The Pluperfect Fraud
Volume 24, Nos. 2 & 3, P. 171

Santa Clara County Hospital was built in 1836 to care for the indigents of San Jose, California. It served this function until the 1960s, when the board of directors decided to lure paying patients through their doors. They changed the name to Santa Clara Valley Medical Center, then forged an affiliation with Stanford hospital, but their efforts achieved only modest success. It was a matter of status. The aristocrats of northern California still referred to Valley Medical Center as the county hospital. They imagined its doctors were all hapless students, and they wanted nothing to do with the riff-raff that crowded its charity wards.

This snobbery stole from me a patient who became a landmark in my career when I diagnosed his disease at twenty paces. Late one night, halfway through my ER shift, I watched a nurse lead Mark Cisko to a gurney. He was a student at nearby San Jose City College, a thin young man of average height, with olive skin and dark hair. His flushed face suggested a high fever. A grimace contorted his mouth every time he lifted his right foot to take a step.

A voice in my head said, I’ll bet that kid has appendicitis. The moment he lay down on the gurney, I introduced myself, explained what I was about to do, then pulled up his shirt and gently pressed my fingertips into the right lower quadrant of his abdomen. He screamed in pain. An ER nurse measured his temperature at 103. Half an hour later, when a CBC confirmed a high white count, I started an IV, then paged Sam Watanabe, the surgery resident on call that night. Sam was six-foot two, the tallest Japanese I have ever met. He examined Marcus and glanced through his chart.

“Good job, Gamel” he said. “It’s been a slow night. Talk to the family, and we’ll get him up to the OR when ortho finishes their case. It shouldn’t be more than an hour.”

So there lay my patient, his lab work done and his IV in place, scheduled for surgery within the hour by a fine pair of hands. The OR nurses all agreed – Sam’s appendectomies were the best, a work of art from first cut to last stitch, but it was not to be. My phone call woke up Mark’s mother in Los Altos Hills. As soon as she understood what was happening, she launched a string of invectives, warning that if any so-called doctor at that goddamn county hellhole laid a knife on her son, she’d sue our pants off.

The battle-axe proved as good as her word. Half an hour later, she stormed into the ER, a scrawny, enraged woman in black leotards. A rope of dark hair swung down her back. Judging by the tantrum she threw, one might have thought we were about to mutilate her son rather than save his life. Poor Mark. Feverish, writhing in pain, he groaned as attendants loaded him onto an ambulance that would bear him off to a private hospital fifty miles away, where his workup would have to be repeated. The mother’s snobbery would delay his operation for hours. I never found out how it went, but I imagined his surgeon to be a doddering old coot with an office in Los Altos Hills, the scalpel trembling in his hand as he tried to remember whether to make the incision on the right or the left side of the abdomen.

* * *

Despite scenes like this, Valley Medical Center held its own with the landed gentry. Every ambulance driver in the county knew where to take the victims of wrecks and knifings and gunshots. Most of these patients had no insurance, but now and then a rich burgher with a crushed chest or a bullet through his abdomen would end up at Valley Medical Center. However fat his wallet, a man with blood pouring through an open wound was damn glad to see two or three of our doctors rush to his side the moment his gurney rolled into the ER.

We also had our share of non-trauma patients. True, the nearby private hospitals offered posh lobbies, catered meals, a battalion of well-paid nurses, but at night, all their doctors went home. Thus the truly sick, no matter how much they paid for medical insurance, often found themselves trundled off to our humble wards, where round-the-clock doctoring came at no extra charge. It was always a treat to admit these members of the upper crust. Their families – frightened by their loved one’s illness, frightened even more when that illness took a turn for the worse – looked on in wonder as ambulance attendants wheeled the patient into a room at the disparaged Valley Medical Center. Moments later, when an intern young enough to be their grandson came to take a history and examine the patient, some of those family members were ready for smelling salts.

Yet we always won them over. We were always there. One night out of three, the interns worked a thirty-six hour shift, roaming the wards until the early hours of the morning. On the other two nights, they would go home somewhere between eight p. m. and midnight, but only after introducing their patients to the colleague who was on call that evening. This beat the hell out of the coverage provided by private doctors, busy fellows who dropped by for a five-minute visit once a day, then drove miles down the freeway to their office or home. At three in the morning, when a patient’s heart went into ventricular tachycardia and his blood pressure dropped to 60/30, an intern at the bedside was worth more than a dozen specialists lying at home asleep. Around the clock, seven days a week, the families huddled outside the ICU saw our doctors rush again and again to the bedside of desperate patients. And when a page operator announced, “Code blue in room A 23,” half a dozen doctors crowded into that room before a minute had elapsed.

Most of these doctors were training for a medical or surgical specialty, but the chain of command was carefully supervised. An intern fresh out of medical school, I was seldom more than fifty feet away from a junior resident who knew twice as much as I did, while he or she answered in turn to a third- or fourth-year resident. At the top of the pyramid stood the attending physicians, board-certified faculty members with decades of experience. They conducted rounds every day and staffed all of the major surgeries.

Irony of ironies, that disparaged hospital delivered the best medical care in the county. I would not have hesitated to have a member of my family admitted to one of its wards.

* * *

Despite this well-ordered arrangement, one rotation at Valley Medical Center plumbed the depths of my incompetence. At first, the west nursery seemed idyllic: all the patients were healthy newborns waiting out their three-day stay in the hospital. If a woman delivered a premie, or if an infant fell ill, the unfortunate child was rushed down the hall to the east nursery, where most of the patients were premies on respirators, with two interns and two residents working around the clock to keep them alive.

The west nursery also featured Mrs. Kanamoto, the only nurse on the ward. The living embodiment of a Swiss watch, she was tiny and elegant, with dark eyes and jet-black hair. Her grooming was immaculate, her face bright and cheerful. Mrs. K., as we called her, had superb management skills. She kept the rooms spotless. In the supply cabinets, the items sat lined up in perfect rows. With little sign of effort, she saw to it that every day in the west nursery ran a smooth and peaceful course.

As Mrs. K. introduced me to my new patients, I thought myself the luckiest intern at Valley Medical. In the main room, where twenty diaper-swaddled newborns lay in bassinets, a large window allowed relatives to view their beloved cherubs. Since the room was kept at a constant 80 degrees, I took off my white coat and worked in my scrub shirt.

“Doctor Gamel,” Mrs. K. said, “your job is to examine each new baby when the OB intern brings it over from the delivery room. After that, you must visit them every day to make sure they’re healthy and feeding well.”

I felt a twinge of anxiety.

“Ah . . . about this feeding business.” I said. “And the diapers . . . er . . . who . . . ”

“Oh, Doctor Gamel,” she said with a reassuring smile, “no need to worry. We have lots of volunteers and nurses’ aides. You’re the doctor, you need to do only the important things.”

Whew – that was close! Some years before, when my sister had delivered her first child, the creature looked so hideous I couldn’t stand to go near it. The smell of a loaded diaper and the sight of its contents made me sick. There were no other births in my immediate family, and during my peds rotation in medical school, I had cared for no infants. Thanks to these privations, my heart carried a dark secret: never in my life had I fed a baby or changed its diaper. And yet, as I looked around at the chubby cheeks and button noses of my new patients, a glow of affection warmed my heart. Thanks to Mrs. K. and her mignons, I could remain aloof, a benign monarch peering down on his helpless needy subjects.

True, I had to examine the little rascals the moment they arrived, still damp from the bath that had washed away the amniotic fluid, but newborn exams are a piece of cake: look in the eyes and ears and nose and throat, listen to the tiny chest, press my fingers against the sweet little belly, check out the genitals and the anus. Oh, and count the fingers and toes. Voila! Finis! If I discovered a cleft palate or an imperforate anus, I would trot the child over to the east nursery and hand him off to my exhausted colleagues.

My first day on the job, I made an astonishing discovery: these tiny bags of protoplasm have people inside them. That one is full of fire, thrashing about until a spindly arm catches the tubing of my stethoscope and snatches it from around my neck. This one lies motionless in the bassinette, her eyes squeezed tight, her balled fists pressed beneath her chin. There a mat of jet black hair sits atop a chubby face. Here is a bald and browless creature with sunken cheeks. One rests in my arms like as a sleeping kitten. The next squirms and squalls the moment I touch him. During midnight rounds, I survey my kingdom, a room filled with life in the making.

The west nursery proved a wonderful awakening, but even here, among the most innocent souls on earth, disaster lurked. My first morning on the job, I noticed that several mothers – an eclectic mix of Caucasians and Hispanics and African-Americans – had gathered in a small room adjoining the nursery. Many looked older than I was. Some had other children with them, children big enough to walk and talk and dress themselves. One by one, Mrs. K. carried out the new infants and gave them to the mothers. Ah, I realized at last, these were the three-day-olds, ready to go home. But why didn’t the mothers take their babies and head for the discharge desk?

“Oh, Mrs. K.,” I said. “What are those mothers waiting for?”

“Ah, Doctor Gamel, they’re waiting for you.”

“Waiting for me!” My pulse shot up. I didn’t like the sound of that. “Why are the waiting for me?”

“Doctor, you must give them instructions.”

“Instructions? What instructions.”

“Doctor, they need to know the little things: how to bathe the baby, when and how much to feed it, what to do when the baby wakes up in the night. And they would appreciate any tips you might have for changing the diapers. Mothers are always afraid they might injure their baby with the pins.”

I stood silent, frozen, staring at Mrs. K. I stared for a long time, searching for the trace of a smile, for some assurance this was a joke. No dice. Her doll-like face remained smooth and stern. But I had to escape. Surely she would relent when I dropped my bomb: at twenty-eight-years of age, I had yet to poke a nipple into a baby’s mouth or wipe its bottom. My confession didn’t work. She held her ground.

“You’re a doctor,” she said, meeting my panicked eyes with a hard, steady gaze. “Your patients expect you to know these things.”

“But Mrs. K.,” I said, grasping at one last, desperate hope. “Don’t you have any children?”

“Oh, yes.” Her face brightened. “A little girl three years old. If you’d like, I will show you a picture.”

“Good! Perfect!” I said. “See, you’re a nurse, you’ve taken care of babies for years and years, and you have a baby of your own. You’re the one who should talk to these mothers.”

“Oh, no.” Her smile vanished. “That won’t do – they don’t want a nurse. They want knowledge from a doctor, so they will know they can trust what you tell them.”

Four decades later, that last sentence – which I recall with exquisite clarity – strikes me as the funniest thing I’ve ever heard, but at the time I was too terrified to see the humor. Logic had failed. My only hope was to turn on the charm.

Over the course of my life, I have begged many women. I have begged for love. I have begged for money. And yes, I have begged for sex. But all my other efforts seem mere trifles – paltry, half-hearted requests, hardly worth the effort – when compared to the show I put on for Mrs. K. I was by no means a handsome man, but I was young, vigorous, skilled at the persuasive arts that had served me so well with my mother and sister and girlfriends.

No dice. My pleas fell to the ground like spent arrows. Mrs. K. – five feet tall, rail thin, the face of a China doll – stood solid as a rock.

I stood on a plank, an ocean below me, a saber goading my back.

* * *

A few years after this humiliation, I distinguished myself by walking into a delicatessen wearing only a tee shirt and boxer shorts. It was all quite reasonable. When I met a friend at a men’s club in San Mateo to play a few games of squash, there were no tennis shorts in my gym bag, but the club didn’t allow women on the premises, so I slipped my boxers on over my jock strap and headed for the court. After the games, I threw down the racquet, mopped the sweat off my face, grabbed my wallet and rushed to the deli next door for a quart of soda water. While waiting in line to pay for the soda, I became aware of two sensations: I felt more air circulating about my nether parts than was usual for a man standing in a public place; and the others in the line seemed to be casting sidelong glances in my direction.

A lucky man would have worn a pair of plain white boxers on that fateful day, leaving bystanders uncertain whether they were tennis shorts. Not me. My underdrawers were unequivocal, adorned front and back with paisley gewgaws. I fought an urge to rush from the store, but that would have encouraged my audience to collapse in peals of helpless laughter. Instead, my face aflame, I shifted from foot to foot for what seemed like an hour, paid for the soda, then strolled back to the club at the leisurely pace of a man with all the time in the world.
I mention this episode because it proved the second most humiliating moment of my life, measuring only seven on a scale of one to ten. My west nursery debasement measured ten and a half. There is perhaps a man on earth who felt himself a more ridiculous fool than I did as I spoke to those mothers. There is perhaps a man who choked more painfully on his words when he told them how to change their infant’s diaper and mix its formula. There is perhaps a man whose face turned a brighter shade of red, or who came closer to fleeing the room with his coattails flying, but I doubt it.

So great was my panic, I would have collapsed had Mrs. K. not handed me a crib sheet at the last moment. There, in clear bold letters, she had written an outline to guide my learned discourse:

Diapers Check for moisture or odor every hour or when baby cries
Clean bottom with moist tissues
Dry and powder every time
Keep pins pointed away from baby’s skin
Formula Heat in pot filled with water
Test temperature by sprinkling a few drops on your wrist

. . .
* * *

My first wife was a cool, aloof woman, given to subtle humor and quiet laughter, but when I told her the west nursery story, she lost it.

“You!” she shouted, clapping her hands and rocking back and forth in her chair. “You – telling mothers how to take care of their babies!”

She laughed off and on all evening, laughed until tears streamed down her cheeks, then woke me several times in the night. Her performance gave me an idea. The next day, as Mrs. K. shepherded me out to the waiting room for my second morning debacle, I made one last attempt at escape. Logic hadn’t worked, so it was time for a little humor.

“Mrs. K.,” I said, “if you make me do this again, God will laugh so hard, she might fall off her throne.”
“Ha ha ha,” she said. “Oh, Doctor Gamel, you very clever.”

No smile. No dice.

I settled into my chair. The mothers fell silent and pulled their chairs in a semicircle. Some gathered their older children around them. I heard one whisper, “You shush up – this here’s the doctor.” I gazed around at the pleasant, trusting faces of women who had nursed two or three infants and changed a thousand diapers.
“Now,” I said, “I know many of you worry about how to manage your child’s diapers. You don’t want him to lie around for hours in a dirty diaper, but then you don’t want to drive yourself crazy fussing over him all the time. And I know you worry about sticking the baby with a pin. Here’s what I suggest . . . ”

* * *

Fifteen years later, when my son Richard was a few days old, I changed my first diaper. Two years after that, I was invited to Chicago to give a talk on ocular cancers. It was the annual meeting of the American Academy of Ophthalmology, and thousands of physicians and scientists filled an amphitheater the size of a ball park. An hour before my talk, while sorting through my slides in an alcove beneath the amphitheater, I noticed that the man sitting next to me was in bad shape. Sweat beaded his forehead. His hands trembled as he sorted his slides. When he glanced over at me, I responded with a sympathetic smile.

“Oh, my god,” he said, “I hate this stuff. I’ve never given a talk before, and the thought of all those people watching makes me nervous as hell. I couldn’t sleep a wink last night. How about you?”

“Oh, no,” I said. “This stuff doesn’t bother me at all.”

I wanted to explain how Mrs. K. had cured forever my fear of public speaking, but the poor man would not have understood. You had to be there.