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Friday, December 15, 2017
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            THE LONG CLIMB, by Carl Douglass, is the irreverent and uncompromising saga of a surgeon in training during the bygone era during which I did my own training. The protagonist in this, the fourth book in Douglass’s SAGA of a NEUROSURGEON six book series is Garven Wilsonhulme, M.D., a recent graduate from medical school, who is now off to his surgical internship and general surgery training programs. The story is accurate and brings back memories--not all of which are good--but the gripping reality of the author’s narrative is spell-binding.

            Garven makes the obligatory trips to prominent hospital training centers on a financial shoestring that characterizes most of his existence to this point in his life. When he visits the university in Dallas, he meets the chief of the division of neurosurgery who tells him, “Sorry, I don’t have time to talk to you right now…[but] I have a case you might find interesting.”

            “The two neurosurgeons step aside and open the curtain front on the exam cubicle. Garven walks in and almost jumps out of his shoes. There, sitting propped up on a gurney, is a thin, wasted, Negro derelict with a hatchet imbedded in the right side of his forehead. Garven is offered the chance to apply for the beginning years of his residency at Dallas, but the intern matching program ends up with him going instead to  the University of California Osterlund Memorial Hospital in downtown Los Angeles—a thoroughgoing blood-and-guts training institution.”

            Just before he leaves to start his advanced training, Garven presents a voided check from his prospective father-in-law to his fiancé and her mother as proof of their father and husband’s manifest ill will. Mrs. Fletcher and Elizabeth assure him that he and Elizabeth will marry; there will be no pre-nuptial agreement, and Mr. Fletcher will come to his senses. Garven and Arthur Fletcher enter into a grudging civility, well short of cordiality, but enough to get a marriage planned, to allow Garven to see a termination to his seemingly endless financial problems.

            On the first day of his internship, Garven is assigned to the notoriously man-killing work service of cardiovascular surgery. His first day is forty-two hours long. His first time as a surgical assistant involves a surgical blood loss of 114 units of blood and a twelve hour stint of being unable to get a drink of water or go to the bathroom. That proves to be a harbinger of things to come.

            Time off to get married is prohibited by the chief of surgery at Osterlund Memorial. When Garven approaches him for an exception to his rule, Dr. Lyons tells him, “You don’t need to be married; that’s what back stairs and student nurses are for.” Garven goes ahead anyway and makes a pact with his fellow interns and residents to cover for him in exchange for a herculean stint of Garven being on-call in payment. Somehow, the exhausted Garven makes it through the ceremony and spends his first night of nearly stuporous marital bliss in the Camelback Inn in Phoenix before getting back to the grind. He has gained a wife and an insurance policy against starvation and homelessness.

            He finishes the cardiac surgery rotation with the chief of the surgery being sanctioned for gross negligence of a patient, and the chief resident being fired just for being in the operating room when it happens. Garven can see that his road ahead is fraught with hazard. Garven’s internship year is one long pattern of lack of sleep, atrocious diet, odious duties on the wards, and demeaning servitude in the operating room. He does grow as a real physician and toughens into a nearly indefatigable workaholic. From time-to-time, Garven is able to steal a case or two and begins to make his way as a cutter and a sewer. His reputation as a man who can be counted on to get things done and a bad man to have as an enemy grows apace with his crushing work load and indomitable work ethic. His new wife is roundly neglected as was his mother before her, all in the quest for success at any cost.

            At critical junctures along the way through his two general surgery years, he encounters neurosurgeons who always seem to be the knights on white horses who save the day—at least in the mind of Garven Wilsonhulme. Garven sees mistakes and triumphs and makes a few of his own, all in the course of his growth and at the expense of some patients and his long-suffering wife. He develops an inner toughness that determines how he will handle the experiences that would defeat many a lesser man.

            Douglass describes Garven’s first day in the emergency room—The Pit: “Garven’s first patient was violent. Two burly orderlies were holding him down when Garven entered the man’s curtain-enclosed cubicle. The man was yelling and blaspheming. He hurled invectives at the young intern…Garven could not do a thing with him.” The deputies assigned to The Pit were called to help as a last resort. “The guy in three is having trouble understanding the rules,” the nurse said…“We’ll pay him a visit,” the deputy said. There were noises in the cubicle…and shortly the two neckless deputies reported to Garven, “He has had an attitude adjustment. He is looking forwards to cooperating in every way.”

            He misses his wife’s birthday and forgets to give her a present because he spends the day in urology clinic ministering to uriniferous old men. Through the year he assists on sex-change operations, conditions of massive hemorrhage including a tonsillectomy he performs that goes wrong, aids derelicts; so, they could return to their homes under Los Angeles highway bridges and their bottles of Thunderbird wine and Everclear. He watches Dr. Stark, head of neurosurgery, rescue a patient who had fallen into the hands of the orthopedic surgeons, and confirms his opinion that the University of California Osterlund Memorial Hospital neurosurgical training program is the place for him. To save his sanity and his marriage, Garven applies to and is accepted by the VA hospital for his core year of general surgery training--a program noted for its easy call schedule and gentlemanly hours. He is rudely surprised when that opportunity is cancelled, and he is forced against his own desires to continue at Osterlund Memorial when the University takes over the VA training program. Elizabeth is heartbroken to learn that she will be a residency widow for another year. Nevertheless, by some apparently parthenogenic miracle, she becomes pregnant. Garven tries to appear happy at the coming of the blessed event.

            His last internship rotation is on neurosurgery, the service he has so longed to be a part of. It proves to be a nightmare because he has to take the place of a resident who quits out of sheer exhaustion and the quaint idea that he should actually have a life. Garven is on call and in the hospital almost the entire two months of his internship and can never do anything to please the chief. That notwithstanding, Garven develops a measure of confidence in his ability to withstand the rigors of neurosurgery and that he will be able to master the discipline eventually.

            Garven learns the core requirements of being a surgical resident: how to convince families of patients to donate more blood than the patient needs; how to finagle a way to get the good surgical cases for himself and to foist the bad ones on to his unsuspecting colleagues; how to dump bad cases onto the medical service; and how never to be tricked into accepting a patient with a medical problem who might possibly need surgery someday; and how to dump a patient to the VA hospital. He learns the language, such as: “onions” [hernias], “fireballs of the Eucharist” [fibroids of the uterus], “fleas are bitin’” [phlebitis], and “henfections in the grimes” [infection in the groins]. He treats heroin addicts, violent drunks, a world-renowned concert pianist, stabbings, gun-shot wounds, crazy people, and has his heart strings tugged when he saves a little black boy from “the smilin’ mighty Jesus” [spinal meningitis]. He misses an impending ruptured appendix and a tubal pregnancy.

            After a particularly long stint on the surgical wards, he comes back to his apartment to discover that his wife and baby son have left him and have returned to Phoenix. This precipitates a second rancorous exchange of threats between Garven and his father-in-law, Arthur Fletcher, concerning who was the head of his household. He tells her irate father, “Elizabeth has led a spoiled child’s life, and it is time she learns to put up with a few things. You tell her for me that I will expect her to back at our apartment in two days from now.”…and hangs up on the powerful business executive. Elizabeth grudgingly returned, but their marriage is passing over rocky shoals. He begins a serious flirtation with a VA secretary and sufferes a few, but no particularly serious, pangs of conscience in so doing.

            Near the end of his general surgery training year, he receives official notification of his acceptance into the neurosurgery training program. When he awakens on that first day of training, he is a neurosurgeon, and has a smile for the old coyote he used to see in Cipher, Arizona during the days when he was expected to amount to nothing just like the town where he grew up.

-Robert  A. Jacobsen, M.D., F.A.C.S.

Retired General Surgeon,

Tanner Memorial Clinic, Layton, Utah

Former Chief of Surgery,

Davis Hospital and Medical Center, and

Past President Davis County Medical Society