Heirs of Asclepius. Chapters from the book

HEIRS OF ASCLEPIOUS About doctors and healing [1]

Fee Waiver Cost

Jewish law, based on the Torah, says that the work of a doctor, like any work, must be paid. But there is another important aspect that this legislation addresses. A doctor's refusal of a fee may cause an undesirable line of thought in the patient or their loved ones. Perhaps they will decide that the condition is hopeless, and the doctor considered it immoral to take payment for work that did not produce results. And such a line of thinking can negatively affect the course of the pathological process.

Now I understand it. And yet, already being retired and not receiving a salary, I only accept a fee in the rarest cases. And in my youth, I considered it simply criminal to receive bribes from patients. After all, I received a salary for my work! To what extent it corresponded to my work, I did not think about it.

In Israel, this attitude towards fees initially created a false impression among patients about my professional suitability.

Our good friend Hana, one of my first Israeli patients, said that my refusal to take money from her made her wonder if I was a doctor. After unsuccessful treatment with health insurance doctors, she turned to two private professors, and they did not help her. And then some newbie appeared at the health insurance fund; the head of the department where she was treated recommended that she contact him, and, thank God, she recovered. So, he is still a doctor. But, on the other hand, he didn’t take the money. So, maybe he cured it by accident, he knows this and his conscience did not allow him to take the money?

Hana wasn't the only one who had these thoughts. And I considered it immoral to take money from patients whom I treated at the health insurance fund, which paid my salary. And not only them.

We have lived in Israel for about two years. My wife asked me to host a relative of her colleague. A young man wearing a black skullcap came to see me from Jerusalem. So, an Orthodox Jew. The fear of the operation for which he was scheduled was visible in his eyes. He came to get a second opinion.

One minute was enough to make a diagnosis, eliminating the need for surgery. Naturally, I examined him for more than one minute. During the examination, I noticed that his kidneys were sick. He confirmed this. At the same time, it did not escape me what an impression the phrase about kidneys made on him.

The orthopedist who prescribed the hand surgery was clearly a follower of the American school. There was no need for surgery. I would even say that to some extent it was contraindicated. This method of treatment can be explained by ignorance or neglect of the laws of biomechanics. Closure of the first carpometacarpal joint in the future will inevitably lead to pathological changes in the higher joint. If you perform an operation on an eighty-year-old patient, he may still have time to go to a better world before changes appear. But my patient is only thirty-two years old! (Reflecting later on this case, I assumed that the American authors who proposed surgical treatment simply did not have young patients with such a disease. Otherwise, it is difficult to explain such an approach.)

Of course, guided by the rules of medical ethics, I didn’t even show what kind of thoughts came into my head. I prescribed him conservative treatment and gave him recommendations on diet. The patient was happy. He asked me how much he should pay for the visit. I replied that he did not have to pay, since he was accepted under the patronage of my wife.

Unlike most other patients, he did not insist, did not argue, but said goodbye and left.

The next day, my wife told me a colleague’s story. Her relative, whom I advised, is an ordinary millionaire, the owner of jewelry factories in Israel and Hong Kong. He, who knows how to count money, rated the very fact of canceling the operation very highly. And at that moment, when I said about sick kidneys, he decided that this was the very doctor in whom it made sense to invest capital. That is, to open a well-equipped clinic in which I will have very high income, part of which will end up in his pocket. But when I refused the fee, his opinion changed dramatically. It’s worth being treated by this doctor, but under no circumstances invest money in him! The millionaire recovered without surgery and sent us a flowerpot, huge and luxurious.

Now I already have several such millionaires on my account, including one from Australia, one from Germany and two from the USA, from whom, for various reasons, I did not take a fee. I must note that millionaires took my refusal much more calmly than poor patients.

But there were cases for which I rightfully scolded myself.

One of them happened the day my grandson was circumcised. After a modest celebration (there were only three hundred guests in the hall), we went to see our son. Guests also came here who, for various reasons, could not come to the celebration, mainly neighbors in the village. Among them was a lieutenant colonel of the Israeli Air Force. His right arm was in a plaster cast. I asked what happened.

It turned out that twelve days ago he broke his radius. The doctor was unable to eliminate the displacement of the fragments, and surgery is scheduled for tomorrow. I asked him to show me the x-rays. He lived nearby, and within a few minutes I was looking at the X-rays. A common fracture of the radius in a typical location. And the displacement of the fragments is typical. It is difficult to explain why the bias could not be eliminated. Twelve days have passed. Tomorrow it will be thirteen. Too much for conservative removal of bias. And yet, I told the lieutenant colonel to come tomorrow not for the operation, but to see me. The next day, without much difficulty, I eliminated the displacement of the fragments (why didn’t the doctor do this on the first day?), applied a plaster splint and told the patient to come to me in four weeks. On the appointed day, I removed the plaster splint, diagnosed the fusion of the fragments and prescribed easy treatment for several days.

A little embarrassed, the lieutenant colonel made a timid attempt to hand me the fee. I think that he never received such a beating, even as an ordinary soldier.

Several days passed. Arriving at work, I parked the car in the usual place. Immediately a lieutenant colonel came out of his car with a beautifully decorated basket of respectable size. I tried to explain to him that he was my son’s friend, that he was a soldier in the Israel Defense Forces, that it was not he who came to me, but I who imposed my treatment on him. But here he was adamant. I still have the basket. And in the basket there are several bonbonnieres, chocolate, two bottles of good wine - white and red - and a very beautiful bottle of Hennessy XO cognac, drowning in sweets. If I had noticed this cognac right away, I still wouldn’t have taken the basket. The bottle cost three hundred dollars. Maybe the fee in monetary terms would have cost him less?

Ability to walk

I have often wondered if there is some kind of universal conservation law? Not just matter and energy. Are we not losing exactly as much as we are gaining? Acquisitions are visible and understandable. What about losses? Will, say, a soldier who is used to driving up in a jeep almost to the front line be able to make a forty-kilometer night forced march with full equipment through swampy terrain and immediately enter into battle? Doesn't a surgeon who uses amazing instruments and equipment lose qualities that can be useful in an extreme situation? Loses!.. After all, he didn’t even acquire them! The surgeon, accustomed to cutting bone only with a perfect vibrating osteotome, gives up when he needs to pick up a chisel and hammer. He falls into complete confusion if the electron beam converters suddenly stop working. Accustomed to the car, he forgot how to walk.

This happened at the end of the first month of my work in Israel. In the morning, Professor Conforti told me that he was going to assist a young orthopedist in the operation of osteosynthesis of femoral neck fragments with a three-bladed nail. The young doctor had never performed this operation before. But the professor was urgently called to the university.

- Please assist for me. Of course, you are in charge of the operation.

The professor headed towards the exit, and I went to the operating room. Along the way, I noticed that the anesthesiologist had already given the patient, an elderly woman, premedication—an introduction to anesthesia, so to speak.

The young orthopedic surgeon wandered aimlessly, peering into the operating rooms.

- Why don’t you wash? - I asked him.

- There will be no operation.

- How can this not happen?

— The monitors are not working.

- So what?

The young doctor looked at me with pity, clueless, probably not understanding what he said in Hebrew.

- You see, the monitors don’t work.

- Understand. Do you understand that the old woman has already been given premedication?

— But the monitors don’t work!

“I’ve already heard and I’m sorry.” And if it were your mother, would you agree to have the operation canceled?

— But the monitors don’t work! - he shouted in despair, outraged by my stupidity.

- So, we will work without them. Come on, wash yourself.

— Without monitors?

He jumped out of the operating room as if scalded.

Until I saw an X-ray machine with electron beam converters at an exhibition in the Kiev Chamber of Commerce in the early 70s, it never occurred to me that it was possible to insert a wire into the center of the femoral neck, looking at television screens showing the bone and what was being inserted into it. knitting needle in two projections. More than twenty years earlier, I, a beginning clinical resident, watched an assistant professor perform osteosynthesis of femoral neck fragments with a three-blade nail. Very difficult. With a dozen x-rays during the operation, which naturally took time, not to mention the radiation. And the patient is under imperfect ether anesthesia. And this operation was performed at the clinic only by an assistant professor. It turned out that this was the topic of his doctoral dissertation.

I read A. V. Kashtan’s monograph about this operation. At that time, I could not have even dreamed that Arkady Vladimirovich Kaplan, an outstanding Moscow orthopedic professor, and I would become friends. But that's in the future. And then I didn’t even know the past, I didn’t know that Arkady Vladimirovich operated on me, who was unconscious after being wounded, in a military field hospital. But I already knew for sure that osteosynthesis of the femoral neck needed to be simplified.

Shouldn't we apply the artillery principle of firing at closed positions? That's where I started. Step by step I walked towards the goal. Finally, in the experimental workshop, according to my drawings, they made, one might say, the most primitive device, built on the principle of parallel lines. It's so obvious and simple! How did I not think of this right away? And most importantly, how did no one think of such a simple solution before me?

I showed the device at a conference at the clinic. Even the always indifferent and phlegmatic Professor Yeletsky could not hide his satisfaction and declared that as soon as a patient with a medial fracture of the femoral neck was admitted, I would operate on him using my invention. In short, general delight.

No, not universal. The assistant professor was not enthusiastic. After the conference he came up to me.

— Ion, are you going to report this at the institute conference?

— Yes.

- Do you know that this will fail my dissertation?

I was taken aback. I still had no idea about all the undercurrents, shoals and reefs in scientific seas.

“In that case, I won’t report.”

- Thank you. Wait a bit.

We really didn't have to wait long. A week later, at the next clinical conference, the assistant professor demonstrated a device that was almost no different from mine. Almost, because there was another completely unnecessary detail. The assistant professor's report was met with embarrassed silence. I didn't discuss this with anyone, but it seemed to me that everyone experienced a feeling of unease similar to mine. I didn’t discuss anything with the assistant professor either. And in general I doubted whether I would talk to him. If after my report he had only stuttered, I would have given him my invention with my dear soul. I didn't intend to write a dissertation on this topic. And anyway, what kind of dissertation is this? Just a device for inserting a needle into the femoral neck.

This invention helped me a lot in my work. But after the thirtieth or fiftieth operation, my arm was so full that I didn’t need it. I simply inserted three wires into the femoral neck, determined from the radiograph which one was the most central, removed two unnecessary ones, and put a three-bladed nail on the remaining one, in the center of which there was a channel for the wire. That's exactly what I was going to do now.

About five minutes later the young doctor returned with his tail between his legs.

- The boss told you to start the operation. And when the needle is already inserted, I will continue.

I nodded and told him to wash himself.

Professor Conforti told me that the doctor caught up with him in the parking lot at the last moment and complained indignantly about this madman who forced him to operate without monitors. The professor laughed and told me to tell me that the doctor would continue the operation after I inserted the needle.

I don’t know when and how the news spread that they would perform osteosynthesis of the femoral neck without monitors, but a lot of people gathered in the operating room. Not only all the orthopedists and surgeons came, but even urologists.

And then I did something that even today, twenty years later, I cannot forgive myself. I introduced not three, but only one knitting needle. Why? What did I want to prove with this? The skill of a doctor who came from the Soviet Union? Or was it simply unacceptable recklessness? Of course, if the pin had not been inserted centrally, I would have inserted another one. But these are two more radiographs. Even if the radiation is insignificant, it is still radiation. And a long duration of anesthesia. But what about the principle “do no harm!”?

Luckily, the X-ray technician walked up to the operating table with two wet films in his hands and excitedly proclaimed:

- Be!

Indeed, the needle was located exactly in the center of the femoral neck. There was unnecessary applause in the operating room. And the young doctor, with eyes shining above the mask, said:

— From lo roiti menathim kamoha!

“Od lo roiti menathim” I understood. “I haven’t seen (met) surgeons yet.” But I had no idea what “kamoha” was. I didn’t yet know that in Hebrew “how are you” (“kmo ata”) is pronounced as one word - “kamoha”.

And yet I am ashamed that instead of three knitting needles I introduced one.

The young doctor continued and completed the operation. He has long been an orthopedic specialist who enjoys well-deserved respect from patients. But he treats me with reverence, caused not by what I taught him after that operation, but precisely by one ill-fated knitting needle.

Author and reviewers

A device for osteosynthesis of the femoral neck was not my first invention in medicine. It was not by chance that I wrote “In Medicine.” I invented while still a cadet at a tank school. And one invention of that time was even introduced into all tank schools in the country, since it saved shells. But we are talking specifically about my first medical invention.

Lying in skeletal traction after a very difficult operation for one of the wounds, I already knew for sure that I would be a doctor. Every day the sister added more weight, pulling on the clamps driven into his ankles, until he reached twenty-two kilograms. And although I weighed sixty-eight, the weight dragged me out of bed. They placed the foot end of the bed on stands. I was already lying somewhat upside down. But the vile load, clearly violating the laws of physics, for some reason continued to pull me down. From time to time I was forced to pull myself up, which, of course, was accompanied by pain. I didn't like it. I lay there and thought about how to replace this instrument of torture of the Spanish Inquisition with something more humane. And I thought of it.

At my request, they built a music stand for me from a piece of plywood, on which I could write, draw and draw. Before leaving for Israel, for three days I destroyed my priceless archive, not having the right (and opportunity) to take it out. I cannot understand how the vigilant border guard, who checked every page of the book, every slide, every gramophone record and tape cassette, missed the yellowed drawings, drawings and the typewritten sheet that explained them. After all, I was not allowed to take out even reprints of my own scientific articles in the covers of the journals in which they were published, if I could not present the actual journals to the border guard. And these papers from more than half a century ago, inexplicably violating the inviolability of the sacred borders of the Soviet Union, are still in my possession now.

The idea was as simple as washing your hands. If you need to pull out a lower fragment or segment, you can create a stop in the upper fragment or segment, and install two screws between the upper and lower stop (for me it was a Roman nut) and, gradually tightening them, provide the necessary traction. And the load that is not there will not be pulled off the bed. And even a bed is not needed, since the patient can move around with this device. I drew all this on sheets of paper paper, drew a diagram of the apparatus, wrote an explanation, and a nice librarian typed it out. And I began to look forward to the professor’s rounds.

Finally, the long-awaited morning of the big round arrived. I handed the sheets to the professor. He looked casually, read the explanation and said:

"Not physiologically."

Such lofty formulations were inaccessible to me at that time. I didn’t have the slightest idea about what is “physiological”, and even more so “non-physiological”. But the professor’s verdict was final for me, not subject to appeal.

I have to review the inventions of doctors (and non-doctors) who want to patent or implement their work. Often they send me bullshit for review. But even in this nonsense I am trying to find a rational grain. I pay very close attention to every drawing, to every word of description. Why didn’t the professor, who barely glanced at my drawings and drawings, take them into his office and examine them while sitting?

Several years have passed. I have already graduated from medical school. The Kurgan doctor Ilizarov, having no idea about my hospital creativity, invented a device that almost completely repeated my design. The idea was so simple that it was impossible not to think of it. Ilizarov wrote his Ph.D. thesis. At the defense of this dissertation, he was awarded the degree of Doctor of Medical Sciences. Having learned about this, the professor said to me, no longer a wounded tanker, but a young orthopedic doctor:

- Don't be sad. You'll come up with a lot more. I remember it after all!

I wasn't sad. At that time, already having some experience, I did not yet object to the reviewers. I'm talking about the reviewers who rejected papers I submitted to journals. It's funny that articles that weren't very original were passed without any obstacles. But if there was anything in the article that contradicted the orthodox point of view, the reviewer immediately attacked my “sedition” and the article was not published. I began to fight with them much later, already able to compare my own knowledge with the knowledge of reviewers.

That day I came to the hospital for daily duty. A colleague reported to me that a fifty-one-year-old woman was admitted with a fracture of the lateral malleolus. He applied a plaster cast and was about to send her home, but her leg felt strange. The doctor asked to look at the patient and decide whether to release her or hospitalize her.

The leg really looked very strange. I have never seen such a swollen foot. X-ray shows a fracture of the lateral malleolus. But the bones of the foot looked very unusual. Neither in my fairly solid practice, nor in any manual have I come across anything like this. Due to the swelling, I was unable to clinically examine the foot masses. We had to rely only on the radiograph. However, something could be extracted from the patient’s story about what happened. In the diagnosis of orthopedic and traumatological diseases, the so-called mechanogenesis, i.e., what mechanical forces caused the injury, is of no small importance. The woman was sitting in the back of a truck. A gas cylinder exploded under the body. The blow to the foot came from below and slightly from the inside.

Usually I take radiographs and other studies in my hands, having already made a preliminary diagnosis. In this case, there could be no talk of any preliminary diagnosis. I don’t know how long I looked at the pictures until I realized that it was a complete dislocation of the heel bone. The medical literature does not say a single word on this matter. I decided that the most sensible thing to do would be to apply traction to the body of the calcaneus.

The next day, after taking a control photo, I saw a completely wild picture. The traction tilted the heel bone almost ninety degrees. It seemed reasonable to me to pass another wire through the anterior heel. Indeed, the situation has improved. But the sneaky heel did not want to take its rightful place. None of my actions gave the desired result. All that remained was to resort to surgery. But even here I foresaw difficulties. We didn't have an anesthesiologist. Anesthesia was usually given by nurses by dripping ethyl ether onto a mask. And my patient has a heart condition. Under such circumstances, I was afraid to operate on her under general anesthesia. And without anesthesia there will be no necessary muscle relaxation. And who knows whether it will be possible to cope with the wild resistance.

Three weeks after the injury, when the swelling had subsided, I had surgery under local anesthesia.

Even now I am not very weak, but at that time it was difficult to defeat me in arm wrestling competitions. In order for the reader to be convinced of this, I dare, without asking the author’s permission, to quote two quotes from L. I. Lazarev’s book “What I Remember” about the celebration of Victory Day at the Literaturnaya Gazeta office in Kyiv.

“The absolute champion in another type of competition that often took place there - you had to rest your elbow on the table, connect your palm with the opponent’s palm in a handshake, and press his hand to the table ... - was Leonid - or, as everyone called him at home, Lelya - Volynsky. I was also present when he lost his high rank. <...> At this celebration, which began, as was customary back in the war years, by silently, without clinking glasses, remembering those who lost their lives in battle, after having drunk a fair amount, after all the same, despite In response to the call, many front-line stories were told - however, only funny ones; they started a competition, where Volynsky lost his championship, which, in my opinion, he was very proud of. At first everything went as usual, no one could resist him. But one doctor, it seems a surgeon, entered the fight with him, and without much effort he broke the champion. The rematch ended the same way. Nekrasov was very pleased that Volynsky’s sporting arrogance was taught a lesson.”

As you guessed correctly, I was that same doctor, “it seems, a surgeon.” So with these very hands that defeated the arm wrestling champion, I, sweating profusely, could not set my heel. If the patient had been under anesthesia with relaxed muscles, everything would have been much simpler. But then, from excessive effort, I felt my soul jumping out of me.

Our department was the base of the Department of Surgery of the Institute for Advanced Medical Studies. The department was headed by the extremely decent Professor Karavanov. He came into the operating room several times and, seeing my suffering, recommended reducing the bone by discarding the articular surfaces. That is, close the joint. And this means disability. I couldn’t do that and, not paying attention to the professor’s advice, I continued to set my heel. At some point my efforts were crowned with success. The heel bone took the place prescribed by the anatomy.

When the patient completely recovered and no one could notice the lameness during the most meticulous examination, when, apart from the postoperative scar, there were no signs of the former injury, I wrote an article in which I consistently described the entire chain of my mistakes - from diagnosis to surgery. I was proud of this article, written in the style of Professor Voino-Yasenetsky, who was a model for me (I do not write as an “idol”, remembering the second commandment). I sent the article to the journal “Orthopedics, Traumatology and Prosthetics”. Several months have passed. The editorial office returned the article and the anonymous reviewer's conclusion to me. He wrote that there was no point in publishing the article, since this was an isolated case, and the author himself admits that he made a bunch of mistakes.

The review pissed me off. I was no longer a fledgling chick who did not know what “physiological” or “non-physiological” meant. And I wrote an angry letter to the editor. Yes, this is one case. Is the reviewer aware of at least one other similar case described in the world medical literature? If known, I will apologize to him. But there will be no apologies, because the reviewer not only does not know the literature, he does not even know the initial section of anatomy, which students study in the first year of medical school. I wrote that during the war, when mines exploded under tanks, there could have been cases similar to what I described. But doctors did not recognize them, because there is not a word in any manual about isolated dislocation of the calcaneus. It can be assumed that all patients with this pathology became disabled. And they will continue to be disabled if illiterate reviewers who, it is unknown how, received a medical diploma, find refuge in the leading orthopedic journal.

After some time, Corresponding Member of the Academy of Medical Sciences Fyodor Rodionovich Bogdanov, with whom we were on friendly terms at that time, called me. He had just attended a meeting of the editorial board of the journal Orthopedics, Traumatology and Prosthetics. According to him, my letter sounded like a bomb explosion. Academician Chaklin laughed and said that he, presumably, was also somehow involved in this letter, since he pulled the hooligan author out of his grave when he was still a tanker. This is true. The great doctor Vasily Dmitrievich Chaklin brought me back to life. And Fyodor Rodionovich also said that I was staring at the water when I called the reviewer illiterate. He did not tell me his last name, but confirmed that this guy became a professor thanks to extremely active trade union and then party activities. Unfortunately, this happens. The article was published out of turn in the shortest possible time.

This is how ideas arise

Another story related to the heel bone occurred long before the one described. This happened when I worked as a doctor for a little over six months. One day, the deputy director of the orthopedic institute for research, who appeared in our clinic as a senior researcher, turned to me with a request: to perform an operation on his wife, who was suffering from severe pain due to a calcaneal spur. This request surprised me incredibly. Any professor would have operated on his wife. But should you consult a novice doctor about this? This incident became a favorite topic for the institute's wits. You must hate your wife so much to almost give her away to a student! The deputy director explained his choice to me. Observing me in the operating room, he came to the conclusion that I operated anatomically and delicately.

I did not know that. But I found two explanations for this. First: I took the study of anatomy very seriously, believing that without fundamental knowledge of the structure of the human body there cannot be a doctor, much less an operator. The second had a very unpleasant backstory.

In the summer of 1941 I was wounded. The wound is trivial. The bullet went right through the soft tissue of the thigh. But for nineteen days, while we were leaving the encirclement, I was without medical care, even without normal dressings. And when I was taken to the hospital on the twenty-third or twenty-fourth day after the injury, my leg was in terrible condition. A military doctor of the third rank decided to amputate the leg. I was sixteen years old. The prospect of being left without a leg did not suit me, if only because I had to take part in the defeat of Germany. In short, I categorically refused amputation. In retaliation for my refusal (so I thought), the doctor began to treat me in a brutal manner. He dragged the swab from one hole to another and poked it in the wound like a ramrod in the bore. I was dying from pain, squirming like a loach, suppressing the scream bursting out of me.

Therefore, even when removing the bandages, I tried not to cause pain. The highest title in my life was given to me by my little patients at the children's clinic: “Doctor Nebolit.”

Probably, it was these two reasons that determined the choice of the deputy director of the institute.

During the operation I was very surprised at how the spur looked. On a profile x-ray (and only in this projection can the spur be seen) it is a narrow wedge. I removed the spur, which turned out to be a rectangle, using a chisel to separate it from the heel bone. After two weeks, the patient was putting weight on her leg without experiencing pain. Naturally, I was in seventh heaven.

Three months later, the deputy director showed me an x-ray of the operated foot. The spur was larger than the original one. Relapse! I did the surgery poorly! I was ready to fall through the ground. But the deputy director calmed me down. My wife has no pain yet.

Some time passed and I forgot about this incident. I remembered him only a few years later. Looking at the X-ray of a patient with a fracture of the lateral malleolus, I saw a huge spur on the calcaneus. However, the patient assured that he had never experienced pain not only in the heel, but in his legs in general. I conducted an x-ray study of one hundred healthy people over the age of fifty who had never felt pain in the lower extremities. Ninety-two had spurs of different sizes! Only eight people with low weight had no spurs. I remembered what a spur looked like, and everything became clear to me. But still, you should check yourself. I went to the anatomy and dissected the heels of the corpses of eight old people. All of them had spurs that looked the same as those of the wife of the deputy director of the institute.

Therefore, the cause of pain is not the spur. She is a kind of age norm. The plantar surface of the calcaneus is spherical. The load falls on virtually an insignificant surface of this ball. In old age, as muscles weaken, the body protects itself by increasing the area on which the load falls. This reduces the specific pressure. And the pain is explained by the specificity of the soft tissues in this area. From the rough skin to the bone itself there are connective tissue bridges that form peculiar chambers. Swelling that occurs during overuse fills these closed chambers. There is nowhere for it to spread. The fluid puts pressure on the nerve endings, which causes pain.

By this time, I had five hundred patients whom I treated for “calcaneal spurs” with novocaine blockades, and even administered corticosteroids to two, which I then abandoned. More than two hundred more patients with the same pathology were treated with various physical methods. Before sending it to the journal, I read the article, which rejected both the very name of the disease and the recommendations to operate on the spur, to my relatives - my brother and nephew. My brother, an engineer, rated her positively. And my nephew, a theoretical physicist and corresponding member of the Academy of Sciences, took the article with hostility. He attacked me:

- It turns out that you are the only one so smart, and the rest are fools. If everything is so obvious and simple, why didn’t anyone else think of it?

I didn't have time to answer. The brother was surprised how the scientist could even formulate the question in such a way. It just so happens that seemingly obvious things come to someone’s mind first. This is the progress of science.

The article was published. The first to respond was the prominent English orthopedist Dr. R. Watson-Jones, the author of an internationally recognized manual on orthopedics and traumatology. He congratulated me and wrote that he accepted all the provisions of the article, although he understood whose garden I had thrown a stone into, speaking about the pointlessness of surgical interventions. He promised that in the next edition of the manual this nonsense will no longer be there.

It was with great sadness and sadness that I learned a few months later of the death of Dr. Watson-Jones.

And today, most orthopedists continue to call the disease “calcaneal spur.” Thank God, at least they are not operating. Except for those rare cases when they want to make money on an unnecessary operation. But these are no longer doctors, but criminals.

But a real doctor dies with each of his patients.

A doctor dies with his patient

Forty-five years have passed since the misfortune that I will now tell you about, but the feeling of guilt does not leave me, and there is no way for repentance.

I operated almost all night at the Kostanai regional hospital. I managed to sleep for an hour and a half before flying to the hospital of a large grain state farm. There are two operations in the hospital. Reception of approximately ten patients. At this time, an eighteen-year-old soldier-driver was brought in. Having just drunk heavily, he overturned a truck loaded with grain. The case is trivial. The number of injuries during the virgin soil rising was the same as during the war. Especially among the military, who made up a significant part of those brought in for harvesting.

Together with the chief doctor of the hospital, we examined the injured soldier. The smell of alcohol emanating from him could be felt even from a distance. The bones are intact. The stomach is soft. Diagnosis: multiple body bruises. The patient was hospitalized. We decided to examine him again when he sobered up.

The head doctor invited me to lunch. This was very helpful. We had a leisurely lunch in the chief physician's apartment not far from the hospital, without depriving ourselves of the pleasure of drinking a little alcohol. The head doctor turned out to be a pleasant conversationalist. And suddenly, in the midst of this idyll, some incomprehensible melancholy, some wild anxiety fell upon me. We need to go to the hospital and examine the soldier. The head doctor tried his best to calm me down. We left the soldier in good condition. The owner of the house offered to drink another glass. But eventually my anxiety rubbed off on him. We arrived at the hospital.

It was late evening. The soldier sobered up. He moaned and complained of pain in the left side of his abdomen. The abdominal muscles were tense and hard as a board. In the light of a kerosene lamp (there was no electricity in the state farm village), the deathly pallor of the young man attracted attention. The pulse is threadlike. There is not the slightest doubt that there is a catastrophe in the abdominal cavity. Urgent surgical intervention is required. Of course, only under local anesthesia. In the operating room, illuminated by kerosene lamps, there could be no talk of ether anesthesia. A bottle of highly flammable ether could explode.

We started the operation. As soon as the peritoneum was opened, at least two liters of blood spilled out of the abdominal cavity. There was nothing to replace it. There was not a single ampoule of blood in the hospital. None of the personnel had a blood type that matched the soldier's blood type. The source of the bleeding was the spleen, torn into small pieces. It should have been removed. Additionally, the leg of the spleen was anesthetized. And suddenly - death at the moment of applying a clamp to the leg.

If only there was blood for transfusion! If only there had been such blood loss! The diagnosis should have been made a few hours earlier. But you didn’t have to leave the hospital for this. There was no need to enjoy dinner and alcohol. Then there would be no need for kerosene lamps, in the dim light of which we acted almost at random. In daylight it would be possible to operate under ether anesthesia. It was possible to call out, find people with zero blood type on the state farm and do a direct transfusion. An eighteen-year-old boy died. If only I had made the diagnosis in a timely manner!

Not a single highly qualified commission can blame me. Not even the most bloodthirsty prosecutor can accuse me. But for forty-five years now a heavy burden of guilt has been hanging on me for the death of an eighteen-year-old soldier. My medical conscience does not give me amnesty.

And one more incident that occurred literally a few days after the death of a soldier. In Kustanai, I had at my disposal a Po-2 ambulance plane - a “corner”. I sat back to back with the pilot. The rest of the space was taken up by stretchers. But the plane failed. In exchange, they gave me a plane with two passenger seats. On it we flew to the field camp, where an accident happened: the tractor crushed the legs of the foreman, a man of about fifty. Here, in incredible, indescribable conditions, I had to amputate both legs at the level of the middle third of my thighs. So what is next? The nearest hospital is more than a hundred kilometers away. Leave it where it is? But this is a death sentence! If there had been a stretcher on the plane, I could have taken him to the hospital or, even further, to Kostanay, where he would have been under my supervision. But the plane only has seats.

The patient asked me to take him with me to Kostanay.

- I'll do it. I'm tough.

Indeed, he gave the impression of a healthy, strong man. He tolerated the amputation well. It was not without difficulty that we loaded him onto the seat. It’s a little over two hours’ flight from Kustanai. I entertained him with conversation. He answered me willingly. And suddenly he choked, snored and stopped breathing. The eyes rolled back. The pulse was not palpable. I understood the hopelessness of the situation and felt disgusting helplessness as I injected caffeine. In Kustanai we unloaded the corpse from the plane. At the autopsy, as I expected, they discovered a pulmonary embolism. A blood clot broke off in the stump and blocked the blood flow.

Yes, the doctor dies with each of his patients. Part of me left with this handsome foreman. And again the feeling of guilt. Perhaps he should have been left at the camp. Then the blood clot would not have come off. Wasn't it frivolous to put a man in the passenger seat after two amputations?

But, I’m ashamed to admit, these painful thoughts were mixed with a petty, petty, shameful feeling of medical vanity: on the plane I absolutely accurately established the cause of death.

Now I find some justification for this. I was a young doctor. There were no outstanding deeds on my account. Hard labor. Life is terrible. Material compensation for labor is not only below criticism, but even beyond logic. Something had to be done to feed the emotional sphere. This is how exaggerated satisfaction was born after each correctly made diagnosis, if it was not obvious. Over time, I recovered from this stupid disease.

But still she spins

Just recently I witnessed the work of the resuscitation team. My friends and I were worried about unanswered phone calls to our friend. He lived alone. And he’s no longer a young man—he’s nearly eighty. We had a key to his apartment. We arrived and found a terrible picture. Our friend was half-sitting on the sofa, his head lifelessly thrown back. A stream of half-dried foam flowed from his open mouth. The pulse was almost not palpable. Breathing, if it can be called breathing, was shallow and running out. We knew that our friend had a very bad heart. They immediately called an ambulance. Eight minutes later, four men entered the apartment. It was impossible to determine from their appearance which of them was a doctor, which was a driver, which was a paramedic, and which was a medical brother. During their entire stay in the apartment, they said almost not a word. They acted like the fingers of one hand.

You can imagine what mood I was in. But I forgot about him. I was delighted, I admired the work of this amazing team. And then, when they revived what was essentially a dead man, there was no sentimentality. They answered my question in monosyllables about which hospital they would take our friend to. But you should have seen how carefully, how carefully they took him and carried him down the uncomfortable stairs.

Then, in the hospital, treatment is at the highest, most modern level. And leaving! I could blame the attending physician for being somewhat dry. But she was highly professional and responsible, answered all my questions clearly and competently, and gave advice on where and how to turn to solve social problems. However, this function was conscientiously performed by the social worker of the therapeutic department.

A few days later our friend was discharged home in the same condition in which he was when we considered him healthy. Of course, his heart was not replaced.

This incident got me thinking. Maybe I'm just an old curmudgeon who believes that each new generation is flawed and inferior in everything to the previous one? Maybe now there is no need to compensate for ignorance and helplessness with a cordial attitude towards the patient?

I cannot answer these questions unequivocally.

Medieval doctors and alchemists dreamed of a panacea - a remedy that would cure all diseases. Doctors of my generation dreamed of preventive medicine, preventing all diseases. It seemed that antibiotics, genetic engineering, fundamental discoveries in medicine were bringing closer the golden time, when of all medical specialties only preventative doctors, gynecologists (or rather, obstetricians) and traumatologists would remain, because the human race will continue, and injuries, alas, cannot be prevented .

But the unnecessary and incorrect use of antibiotics has led to the emergence of new strains of microorganisms resistant to antibiotics, and everything must be started all over again. New viruses have appeared that cause severe diseases. Doctors' rosy dream of preventive medicine is still unattainable.

Therefore, the wish for good health is still very relevant. And if you have to turn to doctors, then let them be excellent specialists with a kind, compassionate soul.

June 19 - August 11, 1999

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[1] Chapters from the book. Ending. Started in No. 1 for 2006.