Chapter   1 

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​

Ammunition

It was eight o'clock in the morning when I left our village and took the winding road down to the city. The village is a pretty cul-de-sac settlement in the western Galilee, named after the mountain on which it was built. The mountain is high enough to catch some snow on random winters and its top is flat enough to support a dense oak forest, checkered here and there with olive groves. We had arrived twenty years earlier with a small girl and a romantic dream of a log house. The walls needed a new coat of paint now and our threesome wasn’t so small anymore, but the Galilee romanticism, albeit somewhat frayed at the edges, was still there.

I was on my way to the clinic, when Danny, Ferraro's son, called.

Polite as always, he first inquired about my well-being.

Then he said: "Dad's decided to go for the colonoscopy and I wanted your opinion."

The answer wasn't simple, like most aspects of Ferraro's case. I asked how he was doing.

"The best he’s been since you met him," said his son. "We think that if a colonoscopy is an option and maybe an operation after that, then the time for a decision is now. You know," he added, "that we don't make a move without you."

I thought that the fact that we were even considering an operation was a major success. If anyone had told me back then that we'd reach this juncture one day, I would have had trouble believing it.

Especially because the first time I met Joseph Ferraro, he was dead.

     

It was in January, on an especially wintery afternoon. The sky above Haifa bay was dark and heavy. The building, one of those erected in the urban boom of the sixties, had three entrances under a deep overhang. The rain however, was spattering down diagonally, and by the time I made it to the cover of the central stairwell, I was drenched.

I found the apartment on the second floor, a simple brass plate on the door.

Ferraro.

I shook off as much water as I could and pressed the buzzer.

The door opened to reveal a short man in his late fifties with silver-gray hair parted on the side. Just in from work, judging by the nametag on his blue polo shirt pocket. Precision Systems, Inc.

An engineer, I guessed.

The shirt was neatly tucked into gray cotton slacks and a cellular phone was clipped horizontally on his black belt. He greeted me pleasantly. It was the same pleasantness that made me accept his urgent call, a type of call that I prefer to avoid. Urgent house calls don't allow enough time for adequate preparation and often stem from problems that do not require or enable a comprehensive geriatric assessment. An elderly person with dehydration or an infection is entitled, like anyone else, to a prompt and condition-specific response. There is no point in inviting a specialist just to prescribe an antibiotic or write a hospital referral, when a family physician can do it quicker, cheaper, and just as well.

That said, Danny Ferraro had me complying with his request with one day's notice.

I think it was the way he made it, clear-headed and matter-of-fact, polite and non-demanding, despite the evident gravity of the situation. He described his father's predicament succinctly, without omitting the important facts and faxed all the relevant data immediately after the call. This included three discharge letters from three consecutive hospitalizations, all in the same medical ward, and all with a diagnosis of pneumonia. Each time Ferraro was treated with intravenous antibiotics and fluids, and sent home once his condition had stabilized. Each time, within days of discharge, his temperature rose, his condition deteriorated, and he was rushed again to the E.R.

Each hospitalization left him in a poorer state.

"He's extremely weak, totally spent," the son's concern carried across the line. "Yesterday, his fever spiked again, but he won't hear of returning to the hospital. He's in really bad shape, but he is my father and I can't go against his will. Our family physician is on vacation and his replacement told me over the phone that readmitting him was the only option."

The son's composure and level-headedness, despite his obvious stress, impressed me. I knew the system's response in such cases. Old age pneumonia is a fatal disease by definition, let alone a deteriorating patient’s fourth recurrence within six weeks. The indication for hospitalization could not have been clearer.

Against this medical reality stood two facts, the first being that three hospitalizations had not improved Ferraro's condition; on the contrary - he was getting worse. The second was his absolute refusal to return for a fourth go-round. The system's reflexive response in these cases was to shirk responsibility.

Despite being informed of the gravity of his condition, the patient declined referral to the emergency room, is one common phrasing.

Over the phone, I told Danny Ferraro that it sounded like his father was very ill indeed, and that if the hospital combination of I.V. antibiotics, fluids, and oxygen hadn't done the job, the chances of turning the tide at home were slim.

"Even without seeing your father," I told him, "it's pretty clear that his life is in immediate danger."

"I'm fully aware of that," he answered, "but I can't just sit and do nothing and I would really appreciate your advice."

Now, twenty-four hours later, Danny Ferraro was welcoming me into his father’s apartment. He stood in a short, narrow hallway, from which I could see the entrance to a modest kitchen on the right and a living room on the left.

I wished, and not for the first time, that I had a magic wand, a Harry Potter wand, with which I could cast a spell. The spell would paralyze the occupants of Ferraro's apartment and render them oblivious to their surroundings. I could then take an undisturbed tour of their kingdom. First the kitchen, then an inspection of the living room and bedrooms. I'd peer closely at family photos, and look for ones from when Ferraro was young. I'd have a good time scanning the bookshelves, and might even sit down among the frozen figures and have a short read before waking them up again with another wave of the wand. It was always interesting to have a look around, but unfortunately, in real life, there is rarely enough time for a thorough investigation. The focus is first and foremost on the patient and his family. The gaze does wander a bit, but carefully, so as not to make people think you've lost interest. Over the years, I learned to pull the surroundings into the conversation. Who made that fine embroidery, the one in the frame? Is that your father's picture on the wall over there above the T.V.? Can I please see the book you're reading now? People willingly respond to these questions and their answers illuminate them in a way possible only in the patient's own home. I had also discovered that conveying interest in homes and histories was an excellent icebreaker, boosting confidence and openness. After all, they were the hosts and I was the visitor. It was also an unobtrusive way to get a first feel for the patient's long-term memory and verbal capacity. And, of course, it allowed me a tour of the sites without seeming ill-mannered.

I entered Ferraro's apartment slowly. Big is perceived as slow and bigger as slower and my natural dimensions, augmented by my bulky Lowe-Pro backpack, made for a naturally slow entrance into the tiny hallway. A slow enough entrance for a first scan, a right to left arc, counterclockwise.

The kitchen was small, with a Formica-topped dining table, three plain wooden chairs and a limestone countertop. The cabinets were laminated with the same Formica as the table. The living room was spacious enough, its main wall taken up by an old wood pole-shelf library. What looked like all thirty-two volumes of the Hebrew Encyclopedia were there, as was the Duvnov History Series, and a few shelves of books in Romanian. A rectangular coffee table, the same make as the library, stood on a carpet in the middle of the room.

A woman sat on a couch under a floor lamp and knitted. A second sofa stood at a right angle to her, a yellow pique blanket lumped on it in disarray. The disarray was not due to the blanket itself but rather to the faint figure lying beneath it, its head on a white pillow propped against the armrest.

Joseph Ferraro's face was ashen, his eyes closed and sunk, his mouth open and lax. Completely motionless. Still as could be. Not even an intimation of movement. I looked for a slight ripple in his features, a fractional lift of the flimsy chest under the blanket. Nothing.

He was dead.

I understood that neither the woman on the couch, nor the son standing before me was aware of this development. My gaze lingered for another second on the figure that was once Joseph Ferraro, while I loosened my backpack straps and eased it down to the floor.

S l o w l y.

I went over the procedure in my head. An ambulance with a paramedic, an ECG, a flat line, instructions to the family. I did not carry death certificates, but the ambulance team probably would. My sincere condolences. Goodbye.

Danny bent over his father.

"Dad, wake up. The doctor's come to see you."

There was no response, of course.

The son shook his father's shoulder lightly.

"Wake up Dad. Dad?"

Nothing.

"Dad!"

Joseph Ferraro slowly opened his eyes.

He was alive.

I silently let out a breath of relief. Then I thought that he could still very well die in the middle of the examination.

I went over to him, leaned over and said, "Hello Joseph. I'm Dr. Rabinowitz and I've come to examine you."

His eyes went cloudy and then refocused.

"Yes. Thank you," he whispered in a cracked voice and closed his eyes again.

The woman followed the events from her couch, knitting needles resting for a moment in her lap. She looked to be eightyish. Her figure was slim, and her left pant fold, the one pointed at me, was razor sharp. Her features were sharp too, and her white hair was pulled back with a blue pin.

"And this is Matilda," Danny introduced her. "She and my father have been living together for the last twenty years."

Her handshake was firm, her gray eyes direct, and her manner no-nonsense.

"Hello doctor. As you can see for yourself, we have a situation here and it is very bad. Lying there like a log, is Joseph. Two days already. Not one teaspoon, not one bread crumb will he put in his mouth. I don't know how long he can go on like this," she said and pointed a knitting needle at the sofa.

Doctor, Joseph, lying. Spoken in a heavy Hungarian accent, initial syllables stressed.

Then she added, "A little soup Joseph, I tell him, have some chicken, Joseph, not much, just one fork. Nothing. Like he's on strike."

Yes, strike three, I thought.

I turned to Danny and asked him if we could sit and talk.

"I'd like to try to understand the last month and a half better and also learn some more about your father," I said.

"Sure, of course. Dipak! Can you come here please?"

"Coming," answered a sing-song voice from the corridor, followed by brown-skinned man in his thirties, wearing a blue jumpsuit and orange slippers.

"This is Dipak, dad's caregiver. We obtained a foreign-worker permit after the second hospitalization. He's been with us for three weeks now."

"Hello Dipak, nice to meet you. I'm the doctor," I introduced myself.

We shook hands.

"Where are you from, Dipak?" I asked.

"I am from India, doctor, thank you," he answered with a wide smile.

"English or Hebrew?"

"Oh, only English, sir. I am new here. No Hebrew."

"No Hebrew yet!" I smiled back.

He had an easy laugh. "No Hebrew yet!" he repeated. "Would you like some tea, Doctor?"

In my damp condition it was a welcome offer and I nodded willingly.

He laughed again and turned to the kitchen. On the way after him, I glanced back at the sofa. No change there. Matilda's needles resumed their busy knitting.

Danny and I pulled out two of the wooden chairs and sat down.  I took my laptop out of the Lowe-pro's rear compartment, set it on the Formica table-top, pushed the cable’s plug into an empty socket beside the microwave, and opened Joseph Ferraro's file.

"Shall we start at the beginning?" I asked.

"Whatever you say."

I laid my regular page on the kitchen table beside the computer. It's a sort of template with a few empty lines at the top for personal details and a table below for reviewing the geriatric syndromes. The geriatric syndromes are the backbone and heart of the whole geriatric approach, a solid and trusty framework for the working geriatrician, be it in the hospital, clinic, or home.  In the elderly, a specific problem can be exacerbated by seemingly non-related conditions. The template helps me to keep the assessment comprehensive, especially when a dominant problem risks narrowing the diagnostic field prematurely.

Joseph Ferraro was an eighty-five year old widower. He had immigrated to Israel from Romania in the early sixties, and worked as a customs official. Matilda had been his life partner these last twenty years. The couple led a quiet routine that revolved around household chores, some shopping, and a bi-weekly get-together with friends for cards, coffee, and gossip; Danny had them over for Friday dinner twice a month. Ferraro's problem list included a diagnosis of Parkinson's disease (for which he received two drugs), a cardiac arrhythmia (one drug) and mild heart failure (a diuretic). He also had medications for lowering his heart rate and blood pressure.

"When did things start going wrong?" I asked.

"It began just before the first admission," Danny answered confidently. "Up until then he was one hundred percent."

"Define one hundred percent," I requested.

A patient's previous functional status is usually clear to his family but not at all to the physician examining him for the first time. Having a good mental picture of the patient's day-to-day capabilities before the illness is important, both for understanding the magnitude and steepness of the decline and also for determining the height of the bar to which to try to restore him.

"What would you say, if I told you that two months ago he was still driving? You see, he was totally independent!"

"How far did he drive?" I persisted.

"Short distances, mostly. Driving out of town was getting hard and the truth is, there's really no reason for it anymore. Everything they need is in the city." 

The building had no elevator. This meant that Joseph Ferraro had been capable of walking down the stairs, crossing the road to the parking lot, driving his car through Haifa's tortuous and often steep streets, and after conducting his affairs, doing the same thing all the way back. A high functional level for an eighty-five year old.

"Tell me what happened," I requested.

Danny Ferraro spoke. I listened to his story, using the hospital discharge letters to fill in the gaps.

Ferraro had come down with a fever and a cough a month and a half earlier. His doctor diagnosed probable pneumonia and prescribed an antibiotic. Three days later a weaker Ferraro, still febrile and coughing, was admitted to the internal medicine department in the nearby hospital. A chest x-ray revealed an infiltrate in the base of his right lung. This, together with an elevated white blood cell count and increased inflammatory markers, confirmed the diagnosis of pneumonia. Intravenous antibiotics and fluids, along with oxygen through nasal prongs, had him feeling better within two days. Another two days and he was switched to an oral antibiotic and discharged.

"One day after the last pill, his temperature rose again," Danny continued. "We tried to treat him at home but he got worse, so we took him back to the ward."

The course of the second hospitalization was similar to the first, except that this time, when Ferraro returned home, he was bedridden. Right before discharge, the ward's social worker helped them obtain a temporary foreign-worker permit. Enter Dipak.

Danny went on.

"The second time he returned from the hospital, he was totally spent. Even moving him from the bed to a chair was a struggle. We had to start using diapers."

Five days after that, the story repeated itself. This time he was hospitalized for ten days and discharged only after a full I.V. course. That was one week ago.

"Two days ago, his fever spiked again," Danny said, "and we wanted to take him to the hospital. The problem is that right after we got home last time, he made me promise I won't take him back. Yesterday his temperature was a hundred and three and I told him we had no choice, we had to return the hospital, but he wouldn't hear of it. Today, it's almost impossible to speak to him. I think he's barely conscious."

Dipak set a cup of steaming tea on the table. I took a careful sip and felt a movement behind my back. I turned to find Matilda standing over us. It was the rubber tip of her cane that gave her away. She was shorter than she looked sitting on the couch and I understood her slim, sharp features had given an illusion of height. Her gaze and manner were direct.

"I have seen people like this, doctor. I think nothing to be done. Joseph does not get out of this. Nothing to fight with."

I noticed the concentration camp number on her arm. She was speaking from experience.

"Let me examine him and then we'll talk, okay?"

"Finish your tea first, doctor. It will get cold."

"I was raised to work first and drink later," I smiled at her, unzipping my pack and withdrawing the stethoscope and blood pressure cuff from their compartments.

Inwardly, I imagined her sitting in her couch at the shiva, recounting to fellow mourners in dry Hungarian, “So this doctor comes over, big fellow, dripping from the rain but very thirsty, mind you. Sat down over there in the kitchen drinking tea and chatting up the Indian. Drinking and chatting in English with the Indian, all smiley and friendly and all the while Joseph right there on the sofa breathing his last, returning his soul to his maker.”

I pushed the coffee table aside to gain some access to the man on the sofa.

He was barely conscious and had trouble keeping his eyes open during the examination. His skin was pale-gray, his muscle mass all but gone, his blood pressure low, pulse rapid and weak, respirations shallow, almost imperceptible. I passed my stethoscope over his back and heard the telltale cellophane rustle over the base of his right lung. Dipak helped me prop him up and together we supported his limp frame with some pillows from the sofa.  I eased back a foot, sat on the edge of the coffee table, a robust piece of beech-wood furniture, and took a good look at Joseph Ferraro. I thought he looked drained, depleted, shipwrecked. One misplaced touch away from disintegrating into a mound of dust.

 I also thought these were very non-medical terms, unscientific, not to be found in any textbook. Modern medicine strives for objective criteria, ones you can measure and compare against validated norms. Pulse rate, blood pressure, respirations per minute, oxygen saturation. Search as many hospital discharge letters as you may, you will not read that, "the violence of the disease is gaining the upper hand," as Hippocrates described pneumonia’s lethality.

The reality, however, is that two patients with the same measurable parameters can be in very different conditions. One relatively vital, with a good chance of recovery. The other - dying. Ferraro belonged to the second group and it looked like Matilda was right. He had nothing left to fight with. His arsenal was empty, his magazine out of ammunition.

An antibiotic was a no-brainer and I decided to give him a type used for both community and in-hospital pneumonia.

I also decided to give him some ammunition, some bullets for that empty magazine. Not the elongated kind with the projectile at the end, but rather the small pink round kind. The pill kind. Cortisone. Steroids. Because his personal supply, I thought, was finished.

In the past few decades, steroids have come to symbolize everything bad and shortsighted in modern medicine. Steroid treatment has become synonymous with weight gain, hypertension, diabetes, bone loss, decreased immunity, and this is only a partial list. And indeed all this is true, when steroids are used in significant doses over extended periods. Even then, sometimes there's just no other choice.

But the truth is that we cannot live without steroids. That’s why we have our own supply. The chief steroid we produce is cortisol, and it is a part of a hormonal axis that is vital to our survival. 

This axis, or pathway, runs from the base of our brain to our abdomen and is called the Hypothalamus-Pituitary-Adrenal axis or HPA for short. Cortisol, one of the end products of this axis, is secreted into our bloodstream regularly and cyclically, peaking in the early morning hours. In conditions of physiological stress, like pneumonia, this axis picks up and increases cortisol production, hence its earned nickname - the stress hormone. In other words, cortisol perks up the body's defense system in bad situations.

As often happens, the robustness of the HPA response can falter as we age, and in a certain percent of acutely sick elderly, low cortisol levels have been measured.

What happens to the HPA cortisol response in an 85-year old man after six weeks of unrelenting pneumonia? How much cortisol was Joseph Ferraro still capable of producing? As usual, the literature seldom supplies answers that fit the specifics of the lone individual case. There was no choice therefore, in the special and private matter of Mr. Joseph Ferraro, but to resort to that old and treacherous tool - human logic.

I decided Ferraro was out of cortisol and that he needed of some emergency supply.

This was not based on intuition alone, as there were some preliminary case reports of speedier recovery in elderly people with pneumonia when steroids were added to the antibiotics. However, the fact that Ferraro had not been offered this treatment in the hospital came as no surprise. Hospitals tend to adhere to conservative protocols. Exposure to internal and external scrutiny inhibits their turning to less orthodox approaches.

We were in the kitchen again now. Dipak's tea was still hot. Joseph Ferraro was still alive. The hospital protocol had not done the job.

I told Danny and Matilda what I wanted to do. I cautioned them it was probably too late, but told them it was the only way I thought Ferraro would have a chance. I wrote two prescriptions, one for an antibiotic and the other for 20 milligrams of prednisone. A relatively low starting dose, but I assumed that if Ferraro's own tank was dry, even a modest dose might make a difference. I stopped his anti-Parkinson's and anti-hypertension pills, which were probably only aggravating his confusion and decreasing his already low blood pressure. Then I asked Danny to repeat the instructions, just to make sure he had it all down. He did.

I asked them if they still felt sure about the decision to treat him at home.

They were.

I emphasized that it was totally understandable if they changed their mind and decided to hospitalize him again.

The son thanked me warmly. Matilda nodded her approval.

Despite Ferraro's condition being no better than it had been at the visit's beginning, Danny's faced registered relief. Partly, it was the support given, the plan laid out, the sharing of the burden. But I felt that it was also because that path accorded with his father's specific condition and, more importantly, respected his father’s wishes. I asked for an update in two days time and we said our goodbyes.

Two days passed. Danny called to report a miracle. Ferraro had returned to the land of the living. He was alert now, responsive, talking. He had started eating and his temperature was down.

"It's unbelievable! He perked up a bit on the first day, but today he's come back to life. Like somebody plugged him into a socket. What is this pill, anyway?"

I was glad to hear the news and instructed him to give him twenty milligrams for another three days, then drop to ten and keep me informed.

He called after five days.

"No comparison", he said brightly. "He's sitting right here beside me and eating lunch! How do you feel Dad?"

"Better," I heard a weak voice across the line, and then a familiar, heavy Hungarian accent, initial syllables stressed, "and a piece of schnitzel also, he ate, tell him."

"Did you catch that?" sang out his son. "And he's got some color back, isn't that right Dad?"

A few months passed.

Ferraro had not returned to the hospital. He was getting stronger and one day, when I drove through the neighborhood I caught sight of him in the park with a walker, Dipak by his side.

His fever had recurred twice, and had responded both times to the same antibiotic-steroid combination. He really was a different person. I would find him sitting in his couch, alert and comfortable, gaining weight from visit to visit. Not the talkative type, he let his son handle all medical matters. At some point he started passing bloody stools once a week or so. I thought that an intestinal tumor could well explain his complicated course. Ferraro was still too weak for a colonoscopy so I sent to him for a CAT scan. The imaging revealed a mass in his left colon. Ferraro was still growing stronger, but the operational risk was high. He was eighty-six now and feeling pretty good. 

***********

"So what do you think, doctor?" asked Danny. "Should we go for it?"

"Did you talk to him about the risks involved in a colonoscopy and maybe an operation afterwards?"

"I did. He's ready. He says he wants to know if it's a tumor and he's willing to have it taken out."

"All right then," I said. "Let me talk to a doctor I know, a pro. I'll get back to you with an answer."

"Take your time, Doc. Every day he's like this is a blessing."

I hung up and thought about the sheriff. Many years had gone by since the incident between us. I was sure he wouldn't remember. I, of course, had not forgotten. When it happened, he was already a senior physician and I was only at the start of my professional life, a mere intern. For him it was a passing incident. For me - a defining event. I dialed his hospital and negotiated the usual obstacle course of switchboard -medical ward - surgical suites. After two accidental disconnections and three tries I made it through. A recovery-room nurse answered the phone.

"He's in the middle of a procedure," she said, "and then he's off to a conference. Try tomorrow morning. He should be here all day."

The sheriff was a busy doctor. Not surprising for a man with his ego. I asked for his direct number and got it.

 

 

 Chapter   2 

​

 

The Most Worried Patient

 

The incident between the sheriff and me took place in a hospital in the north of the country, during my year as an intern. The hospital was undergoing a massive upgrade, and from some angles it looked more like a construction site than a medical center.

The internal medicine ward to which I had been assigned was designated to move to one of the new wings. In the meantime, however, it remained, as it had for decades, in one of the old army barracks left over from the British pre-war occupation.

This was a low and elongated structure with a corridor running its length. One flank of the corridor housed the patient rooms, four beds in each. The other side was for utilities: showers, kitchen, a basic laboratory, a laundry room. The nurses' station and doctor's room were positioned at the end of the corridor opposite the official entrance, although you could exit and enter from whichever end you wished.

The resident-in-charge-of–interns was a doctor named Haled, who suffered from a chronic longing for his student days in Italy, the best time of his life. After beautiful Bologna, his next favorite subject was expounding on his architectural plans for building a Syrian house.

I wrote admission and discharge letters on a shaky wooden table in the yard beneath an old olive tree. Haled would come out occasionally, sit on the stairs opposite me, smoke a cigarette, and tell me about the Syrian house, about the low entrance in the wall surrounding it, the visitor having to bow slightly when entering, a gesture of respect toward the patron.

I had set up the table outside as a means of avoiding the claustrophobic atmosphere of the doctors' room. But it was also a statement: “Beware! Independent intern on the grounds.”

Unlike most of the interns in the hospital, I was there by choice. I had listed the hospital as my first priority in the internship lottery list, because by then Orly and I had decided to build our house in a small village in the Galilee Mountains. The fancy Tel-Aviv and Jerusalem hospitals occupied the top of the roster and the odds of landing them were statistically low. But there was no doubt in my mind that I would get my choice - a year of internship in a peripheral northern hospital, habitually residing at the bottom of the intern wish-list.  The shaky table, olive tree, and cigarettes with Haled were a bonus. Internship is a yearlong affair, coming after six years of medical studies, and although from the fourth year on most of the teaching took place in hospitals, this was different. Now the system accepted us as doctors, or at least, as almost-doctors.

The year had a fixed structure – nine months of obligatory rotations, and then three that you could choose. The internal medicine rotation was one of the required ones, and also the longest. What you were actually permitted to do in this seventh year of med-school/first year on the job, ranged from errand boy to actual doctor. It depended on three variables: The department chief, the resident-in-charge-of–interns, and yourself. Over the first two I had limited control. With the third I had every intention of doing my best. I wanted to be a real physician. Six years of preparation were enough.

The acting department chief was an articulate and elegant man, just returned from the United States with a professorship in infectious diseases. Professor Bright arrived each morning in an ironed shirt and colorful bow tie, American style, and this caused much mirth in the nurses' station. The official title of boss was still pending an in-hospital committee but the matter seemed settled. Bright, however, was no novice and thus treaded carefully, avoiding conflict. He was the picture of attentiveness and support.

And so it happened that with Haled's casualness and Bright's congeniality, I found myself in an environment of least resistance for realizing my ambitions as an intern, ambitions which I did not think excessive.

In fact I only had one.

I asked to have two rooms placed under my care. I promised to treat the patients of those rooms to the best of my ability and to consult with my two superiors, Haled and Bright, every step of the way.

Bright was hesitant at first and seemed to weigh the potential risks. I saw this and vowed to report on my patients every morning and subject every instruction to his approval. The same for evening rounds, I assured him. Bright mulled this over with some apprehension but finally agreed. Haled was easy and nonchalant about it. But that was Haled.

And so, they entrusted two rooms to me, and as it happened, they were women's rooms. Numbers 7 and 8.

I laid down a routine.

Every morning I arrived at a quarter to eight and peeked into my rooms, both to make sure all my ladies had made it through the night and also to meet new arrivals if there were any. Then, came the ritual morning briefing by the night-shift doctor, followed by a quick coffee, and - off to work. I toted a pocket notebook and gave every new patient her own page in it.

I used the SOAP method.

Subjective, Objective, Assessment, Plan.

Subjective - the patient's complaints and symptoms.

Objective - the findings of the physical examination and the laboratory and imaging tests.

Assessment - the differential diagnoses: An evolving list of possible diagnoses that might fit this particular patient's Subjective and Objective.

Plan - the diagnostic and treatment steps to be taken.

Every morning and every significant change in a patient's condition yielded a new page in the notebook, a new SOAP. I finally felt like a real physician. It was thrilling and intimidating. I consulted with Haled often and learned to appreciate his clear and helpful advice.

A lot of my patients were elderly, wheelchair-bound women, admitted due to acute illnesses such as pneumonia or urinary tract infections, which complicated their basic chronic conditions. Worse, some were totally immobile and lay still in bed. It was important to mobilize these patients into a chair as quickly as possible to prevent more complications. However, some were heavy and the nurses were not enthusiastic about making the effort, especially on an intern's request, so I helped them physically with the lifting and transfers. I came to notice that once seated in the wheelchairs, they stayed in whichever random position the chair happened to be in. The women sat staring vacantly at walls, corners, closed drapes, floor paneling. It was a difficult sight to bear, so I began maneuvering the chairs to face those windows that had an outside view. I rolled the more stable ones outside to the yard for some fresh air. Some of the nurses thought it was a pointless waste of time and did not bother concealing their derision.

But there was one nurse in the ward, Rosie, who caught on quickly to what I was doing and gave me a hand. Rosie was a wonderful nurse. She was intelligent, hardworking, and empathic, and she possessed a nice sense of humor. The other nurses respected her, and their cooperation with my “grandma maneuvers,” as Rosie playfully called my enterprise, increased.

Rosie was a ray of sunshine in a place with an otherwise grim atmosphere. The hospital chief reigned over his kingdom with an iron fist. Regiments of new doctors, immigrants from the just-collapsed Soviet Union, comprised the hospital’s main work force, and these newcomers worked in a state of constant dread. They were a group without clear rights or status, but with one collective dream - to gain access to a residency, any residency, as long as it came with a contract from the Health Ministry and a real paycheck.

Most, however, toiled for years as non-residency "house doctors," under "observation" status and on ridiculous salaries. These doctors were inclined to accept authority without question. The fear of losing their precariously-held jobs and hoped-for residencies was too great. It was a depressing reality.

Not that I had anything to worry about, I thought.

First, the hospital treated Israeli born and educated interns with respect, especially since most of them were not there by choice, so the hospital had to make an extra effort to entice them to stay on. Second, I had no intention of working in this hospital, or in any other hospital for that matter, as I had already decided to become a family physician.

Fania Groznashvilli was admitted to the department two weeks into my rotation.

I arrived at the usual hour and stuck my head into room number seven. All four patients were alive and breathing. One even greeted me with a cheery “good morning.” Room number eight had two patients. The third bed was empty, as its occupant had been discharged the previous day. The last bed was at the end, near the window. A woman lay in it and opposite the foot of her bed stood a stocky well-built middle-aged man.

Two things stood out immediately.

The first, was that compared to the average age of my patients, she was relatively young, no more than sixty.

The second was that she was very, very yellow.

I entered the room, walked over to them, introduced myself, and asked her name. Fania Groznashvilli. I shook her hand and then her husband's. He had a wide face, black eyes, massive shoulders, and a powerful grip. I asked about pain and she said she didn't have any. I said I would be back to examine her right after the morning meeting. Mrs. Groznashvilli thanked me in a quiet voice. Her husband nodded, returned to his corner, and leaned his frame against the wall, the heel of his shoe moving rhythmically up and down above the floor panel. I made my way to the doctor's room with one term flashing in my head.

Painless Jaundice.

The term usually has another one tagging right behind it - cancer.

The morning meeting convened in the doctors' room. Present were Professor Bright, Haled, Larissa, Dimitri, and the night-shift doctor. Larissa was a young doctor with an M.D. from the University of St. Petersburg. Her features were delicate and her figure trim, and you could not look at her without thinking: Blue blood. Quick and efficient, she was Haled's unofficial right hand, and the energetic clicking of her high heels was part of the ward's soundtrack. Having just secured a residency slot, her demeanor was confident and upbeat.

Dimitri was an older doctor, from one of the former soviet republics. This was the third department to which he had been transferred, and he was still toiling under "observation" status. His confidence and morale were at floor level and he was down to drawing blood, fetching lab results, and painstakingly writing discharge letters in a language for which no one had prepared him.

Giving his report, the night-shift doctor arrived at room eight. His delivery style was telegraphic and he had a problem with the word "the," nonexistent in his native Russian language.

"Room eight. New admission. Fania Groznashvilli. Painless jaundice. Patient has bilirubin level of 14. Liver enzymes in sky. Alkaline Phosophatase also high." He read out some more numbers. "Family says patient is yellow four days, no appetite, vomiting times one, urine is dark. Referral for CT - on nurse counter. Referral for blood work - on counter."

Bright turned towards me.

"Number eight. That's your room, isn't it?"

"Yes it is."

"Well it seems that we've got ourselves a lady with serious liver failure. Measure her clotting factors too, okay? Very, very important."

The liver is a miraculous organ. Its soft, smooth, and slightly rubbery texture discloses nothing of what becomes apparent under a microscope. Under adequate magnification, an industrial complex is revealed. A factory of immense proportions, with floor upon floor of neatly arranged cubicles. These are the liver cells, home to amazingly sophisticated processes - molecule packaging and breakdown, protein synthesis, waste product disposal. One of those waste products is a component of red blood-cell disintegration called bilirubin. Fania Groznashvilli's liver wasn't removing the bilirubin from her blood fast enough and this was causing her skin to turn yellow. Was the damage to her liver in the cubicles (the cells) or in the drainage system (the bile ducts)? The greatest fear was that a tumor of the head of the pancreas was pressing against the main bile duct and occluding it. If this was indeed the cause of Groznashvilli's jaundice, then her condition was terminal.

I waited impatiently for the meeting to end and then took Groznashvilli's file from the nurses' station and went back to room eight. She was lying in the same position, her food tray untouched on the rolling table beside her. I pulled up a chair and sat down. The morning light streamed in through the window above her bed, accentuating the lemon hue of her skin and sclera. Her husband stood in his corner, silent and alert. A dark and brooding mass of condensed energy.

I scribbled in my notebook as we talked.

 

Fania Groznashvilli, ♀ , 58, married +3, P.O.B - Georgia, housewife.

S – subjective - general malaise - one week, no appetite, weakness, vomiting (x1). Yellow 4 days. No pain.

Under O – objective - I wrote down her medical problems, her medications, the findings on the physical exam, and the lab results.

I told Fania and her husband that a liver problem was causing her jaundice and that we were working to find out what kind it was. I explained that we had scheduled a CAT scan of her abdomen and some more blood tests for the morning. I asked her whether she had had anything to eat or drink. She said she found both difficult, so I wrote an order for an I.V. drip and promised to return later.

I took Harrison’s Principles of Internal Medicine, the holy bible of internists almost everywhere, from the doctors' room, and went out to the olive tree. Consulting the test and tables of the chapter on liver diseases, I wrote down under:

A- assessment- all the possible diagnoses for Groznashvilli's condition. Heading the list were tumors, then infections, auto-immune and metabolic conditions, and toxin or drug-induced diseases.

Then I wrote under P – plan - abdominal CAT scan, liver function panel, blood clotting, viral panel, review of drugs.

Next, I went over Groznashvilli’s medications once more. It wasn't a long list. One blood-pressure pill, one for diabetes, and one antibiotic named Furantoin. The first two were very common and the chance of either of them causing Groznashvilli's liver failure was low. The third one, the antibiotic, caught my attention.

Furantoin is an old and safe antibiotic drug, prescribed mainly for urinary tract infections. In patients with frequent infections, it is sometimes taken preventively, one pill a day, to decrease recurrences. The library was quite a distance away on the far side of the construction site, but fortunately, a novelty had just been introduced into the doctor's rooms all over the hospital. It was called the internet.

A search of which yielded several case reports of Furantoin-induced liver injury. The mechanism described was autoimmune, the drug somehow activating the immune system against the patient's own liver. Furantoin-induced liver injury is more common in women and the time span from starting the drug to liver damage can range from a few weeks to several years. Some of the patients recovered by simply stopping the drug, some required steroid treatment, some died.

I went back to Groznashvilli's room. She confirmed that while having taken the anti-hypertensive and anti-diabetic for many years, the Furantoin was only ten months old. I consulted Haled and we stopped the drug.

The morning hours flew by as I tended my other patients. A new patient was admitted. I wrote one discharge letter. Groznashvilli was wheeled to Imaging for a CAT scan. The imaging specialist inspected the scan carefully and declared it W.N.L, short for within normal limits, which means nothing serious found. Noon came and with it Fania's blood tests. They were worse than before. Her Bilirubin had climbed to 16, her clotting functions were poor. Tests for viruses returned negative.

Now, with cancer and infectious diseases off the list, the diagnosis of Furantoin-induced liver injury became a real possibility. A liver biopsy was the way to confirm the diagnosis or rule it out. The problem was that Fania's clotting proteins, also produced by the liver, were down to a trickle and there was a high risk that inserting a biopsy needle into her liver would result in a life-threatening hemorrhage into her abdominal cavity. But whatever the final diagnosis, her liver functions were continuing to deteriorate toward fatal liver failure. In this scenario the only chance of survival, slim as it was, lay in a liver transplantation.

Haled suggested we call in a specialist.

The hospital did not have a specialized liver unit, but because this organ is part of the gastro-intestinal system, its diseases fell under the authority of the gastro-intestinal department. The department head was referred to as the sheriff. I had already caught wind of this nickname in connection with other consultations and asked Larissa for an explanation. She smiled and said I would see for myself. Then, as an afterthought, she added that the sheriff's department extension number was “1,” with no zeros; “just dial number ‘1’” said Larissa. Apparently that was the way the sheriff wanted it.

Personally, I thought that no matter how knowledgeable the sheriff might be in his field, this hospital did not perform liver transplantations. The rate at which Groznashvilli's liver was going justified, it seemed to me, contacting one of the transplant units in the country's center. I voiced my opinion to Bright and Haled.

Haled remained deferentially silent. Bright seemed hesitant.

I understood Bright's dilemma. Transferring a patient to another hospital was a statement of short-handedness. This was not an impression he wanted to make on the eve of officially landing the title of department chief. On the other hand, the life of a patient was on the line, and even if a liver transplant was a remote possibility, it was his responsibility to give her any chance there was.

To his credit, his hesitation was brief.

He wrote down the details of a liver unit in one of the large Tel Aviv medical centers.

"Ask for Professor Azulai, he's the department chief. We go back a long way, studied together. Tell him I referred you and let me know what he has to say."

Professor Azulai listened intently over the line.

"Look," he said supportively, "it certainly could be a case Furantoin-induced liver injury. You stopped the drug immediately, right? Very good. Let's hope it wasn't too late. It sounds like it's touch and go. Anyway, in these cases we would perform a biopsy for a conclusive diagnosis. We'll be glad to take her from you if you decide to transfer her."

I felt grateful for his willingness to help.

"Thank you very much. I'll relay this to Professor Bright and get back to you soon. One last question, if I may?"

"Of course."

"How are you going to perform a biopsy with her clotting factors so low?"

"Oh, well, in these cases we perform a trans-jugular biopsy. It usually goes just fine."

I thanked him again. I felt that there was some path now, a direction in which to proceed.

Back to that fabulous invention, the internet: Trans-jugular biopsy.

A catheter is inserted at the neck into the jugular vein, then lowered through the right atrium of the heart, into the inferior vena cava and finally into the hepatic vein, which lies on the posterior wall of the liver. The biopsy is taken through the vein wall, so any bleeding will drip right back into the circulation. Clever.

I reported the conversation with Azulai to Bright and Haled. They both thought it a logical way to proceed. Bright asked to postpone a final decision until after the consultation we had requested.

The sheriff's department said he'd be over in two hours time.

I hurried into room eight, to Fania's bed and her husband's corner. She looked yellower and weaker. He seemed darker and tenser, his large head bowed on his thick neck, his heel moving rhythmically up and down above the floor panel, a bull of a man, poised to charge. I told them about the developments and explained that further tests and treatment would probably be given in a specialized liver unit in Tel Aviv.

Something stirred in Fania's eyes, perhaps a glimmer of hope. Her husband merely nodded in understanding. Outside the doorway, in the corridor, two sons had materialized. They were younger, bigger, and darker versions of their father. They sat silently side by side, guarding their mother's room.

The sheriff came at two o'clock, probably after completing his morning colonoscopies, a procedure in which he was making a name for himself. He entered from the far end of the corridor. His step was confident and light, as he surfed toward the nurses' station, white robe tails sailing gently in his wake, thick graying mane brushed carefully back, black leather boots shining on the green linoleum floor.

The sheriff had arrived, and you could not help but notice that he had not come alone.

Four white-clad, grim-faced doctors marched ceremoniously behind him. I assumed they were a mix of residents and residents-to-be, but at that moment the term coattail-bearers seemed more appropriate. The whole white cloud stopped in front of the nurses' counter. Professor Bright came out of his room and greeted the sheriff heartily. The sheriff's tone of voice was honey-smooth and completely devoid of warmth.

"And a good day to you too, Professor Bright. A pleasure meeting you here in your very own department."

"The pleasure is truly all ours", replied Bright in his naturally courteous manner, "and please accept our thanks for coming to our assistance. We would greatly appreciate your opinion in this case of acute liver failure. Dr. Rabinowitz is treating the patient and he will present the case details."

I was standing nearby the whole time. I am not small today and I wasn't small back then either. The sheriff, however, turned to me as if seeing me for the first time. He eyed me with a slight tilt to his head, as if assessing the unexpected intrusion.

"Dr. Rabinowitz… and what, if I may know, is your status in this department?"

"An intern," I answered pleasantly.

He stalled for a brief moment, but the slight pause conveyed his dissatisfaction clearly.

"Well doctor, what can we do for you today?" he asked, airily waving his palm at himself and his entourage.

I began recounting the case, trying to summarize without omitting important details. The sheriff listened with an expression of forced patience and mild distaste.

"We stopped the Furantoin hours after her arrival, but her liver functions are continuing to deteriorate and we're considering transferring her to a liver transplant unit in Tel Aviv," I concluded my presentation carefully.

The sheriff reached for Groznashvilli's file on the nurses' counter.

"Is this hers?" he asked. A superfluous question, as her name was typed in bold black letters on the binder's white spine.

"That’s the one doctor," Rosie assured him, with what I thought was an amused twinkle in her eye. From behind the half-opened door of the doctors' room, I could see Haled following the proceedings with interest.

"Room?" The sheriff asked.

"Number eight, doctor, by the window," answered Rosie.

The sheriff turned to face Bright.

"It was a pleasure seeing you professor. You'll have a written report by the end of the day."

Translation: if you saw fit that a mere intern should present the case to me, don't expect any personal treatment.

A choked cough escaped from the doctors' room. Haled. Too many cigarettes probably.

The sheriff turned smoothly on his shiny heels, coattails spinning, and headed for room number eight. His escort parted to make way, closed ranks behind him and followed.

On the way into the room he passed Groznashvilli's leather-jacketed sons who had taken position on both sides of the doorway. He strode confidently to the end of the room to Fania's bed, four doctors in tow, one apprehensive intern closing the rear. Fania's husband, still in his corner, tensed at the sight of the unexpected doctor convoy. I took a small step backwards and watched.

The sheriff introduced himself somewhat ceremoniously and asked a few questions about Groznashvilli's medical history and current symptoms. All this was already in her file but a doctor should hear the story firsthand whenever possible. He bent over and palpated her abdomen with long manicured fingers, then straightened his back again. The sheriff was not a particularly large or tall man but his erect posture, white coat, and wavy hair certainly gave an impression of height and strength. Groznashvilli's bed barely reached his knees. He clasped his hands behind his back, rising up some more above her, and said authoritatively:

"Well, madam, I would not like to frighten you, but from of all the patients in this department, it is you who should be most worried."

The room and everyone in it fell into total silence.  I could not believe my ears. Fania's eyes widened and her skin seemed to pale under its yellow tint. Her husband's face, on the other hand, was growing darker and the rhythm of his heel above the floor panel was rising at an alarming rate.

The sheriff, oblivious to the effect of his words, went on:

"The department will keep me informed, madam, and we will closely monitor your condition."

And with that, he turned and left the room.

I hurried after him and called his name.

He turned to me with a sigh.

"You'll have a written report by the end of the day," he said in a measured tone.

"But what if she continues to deteriorate?" I asked.

He looked at me, smiled in assurance, and tapped himself lightly on the chest.

"I'm here. Just dial number ‘1'," he said, and left the building.

I felt the blood rushing to my head. I went back into number eight. Fania Groznashvilli was indeed the most worried patient in the department now. She lay on her back, petrified. The husband's corner was empty. I noticed the plaster above the floor panel had worn down to the cinder block.

"Fania," I tried to calm her down, "don't worry, I'm going to check a few things and I'm coming right back."

I walked into Bright's room and told him about the sheriff's visit and about our exchange. I said that if Groznashvilli died, it would be hard to justify keeping her in a place technically incapable of providing optimal diagnosis and treatment, especially when both were just a two-hour drive away. I also added my impression that her family had reached boiling point. I wanted him to factor a scandal into his personal scenario. I suggested we contact the transplant unit without further delay, before Azulai called it a day and left for home.

Bright hesitated a fraction unhappily and then gave his approval.

Azulai was still in. We agreed on an evening transfer and he promised to keep us informed. I went back to Groznashvilli's room and found her in the same position and state. Her husband was back.  He and the boys stood in the corner. A third one had joined his brothers. He was thinner, darker, and tenser. It was clear their father had briefed them on the sheriff's visit and their collective mood was foul. I outlined the plan simply and asked them to prepare her things for moving. The men nodded their heads as one. Fania was too exhausted to respond. On the way to the olive tree, I passed by the nurses' counter and asked Rosie to order an ambulance.

"One ambulance in half an hour," she called back.

I wrote Groznashvilli's transfer letter. I emphasized her previous good health, the need for a trans-jugular biopsy in order to reach a definitive diagnosis, and perhaps a liver transplant in case of end-stage liver failure. Haled came out and lit a cigarette. I handed him the letter.   He read it beginning to end, then signed it without a word.

Groznashvilli was already being rolled out to the ambulance and I gave her an encouraging pat on the shoulder. I handed Rosie the letter and asked her to give it to the driver. Then I went looking for Bright, but he was nowhere to be found. Rosie said he had already fled, pardon me, left.

Through the entrance at the far end of the corridor, I saw the ambulance doors open. I was on my way for a final farewell when Groznashvilli's husband suddenly emerged from room eight. Instead of heading after his wife, he turned and advanced forcefully in my direction. I assumed that there was some final paperwork at the nurses' station, so stepped aside to let him pass. Groznashvilli, however, sidestepped too, blocking my way. He looked at me and his dark eyes bored straight into mine. He then raised two hairy arms, grasped my white-coat lapels and propelled me with one powerful swing into the department's laundry room. It was a tiny space, a cubicle really, and when he kicked the door shut from the inside, a flurry of bed linens and pajamas rained down on us from the flimsy shelving. Then, my lapels still bunched in his big knuckled fists, he pushed me back once, pulled me forward again, planted one kiss on my right cheek, one kiss on my left cheek, and bolted out of the room. For a few seconds, I stood there alone, stunned, ankle deep in a pool of blue and white laundry. Then I burst out laughing.

It was ten o'clock the following morning when I was called to the nurses' counter to answer the phone. Someone was asking about Groznashvilli.

"Hello?" I asked.

"Whom am I speaking to, please?"

Number 1 flashed on the phone's extension display. It was the sheriff.

"Doctor Rabinowitz, here. Good morning, sir," I greeted him.

"Good morning. How is the lady with the jaundice doing?" he inquired.

I told him briefly about Groznashvilli's transfer to Azulai's unit in Tel Aviv, relaying his plan to reach a diagnosis by way of a trans-jugular biopsy.

A short silence ensued.

"Excuse me???" his voice rose incredulously. "And how did this happen without my approval?"

I put some distance between my ear and the phone. The sheriff was furious.

"Her liver functions were deteriorating. Our hospital does not perform trans-jugular biopsies (I was growing fond of this cool-named procedure). Nor liver transplantations, for that matter," I added casually.

I knew that would really do it.

"And what, if I may inquire, is your status in the department???" roared the sheriff.

"I'm an intern," I answered in a friendly voice.

The crash of the handset on the cradle carried loud and clear across the line.

A week passed. Azulai, true to his word, performed a trans-jugular biopsy. The pathological findings were consistent with Furantoin-induced liver injury. Fania's condition continued to deteriorate. Her bilirubin level climbed to 20 and steroid treatment was begun. Preparations for a liver transplantation were made. The bilirubin climbed to 21. After three more days it started to go down, first to 18 and then, gradually over the next week, down to 7. After three more weeks they discharged her with a normal bilirubin level and in good health. The Furantoin had been stopped at the very last minute.

Bright beamed and congratulated me and asked me to present the case in the upcoming regional internal-medicine conference. Azulai helped by sending Groznashvilli's biopsy slides. On the day of the convention, I came in early to tend to my patients. Towards noon, before taking off, I went over my presentation beneath the olive tree. Larissa caught me there with half a cafeteria baguette stuffed in my mouth.

"In Russia we say, eating before stressful event means strong person," she offered.

I hoped she was right about the strong part. As for the stressful part, well, there was no question there.

The large convention hall was full of senior doctors, residents, and interns from all over the county. The name of the lecture was Furantoin-induced Liver Injury. I described the patient, the symptoms, and the lab results. I went through the differential diagnosis. Then came an illustrated explanation of a trans-jugular liver biopsy. Fania's liver slides were up next and I ran the audience through the typical microscopic findings. I concluded with the happy end: Fania's Groznashvilli's complete recovery.