*20. The Great Paul Dudley White ---
---taught on a rarefied plane at Harvard Medical School as the cardiologist of the 20th Century. Not only is his Heart Disease, the classic tome but he also is the mentor of Milford Fulop, chief of medicine at Einstein and much feared by insecure students. So it is with almost horror that a poster is read, Dr Paul Dudley White will make rounds with Dr Fulop, Monday morning at 9. All student-clerks expected to attend.Eddie and Danny must attend.
Breakfasting in cafeteria over kosher sunny-side-up eggs, hashed brown potatoes, cooked string beans and toast with margarine instead of butter, Eddie and Danny discuss the coming rounds.
"It's all gonna be about heart murmurs. The guy is crazy about 'em. Especially mitral stenosis and its opening click sound. Watch for that!" says Danny who has spent weeks under Dudley-White at Harvard and also, as he's told Eddie, is boffing a secretary who passes on the info.
Eddie has become an idiot savant, reading Dudley-White's Heart Disease over and over nights at the library under Nina's loving care. He smiles inside because he knows the chapter on heart murmurs cold. He guesses Danny knows what patient will be chosen for quizzing the students but it is a mystery what proficiency of sex technique or physical excellence of Danny's organ allows him to boff the secretaries for the secret.
Danny changes subject. "Hey kid! Aren't you doing Nina yet? She can't resist any dick and you been up in that library nights for the last month. C'mon tell me! Are you also up in her?"
Eddie smiles, drinks down his last coffee and stands to indicate they should go to rounds.
Fifteen minutes later, 9 students in white intern jackets follow Dr Fulop and Dr Dudley-White, both in long white coats over conservative suits, down the hall of the ward and enter room 6B followed by the chief nurse and several nursing students in white. The advent of Paul Dudley White is not to be taken light.
They gather round a bed on edge of which sits - obviously waiting for the entourage - a middle-aged white man in pajamas with top unbuttoned and pulled back off shoulders to bare his chest.
Dr. Fulop introduces PDW (as is the custom to refer to him among the students) as "Dr White." The patient already knows and is proud to volunteer. As this is a teaching-testing rounds to learn heart murmurs, the patient's history is not at all recited. Fulop stands by as PDW applies stethoscope over patient's chest. Eddie notes that Dr White, true to his writings, first examines the patient sitting up and then again lying down and he listens to the chest over specific points and with both the flat diaphragm and the bell chest piece of his stethoscope. It takes Dr White a minute and as he finishes he reassures the patient "Sounds very good to me, Sir. You will do well on the treatment." Then Dr Fulop examines and Eddie thinks It's just like the famous pecking order - the head cock first.
When Fulop finishes he turns to the students. "Who will volunteer to make a heart murmur diagnosis?"
Danny raises his hand, to the collective relief of the others. Eddie already knows Danny's system: he finds out the name of the patient the night before. Then he gets hold of the chart and memorizes Dr Fulop's description of the heart murmur on admission. This case is mitral stenosis, an abnormal narrowing of the mitral heart valve between left atrium and left ventricle. It is a late effect of rheumatic fever leaving a typical heart murmur that starts with a distinctive opening click and then a rumble at the timing point after the 2nd heart sound so it sounds like lub-dub it rrrr - the r's like a dog's low-pitched growl.
Eddie watches Danny listen to the patient's chest with stethoscope.and thinks: He is going to BS it.
Sure enough, Danny gives Dr Fulop's written description of the mitral stenosis murmur that he'd memorized.
Dudley-White asks, "Sir, what is the patient's heart rhythm?"
Danny is nonplussed. He was sure he had memorized the chart right. So sure, he neglected to time the patient's carotid pulse as every examiner should in evaluating a heart murmur. He had not paid attention to heart rate, his mind being filled with scheming. And, as Eddie discovers later from a nurse, what Danny did not know at this time was that the patient's heart rhythm had changed since Dr. Fulop's admission note.
"Uh, it seems a little irregular, Dr White."
"Seems? Please check it again, sir."
The patient, enjoying the interplay especially the embarrassment of the medical student, offers Danny the front of his neck to check the carotid artery pulses and Danny does so and after a minute. "Grossly irregular, Sir."
Dr Fulop takes up the harassment: "Grossly irregular? Well, what does that suggest?"
Danny would normally answer correctly but he is now completely flustered.
Fulop turns to the other students and singles out Eddie. "Mr. Steinowitz, can you tell us?"
Eddie answers, "Atrial fibrillation, sir."
"Good!" It is Dr. White. "Young man, will you give a listen to this gentleman's chest and tell us your interpretation?"
Eddie presses his stethoscope against the patient's chest. Realizing it is probably a case of mitral stenosis because of the atrial fibrillation, he quickly switches his stethoscope head piece to the bell head. He listens over the mitral valve but does not hear any murmur or click of mitral stenosis and he is not surprised because he recalls from his multiple readings of Dudley-White that patients with mitral stenosis and atrial fibrillation rarely if ever show the murmur and click so typical of the mitral stenosis. But he also remembers to listen over the top of the right side of the heart. He does and - Lo! - he hears a soft, blowing late phase murmur that is a sign of pulmonary valve failure to close completely. Suddenly the words and spelling Graham Steell murmur appear in his brain. And he recalls the sentence from a page of Dudley-White's Heart Disease "The Graham-Steell murmur with atrial fibrillation is a sign of mitral stenosis".
Turning to Drs Fulop and Dudley-White, Eddie says "I hear a soft blowing murmur along the left border of sternum, like the murmur we read about of pulmonary heart valve regurgitation. But in a case like this with atrial fibrillation it must mean the patient has a mitral stenosis whose murmur is masked by the atrial fibrillation but which is causing a murmur of the pulmonary valve on right side of heart.
"Remarkable!" Exclaims Dudley-White to Fulop, and Fulop's thought is Thank heaven for Steinowitz! Had Dudley-White only seen Stern in action he'd think my students were dolts. Now, I can probably convince him to become an adjunct honorable professor in the Department, which will be worth at least a million dollars a year in extra grants on his name alone.
Thus the idiot savant triumphed over the smart guy, similar to the tortoise over the hare.
For next, click 15.21 An Old Person's Worldview
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