Saturday, August 29, 2015

Remembering Dr Red Duke

James Henry "Red" Duke, Jr. 
November 16, 1928 – August 25, 2015

I met Dr. Duke my first day as an intern as I waited
wide-eyed and apprehensive in a  conference room 
at The UT Health Science Center at Houston in 1993.
It was the first day of our surgical internships, and 
we had no time to enjoy wearing our freshly starched
white coats for the first time. And with good 
reason: the program was structured as a “pyramid"
in those days, which meant that of the 9 interns sitting 
in the room that day, only 5 would make it to a coveted 
Chief Resident spot after a grueling 5 years of clinical 
training, plus additional years  in the laboratory.  
In my case, I would be the sole survivor of the 
intern class of ’93.
But I didn't know that then, and as Dr Duke entered
the room we were at once mesmerized by his larger-
than-life presence.  He was the classic Texan, surgeon, 
cowboy, and movie-star all rolled into one. He made 
his appearance and brief speech to us with panache, 
a cup of coffee in a styrofoam cup in his hand. 
A down-to-earth welcome flavored with true Texas 
hospitality greeted the group, many of whom were 
out of state. A nice letter typed up on the departmental 
letterhead completed the process.  

He seemed genuinely concerned about all of us interns, 
I could tell. Today, I know he was also giving us the once-
over. He knew he would be having each of for lunch 
before the year was through.
A week later in the ICU, I had my first teaching from 
Dr Duke as I prepped a patient for a minor procedure.  

“One thing, it was just one damn thing I asked you to remember.”  

He strode off out of the unit to go attend to other things 
while everyone looked at me, standing there stupidly at 
the bedside. I honestly didn’t know what a DeMartel 
clamp even looked like, but then suddenly remembered 
that he’d asked me to have it ready the week before.  
I carried one around for the next 5 years in my white 
coat pocket, and there's still one in my desk drawer to 
this day.
He was that kind of surgeon: regimented, by-the-book, an 
Eagle Scout, and not too tolerant of poor preparation
Worse yet, he often loathed the “new silly shit” we were 
always pulling on him.  He would listen to our proposed 
treatment plans on occasion, but I learned mostly to shut 
up and watch. 

I learned, way later than you might think, that his chief 
concern was for the well-being ofhis patients. His version 
of teaching was not trying new things or doing research, it 
was showing us the value of what was tried and true to 
keep patients safe and outcomes predictable. As such he 
was often at odds with his colleagues at the University,
and even us, the lowly trainees.  

As I advanced in the program I was at times frustrated 
by his ways until one night during my 3rd year. I was 
hurrying off to surgery with another doctor to use the 
newly developed video-laparoscope to remove the
gallbladder of a very ill patient, I excitedly told him 
of our plan. He remained silent, and we 
parted ways.  

Five hours later I emerged from the ICU after barely 
stabilizing the patient, who ended up never leaving the 
unit. As I left, ashen-faced and in disbelief, I looked up 
to see Duke in front of me.  He would be in the 
hospital at the oddest hours.

 “Bit you in the ass, didn’t it ?”  

That was his way of saying “the procedure you selected 
didn’t afford you the exposure needed to get control of 
the bleeding. And you ought to have expected that, 
but by the time you opened up to get in there and stop 
it, it was too late.” 
In the years ahead, I was to learn that he was intolerant 
of a lot of things. And I realized it wasn't really the new 
procedures he didn't like, it was the bad outcomes he 
so hated and strived to avoid. 
Today, I navigate a system driven by cost-containment and 
"efficiency." I also drive by billboards and see the TV ads of 
the personal injury lawyers. Drug and medical device 
names explode the headlines, promising millions in malpractice 
and product liability settlements"

"These are different times" I think.

But then I realize that not everybody got to train under 
Dr Duke.

We spent hours together in the emergency room, his second 
home.  He’d sit an an old schoolroom style wooden chair with 
side-arm desk attached. The thing was from the 60's and 
encrusted with carvings, inscriptions, and medical graffiti. 

When needed, he'd be in the room directing the organized 
chaos that was a trauma resuscitation.  When multiple 
patients would arrive, he might get up and enter the room
to help us prioritize the plethora of xrays, lab tests,
IV catheters, and drainage tubes that critically injured patients 
were subjected to. 
“Now it’s gittin’ interesting” 

He was always an island of calm, and never lacked direction. 
In emergency surgery, he stayed as calm as the goats they put 
to pasture with racehorses to prevent them from getting 
too riled up. 
When, and if, you earned the right to actually hold an 
instrument during surgery, his demeanor was an immense help. If you were 
clumsy or unpracticed, you would be quickly be relegated to 
cutting stitches the rest of the case. For good measure, he 
would add a few choice comments, ensuring that we had a 
good case of "chewed butt syndrome" to think about on the way 
out of surgery.  
“Shortcuts and shit? Is that what they teach you here?” 
It wasn't easy working with him much of the time, but we 
warned the junior residents what to expect, and it seemed they 
either "got it" after a short while or they didn't.  
Those who didn't usually weren't in the program too long. Fair 
or not, that was the nature of the training and Dr Duke and 
the other faculty put out a fine group of surgeons, and 
many of them now lead their own departments at prestigious 
institutions across the nation.

Dr Duke founded Hermann Life Flight. You couldn't think of 
those big red helicopters without also imagining Dr. Duke 
being on the other end waiting to care for you. It was an 
enormously reassuring feeling, and we felt special that our 
city had those angels buzzing around overhead. Ours was 
one of the earliest helicopter evacuation services in the 
country, and Dr Duke he knew the flight crews like family.
It was his idea to assign the interns to "do scenes" on the chopper. 
That meant strapping in, holding on, and trying to 
stay out of the way while the flight paramedic and nurse 
sorted things out in the middle of a highway or at some job site 
where something had gone terribly wrong.
Assigned in 24 hour shifts, I was just coming "on" one evening 
when I heard a "physician to the helipad call" from my 
counterpart on the helicopter.  I ran to the OR and tried to 
help the nurses set up.  
"Lets get a  chest set out, Bobbie."

"It's in the room, you open it."
Minutes later the patient exploded in the room, CPR in progress, 
right as anesthesia arrived. My buddy had managed to get a 
breathing tube in and he had an IV.  A quick look at the 
monitor showed his heart was beating but his color and a 
quick pulse check showed that he wasn’t pumping blood.  
His left chest was rounded and bulging out.  

Dr Duke walked in, took one look, and barked "get a damn chest 
tube in him."  

He turned to find me standing there with a clear tube resembling a 
small garden hose in one hand and a scalpel in the other.  

2 AM with Dr. Duke
The author performing a repair of a ruptured diaphragm with Dr Duke
Hermann Hospital 1997

"Are you gonna put it in, sunshine?"  

Seconds later a huge rush of air and blood shot out across the 
room from the small incision between the patient's ribs. 
That which didn’t hit me splattered on thewall. The room 
seemed frozen for that few seconds as the patient's color 
immediately came back. I don’t remember anything else other 
than Dr Duke using his funny, Jed Clampitt singsong voice he 
reserved for moments of extreme light heartedness: 

"Well lookie there."

It was small victories like this and Duke's way of acknowledging 
them that gave you hope you might survive, but also kept 
you on your toes.
Our training extended beyond the O.R. with "Red", as I came to 
call him in my final years in the program.  He could be found 
cooking a pizza during happy hour in the kitchen of 
our favorite dive bar in Rice Village. He'd bring turkey every 
Thanksgiving to his call room in the hospital that served as his 
apartment much of the time.  The small group of tired residents 
unlucky enough to pull call that day were all invited.  
As residents, he knew we were under a lot of stress and were prone 
to excess in our time away from the hospital. He briefly attended 
one of our happy hours, and a few of us remained there well into 
the evening. The next morning on rounds, Red noticed a team 
member absent from the lineup "Where's sunshine?" (his name 
for any generic junior resident whose name was not yet worth 
"Umm he didn't make it in this morning." I said.
"What, he get drunk....arrested ?"
"Yeah, in the parking lot before he got in his car. We tried to stop 
him but the cops got there first."
"Aw hell you should have called me, I would have bailed him out." 
He was just that kind of a person, true to himself and understanding 
of others.  His TV persona was as big as Texas, but that was just 
one color in the palette. He had a heart big enough to share with a 
lot of people in many ways.  Dr Duke the Eagle Scout, the Aggie,
the tank commander, the Afghanistan field surgeon, the cowboy, 
the professor, and more.  

Simply knowing him you got a taste of all of that. He would tell 
outlandish stories, and we would make our own as we went 
along too.
"Back in '71 we were developing this new dialysis solution in the 
laboratory, you see.  There at Parkland Hospital.  This other 
surgeon and I would mix this stuff up in a big vat.  
And that crazy bastard was funnier than a rubber crutch, 
he'd be smoking a cigarette the whole time." 
My memories of Dr Duke are many, and they run the while 
spectrum of what we all went through doing what we did 
in those days. Although 2 decades have passed, it still seems 
like yesterday.  I never once felt sorry for myself after his 
numerous reprimands, because even then I knew 
where they were coming from. Today I am grateful for them. 

Words are hard to come by when writing about someone 
who made a difference for so many but I know that I, 
and all of us who trained under him honor him every 
day in caring for our patients the way he would have.