting. The cure at the time was a bypass where a larger vessel in the thigh was connected to a smaller vessel in the foot or leg to increase blood flow. Today interventionalists can stent or roto root vessels and save limbs but not so thirty five years ago. Dead black tissue is called demarcation, and the line between living and dead flesh is the line of demarcation. We wait for tissue to die to estimate where to amputate the limb. Before cholesterol management and anti-smoking campaigns, these patients faced a series of bypasses followed by the inexorable need for an amputation. Midfoot. Syme. Below Knee. above Knee. These vasculopaths, diseased blood vessel sufferers, had serial marching amputations up the leg as the line of demarcation marched up the leg like a DMZ of death, flesh where the immune system could no longer go and simply quit trying. Watching these patients was heart breaking. They occluded arteries as fast as we could heal the last amputation site and the pain of a vasculopath is unresponsive to morphine and fentanyl. They scream continuously as their tissue fails, corrupts and dies.

Debbie was the first wound to my soul. She had long since lost the battle and was now left with two tiny pegs at the top of her thighs. Even as she lost her legs, Debbie went home and smoked four packs a day. She skipped her cholesterol medication and often waited for the stench of dying tissue before she showed up needing her next amputation. Debbie was the poster child of denial and self care had no place in her vernacular. I Met her three months into my internship. I dressed her wounds daily while she screamed and pummeled me out of fear and frustration and anger as I hurt her everyday. She was on a morphine drip which did nothing for her pain.

I walked into her room a month into her suffering with the Chairman of Vascular who had more titles than you could count. But he liked to be called Bruce at informal moments and Dr G the rest of the time. He looked at me and at Debbie and then back to me.

“What’s your plan?”

Thirty days into my vascular rotation left me with dressing changes, pain management, and nothing else. There was no more tissue to amputate.

Dr G turned to me and said, “ Turn the morphine up every hour by 4 milligrams until she is no longer in pain.”

To my surprise I said, “No.”

Gainsaying a chairman of a department was a death sentence but I couldn’t do this. Morphine not only helps with pain but high doses cause the patient’s brain stem to forget to breathe. He was asking me to kill her. Dr. G was using me to commit murder.

He smiled at me wryly and gave a knowing look to my Chief Resident Chuck. I was convinced Chuck hated me because I was inexperienced, disorganized and didn’t know a damn thing. All true. But for a moment Chuck had empathy for my position.

“It’s all we have,” he said. “ we can stave her tears and let her go with dignity.”

Three days of turning up the morphine drip left her breathing shallow and rapid. Sometimes she didn’t breathe at all and it was all I could do not to rip out her IV. On day three she opened her eyes and her face did something I had never seen. She smiled at me.

“It doesn’t hurt today.”

Damn straight it didn’t at 44 mg/hour of morphine. How she lived through that drip I will never know. I called her family who knew she wasn’t going to leave the hospital alive and told them to make their visits. Soon. She died that night at midnight. I was on call and between other duties, I did breathing checks on Debbie.

I walked in and that evening and for some reason the cloying smell was gone. She was no longer breathing and after ten minutes I found her nurse so we could start the paperwork of pronouncing her dead. She passed quietly, silently, peacefully.

Not with a bang but a whimper.

As I write this 35 years later, I am still saddened that an inexperienced younger me had become Debbie’s executioner. I led her down the path of opioid overdose even if others had directed me. I had been reassured by the best that there was nothing more we could do. But if you could see her torso propped on the nubs of her thighs, screaming in pain for months on end, you would compromise your principles of Primum Non Nocere. First Do No Harm.

Right?

Right??

Right?!!

This is the first in a series of Wounds to my Soul, describing the places in medicine where there is no right choice and the practitioner suffers injuries that can not be forgotten.

2023 was our 40th high school reunion and those of you who have read my musings have asked to hear about our connections at this institution. Memories twist and change in the vaults of our mind and if any of you remember it differently feel free to add your thoughts to the comments.

Freshman Year:

My year begin in the summer before high school in 90° heat on the football field. I was in band, marching band, and our band Director somehow dreamed of pulling this ragtag group into an organized chaos. We weren’t very committed and we weren’t very good but there was always somebody who was at the top of their game. I remember Tom May playing Mangione’s Feels so good. He was amazing and I only felt ashamed that I was so mediocre. We had one of the Merrill sisters, I can’t remember which one, but she was a natural phenomenon and I’m sure there was a tremendous amount of practice and push behind it but to me it seems like it just came to her as a God-given gift. I was the Salieri to her Mozart, the saint of mediocrity and I wondered often what I was doing there.

 I lived in a subdivision called Indian Hill and I was perhaps a mile and a half from the school. I struggled with oversleeping and missed the bus far too often. My worst nightmare came true on the day of my English final with Mrs. Martin. I woke up with five minutes to spare to get to the bus stop and I don’t think I’ve ever gotten dressed that quickly. I was carrying 30 pounds of books on my back because we didn’t have iPads  with the foolish notion that somehow  I could still study between exams. If anyone remembers me I wasn’t much of a cross country runner but I was that morning. I ran to my bus stop and saw the bus leaving about a quarter of a mile down the road. It was 7:15 AM and my final was at 8 AM. It didn’t occur to me to just go to the school, and instead I did my best road runner to get to the next bus stop where I missed the bus by another 500 feet. I ran by Iroquois Park and turned down Columbia trying to catch the last stop at Columbia and Ogden. I was at least a half a mile farther now from the high school and yes I missed the bus for the third time. There was no hope now of catching the bus while it was racing down Ogden on icy streets. I cursed the people who never shoveled their sidewalks never mind that I never did either. I did a slow and steady 35 minute run in 0° weather and I was both frozen and cooked inside my parka depending on which part of me was exposed. I got to that English final 10 minutes into the start time of our final exam. I could see Mrs. Martin was very confused by my appearance dripping like a marathon runner in December, but I didn’t care. I was hearing Vangelis and Chariots of Fire in my head as I scooped up the exam. I was done 15 minutes early. Nailed it by the way.

In some ways we were the Breakfast Club of high school. We had jocks, cheerleaders, burnouts, nerds and every classification in between. There were four of us in that class that were not white. I was the only Indian, Maria was Hispanic, Jamie was Asian, and Monique was black. We all knew each other and each of us did different things to find a sense of belonging and a place we could call our own.  I looked up the Wikipedia page for our high school and the only people who are considered successful were either actors, producers, politicians or professional athletes. To me that is a sad reflection of our era where so many people did so many things with their academic achievement and nobody noticed except for a dry award at the end of the year that likely settled into the dust of our basements. Dan Baker is an accomplished author in the field of childhood disability and has published numerous books and remains a leader in his field just to name one person that should have been on that list.

The highlight of my year was my second semester in Mrs. Barbara Eiserman’s English class. I can’t quite explain, but she took an interest in me that nobody else ever has. For some reason she thought I was a good writer and by the end of the year she made me believe it. I worked harder on her projects than anyone else’s because I was addicted to her praise. And perhaps she knows it and perhaps she doesn’t but she is the reason I majored in English literature in college. Honestly if the medical school thing hadn’t come along as a guaranteed admission I would have likely been a writer or an English teacher in some obscure college. Neither would’ve been a bad thing and perhaps I can still write of things people want to actually read. Many years later, I received a random phone call from one of Mrs. Eiserman’s colleagues  who called me before there was a useful Internet. She found my name at random in the phonebook and was hoping that I was the same person. Realistically how many people do you think had my name? But the honor was all mine as Mrs E was retiring and I came to her retirement party flowers in tow. It was a lovely event at the school and I couldn’t have been happier that I was able to attend. I asked on the phone call why me? And the teacher on the other end said she thought of students that she remembered and I was one of them. Did I say it was my honor? Yes it was.

The summer before high school my family visited our relatives in India. We went to a town called Guntur where mosquito abatement was never really attempted. 15 foot elephant grass was everywhere in damp ponds and the mosquitoes could actually bite right through the netting. Needless to say it was my first bout of malaria when I arrived home. It turns out there are four species of malaria and the most virulent Vivax/Ovale not only attacks your bloodstream but hides in your liver if you were given the wrong course of antibiotics. When you are blowing up your blood cells with protozoan invaders, the first symptom is severe abdominal pain. So six months later I showed up in the nurses office to see Mrs. Stajdohar, our school nurse.

I said “I have malaria”.

Mrs S” What are your symptoms?”

Me”My stomach hurts.”

Mrs S “I have heard a lot of excuses but I’ve never heard that one. No you don’t.”

I wanted to say have you had malaria and do you know what it feels like? I was right I had a second bout of malaria coming out of my liver like a Trojan horse in the middle of the night, laying stake to my bloodstream. I eventually got the right antibiotics and spent an entire week shivering continuously and feeling like it wasn’t going to work out. Malaria is a terrible disease and still kills hundreds of millions a year. I was lucky to survive.

Academically, my first year in high school was a breeze. Things just came to me easily and it was obvious to my fellow students. I was in French class and one of my neighbors in class Derek ? was a classic burn out. We had a quiz and he was ruminating on his F which in my mind was from a classic lack of trying. He came to me at the end of class and said can I help him with his homework. We shared a study hall so I went with him and worked with him for an hour on his basic skills and by the end of it it appeared that he might actually pass. He tried to pay me with three joints, but in all my naïveté I refused because I didn’t know what a joint was and I didn’t certainly want to be caught with one. I suppose I could’ve asked Derek to teach me but I was too nervous and too scared to learn. It occurred to me that my fear was no different than Derek’s fear of French and that we really weren’t that different. At 57, I wonder what I would’ve done had I learned to get high, and that story is a mixture of relief and regret.

 I was good friends with a number of kids that ended up doing some interesting things with Bob Teela in the Wargamers Club. John Iglar dragged me there and I made some lifelong friends and acquaintances. David McGuire, Glenn Iwerks, Dan Baker, Peter Graziano, Brian Pilz and a host of others. It turned out that the club was mostly about mental exercise and many of us became world-class sprinters in the world of thought manipulation and visualization of our goals. I wonder if Mr. Teela knew what he was accomplishing? Did he know he was turning out rows and rows of mental athletes? Bob was one of my favorite teachers at north and I had not even taken a class with him until Ancient History in sophomore year.

Sophomore Year:

I spent my summer riding my bike everywhere. Flip Side, the adjacent arcade, Tongs, Jake’s pizza, Andersens Books. Sometimes an older friend with a car would give me and 7 others a simultaneous ride. Clown cars had nothing on us and no one was uptight about nonexistent seat belts. We played chicken in Nate’s red Chevy something or other behind the K-mart. We were invincible and the risks we took were just bridges to adventure and emotions we were all feeling for the first time. It was an exhilarating time to be alive and we fell in love a thousand times a day, each heartbreak lasting a nanosecond until the next.

I began sophomore year in what was to be the class with the greatest impact on my life and I only realized it years later. Mr Dikelsky taught us Speech but little did I know we weren’t going to give speeches. We acted, we wrote plays, we recited, we sang, we emoted and for the first time I realized that I had depth. Depth of character, of emotion, of passion and the way this interconnected with my experience in English was explosive. I memorized the Tell Tale Heart and gave it back to my classmates in a version that had me squinting with my pale blue vulture eye one minute and the next I was a conniving creature planning murder to assuage my mental illness. I BECAME in that class. I became those characters and I became confident and I became proud of that which I was capable. To Mr. Dikelsky if he is still here to see or hear this, I owe you so much more than I can write.

So many things swirled together that year. National Honor Society which I never really understood because this academic group met and decided that our acumen was going to be best used to throw a party. Secretly I was imagining our invite: IQ 140 required, jocks back of the line. I went to one meeting and decided I had better things to do. Model United Nations taught me that being a politician is arguably the least satisfactory job in the world where principles only exist to be compromised and the world always sinks to the lowest common denominator because at our core, people are selfish and self serving.This for our nuclear phobia as every other headline and story was a T S Eliot whimper about how the world ends. I began to write for the paper and somehow became a political writer during the election of 1980. I was a conservative at heart but certain liberal themes caught my eye and ear. Most of my friends would be surprised if they knew I went door to door trying to drum up support for the Equal Rights Amendment or that I filled mailboxes with fliers from NOW. I am kind of surprised myself but I would do it all over again.

 I took French again and to be fair I lounged around quite a bit. I pulled a lazy 89 each quarter and then inflated my grade with a 97 on the final. Considering the weighting I should’ve gotten the A but our French teacher in all her wisdom decided B+B+A equals a B. This is my first lesson in understanding the world is not fair and even teachers don’t follow the rules that they set out for themselves. My French lesson was not about quand les fleurs est tres jolie au Paris but more about trust. John Donne was right:

If thou be'st born to strange sights,

Things invisible to see,

Ride ten thousand days and nights,

Till age snow white hairs on thee,

Thou, when thou return'st, wilt tell me,

All strange wonders that befell thee,

And swear,

No where

Lives a teacher true, and fair.

So I was seething when I entered the second semester, and I was determined to trust no one and to never give another teacher a chance.  By accident or by chance I fell into ancient history with Bob Teela. Every lesson was a story with real history behind it. To this day I know the meaning of 1066, 1099, 1453. Have you met Ethelred the unready or William of Normandy?  Do you ever wonder how the English archers of Agincourt were able to pull a 120 pound bow while barely standing 5 feet tall? Come spend a semester in ancient history with Mr. Teela and you would know these things too. The history was much less important than the understanding that the world is so much bigger than I had ever imagined. The lessons of our past are so clearly written and oh the stories the stones of an ancient Roman Road could tell. Ancient history went from a subject that I didn’t know to something I deeply connected with and honestly I think our teacher could have made me like just about anything because he was just that good.

Junior Year:

By contrast and comparison I had advanced algebra with a teacher that needs not be named. He buried his face in the blackboard and wrote smaller and smaller as if he was afraid that he was going to run out of blackboard. His voice was unintelligible and his class was utter and sheer boredom. We all had to teach ourselves how to pass the class and we weren’t going to do it sitting in front of that chalkboard. This too was a lesson for the future and how to survive teachers that don’t teach and ultimately learning to teach ourselves.

Socially I was inept but for reasons that weren’t always clear. It was the early 80s and I was the only Indian kid in Naperville North. The idea of sticking to one’s clan or group was not something I chose but was essentially forced upon all of us. It just was the way things were. Not to make it any easier was the fact that I had skipped a few grades and I was two years younger than everyone else. I graduated high school at age 15 and I was too young to get a drivers license until I started college. So dances came and went and I never attended them. Being a first generation immigrant doesn’t really give you the tools to develop social context and confidence. I would’ve done things differently knowing what I know now and I am more than a little sad that I missed out on those experiences. The age difference had a lot to do with my maturity and lack of confidence in general.  It didn’t help that I came from an incredibly conservative culture and that my parents really didn’t have the capacity to teach me the first thing about dating.

And then there was Jim Eminger in biology. Something about his class just clicked for me. Whether it was dissecting frogs or discussing the origins of multicellularity, this class caught my eye and imagination. I suppose it was a good thing because I ended up becoming a physician, but I’m pretty sure that I wouldn’t have cared if it wasn’t for Jim.  I liked him so much that I ended up doing a research project with him in my senior year. It was the best of times in biology and I thought I would never find another subject I loved as much… until junior year.

 So the year ended without much of a surprise.  It was the year that I met a young good looking Steve Mazzarella who probably couldn’t have been much older than 24. Hats off to a great teacher who is no longer with us. Bill Bennet who somehow made American history palatable and clearly was passionate about what he was teaching even if I was not.  There were so many others . I think the best part of this story isn’t mine but how it evokes your own memories and reminds you of that time of your life.

Senior Year:

I had just spent the summer taking tests, including the ACT and SAT. I only took them once and was fortunate enough to do quite well. I spent the better part of the year cutting up flat worms into sections for my biology senior thesis. We were looking at regenerative potential of different portions of their anatomy based on amino acid analysis. It was a rudimentary science project, but it helped launch me on my medical career. I was applying to colleges and and got a surprising number of positive admissions. The surprise was all mine, although none of my teachers felt that it was at all in doubt.

I sweated through calculus with Mr. Morse Who did his best to make an unpalatable subject at least something we could swallow. I fell secretly in love with a girl who sat in front of me in that class that I can barely remember. We talked too much and constantly got in trouble. I loved to go to the class I hated because of her. I received a scholarship to the University of Miami that made it possible for me to go, and after a lot of begging, my parents agreed. I’m sure they thought that I was too young to go so far and they were probably right. Things worked out for the best.

We graduated in the summer heat, all of us scattering to different parts of the world. It was a time of desperate connection and sudden separation. The safety and knowing that the faces we had seen for four years would always be there was gone. It was difficult, it was exciting, it was overwhelming. Coming of age is never something that happens without tumult and upheaval. It was the best of times, it was the worst of times. There are so many things I could have done better, but the not doing of them is what allowed me to find my next leg up in growth as a person.

It was 1995 and I was six months into my practice. I was paged to the pediatric floor at St Joseph Hospital for an urgent consult on a five-year-old boy who was hit by a car while riding his bike. Gina and I arrived on the floor and began searching for his x-rays. This was before we had digital x-rays and we had to find the envelope with his silver colloid films which we held up to a lightbox. What we saw was terrifying and knee weakening.

Both of Kyle’s femurs had come through the skin and were simply shattered. The right one was split vertically in an oblique fashion and the left one was crushed and broken up transversely about 3 inches above the knee. The left tibia was broken into three equal parts somehow sparing the knee and the ankle. One of the pediatric nurses pulled me aside and said:

“ they want a second opinion. But it’s really bad.”

I walked into the room defined by a circus trapeze of overhead traction. Traction is a dance of push and pull and straightening of fractures indirectly while supporting the patient and reducing their pain. But this was all wrong. His left femur was bent 30° and was likely to come through the skin if the traction wasn’t corrected quickly. There was no Thomas splint or Pearson attachment. The child should have been screaming and cringing in pain. But somehow he greeted me and gutted out a smile.

His mom looked exhausted and like she had been crying recently. We talked about what happened. You could see how guilty she felt. That feeling that all mothers get even though they can’t possibly be at fault. I explained that the fractures above and below the left knee made it a floating knee and that he needed imminent surgical fixation. I was worried that the right hip would lose its blood supply and could die. At some point the conversation became more about would he walk, how tall would he grow, could I guarantee his recovery. It was a whirlwind of questions but what I knew is I had to get him out of that horrible traction before things got worse.

Brenda, his mother, tells me that Gina, my nurse, took her out in the hallway and told her to trust me. That she felt that I could provide the necessary care. After a long conversation she decided to think about it. I got a phone call from one of the senior orthopedic staff at Shriners hospital. Somehow through whatever connection he had with the family, he had heard about the case and wanted to know my operative plan. I walked through the fractures with him and after a 30 minute conversation he agreed that we were pursuing the correct path.

Kyle had open fractures and the wounds needed tending. So I chose to put him in external fixators on all three bones. We used a rail fixator on the left tibia which allowed us to compress at each fracture site and realign the multiple pieces as needed. External fixators require extensive cleaning of the pin sites. We taught Brenda how to clean them with iodine and peroxide with a Qtip. She had to be aggressive and clean the pins of all debris meaning that Kyle would feel pain with each cleaning. Sometimes he would come in the office with an early pin site infection and these had to be lanced with a scalpel under local anesthetic in the office. I am so fortunate that I was young and without children because my heart breaks about doing this to a five-year-old and I am not sure I would have the strength now.

The left leg healed both femur and tibia. But the right femur did not. We tried a bone stimulator and a lot of prayer. Eventually the solution became to take him back to the operating room and insert a blade plate. The device has a sharp wedge at one end that is hammered into the neck of the femur and an angled plate that is screwed into the femur. The device was invented for proximal femur fractures and children with cerebral palsy. As far as I knew it had never been used for this circumstance.

But it worked. Kyle healed. He went to months of therapy and he began to walk. With a limp at first but over time that disappeared. Children are elastic and the amount of damage they can withstand is unbelievable. Kyle healed and healed all the while throwing off his electric smile and hope and happiness everywhere he went. Our staff learned to love him and always made sure to tell me:

“Kyle is coming in today!”

So he healed and he left us wondering if he was okay or still struggling. I worried that his growth plates were traumatized and that he would be physically limited. The next time I saw Kyle he was in high school. He came to my office to bring me his football picture because he had made the football team. I can’t quite tell you how he made me feel. I was family and Kyle included me in his success.

The next time I saw him he was working and was over 6 feet tall. He was the marketing representative for ATI physical therapy. We talked for 30 minutes that day. I even introduced him to numerous contacts I had in the medical field to see if there were other jobs that he could pursue. Sinc then he has met the girl of his dreams and he has a beautiful child. In a way, his success and happiness is mine. When St Joseph Medical Center gave me the Founders Award in 2016, Kyle and his wife were my guests at the event.

I told his mom how much the experience of caring for Kyle meant to me:

The impact Kyle had on my career can not be measured. He taught me how to be patient, compassionate, and determined. And you taught me the meaning of faith and trust. Your family is always in my heart.

And now you know the whole story.

Prepping is a word in the operating room that holds many meanings. The word means preparation. But for what? We prepare for so many things. The surgeon prepares Mentally, Physically, Emotionally. We prepare the room, cleaning every evidence of any prior surgery, sterilizing every surface. We prepare for anesthesia. We prepare the patient’s body both externally and internally. So much activity is included in such a short word.

The first part of preparation comes months if not years before the surgery. Patients are evaluated and diagnosed. We present options for treatment. Early on they are nonoperative and include rehabilitation, medication, and home exercise. We refine our diagnosis through the use of imaging, X-ray, CT and MRI. And then we wait. Data points about strength, pain scales, range of motion and others are gathered over time. Some diagnoses like a fracture are clearly surgical or nonsurgical. Other injuries like a rotator cuff tear declare themselves over time. All the time we are waiting and preparing for the next step.

If a Decision for Surgery occurs than our next job is to prepare the patient medically. This starts with a careful medical history, thorough review of medications, and obtaining and reviewing the appropriate laboratory tests. The surgeon involves the right specialists and the primary care physician to move forward. A long term smoker with shortness of breath might have to see a pulmonologist and a cardiologist for example. This moment is the surgeon’s best opportunity to advocate for conservative care. We educate the patient about alternatives and explain how their past health history and personal choices can increase risk of complications and poor outcomes. Smokers hate me, because there is no reason to choose elective surgery, and most orthopedic surgery is elective, while there is an opportunity to stop smoking. Why smoking is so bad is a lecture for another day, but we all know it is detrimental to the outcome. To this day, this process is complicated and fraught with error and often not predictive of the unusual things that happen after surgery. Still, it is the best preparation we can undertake prior to surgery.

Assuming the patient’s labs, tests, and treating physicians all agree that the risk is acceptable to the patient we can proceed. The concept of risk stratification is foreign to most patients and they would just as soon be told that nothing’s going to go wrong and everything will be great. If that sounds like a lie, it is. Risk stratification breaks down patients into low, moderate, and high risk. If someone told you that the procedure that you don’t have to have is high risk you most likely would choose not to have it. That would mean living with the consequences. There are times when people have high risk surgeries like removing a brain cancer or heart surgery, which are by their very nature dangerous but medically necessary. Most orthopedic surgery falls in the moderate risk category as there are risks of blood vessel and nerve injury and blood clots. The person that has to accept their risk stratification to move ahead is not the primary care physician or the surgeon. It’s the patient who has to make the decision that their level of risk is acceptable to them to move forward. This requires proper education and preparation of the patient for the surgery.

Now we have a patient who has failed conservative care, undergone, preoperative medical clearance, and understands their risk profile for surgery and still wants to proceed. We prepare for complex procedures by ordering blood to match the patient’s blood type, and in some cases, we even bank the patient’s own blood planning for the surgery. As procedures become more efficient and less bloody, the need for blood products has substantially diminished in our field. The next step is to prepare technically for the surgery to make sure appropriate orthopedic equipment has been ordered, prosthetics have been sized on Xray so we have an estimate of what we need, and the appropriate ancillary equipment like braces and postoperative cooling devices have been ordered. This preparation is generally handled by ancillary staff, but it is just as important as the technical part of the surgery. Surgical, schedulers, bracing, representatives, and durable medical equipment distributors all contribute. We are preparing to move forward and this necessary equipment has to be there on the day of surgery.

I have often heard patients joke that we ask the same questions many times over. Why does every nurse and every surgeon and every staff member that the patient see is asked for their name tag and birthday? What is the importance of marking the appropriate limb for surgery? These processes didn’t always exist, but were created to prevent errors that occurred elsewhere. In a facility where there might be 80 patients having surgery on the same day and 60 of them are orthopedic, the possibility of mixing up a patient name, a limb side, the exact procedure being performed are all possible. If you can imagine it, it has happened somewhere in another hospital system. So as cumbersome and repetitive as the system appears, it is designed to prevent wrong site, surgery, wrong, limb, surgery, wrong procedure surgery. The fact that we have names for these outcomes should be sobering, and remind all of us that these things have occurred to a patient, to another human being somewhere. And it is our job to prepare to never make the same mistake twice. We prepare the limb by cleaning it thoroughly often with a sterilization solution and shaving the limb appropriately. We don’t use razors because they leave wounds that can get infected behind. We use clippers that trim off the hair at the skin level. Every one of these decisions is based on literature that documented higher infection rates with razor burn and lower infection rates with clippers.

The next stage of preparation involves Anesthesia. They inspect the throat, The access to the airway, and the fluidity of neck motion so that they can position the patient safely to obtain airway control. Sometimes they do preoperative nerve blocks to prepare for postoperative pain. The frequency of these blocks in orthopedic surgery has dramatically increased as we have found that they reduced the risk for narcotic addiction postoperatively. In many ways, this is one of the most most important steps to prepare The patient adequately for a safe transition through the surgery. The anesthesiologist in this process will review the labs again, review all of the specialist recommendations prior to surgery, and will review the operative plan by the surgeon to make sure that there are no contraindications. This is the last chance to stop the procedure before the patient signs their consent and agrees to move forward.

Once the patient is in the operating room and asleep, assuming general Anesthesia is chosen, the operative limb is prepped and draped. Orthopaedics commonly treats a side right or left. Of course, orthopedic spine only has one place to go But there is still a right and left to the vertebrae and there is just as much concern in spinal surgery as there is in any other peripheral surgery to make sure they’ve obtained the correct surgical level and the correct surgical side. Once the correct side is identified, the patient is prepped and draped. This form of preparation involves evaluating the surgical skin site carefully for any skin breaks, infection, or medical reasons not to proceed. Assuming we can go forward, the skin is cleaned with a combination of chlorhexidine, Alcohol and sometimes an iodine solution. The dirty little secret is it’s impossible to make every single bacterium disappear. We are not clearing the battlefield of all risk of infection, we are just removing as many soldiers as possible, so that the risk is limited and likely to be defeated by the patient’s own immune system. This form of preparation is by its very nature, incomplete and impossible to perfect.

While the patient is being seen by Anesthesia and brought to the room and prepped and draped, the surgeon is preparing as well. Every surgeon reviews mentally the last time they performed this procedure and every time that the procedure went well and every time the procedure did not go well. The frequency of failed procedures is often extremely low, but they live forever in our minds. Every complication, every infection every failed outcome gets played over and over and over. Most surgeons can recollect the date time and name of the patient that had a complication. Part of being a surgeon is admitting when something did not go well and learning from it so that it doesn’t happen again. We share our morbidity and mortality data in a Conference with our peers Where we accept responsibility for our actions and the outcomes, good and bad. The purpose is so that everyone can learn from a negative outcome so that no one needs to repeat the same mistake twice. In this process, we prepare to learn from our mistakes, whether they are our own or our colleagues.

So prepping for surgery is a complicated process. We prepare to be right we prepare to be better and we prepare to avoid complications that we can perceive. Despite every possible attempt to prevent complications, they still occur. Preparation is a never-ending process for a surgeon and we prepare to be better every time. Even when a procedure goes well, there is something to be learned from it. This shared experience creates a gestalt of confidence and comfort that we can share with the patient to help combat their fears of the known risks. So will we ever be fully prepared? Not if we want to be the best we can possibly be. That surgery is always just over the horizon.

I met with the zoo medical Director, and we discussed his recent CT scan of his knees that showed large chunks of bone and debris floating in his knees. It seemed likely that we could help surgically by removing the debris but meanwhile I helped provide lubricants that could be injected into the knee.

A few months later, we got the call that Ramar Would be under anesthesia for a dental procedure, which would allow simultaneous knee arthroscopy to occur. There was a flurry of activity while we got equipment donated, lubricant, and medications to place in the knee, and other services specifically for the knee joint.

The day arrived, and everyone was on site, excited and prepared to help the gorilla. It was the zoo, director’s job to get the gorilla sedated and asleep on a special table designed to hold his massive weight. The intubated gorilla came rolling into the operating room. Something I learned about gorillas that day is that when they are stressed, they release an extremely pungent pheromone that literally burns the inside of your nostrils. Every one of us was double masking trying to breathe through the strong odor.

An interesting sidenote was that we had so much hair on the legs that we had to shave so we could expose the underlying knee joint. Gorillas are interesting because they’re not the cleanest of animals and he had excrement all over his fur. The anatomy was surprisingly similar to humans except it looked like a hand had been attached where there should’ve been a foot. The prehensile limb was easily able to grip and grasp because it functioned just like a hand.

The surgery was remarkably simple and easy. It was as if we were operating on a 300 pound lineman. The knee was about one and a half times larger than I expected for a human of the same size. Chunks of bone and debris were removed arthroscopically and we smoothed out the joint as best we could. We injected the knee with local anesthetic and lubricant for additional pain relief and closed his wounds normally.

Ramar appeared to walk better after his surgery and was able to climb higher to get his food enrichment. He lived another three years, but unfortunately died from a gastro intestinal complication. I’ve treated a lot of patients over 30+ years, but it was extremely satisfying to treat this animal who had no expectations and was simply trying to live his life without pain.

It was a routine Friday morning clinic. Karen was an average housewife who had an ankle sprain that was treated nonoperatively elsewhere. But nine months later she was still in pain. She came to me for a second opinion. I examined her ankle from a low stool and identified that she had a chronic rupture of the syndesmosis. This easy to miss injury of the ligament between the two bones in the lower leg is sometimes called a high ankle sprain. Karen had gone to an urgent care where she saw a nurse practitioner who unfortunately didn’t know what she was doing. Three braces later, months of therapy and she was still left with radiating pain up the leg. I explained to her it could be fixed but the outcome was uncertain and it might be best to tolerate the injury. Her heel was sitting on my knee and I looked up to explain and then it happened.

My mouth opened and my jaw dropped. Karen was wearing a mid thigh skirt and as I looked up to make eye contact, there was a watermelon sized mass in her lower right thigh, screaming at me to look. I stopped. I looked at her questioningly.

“What’s wrong?” she said.

“How long? How long has that mass been in your thigh?” I knew this was about to get very ugly for her and I couldn’t stop the freight train that was about to hit her.

“Three months. Maybe six.” She was crying because she knew I was upset but didn’t know why.”What is it?!”

“Look. There is no time. That is cancer until proven otherwise. We need an MRI, CT, Xray, abdominal and chest CT to make sure it hasn’t spread. I will call the University of Chicago Orthopedic Oncologist. It’s Friday and I want you seen yesterday. There is no nice way to say this. If that is what I think it is, you need urgent surgery.”

She began deeply sobbing, aching racking sobs of a patient who knew something was terribly wrong but kept filing the problem under “I’ll see about it tomorrow.” Tomorrow was here and the mass was likely a highly malignant often fatal tumor that arises behind the knee called a synovial sarcoma. So many people had seen her over six months. The NP. Four separate physical therapists. Her primary care. Her spouse. No one said what the hell is that 20 cm mass in your thigh? I moved heaven and earth that day, begging for emergent studies, explaining to University of Chicago that I needed an emergent appointment. After four hours of phone calls and begging everything was arranged for the weekend and a Monday morning appointment with the tumor specialist. I was feeling pretty damn good about myself and my clinical acumen. If Karen lived, I saved her life.

I kept in touch with the orthopedic oncologist who told me it was too late to save her leg and the chance something this big had spread to her organs was high. Karen needed the worst kind of operation, a hip disarticulation, They were going to take her leg off through the joint like it was a chicken leg. Her limb was a seething mass of angry cancer cells that had likely contaminated the entire limb. I got regular notes from the orthopedic specialist until they abruptly stopped three months in. That was my sign that something was wrong.

Four months in I was served with a lawsuit. It alleged that I hadn’t reacted fast enough. I was the first to diagnose her and had her at a specialist in 72 hours from a Friday morning to a Monday morning. That she had lost the right to congress with her husband. So hubby was pissed he couldn’t have sex while her leg was ripped off at the hip? And it was my fault?? They sued the NP, the physical therapists, the institution where I worked and my partner who had seen her for an unrelated knee sprain a year ago. She lived eight months after they did the hip disarticulation and died of liver failure from chemotherapy drugs. Her husband and the attorney modified the suit to claim I was responsible for her death.

It turns out you can sue if the sky is the wrong color of blue in the US. There is no barrier to stupidity. I was so quick to anger then. “I saved her goddamn life” I said to my attorney. Granted she did not live that long but that wasn’t my fault. Everything was couched in terms of fault and the terrible disappointment of an unfair life dealing Karen some terrible cards.

It was time for my deposition and the family had hired Coirboy and Coirboy. Physicians whisper that firms name like the Angel of Death had entered the room. Phil Coirboy had crushed so many doctors and their dreams by suing them for millions. He had a fancy downtown office that rivaled any five star hotel. Coirboy thought this was a slam dunk. Missed Cancer. Horrible Surgery. Dead eight months later. No sex. Young women in her thirties. Crucify the doctors! They got it wrong! I was ready for bear. Every question I got I answered with “I saved your client’s life” at the end of my answer. Coirboy had sent an attorney who was in a previous life a thoracic surgeon. He thought an MD JD would be intimidating. Maybe in another life, but I was angry.

My attorney pulled me to the side and said, “Look we are winning but tone it down. Sounding overly confident isn’t a good look.” Humility was a tough pill to swallow considering the circumstances. But I toned it down. A week later I was dropped from the lawsuit. It went on for months. I will never know if anyone settled or went to court but I exalted in the knowledge that I was correct.

That was 1997, nearly thirty years ago. We were both quick to anger, the patient and I. Her only recourse was to blame someone, anyone, including the person who saved her life. I wonder who drove the process? The patient, the husband or the attorney? I wonder what she would say to me about my actions if we met today? I am not angry anymore, just mostly sad. Sad that the chemotherapy killed her. Sad she lost her leg. Sad that at least ten providers didn’t look or do a thorough physical exam.

I was scarred for life, never quite trusting the intentions of my patients after that. I ordered more tests and spent hours every week doing CYA. Cover Your Ass. I wasn’t a better physician for it and perhaps I was less sympathetic for a long time after it. You see nobody won. We were both quick to anger and nobody won. I wouldn’t have done anything different in terms of patient care and I stand by my choices. But sometimes the outcomes are so bad, the scar tissue so deep, that no one can forget and forgive.

A short warning because this is a gory orthopedic story, and some of you have asked for more intimate details of surgical travails. So if you’re easily sick or nauseous or don’t like stories about blood stop reading here.

The picture below is a device called a Gamma nail. It’s designed for fractures in the red area of the image or intertrochanteric/subtrochanteric fractures. The trochanter is the funny bump on the side and there’s a big one on the outside of the femur and a little one on the inside of the femur. The zone in between those two bumps is the intertrochanteric region. It’s a commonly broken part of the femur after a fall and it’s associated with osteoporosis and age.

The patient I am discussing has Long since passed away. She would probably get a pretty good giggle and a snort out of being the center of attention in this article. To avoid being completely impersonal we will call her Kathy. Kathy had a Gamma placed after a routine fracture that occurred while on vacation in Tennessee. For reasons that are not clear her fracture did not heal, and there was no evidence for infection. But she was riding the Rod as her only connection between the top half of her femur and the bottom half of her femur. Think of a paper clip bending back-and-forth and back-and-forth. Any metal rod will eventually break because it can’t sustain the kind of forces that your living bone adjust to on a daily basis.

After failing extensive conservative care, our plan was to remove the old screw and shaft of the gamma nail and converted to a partial hip replacement or replace it with a longer gamma nail and compress the fracture and bone graft it. This story isn’t really about how we fixed the problem which we did, but how we got the original nail out of the Bone.

It turns out Kathy had a medical condition called osteopetrosis. There is an imbalance between the cells that make new bone and the cells that break down and remodel the Bone. The bone that forms is too thick and much too strong. It is also slow to heal, and once it grows into the Rod, it is nearly impossible to remove the metal.

The first step was to remove the screw that runs into the ball and neck of the femur. So we placed Kathy on a fracture table with a leg holder. This lets us run a C arm or a continuous fluoroscopy under the leg, where the table is radiolucent or see-through to x-ray. The first step was to make an incision over the screw which we did under fluoroscopic guidance. We were able to get the screwdriver in the screw and extracted with some force. My Surgical Assist and I took turns unscrewing the screw from the very dense bone. Our hands grew tired. Our palm grew sweaty and our shoulders ached as we backed out the screw. The threads of a screw are supposed to shed material as the screw backs out so it’s easier to remove. But when the bone is hard as a rock, it doesn’t exactly work.

Our next step was to make a second incision above the nail near the tip of the greater trochanter. If you look at the picture, you can see there are screw threads in the long shaft of the nail that runs down the femur. We were able to pass a rod with a screw thread into that tip of the nail and thread the nail. It took a while to get this done because there was bone overgrowing the hole where the threads are supposed to meet you guessed it. We chiseled the bone away with an osteotome and a ronfeur removing debris from the canal of the rod so that we could get our extractor in. The extractor is a rod with a metal hammer that is wrapped around it in a cylinder form, so the rod goes through the hammerhead, and we slam the hammer up against the top of the rod where there is a metal Cap. The idea is that this would extract the nail out through the top of the femur without too much difficulty. We tried. For 20 minutes 40 minutes almost an hour. Our Anesthesia time was growing uncomfortably long. The osteopetrosis Bone had grown into the nail in such a dramatic fashion that we could not overcome the friction.

It was time for extreme measures. we used a device called a triple reamer to make a diagonal pathway to the femur. We drilled a diagonal tunnel below the nail and inserted a curved punch to tap the nail back up.

But it didn’t move.

At this point, we were three hours in and sweating profusely and running out of energy. So a second drill hole was made to make an oval below the Rod, which gave us more access for the punch to get in. And we pounded the nail out after we switched to a heavy mallet and swung for the fences.

Bang! And a shower of blood!

Bang! And the entire table moved!

Bang! Did the rod shift a millimeter?

Of course the risk was that we would shatter the femur. But defeat was not an option, and we succeeded in getting the nail out. The rest of the case involved placing a new nail, which I won’t bore you with. But I can’t tell you that we were Convinced of success or that we thought we would get through the case safely without harming the patient.

Part of our job is taking progressively controlled risks until the patient’s situation is resolved. Using judgment that is carefully controlled to make the best possible decision in the worst possible situation is sometimes the most difficult thing in the world. Let’s just say now that I’ve been retired a couple of years. I’m happy not to have to make those decisions. With all the pounding, there was blood everywhere in the room, and on the masks that we wore which were full facial covers not the standard mask that you’re used to. Our elbows were dripping with gore and we looked like a horror film had just been made.

The ironic thing is the patient did great. Her fracture eventually healed, and the new nail did its job. There are things in life you don’t take pictures of but a picture of my assistant and I would have been hard to look at. I think about the things we did to get the job done, and I wonder if we would ever have the energy to do it again. But every day is a new day and every patient complication is a new problem. It’s cases like these that wear you out and drive you into retirement. And that is the story of how we were beaten into submission, almost until we gave it one more try. I’d like to think we won and the nail lost, but only just barely.

Hobart limped between the vines in the late evening, checking the trellis on either side. He was making sure the fruiting wires were functioning properly in holding the transverse portion of the vine or cordon in place. Several of the wires were cleanly transected, letting the cordon droop towards the ground. Pinioned and crucified, the vines were able to maximally fruit without hitting the ground. These twenty acres were the pride and joy of this particular vineyard, Place de Devereaux, named after the farmer who sold the plot to the vineyard. The terroir was ideal for Bordeaux grapes. A dry hillside moistened by the morning dew from the verdant riverbed far below created a perfect environment for growing grapes. Just enough rain and a fertile loam produced two hundred of the finest Bordeaux bottles one could buy each year. The pre-sale list was ten years long, and collectors could not get enough of the fruit and floral notes of Place de Devereaux. For some reason, these vines in this particular acreage were breaking free of the trellis, snapping their wires, and causing chaos. If this led to a lowered fruit yield, the financial devastation would be very real. As head winemaker or vigneron, Hobart bore final responsibility. He limped, and he sighed, stopping to rest his knee. He reached down to rub the swollen, scarred, and inflamed right knee. He stared across the vineyard and thought about how he had gotten here.

He was nearly sixty years old and limped extensively from a skydiving accident that tore his anterior cruciate ligament, lateral meniscus, and medial collateral ligament in his right knee. He knew it was his fault as he released his chute too late while doing aerobatic maneuvers. Hobart loved the attention, but he took one too many chances and came down hard on the right leg. It was 1985, and he was twenty-one in paratrooper school at Homestead Air Force Base in South Florida. After the base doctor told him that there was nothing that could be done, he went to a private orthopedic surgeon in Hollywood, Florida. He had surgery after being told the procedure had just been invented two years ago, and the outcome was uncertain. After three months in a cast and six months on crutches, he could walk, but he limped, and his right knee was forever swollen. 

He was medically discharged from the military and worked odd jobs until he found his love in running the front of the house in a high-end steakhouse in Orlando. He had a nose for good wine, and he studied on his own, tasting whenever possible and saving for school. He learned terms like oenology and viticulture and dreamed of running his own vineyard. He read about wine growing and wine making. Hobart wanted to attend UC Davis, which had the finest winemaker course in the country, but it cost nearly nine thousand dollars for ten weeks, not including living expenses. He saved every penny but never got close enough to go. Benny Demerjian watched Hobart function more and more as a sommelier in his restaurant, and the size of the customer checks swelled in response. Hobart not only made the customers happy, but he could sell a vision of how notes of cocoa capped by persimmon and peach could make for an incredible steak experience. 

“Hobart!” Benny yelled across the restaurant to get his attention.

“Yes, Benny?” Hobart came over as rapidly as he could manage with the bad knee.

“Customer checks are up 30 percent. You know what that means?” Benny grinned at his best employee. “We are gonna be rich. The offer stands if you want to go to sommelier school.”

“Please, sir, what I really want is to be a winemaker. I have always dreamed of being famous for the wine I produce.” Hobart winced, expecting to be dismissed, but Benny just stared at him. He started back to work after a few uncomfortable moments. By the end of the night, Benny found him again. He had taken the night’s total income, nearly eight thousand dollars, and stuffed it into Hobart’s hand.

“You go to UC Davis. But if things don’t work out, you come back to me, you understand?” Benny smiled at him, but he knew. He knew Hobart was never coming back. Hobart thanked him profusely and quit that night. He signed up for the spring quarter starting in 10 days and drove cross-country to UC Davis. He was a natural, and his teachers introduced him to every vineyard in Napa Valley, about an hour to the north. After exposure to a French-American meritage vineyard, Hobart found himself accepting a job in Bordeaux at Place de Devereaux. The French owner of the Napa vineyard where he had worked and been noticed did not want to squander his talent. He was thirty and an assistant winemaker at one of the finest vineyards in the world. Five years ago, his mentor retired, and the owner of the vineyard made Hobart the vigneron via text. It was unheard of in the wine-making world, and Hobart had called back to make sure it wasn’t a mistake.

“It might have been a mistake,” Hobart said to himself. If he couldn’t figure out who or what was cutting the fruiting wires. Letting the vines grow in a disorderly fashion would destroy the potential future crop. And there goes my job and my lifelong passion. He sighed and squatted by the trellis and examined the wet mud at its base. The usual footprints of the vine workers presented themselves, but there was evidence of a deeper bootprint from a taller or heavier presence. Almost all of Hobart’s workers were short and small with dexterous hands, so they could slip in and out of the trellises and hand-harvest the grapes in October when they had matured. He repaired the damaged wires and decided to camp overnight in the damp vineyard. He found an adjacent tree for shelter and threw a blanket over his shoulders. He clutched a Benelli M4 shotgun in his right hand, hoping to scare off the interloper. He liked the M4 because it had a trigger grip and he could use it one-handed. Hobart had a flashlight clipped to his belt, hoping to catch a good look if anything happened tonight. He was a fairly good shot, but between the impending darkness and his myopia, he doubted if he could hit his mark. He sighed and waited, hoping to catch the unwanted visitor.

The night passed uneventfully until just after midnight. It was pitch black when Hobart was awoken by a grunting noise. He looked towards the trellis and saw the outline of a tall, hulking figure bending over in a trench coat. He heard the zinging of wires being cut under tension and knew he had his culprit. He pinned the figure with his flashlight in one hand and the M4 in the other. Hobart raised his weapon and charged towards the trellis, yelling, “You there! Stop! This is a private vineyard. Don’t move or I’ll shoot!” He made a show of unlocking the safety so that the visitor could see and hear it.

The shadowy figure was visibly startled and turned towards Hobart. He raised his arms overhead in surrender while holding a wire cutter in his right hand. “Don’t shoot! C’est moi.  Allard Devereaux,” said the familiar figure. Allard was nearly seven feet tall, and even in his old age, he was still well-muscled and bulky from years of hard labor as a farmer.

Hobart was stunned that the farmer who sold the land to the vineyard was the vandal. “Pourquoi Allard? Why this? We paid you well for the land, and you were happy to take it?” Hobart lowered his gun and let it drop to his side. He simply could not believe what had happened.

“Can we sit and talk? I have half a baguette and some triple chèvre cheese. I promise I won’t run.” Devereaux sounded beaten and exhausted. Hobart motioned to a couple of large tree stumps at the border of the field where they could sit and talk. 

“I know you, Allard, but don’t think I won’t shoot if you try to run away,” he brandished the gun for effect. Devereaux nodded in agreement, and they sat together, eating silently for a few minutes until Hobart spread his arms, miming for an explanation. 

" You want to know why. The land wasn’t mine thirty years ago. It belonged to my wife and her grandparents before her. After my wife passed twenty years ago, I sold the land to the vineyard. I had only rarely heard from her grandparents until six months ago.” He took a bite from the baguette with freshly spread cheese, chewed, and then continued. “Apparently, they had passed but left instructions in a will. The instructions included a roughly drawn map. There was an inheritance to be had, bars of gold and silver, and gold bullion. Buried in this acreage. If I could easily read the map and retrieve the treasure, I would have done so. So I opted to damage your vines and offer to buy them back so I could mount a legitimate search.” He pulled out a map, scrawled with additional instructions to identify the hoard. “Hobart, you are not wealthy. There is enough here for both of us. I will share with you. Help me find the gold, and we can both live like kings!”

Hobart was silent while he examined the map. The writing was in French in a spider-thin scrawl that could not easily be discerned. But the map was familiar, almost as if he had seen the tree line and hedges marked on the map before. A rough X presumably marked the goal of the treasure hunt between a large pair of trees. “I know where this is. Exactly. I’ve walked every inch of this land for thirty years. But tell me why you believe this? Isn’t this a reach?”

“My wife’s grandfather was a hoarder and didn’t believe in banks. At least that’s what my wife told me. He had a gold mine in South Africa. He took everything he could carry when apartheid collapsed, and the government repossessed the mine through forfeiture. I think he took as much gold as possible by ship to France and buried it, hoping no one ever came to claim it.” His eyes lit up as he said, " And now it’s all ours. Come on, out with it. Where does the map point to? All the trees are gone since you cut them down. Where is this?”

Hobart was silent as he deliberately, slowly pulled out a cigar, cut off the tip, and lit it. “You know what makes an Opus X cigar so good? It’s the Dominican sun-grown wrapper on top of the best tobacco. Others have tried to copy the wrapper, but the cigars were no good.” He took a deep puff, “ You think you know someone from the outside, but it’s not until you get past the cover that you really figure out what you have.” He puffed again, blowing a smoke ring around his folded tongue.

“I have no idea what you’re trying to say… and I don’t have the time to listen. Now tell me what we need to know, and let’s get it dug up.” Devereaux’s impatience was obvious, and it made his voice quiver with anxiety. 

“Isn’t it obvious? X marks the spot.” Hobart grinned and used the heel of his workboot to scratch out an X in the mud between the two tree stumps that served as their seats. “We are right on top of it.” He grinned and walked over to the gardening shed adjacent to the vineyard and pulled out a spade. “Here you dig, and I’ll keep lookout.” Devereaux looked at him with uncertainty, not giving voice to the obvious: that they could do this much faster if they were both digging. He shrugged, grabbed the spade, and went to work. Hours passed. Devereaux was nearly six feet deep in a hole four feet wide and seven feet long. A loud crunch under the spade brought everyone to attention. “I found it!” Devereaux jumped up and down with glee. He looked up to see Hobart screwing an aftermarket silencer onto the M4. He screamed silently, and the bass chug of the M4 seemed much louder than expected. Devereaux grabbed his chest, crimson leaking around his hand, and collapsed into the hole he had dug. Hobart grabbed the spade and methodically filled in the hole, tamping down the dirt as firmly as possible. 

“I’m sorry, Mr. Devereaux, I really am. But can you imagine once the word got out about the treasure on the hillside? People would be tearing up my vineyard day and night. Now, how am I gonna get famous if that’s happening?”Hobart said to himself. He pulled out another cigar and lit up, while silently counting his blessings, and feeling like he had just dodged a bullet. He stared at the sky until the sun rose over the horizon and the morning mist irrigated the vineyard.