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Saturday, July 20, 2024
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               ACADEMIA: THE LAW of the JUNGLE, is the fifth and shortest of the series of books by Carl Douglass, a retired neurosurgeon of my vintage. I vividly remember stories like the ones told here by Dr. Douglass, for their humor, their sorrow, and especially for the level of gripping reality that this fine story teller evokes.

               On the first day as a neurosurgical resident at the University of California Osterlund Memorial Hospital [UCOMH]--an entirely fictitious place--Garven Wilsonhulme meets the faculty and resident staff with whom he will eventually spend the five most tumultuous and life changing years of his career. He encounters their strong personalities, their intense opinions and competitiveness, and their mutual prejudices. Elizabeth, his wife, meets his contemporaries for the first time and finds them to be far too wild a bunch for her cultured tastes.

               On his first day of actual work, he starts at “O-Dark 30” and still arrives later than the other residents, an indication of what the work and the competition is going to be like. The first three patients they see in the neuroICU are brain dead, and part of the daily work is to disconnect them from their life supports. Garven’s job that first 24 hour day is to get all of the ward scut work done and to learn everything there is to know about his patients. He barely closes his eyes that night when he receives a call to go down to The Pit—the infamous UCOMH emergency room.

               “Boogie on down, Garven, we have a chance for you to excel down here,” says the Pit Boss.

               That can only mean trouble, but bone-weary Garven, quickly goes to the ER. The good news is that there is a man who needs emergency brain surgery for a gunshot wound to the head. The bad news is that there were five more like him. Only four of them look like they will live long enough to be candidates for surgery, and Garven calls in the chief resident.

               He takes note of Garven’s bloody scrubs and quips, “Looks like you’ve been celebrating the Black Sabbath, or you’ve had a busy night.” He rounds up two medical students and the four of them do three craniotomies at once. Garven gets squirted in the eye by opening the brain covering which contained a blood clot under tension, and got to meet the eye of a nursing student through a complete tunnel bored through one of the gang-bangers brain by a large caliber bullet. By the time he has done the three cases, he is well on his way to being a neurosurgeon in fact and not just by his title. He learns never to wear shorts or socks in the OR and how to make a satisfying clank of a bullet into a metal pan, which is the only way to deal with bullets removed from a human body. The fourth member of the Los Angeles Weekend Knife and Gun Club sustained only a severe scalp laceration from a glancing bullet, and Garven sutures it up quickly.

               At four-thirty in the morning, the chief resident allows Garven to do his own craniotomy on a man with a hypertensive hemorrhage. He has to find his own medical student assistant. The operation proves to be a fool’s errand. The man bleeds to death because that is the nature of surgery on intracerebral hematomas, and Garven learns not to do another one in his career.

               When he finally gets home the next night at eleven thirty, Elizabeth asks him, “Is this the way it’s always going to be, Garven?” Unfortunately, that is pretty much the case.

               From each of the staff men, Garven learns significant aspects of elective surgery, but is seldom the one holding the knife on elective cases. His time is in the dead of night when citizens are asleep in their beds, and the cops and Garven form the firewall between them and the things that go bump in the night. On one Labor Day weekend when the chief resident has to be out of the hospital, Garven takes care of fourteen GSWs to the head, operates on eight of them, and of the total fourteen, eight die—four immediately, and four in the next two weeks. Neurosurgery is a very tough business, Garven decides.

               Elizabeth has turned cold to Garven, and a student nurse turns hot and attempts to seduce him. She fails only because he gets called to the ER for a five alarm fire emergency before he can be unfaithful to his rich wife. She lingers in his mind, however. In the aftermath of that night of destruction by man versus man, Garven closes his day by making rounds in the NICU only to find that every patient is dead, and that the foreign-born nurses are blithely oblivious to that fact. Garven discovers that the reason is that the hospital’s electricity shut off just long enough to kill them all. Rounds the next morning are an unhappy test for the budding neurosurgeon. He was on call, and he was in charge. That is the rule.

               His work load increases exponentially when the general surgery rotator is caught flagrante delicto with a student nurse. She is fired, and he finds work elsewhere. Garven finally succumbes to the nursing student’s blandishments, and as expected, the other residents and eventually, the staff find out about it, and Garven has to get rid of her. “I’m sorry, Tressie,” he says, “we can’t see each other anymore...” She asks if it is really necessary, and he tells her that it is—absolutely. He tells her, “I have killed myself to get this far. I can’t let anything jeopardize my career.”

               “Or anyone?” she asks, already sure what the answer will be.

               “Or anyone,” he says.

               Things got better with Elizabeth for a three month period during his third year of residency when he is on a rotation to learn the nonsurgical aspects of his neurosurgical career. He learns a few things on his neurology rotation during that quarter such as never to do a lumbar puncture on a person suspected of having a mass pressing on his/her brain, and a fund of anti-neurosurgical jokes that his resident friends find hilarious when he returns to his real world on the neurosurgery service.

               His stint on the VA neurosurgery service is notable because he runs afoul of the head of anesthesiology for the first time. Garven has a patient who needs an emergency subdural hematoma removed. The anesthesiologist refuses to leave the class he is teaching his residents, and Garven marches into the OR and does the operation—simple burr holes—under local anesthetic, thereby incurring the lasting enmity of the offended anesthesiologists. Just in case, Garven takes careful notes of the incident in case such information will become useful one day in the future. Garven is learning to protect number one.

               A worse problem comes a month later when he has a similar run in with the chief of anesthesiology who refuses to come in at night, and Garven abuses the poor timid anesthesiology resident on call. Again, Garven starts the case, but cannot keep up the tasks of the anesthesiologist and surgeon, and has to beg for the anesthesiologist to come in. He finally does, but the entire interchange is dangerously nasty. The anesthesiologist threatens Garven, and Garven takes more notes. The likelihood that the evidence will be needed in the future seems all the more likely.

               Garven’s interpersonal relationships are rife with mistakes. He neglects and is brusque with his wife; he criticizes the VA way of doing things, and he takes up again with the secretary who had been so seductive on his previous rotation. This time he succumbs and starts up his second full-fledged affair, heedless of the fact that he is putting his marriage and his residency career in jeopardy. Like many an adulterer, Garven Wilsonhulme thinks he is invisible.

               At the end of his third (senior) year, Garven receives a letter with good news and bad news from Dr. Stark. He is to become next year’s chief resident as expected, but he has to do an additional—fifth—year of residency, which is not expected and not appreciated. He stands up for himself and is informed that Dr. Stark has no choice. He must comply with a new university policy, and Garven is the unfortunate fall guy. Garven extracts a contract from his boss that he will be regarded as the chief resident and as a junior staff man for the next two years and then he will continue on the faculty of the division of neurosurgery thereafter.

               Elizabeth is once again dismayed at the perfidy of the slave system that holds her husband and herself in thrall, and once again their relationship sours. Garven turns ever more towards his VA lover and trouble, unaware that he is once again coming under observation. His lover begins to pressure him, and Garven begins to realize the immensity of what his affair can cost him, if he fails to divest himself of his entanglement.

               Things get a little better for him. He is now paid a full $200 a month, and he gets to do more significant surgery. He is becoming known as a reliable and capable neurosurgeon by his colleagues and by the neurology service which is the source of valuable patients. He has to do less night work, and is now able to be home more and to begin anew to mend fences with his wife who is the mother of his child and the only source of real money in his life. On the negative side, he develops antagonistic relations with the other two junior staff men who present ultimatums to Dr. Stark: either Wilsonhulme leaves, or we do. Dr. Stark chooses Garven. One of the staff men physically attacks Garven in his OR during an operation, and Garven gives the man a thorough beat-down. The final confrontation results in both junior staff men resigning. Garven’s workload increases significantly, and that further sours his life with Elizabeth.

               The next year, Garven wins a struggle to do an operation that the vascular surgeons consider to be in their exclusive domain, and Garven garners a few more enemies. His world—the world of academia—is a fang and claw jungle, and Garven fights as hard as he once did on the UP docks in Phoenix. He proves not to be a man to cross.

               In 1964, while the chief is away at meetings, the regents of the UC system decide to depose him in favor of Dr. Chou, the second in command. Dr. Stark accepts his demotion quietly but with no measure of forgiveness. He knows that life is long, and he may one day repay Dr. Chou for his betrayal. He chooses to bide his time. Garven continues to write his condemnatory notes and to bide his own time.

-Harvey Birsner, M.D., F.A.C.S.

Diplomate, American Board of Neurological Surgery

Fellow, North American Neuro-Ophthalmology Society

Clinical Professor, Neurosurgery, Univ. of Texas,

Southwestern Medical School, Dallas

Associate Clinical Professor, Neurosurgery,

University of Southern California, Los Angeles