Synapses Vol. 1 (2017)

SYNAPSES MERVYN SAHUD, MD ’64 Platelets and Potassium: How I Learned That Enthusiam and Limited Humility May Lead One AstrayI had been fascinated with platelets throughout my training period and the issue of pseudohyperkalemiawas an “event” to be thoroughly investigated by me through laboratory study. So it was remarkablethat my first “shot” at practicing my skills as a board certified hematologist dealt with that very issue.Pseudohyperkalemia is a term used when potassium is released from platelets during coagulation, leadingto a false reading of hyperkalemia (high potassium levels in the blood) when the patient’s serum is analyzed.This false reading can be corrected by measuring plasma potassium (the true level) and comparing thatvalue to the value of the serum potassium.Having just completed four years of hematology training at a major university center and passed the boardexam in hematology, I received my first request to see a patient on “4North with too many platelets.”The referring physician was an elderly, well-respected member of the Internal Medicine group and I wasexcited — maybe too excited.The patient was a 67-year-old retired pipe mechanic. He had been admitted with some dyspnea and leftchest discomfort that had slowly gotten worse over a two-week period. There was no hemoptysis andhe had not lost weight. Chest films and an isotopic scan of the chest ruled out a pulmonary embolus. Ibecame part of the periphery of the investigation when the platelet count, repeated for the third time, waselevated at 1,200,000 (1.2 x 106).I studied the already hefty chart on this man to acquaint myself with his background and the workup sofar. I introduced myself and told him his doctor had asked me to help explain the elevated platelet countand that I was a “blood specialist.” He immediately asked if it was “leukemia and if so why would it causesuch chest discomfort?”I said slowly and looking straight at him reassuringly, “I don’t think this is leukemia, but let me be sure byexamining you and taking a closer look at the lab results and blood smears.”So far, so good — until I rechecked the chart and saw the patient was on oral Kayexelate (a cationexchange resin that, when taken orally, removes potassium from the gastointestinal tract mucosa andpulls in sodium), and that the serum potassium levels were 6.4, 6.7 and 6.1 milliequivalents per liter (meq/l),which were all high. When I scanned the other lab reports, there was no evidence of metabolic acidosisor renal failure and the EKG showed no peaked T-waves which would have reflected true hyperkalemia.Having come across this several times as a fellow, I strongly suspected pseudohyperkalemia secondary tothrombocytosis. It didn’t answer the etiology of the elevated platelets, but the chance of artifact was highon my concern list and therefore I felt compelled to pursue this issue as well. After examining the patient,no evidence of hepatosplenomegaly or lymphadenopathy was noted and he had no painful erythematousspots on his leg (erythromelalgia). As anticipated, there were decreased breath sounds at the lower leftchest wall posteriorly, but no rub. CHICAGO MEDICAL SCHOOL 51

NON-FICTION MERVYN SAHUD, MD ’64 I said, “I’ll be back shortly,” and went down to check the X-rays and blood smears. The blood smear confirmed the elevation of platelets, which were of varied sizes (so-called platelet anisocytosis) and well- granulated with some clumped forms. The remainder of the smear showed normal red blood cells (no tear drop forms or schistocytes), normal white blood cell morphology, and certainly no basophilia or suspicious blast forms. Although the suspicion that lurked behind the platelet problem was that of malignancy and possible mesothelioma causing a hormonal rise in megakarycytopoieis, I needed to reassure the referring physician that a myeloproliferative disorder (MPD) was unlikely. However, prior to my contact with the physician, I chose to order a serum and plasma potassium, among other MPD tests, which I was certain would clear up the question of pseudohyperkalemia secondary to the elevated platelets, especially since the patient was on Kayexelate. I reassured the patient that the elevated platelets were not suggestive of leukemia but might be related to his chest discomfort and inflammation of the pleural surface. By the way he reacted, I could see he wasn’t totally reassured. I was a young doctor and hadn’t gotten my shoes wet yet. After my note, which included several references on the subject I was most interested in, was dictated, I left feeling quite satisfied and did not make any further recommendations until I bumped into the referring internist the next day. He looked quite smart in his three-button suit and well-groomed graying hair, Phi Beta Kappa and Alpha Omega Alpha keys jangling from his breast pocket, and pant legs with just a bit of a crease at the shoeline. First smiling and thanking me for the reassurance about excluding leukemia, he then showed a strained grimace and began his “lecture to a new physician consultant.” I listened to him tell me about being a “smarty cat” about the potassium (he hadn’t seen the discrepant values in the chart) and that I should have just concentrated on the exclusion of possible leukemia, whether the platelet count was potentially life-threatening, why the patient was not a candidate for a platelet-lowering drug, and possibly the use of aspirin to reduce their stickiness. I listened. I had learned to be a good listener before this and I tried to pull forth my humility a bit before he was finished. As he turned to abruptly leave, a nurse informed him of the discrepant serum and plasma K levels and asked if he would like to discontinue the Kayexelate. He said, “I’ll get to that in due time!” and walked out. I thought about this experience for some time. I thought about my enthusiasm for the subject and perhaps my lack of measured balance (equipoise); the unfortunate patient who turned out to have biopsy-proven mesothelioma; my literature search on mesothelioma, thrombocytosis, and other causes of malignancy- associated thrombcytosis; the gradual normalization of the platelet count in this patient after surgical extraction of the pleural mass; the gradual return of thrombocytosis with tumor recurrence; and lastly, my personal growth that had occurred and my need to proceed differently while still achieving the same objective. Perhaps I could have alluded to the possible causes of hyperkalemia as an aside to the referring internist as an afterthought during my presentation to him. Still somewhat unsure of whether proper protocol is more important than listening to myself, I have continued to hone my skills for more than forty years since then. Instead of accepting that I would never52 ROSALIND FR ANKLIN UNIVERSITY

SYNAPSESMERVYN SAHUD, MD ’64be referred a patient from that internist or his group in the future, he called me as his “platelet expert”many times over until his retirement.Perhaps we both learned something from this encounter.References:Nakano T, Fujii J, Tamura S, et al. Thrombocytosis in Patients with Malignant Pleural Mesothelioma. Cancer.1986 Oct. 15;58(8):1699-1701.Nikolaos S, Theodossiades G, Archimandritis A. Pseudohyperkalemia in Serum: A New Insight into an OldPhenomenon. Clinical Medicine & Research. 2008 May; 6(1):30–32. doi:10.3121/cmr.2008.739.Kaser A, Brandacher G, Steurer W, et al. Interleukin-6 Stimulates Thrombopoiesis through Thrombopoietin:Role in Inflammatory Thrombocytosis. Blood. 2001;98:2720-2725. CHICAGO MEDICAL SCHOOL 53

NON-FICTION A DA M S I LV E R , M D ’ 1 4 , M S ’ 1 1 , M S ’ 1 0 WHEN THE CIRCUS CAME TO TOWN I am in the hospital library, finally finding a moment to study for my upcoming Internal Medicine shelf exam. Just as I find my flow with some practice questions, the hospital intercom interrupts: “Cath Lab alert to the Emergency Department. Cath Lab alert to the Emergency Department.” My inner voice responds: “That’s me — I’m on the telemetry service. But I’m studying. But I’m on the tele service. But my senior told me I could study. But I’m probably going to be writing notes on this guy. But I seriously just started studying. But this could be cool and I’d finally get to see the real deal…okay, I’m going.” These thoughts do not file into dainty linear order. Rather, they superimpose in all of 750 milliseconds. I flip my binder closed, slide my stack of books into my backpack and zip it up in standard muscle- memory fashion. I don my white coat with a well-practiced shoulder dip and a wiggle of the wrist to avoid dislocating my thumb on the sleeve of the overweight garment, filled with toys that drive its many pockets furiously to the ground. “Here we go.” “Oh good, I was just about to page you!” These are the best words a third-year student could hear from his senior resident. Translation: “Oh — you’re actually interested.” She then braces her arm in front of me, like a mother restraining her tween in the front seat when slamming on the brakes. In the ED it’s the universal signal for watch out, back up, here he comes on a stretcher wearing a non-rebreather mask, looking pale and diaphoretic, close to game-over with no bonus life to spare. “Sir, are you still having chest pain?!” “Sir, when did you last eat?!” “Sir, are you allergic to penicillin?!” “Sir, how long have you been experiencing chest discomfort?!” “Sir, how many questions can you answer in rapid succession as 13 people manipulate your body and regurgitate countless interrogations that you cannot comprehend because you’re having a heart attack and if we don’t figure out exactly what to do for you and do it flawlessly this instant you will die today?” Several feet outside the dying man’s room — practically another time zone in emergency department distance — stands Dr. Patel, the attending interventional cardiologist whose suave and polished demeanor suggests he may in fact be the Dos Equis man. At issue is the first decision: Can we cut off his pants while he’s on the stretcher? If not, we swap him to the ED bed. If yes, he is already on his way down to the cath lab. No-go: The seatbelt restraints block efficient access to his femoral artery. Transfer to bed. Suddenly, reality blurs into an interactive daydream. The circus begins. A previously clothed man becomes naked in seconds. Clippers nip at his groin. Women wearing shirts with animals on them toy with lights and wires and machines and tubes and sharp objects. Men wearing blue wigs, blue masks and blue bags for shoes conduct the symphony as they dance on their tip-toes around a table that hides the naked man under plastic sheets, also blue. His fate lies in the hands and minds of the circus performers singing to each other a tune he’s never heard with lyrics he cannot understand. He knows not what to expect as the kaleidoscopic fusion of agonizing stimuli accelerates to the fore. He54 ROSALIND FR ANKLIN UNIVERSITY

SYNAPSESA DA M S I LV E R , M D ’ 1 4 , M S ’ 1 1 , M S ’ 1 0vomits across the great stage. The stagehands dutifully respond to what they consider a routine spill. Anaudience amasses.A movie begins. One of the circus performers holds the camera to the naked man’s chest, twisting hiswrist to right the focus. The naked man has never seen a camera like this before—it requires lubricationand seems to project X-ray vision. On the screen, a massive boot with flaps and giant holes taps up anddown incessantly. It won’t stay still. The heel is much larger than the toe, which according to Dr. Dos Equisis “markedly problematic.” He worries this movie is about a boot that stops tapping.As the show goes on, a nurse asks the patient if he can recite the security code of his iPhone so his lovedones can be called to the hospital’s emergency department, Bed 8. He struggles to utter the numbers, butshe interprets them correctly and places the call. What will they say, he wonders, about all these machines,tubes, wires, tip-toe dancing, unfamiliar song, and the movie about a boot?And then, his blood pressure drops and the boot taps even more frantically, out of sync with the singingcircus performers. To admonish its rogue behavior, they strike the boot with lightening. Thunder crashesas the naked man convulses into the air and the electrical storm rages on. Lightning strikes again. Thunderagain. Rage again. Then nothing.Magically, without a make-up artist, the naked man’s face turns from white to red to blue, then gray. Lightsflicker. The buzz of machines fades from consciousness. Tubes run dry. Colored wires tangle into futility.The tip-toeing, singing ensemble wearily exits the circus tent. The movie about the boot looks paused butin fact has abruptly ended. The curtains close.From the sea of faces emerges a man in a crewneck sweatshirt with salt and pepper hair. On any other daythis man is a rabbi. Today he is a widow. He kneels beneath the curtain, takes the hand of his fallen starand presses it to his cheek. Dr. Dos Equis explains that he missed the show. How ironic, the rabbi thinksto himself, that it is now he who is on the receiving end of a story that seems utterly unfathomable. Dr.Dos Equis expresses his regrets that despite many dress rehearsals and the best training available, theperformers could not deliver a happy ending.The audience disperses. The stagehands dress down the scene. The performers reflect. They are their ownstrongest critics.I reflect as well. What have I just witnessed? I saw a living man who we tried to save, and I thought we hada chance. Not thirty minutes later, I saw the look in everyone’s eyes when that chance had dissolved. I sawthe helplessness on a husband’s face as he was told a true story he did not want to hear. In that moment,the experience was too fresh for me to process. The eerie dissonance between knowing the truth andfeeling its power lingers throughout the day. When the circus comes and goes at two o’clock on a normalTuesday afternoon in the hospital, it shows no mercy to the men and women who must carry on andquickly turn their attention to other patients and their families. A circus performer maintains focus not inspite of the many obstacles, but rather to conquer them. Folding into the dense, palpably fresh grief onlybegets more obstacles — a different circus altogether. CHICAGO MEDICAL SCHOOL 55

NON-FICTION A DA M S I LV E R , M D ’ 1 4 , M S ’ 1 1 , M S ’ 1 0Not until he removes his make-up, his wig, and his ridiculous blue shoes does this performer grant himselfan overdue sigh. Not until he finds that moment alone, driving home with the radio turned off, does heallow a good cry and then ask himself: What if I had ignored that intercom? What if I had studied a fewpractice questions that I would inevitably forget? I juggle these questions, now knowing that my courageto replace the skimming of pages with the living of life led to an experience that seared itself into mymemory, and has become part of my identity. It is the difference between knowledge and experience thatseparates a student from his future — a discovery that stays with me as the next circus comes to town.56 ROSALIND FR ANKLIN UNIVERSITY

SYNAPSESCHICAGO MEDICAL SCHOOL 57

ALUMNI FEATURES58 ROSALIND FR ANKLIN UNIVERSITY

SYNAPSES ALUMNIFEATURES CHICAGO MEDICAL SCHOOL 59

ALUMNI STORIES RICH ARD RAPPAPO RT, MD ’63 A Physician’s Odyssey: From Chicago Medical School to the World Why do people behave the way they do? This was the question that led me from being a philosophy major as an undergrad at the University of Pennsylvania, 60 years ago, to the field of psychiatry, which was considered almost a non-entity in medical school. Chicago Medical School (CMS) at that time was in a very old, somewhat shoddy building across the street from the historic Cook County Hospital. There was only one female in the class of 65 students and no such thing as a computer. I was the only student initially interested in psychiatry and the only one interested at the time of graduation. The typical reason pre-med students at that time gave for applying to medical school was their ostensible interest in helping people, and this ideal also applied to those applying for a residency in psychiatry. As a graduate of CMS, I was quite fortunate to be accepted to a superior residency in psychiatry at Michael Reese Hospital (Psychiatric and Psychosomatic Institute), which was noted for its psychoanalytic orientation due to the director, who had been analyzed by Sigmund Freud himself. Although the “helping of patients” turned out to be a product of my years in practice, it was my original interest in the etiology of behavior which supplied the energy, the persistence and the determination to study, to sacrifice time and social opportunities, and to focus on the pursuit of understanding and knowledge about my patients ­— and, incidentally, many others. This interest also provided a pathway to discover much about myself, which has been useful at times. The first seventeen years of my practice included a teaching position at Northwestern Medical School and a staff position at their Memorial Hospital and two smaller hospitals. I proceeded to build a full- time psychotherapy practice providing individual and group therapy for mostly well-functioning people, occasionally seeing them as inpatients when needed. I learned early on that my interest was predominantly in patients who were able to relate in an intelligible manner despite their serious concerns, emotional pain, anxiety and/or depression. I did not feel as interested in those who were overtly psychotic and non- functioning so referred them to other specialists. Rarely using medications, I was more intent on encouraging my patients to ventilate, to express their feelings and to say whatever came to their minds, i.e. “a free association of ideas.” The uncovering of their unconscious and the etiology of their behavior would be our ultimate goal. With the proficiency I developed in my training as a resident, I was able to assist the patients in gaining insight into their behavior and encourage them to use this therapeutic opportunity to openly express their feelings and consider modifying their behavior for a better future. As this analytic technique proved to be very successful, my patients became more insightful and more in control of their lives, and I grew more confident in my ability to provide what they needed. Feedback from the patients as to their mental progress and relief from symptoms verified the validity of my work with them. As my practice grew in size there developed the additional opportunity to create groups for another form of psychotherapy which I had learned during my residency. Group therapy excited me because of the additional elements available in this form of psychiatric treatment, referred to by Irvin D. Yalom, MD, as “curative factors.” Of the 13 factors he described there were such aspects as “helping others and thereby gaining self-respect,” and “learning that I’m not the only one…”60 ROSALIND FR ANKLIN UNIVERSITY

SYNAPSESRIC HA RD RAPPAPO RT, MD ’63Selection of eight of my patients, from those in individual treatment, to meet weekly with me and a co-therapist as a group afforded us all the chance to interact with each other and not only gain intellectualinsight into each person’s psyche, but to have the very practical advantage of seeing everyone’sinterpersonal behavior in action, which became “grist for the mill.” For me this was such a psycho-dynamically fascinating and productive experience that I eventually created a total of five groups, eachmeeting for many years with natural turnover of patients as the years went by.Creating groups from my individual patients required a special sense of who would work well together inenhancing their mutual ability to participate and expose what was usually kept very secretive. There alsowere requirements imposed on the group members by me for those patients to make at least a six-monthcommitment to the process and to maintain confidentiality within the group members.For me my groups represented a living experience with reality as opposed to just the intellectualpsychotherapeutic experience with them as individuals. It was humanity and the human experience in theflesh.During my residency in psychiatry I was required to create a research project and write a report about it.Because of my childhood interest in prison movies and my current courses in group therapy, I conceived ofthe idea of doing group therapy in a prison. With the Director of the Residency’s permission I proceededto the Illinois Department of Corrections for their agreement to go forward with this project and it wasgranted. This led to my eventually working at Stateville Prison in Joliet for five years where I createdseveral groups and treated dozens of inmates. It was a fascinating experience in itself, as well as my firsttime being a therapist outside of the training program. My research paper was reflective of the intellectualjoy I had in being privy to this population and the thinking of the criminal mind. My research paper on thisexperience won a first-place prize.While conducting the groups at the prison, I learned about the critical importance of prisoners’ dischargeand transition to the outside world. This knowledge brought me into contact with the parole board, avery enlightening and challenging experience. I went on to create a group in which all the members couldbe discharged at the same time so they could continue their therapy together outside of the prison.Additional innovations included some sessions which allowed each member to bring in a friend or relativeto help establish a supportive relationship which could continue after the inmate was discharged fromprison.My participation in the prison research project unexpectedly became the precursor of two of the mostimportant aspects of my future professional practice. Initially, I gained experience not only as a therapistbut fortunately developed some early expertise as a group therapist, which carried over to a major portionof my therapeutic practice. Secondly, my prison project came to be known by some of the attorneys in theChicago area. Thus, once I opened my private practice I began to receive calls to consult with some of theattorneys in criminal legal cases and my life as a forensic psychiatrist was born.I knew of no training programs at that time for this specialty, so I learned on the job, read journals and waseventually invited to join organizations of others practicing forensic psychiatry. I traveled near and far togo to professional meetings and listen to presentations, wrote papers which I presented, and developed CHICAGO MEDICAL SCHOOL 61

ALUMNI STORIES RICH ARD RAPPAPO RT, MD ’63 a whole new professional group of associates. I expanded my work from criminal to civil cases and was spending about 10 to 15 percent of my time doing forensic evaluations, writing reports, and testifying at depositions and in trials, all of which I found extremely stimulating and productive. An especially unique opportunity presented itself when I was engaged to consult on the case of a “mass murderer,” the most prolific in American history. When interviewed by the FBI, I re-named this behavior and referred to the killer as a “serial murderer” (of 32 young men), and this term has become extremely common today. My association with this high-profile case resulted in more forensic referrals as well as further insights into the thinking of this most baffling, if not inscrutable, segment of the population. In fact, soon after my involvement with that case, I had several other high-profile cases referred to me and was called to different states to consult on them. After 17 years of practicing in Chicago, I moved to San Diego in order to have a warmer and brighter environment. I was immediately able to gain a position on the faculty of the University of California San Diego (UCSD) as an associate clinical professor of psychiatry. However, I was not ready to start a treatment practice so soon after having separated from the many patient-relationships I had just left in Chicago. It was a risky move to a city over-crowded with psychiatrists who shunned any additional competition, so I began anew by gaining a position on a court panel of psychiatrists. I received referrals from the courts and then from private practicing attorneys and quickly built a full-time forensic–only practice, a somewhat rare and fortunate development for me. Ten years after my rejuvenation in California, I applied for and was given another opportunity: that of becoming a lecturer on cruise ships. I created a number of lectures which were initially of general psychological interest to guests on luxury liners and later I provided more formal lectures involving forensic subjects (due to high interest in crime scene investigation programs on television). Consequently, I have enjoyed 23 cruises to every corner of the world and to almost every continent in the capacity as guest lecturer. My attraction to cruising and my own travels to foreign sites all emanate from my interest in sightseeing and exploring places which are new to me, as well as my fascination with people and their behavior and thinking. My position as lecturer also gave me the experience of traveling to ports I would not likely have sought on my own. These ventures were enlightening and rewarding intellectually, especially meeting people from all over the world, conversing with them, going into their living environments (such as the dung houses in Africa or the homes of Arabs in the Middle East), and learning first-hand about their culture, their values and their distinctive ideas, customs and thinking. That’s where I started and where I have found a most meaningful perspective, in knowing why people behave the way they do. When I decided to go to medical school, just so I could become a psychiatrist, I had no idea of the great variety and richness of experiences which I would encounter or how my professional life would lead me into unimaginable intellectual and enriching endeavors. My own innate curiosity and creative thinking was largely responsible for that variation. Each new venture inspired pursuits into associated areas which then became new foci for a practical development. Some things did not work but there were those that did, yet I never hesitated to pursue an idea because I feared it would not work.62 ROSALIND FR ANKLIN UNIVERSITY

SYNAPSESRIC HA RD RAPPAPO RT, MD ’63For example, back in the early seventies, in my first years of practice, AT&T had developed a picturephone and was trying to promote it in Chicago. I came up with ideas for several uses of that instrument inpsychiatry and forensics and asked AT&T to work with me on them. I was asked to write a grant proposalwith my ideas, which I did, but before it went to completion, AT&T decided to end their interest in thepicture phone. However, today we have Skype and much more.Today’s medical students have the advantage of a highly technical world which is unbelievably fast-pacedand moving forward in the medical field with applications to medical research and individualized medicalcare. Being immersed in a scholarly life, the student will be witness to new opportunities — any of which,if pursued, can lead to great satisfaction and unexpected achievement. Those who are proficient in somearea of medicine will have the nidus of potential for enlarging their spectrum of knowledge and medicalpractice, particularly if they are also creative, enterprising and uninhibited motivationally.Eric Topol, MD, an authority on the genome, wrote a book entitled The Constructive Destruction of Medicine,which will give all students numerous ideas on the future of medicine and technology. At the same time,this technological medical world will result in more physical distance between patient and physician. Thus,it will be incumbent on the medical schools to provide newly designed courses to enhance the personalrelationships between doctor and patient. It will be their task to increase the sensitivity of those physiciansand spark their empathy and compassion for the human beings for whom they will be caring. CHICAGO MEDICAL SCHOOL 63

ALUMNI STORIES SHERWYN WARREN, MD ’56 A Lesson in Surgery Where does one go to learn surgery? I chose major universities in the Midwest, academic teaching institutions where I learned from eminent professors, surgeons, researchers and contributors to surgical knowledge. Surprisingly, I learned one of my most vivid and enduring lessons in a tiny hospital in Big Fork, Minnesota, from Dr. McCormack, an elderly Chicago ophthalmologist. Big Fork, MN, lies forty miles southwest of International Falls, northernmost and frequently coldest city in the contiguous 48 United States. In 1957, Big Fork, with 450 people, was just half the population of Littlefork. People spoke of “going south to the cities,” which meant Minneapolis and St. Paul, 200 miles away. When I first learned of Big Fork, it was just a dot on a map — until I became part of its life. The federal government had instituted a program called the Berry Plan, known as the doctors’ draft. As repayment for student deferments during the Korean War, doctors were obligated to serve two years in the military. I finished a one-year surgical internship at Ohio State University on June 30, 1957, and had orders to report to Maxwell Air Force Base, Alabama, on September 15. That meant I would have more than two months without an assignment. I saw an ad in the Journal of the American Medical Association from a physician practicing in the “North-woods resort area of Big Fork, Minnesota,” for a “locum tenens” to take over his practice for the month of August, with a reasonable salary and use of his house and car. This seemed a perfect fit. I was eager to practice my intern-sharpened skills as a country doctor. The town had a twelve-bed hospital. I looked forward to interacting with the other doctors in the area just as I had enjoyed working with the other interns and residents at OSU, who came from medical schools all over the country. The last 200 miles of the drive from Chicago with my minimally pregnant wife was a woodland panorama through curving canyons of evergreens. The constant turns, which prolonged the drive considerably, were explained when we took a flight over the area in a light airplane a week later and saw many of Minnesota’s 10,000 lakes occupying much of the landscape. We arrived at Dr. Hardy’s house in mid afternoon. He, his wife, and three school-age children were sitting impatiently in their traveling clothes. Their station wagon was packed and ready. In the thirty minutes before their departure, Mrs. Hardy showed my wife around their spacious house, which we would soon occupy. Dr. Hardy drove me in the car I was to use — a red Chevrolet convertible — to his spacious, plastic-upholstered office, introduced me to his office manager, and walked me next door to the hospital to introduce me to the head nurse. Miss Norcross, a 78-year-old Norwegian whose penetrating blue eyes, straight-combed gray hair and starched, white nurse’s cap topped her ramrod spine, was the hospital’s only certified nurse. Every other employee, medical and clerical, had been informally trained by Dr. Hardy and Miss Norcross. The twelve- bed hospital had only one patient, a young woman scheduled to go home that evening. I was led quickly through the corridors and some of the rooms with their white metal beds. Everything was painted the same cream-yellow, including the operating room, which looked not much better equipped than one of the emergency room treatment areas at the University. Dr. Hardy pointed out the X-ray machine, pharmacy, office, nurses’ station and equipment closet. After being hustled into the red Chevy convertible with the top down, as we raced down the gravel road64 ROSALIND FR ANKLIN UNIVERSITY

SYNAPSESSHERWYN WARREN, MD ’56back to the house, I asked, “Where’s the nearest place to refer patients?”“Nearest doctor’s in Grand Rapids, 26 miles. It has a good clinic and a thirty-bed hospital.”“So I’m the only doctor for 26 miles?” He was driving so I don’t believe he saw the pallor come over my face.“More than that in the other directions. Here’s an extra key to the house and the office and the hospital andthe keys to the car. The bag for house calls is in the trunk. If you want to use the airplane, ask Carl — heowns the drugstore. We’re partners in the plane.”“I don’t know how to fly.”“Too bad. This one’s on pontoons. It’s a big convenience up here.” We had reached the house. His wife andkids were waiting in the station wagon. He drove up and parked behind them, left the key in the ignition,said, “Goodbye,” joined them, and drove away.With trepidation, I walked up the stairs, through the front door into the country-style living room, lookedinto the study with its organized rows of medical books and stacks of unread journals and went into thevast, 1950s kitchen, which my wife was surveying. We stopped and looked at each other. We both hadgrown up in the city and had enjoyed time at summer camp and vacation resorts, but these responsibilitiesin such an isolated setting suddenly hit us. “I think our adventure is beginning,” said my wife as we laughedand hugged. For a month we could play house in this comfortable, rambling home which we realized wewouldn’t be able to afford for many years.Dr. Hardy and Miss Norcross were well organized. Office and hospital records were succinct but preciseand clear. The staff was well trained and conscientious. I soon began to see patients from town and thesurrounding area. The community had many poor retirees and people on welfare. There were small fishingresorts, a sawmill, local shops and retail stores, and tradespeople. When I made house calls in the redconvertible, I saw some homes lacked electricity and running water.My patients were honest and appreciative. I became increasingly busy with their neighbors, relatives andfriends. I’m sure some came just to see if the new doctor had a different or better treatment. I left thecommunity with a net gain of one, attending the deaths of two elderly, chronically ill women and the birthsof three eagerly awaited babies.One Sunday afternoon, three weeks after my arrival, I was sitting in the study and the telephone rang.When I answered, “Hello,” an anxious but business-like female voice questioned, “Is this the doctor?”I answered, “This is Dr. Warren.”The female voice said, “Go ahead.”A deep male voice joined: “This is Dr. McCormack. I’m an ophthalmologist from Chicago. My neighbor justfell into his cesspool and dislocated a shoulder. What do you want me to do?” CHICAGO MEDICAL SCHOOL 65

ALUMNI STORIES SHERWYN WARREN, MD ’56 In my university experience I had learned neurosurgery, abdominal and thoracic surgery, medicine, obstetrics, oncology, infectious diseases, and pediatrics, but I had never rotated through orthopedics. I had never personally treated a dislocated shoulder, either in medical school or internship. Athletic coaches and trainers knew how to reduce shoulder dislocations. A country doctor should surely be able to do it, but this had never been part of my education. “You can’t reduce it?” I asked Dr. Mc Cormack, not too plaintively I hoped. “I’m an ophthalmologist. I don’t know how to treat a dislocated shoulder.” His voice was abrupt and slightly exasperated. I scanned the titles of the medical texts on the shelves. My heart lifted when I saw an authoritative- appearing two-volume tome, Campbell’s Operative Orthopedics, on the top shelf. Even if I read about it, I had never participated in reducing a dislocated shoulder. “How far are you from Grand Rapids?” I asked, hoping to involve someone more experienced. “We have to drive through Big Fork to get there,” he replied, even more exasperated. I wanted to find out whether I would have time to read the appropriate section in the orthopedics text. “How long will it take you to get here?” I asked. His impatient, “I don’t know,” was tinged with anger. The female voice that I assumed was the operator’s interjected, “About thirty minutes.” Time enough! I felt hopeful. “Bring him to the hospital in Big Fork. I’ll meet you there.” “How do I get there?” Back to exasperation. “I don’t know. Ask the operator.” The female voice said reassuringly, “I’ll tell him.” I hung up, leaped for Campbell’s Operative Orthopedics, and quickly read about the Hippocratic method, the Milch method, and Kocher’s method for relocating dislocated shoulders. They are indelibly installed in my memory, although I have never needed to recall them since. I hoped Kocher’s method would work, although “it must be performed with care, as there is risk of fracturing the neck of the humerus,” as the Milch method involved a rope and a pail of water or sand and the Hippocratic method involved putting a foot into the patient’s axilla and pulling the whole arm into alignment. I dashed out and drove the five minutes to the hospital. It was dark, devoid of patients or staff. Scarcely had I turned on the lights when the door opened and a spry, lanky septuagenarian entered, escorting an out-of-shape, forty-something-year-old whose rumpled work shirt and pants were covered with sand. Thankfully, he had been digging the cesspool, not cleaning it. His cupped left hand supported66 ROSALIND FR ANKLIN UNIVERSITY

SYNAPSESSHERWYN WARREN, MD ’56the tip of his right elbow, his face was flushed and contorted with pain, and his pace was measured to avoidjostling the painful shoulder. The older man directed the younger man into a chair in the hallway, thenclaimed the seat next to him, crossed his legs and leaned back in the chair. “I’m Dr. McCormack. Are youthe doctor I talked to on the phone?”I introduced myself and shook his hand while he sat back impatiently. I looked at the injured man sittingnext to him in obvious pain, then rushed to the dressing cart for a sling to support the affected arm andhurried to the pharmacy for a dose of Demerol to ease the pain. I escorted him to the X-ray table, came outto read the instruction sheet for a shoulder X-ray, went back to take the picture, carried the film to the darkroom and developed it. I escorted the patient to the treatment room and then scurried back for the X-ray.The dour Dr. McCormack watched all of this. As I was rushing back to the treatment room with the film, thedoctor looked me in the eye and held up his hand. “Take it easy, lad,” he said. “Remember, you didn’t pushhim into the cesspool.”Doing a double take, I saw the bemused and sympathetic gray eyes, and then I purposefully walked to thetreatment room. I easily reduced the dislocation by Kocher’s method and, precisely following Campbell’sinstructions, applied a Velpeau bandage to the arm. The patient was pain free! The normal contour of theshoulder was restored. I was elated and asked him to return in a few days.Five days later, the patient strode into the office wearing slacks, dress shirt and tie. The Velpeau bandagewas neatly in place, so I recognized him immediately. The right shoulder was also neatly in place.“Thanks for taking care of me last Sunday,” he said earnestly.“Glad I could help.”“I’m going back South tomorrow.”“Don’t you live up here?”“Didn’t Dr. McCormack tell you, I teach high school in St. Paul? I’m building a summer place. You don’t thinkI dig cesspools for a living, do you?”A sheepish expression must have come over my face. He peered at me, smiled uncertainly, then stuck outhis left hand to shake and repeated, “Thanks, Doc. Thanks a lot.”After serving my stint in the Air Force, I finished my training as a thoracic surgeon at the University ofIllinois and University of Chicago. I served as chief of the section of cardiovascular and thoracic surgery ata major teaching hospital and clinical associate professor of surgery at Chicago Medical School, Universityof Illinois, and University of Chicago. I have learned from many mentors and patients.Still, one of the most important and durable lessons I have learned and taught is the one I learned in BigFork, Minnesota: “Remember lad, you didn’t push him into the cesspool.” CHICAGO MEDICAL SCHOOL 67