A new mash for a new millennium

Hymns, novels and phone calls home sustain a Yale alum on the ground in Baghdad.

By Cathy Shufro

Intensive training for handling wounds prepared Air Force Major John C. Lundell, M.D. ’94, for the casualties he might encounter as a battlefield anesthesiologist. But in the weeks after Lundell arrived at his post in a tent hospital at the Baghdad airport in early July, his caseload resembled family practice more than trauma medicine. At Camp Sather Lundell treated several patients who were dehydrated and some who had blood in their urine, sutured cuts inflicted by can tops and pocket knives and took care of an airman having a heart attack.

All that changed with the bombing in August of the United Nations office in Baghdad. Since then, his wife Andrea L. Lundell, M.D. ’94, reports from their home in Texas, he has treated both soldiers and civilians, Americans and Iraqis, some with severed limbs or serious burns resulting from the ongoing violence in Iraq. And it turns out that at Brooke Army Medical Center in San Antonio, where she is chief of cardiothoracic imaging, she has treated patients her husband stabilized in Baghdad. “A lot of the bad cases end up coming here for further work,” she said.

In e-mail messages to Yale Medicine in July, Lundell reported that when he was not working shifts, he kept busy playing bridge with tent mates, washing his clothes and reading novels, the Book of Mormon and the hymns he’d loaded onto his Palm Pilot before leaving his home base in Texas. When he couldn’t sleep, his cycle disturbed by the rotating shifts, Lundell sometimes hung out at the hospital, chatting with those on duty or with other restless airmen who had drifted up to the hospital tent. Twice a week, Lundell could count on phoning his wife and children, 5-year-old Madeline and 3-year-old John W.

Lundell said he felt safe where he worked, well inside the base for 1,500 Air Force personnel. He went to Iraq as part of what he calls “a lean, mean wound-fighting machine,” a five-person mobile field surgical team that also includes a general surgeon, an orthopaedic surgeon, an emergency medicine physician and a critical care nurse. With equipment they carry in 70-pound backpacks, the team can assemble a portable OR in less than two hours. Their supplies can see them through 10 life- or limb-saving operations. The team can also collect fresh blood from any service member whose blood type, printed on dog tags, matches the patient’s.

A week before his departure Lundell explained that his team is trained to treat patients during “the golden hour of trauma,” when the team has the best chance of saving a life by controlling bleeding—which causes about half of combat deaths. “The old system of dragging them off the battlefield and shipping them off to an Army hospital took much more time. …We can pack a spleen or amputate a leg,” he said. Now the team can stabilize patients before sending them on to a larger hospital.

Team members do face limitations. For instance, they can’t use all their fluids on a single patient, even if a life depends on it. “In a level one trauma center, where we have basically unlimited resources, there’s a better chance of saving someone that is severely injured, but in the field there would be nothing left for the nine other patients we’re supposed to treat,” says Lundell. “Sometimes you have to make tough decisions and decide who is going to be treated expectantly, meaning comfort measures—mostly analgesia, morphine.”

The possibility of letting a patient die “is something we’ve had to think about. ... That would be rough, because we’re trained to not let people die. We’re trained to save lives.”

Lundell’s role in the mobile field surgical team brought him what he jokingly calls “my 15 seconds of fame.” In May, he appeared in “Blood on the Battlefield,” a National Geographic Explorer documentary on battlefield medicine. Lundell’s 15 seconds (actually more like 30) showed his team practicing setting up an OR and then operating on “victims” hemorrhaging fake blood. Lundell and his team members actually learned most of what they know of trauma care by treating real-life victims at Wilford Hall Medical Center on Lackland Air Force Base in San Antonio, where they were stationed before going to Iraq. Lundell said taking care of people injured in drunken-driving accidents kept them “up to speed in dealing with people who are bleeding to death.” In Baghdad, the team is working as a “building block” for a hospital staff of about 25. They work in a 20- by 70-foot air-conditioned vinyl tent with a wooden floor.

Lundell supported the U.S. invasion of Iraq, likening it to surgery. “You really would rather not operate on people. An operation is a controlled injury, controlled trauma. But if you have to operate, you want a finely honed instrument. The military is the knife. You have to cause injuries, but hopefully it’s for the greater good. … Certainly I regret some of our troops having to pay the ultimate price to free the Iraqi people, but I do support the president.” He says that his wife agrees, then adds: “I don’t know how our support would change if something were to happen to me. It’s not something we have much control over. We do our best to do what we signed up to do.”

Doing what they signed up to do has made life for the couple unpredictable since September 11. Both were in the Air Force and were periodically “at risk” for deployment, potentially at the same time—in which case the children would have stayed with relatives. The pressure eased in July 2002, when Andrea completed her three-year Air Force obligation and began a civilian job at Brooke Army Medical Center. Both husband and wife, who met as first-years at a volleyball game on Harkness lawn, took part in the Armed Forces Health Professions Scholarship Program. The government paid their medical school costs and provided a salary for John’s fellowship year in cardiothoracic anesthesia. In return, the Lundells spent a year in service for each year of support they received: she for three, he for five.

Andrea Lundell says she is coping with her husband’s absence, expected to last four months, by keeping the big picture in mind: “I try to remember that there are many other men and women over there who are making sacrifices, too, and there have been many others who have in the past. … I keep a positive attitude.” She feels supported by colleagues at Brooke Army Medical Center. “A lot of people over there know what it’s like to have somebody go.”

When John Lundell completes his Air Force service in June, he expects to go into private practice to maximize time with his family. “I like doing and I like teaching. If I can find a place where I can teach some and do, then I’ll be happy.”

Lundell is grounded by his faith as a Mormon, which is “part of the fiber of my being. It helps me feel prepared for whatever may come.”

Cathy Shufro is a contributing editor of Yale Medicine.

Familiar Faces

Medicine and society have changed—but not conditions for residents

Ruth Potee, with her husband, Stephen Martin, also a physician, and their children, Ella and Ben.

When Ruth Potee’s father started his medical residency at Boston City Hospital in 1949, the system was pretty simple: young medical school graduates received room, board and a lab coat in return for patient care and the training that went along with it. At the time, only residents at Bellevue Hospital in New York City received a stipend.

That changed when Gale Potee and his colleagues formed the first house staff association in the country and won stipends from the city of Boston. “It started a movement where residents were recognized as not just students, but doctors who deserve some compensation,” says Ruth Potee, M.D. ’99. But change is slow. Half a century later, when Potee was deciding where to train, she could safely expect a paycheck, but she also wanted an institution where the house staff had a say in how the hospital runs. “I didn’t want to be at a place where I was a voiceless peon in the system,” she says. She joined Boston Medical Center, where in 1972 the house staff association became a union with bargaining rights, and became an active member of the organization her father had helped found.

In 2002, in the final year of her residency in family medicine, Potee became national president of the union, the Committee of Interns and Residents (CIR). (Union rules allow members to remain on the executive committee for two years after completing a residency.) Now the largest house staff union in the country, CIR still represents only about 12 percent of the nation’s 100,000 residents. “It’s hard to organize residents,” Potee says. “They have no time to organize themselves. They are so tired and broken and depressed, they can’t imagine things ever getting better.”

But Potee firmly believes residents need to be organized, especially since medicine and medical students have changed so much since the system was devised. For much of the 20th century, residents were usually young, male and single. Today’s resident is far more likely to be older, female, married and a parent. Potee was a member of the first majority female medical school class in Yale history, entering medical school at age 26 after working in politics in Texas and New York. She married and had her first child while at Yale, and gave birth to her second child during residency. (Half of women in medicine give birth during medical school, residency or fellowship, says Potee, who wrote her thesis on medicine and motherhood.)

Through her position at CIR, Potee works to make residency better for today’s graduates. Founded in New York City’s public hospitals in 1957, cir won a collective bargaining agreement and established a benefit plan for house staff early on, and in 1975 negotiated a contract provision limiting call to one night in three. In a landmark 1999 case brought by CIR, the National Labor Relations Board ruled that residents are employees, not students. CIR helped shape New York state’s Bell Regulations on duty hour limits for house staff, a model for the new duty hours guidelines from the Accreditation Council for Graduate Medical Education, which went into effect in July.

The union also fights for minimum staffing levels for ancillary hospital personnel, so hospitals can’t cut nurses or technicians and expect residents to fill in. Those kind of cuts are bad for residents and for patients, Potee says. “The hospital can’t balance its budget on the backs of residents,” she says. But with budget deficits in most states, hospitals’ finances aren’t likely to improve any time soon. “I worry that residents are the group that tends to fill in the cracks, and the cracks are ever widening.”

—Karen Schmidt

From Brooklyn to the vineyards: how a surgeon became a country doctor

Alexander Zuckerbraun, Ph.D., M.D. ’55, often finds fresh fruits and vegetables in the back of his pickup truck—in late May two sacks of oranges, a week later a flat of Bing cherries. These anonymous gifts come from this “country doctor’s” patients who are farm workers. Although at age 79 Zuckerbraun calls himself a country doctor, he is really a hybrid: a family practitioner who spent 20 years as a surgeon, a California ranch owner with a Brooklyn accent.

Zuckerbraun took a while getting to medical school. After studying chemistry at the University of Michigan, he was drafted in 1943 and spent three years working on the atomic bomb project at Columbia University, Oak Ridge, Tenn., and Los Alamos, N.M. When he applied to study medicine 14 schools rejected him. He’s not sure why he was turned down; perhaps it was because his stellar chemistry grades contrasted with some dismal grades in other subjects. (He recalls a D in history.) Nonetheless, he says, “I was going to do medicine whatever it took.” Figuring a Ph.D. in chemistry would be good preparation for medicine, he earned his doctorate at the University of Minnesota and applied again. He got into Yale.

Zuckerbraun and his new wife, medical technician Ruth Hitchcock, moved into veterans’ housing—a two-family Quonset hut near the Peabody Museum. Zuckerbraun laughs when he recalls inviting an admired professor, pathologist Averill A. Liebow, M.D., and his wife over for drinks. “They acted like they were very much at home. This was almost like a shack.”

More daunting than living in a near-shack, however, was the transition from chemistry to medicine. He didn’t like anatomy at first, and he suspects he would have failed the first few quizzes at some other medical school. “I wouldn’t have made it without the Yale System. Any other medical school would have thrown me out.” After graduation and surgery residency, Zuckerbraun and his wife settled in Santa Maria, a small town near the central coast of California where they raised seven children.

In the late 1970s Zuckerbraun made another radical lifestyle change. “I decided to be a country doctor, to work out of my office. No appointments. You just come in when you’re sick. I won’t see you in two weeks; I’ll see you when you’re sick.”

He still thinks like a surgeon, always considering both a surgical and a medical remedy for a problem. From his patients, most of them field workers, he has learned to speak fluent Spanish.

Along with his prescriptions comes preaching. “I don’t preach religion. That’s personal. I preach education.” He asks a young man, “Would you like to keep doing what you’re doing for the next 30 years? Bent over picking strawberries?”

Not that Zuckerbraun is averse to picking fruit himself. He and his wife own a 317-acre ranch east of town, where nearly an acre of wine grapes should be ripe for winemaking in a year or two. Zuckerbraun has no plans to retire. “I wanted to be a medical doctor since I was five years old. What am I supposed to do, quit now?”

He hopes to be practicing medicine in 2005, he says, and to join his classmates in celebrating their 50th reunion

—Cathy Shufro

On the front lines of the battle to provide affordable care

New Britain General Hospital was the eighth-largest employer in town two decades ago. Now it’s number one. That may sound like good news, but it’s not, says hospital President and CEO Laurence A. Tanner, M.P.H. ’72.

His hospital now ranks as top employer because the city’s seven largest manufacturers all left town, went under or reduced their work force. Tanner has long experience with how that kind of economic pressure affects health care: since studying hospital administration under John Thompson at Yale in the early 1970s, he has served three decades as a hospital administrator, working for 15 years at two other Connecticut hospitals before joining New Britain General as its president in 1987. Now Tanner foresees “chaos” as local economic pressures combine with cuts in government funding and the end of the “Robin Hood theory of health care.”

The struggle to survive financially overshadows all other concerns for Tanner as he runs the Central Connecticut Health Alliance, which employs 3,000 people and comprises three hospitals, two nursing homes, two assisted-living facilities and a mental health center with several locations. Two-thirds of New Britain General’s income comes from “inadequate and drastically shrinking” state and federal funds. Last spring, Connecticut was paying only 50 cents per dollar of costs for Medicaid, while the federal government paid 90 to 94 cents per dollar for Medicare. Insurance companies no longer bridge those gaps through higher fees paid by insured patients. “Industry has said they can’t afford it,” says Tanner. The problem is compounded by the expectation of patients that they will have access to the latest diagnostic technologies and therapies, regardless of cost.

New Britain General has controlled costs by restricting prescription formularies, postponing building repairs and joining with other hospitals to buy supplies. The hospital has also diverted funds from education and prevention into the operating budget. “We think we’re doing a disservice from a public health perspective, but we have a financial imperative,” says Tanner. “I have the day-to-day dilemma of how to provide care for the person in the hospital today.” Tanner worries that recent medical advances and those on the horizon will be denied to patients who can’t pay. For instance, a cardiac defibrillator like Vice President Dick Cheney’s costs $30,000 to buy and implant. Medicare reim-burses less than $20,000. So who gets to have one?

Tanner’s strategy for improving financing long term is to talk to policy-makers. He occasionally visits the Connecticut Legislature and has twice addressed the federal House Ways and Means Committee. His goal is to help lawmakers understand the impact of cuts in funding, of new regulations and of the nursing shortage—“informing the decision makers on the consequences of acting or failing to act.”

In fact, the nation’s decision-maker-in-chief visited New Britain General on June 12. President George W. Bush chose Tanner’s hospital as the venue for a speech on Medicare reform and prescription benefits. The president addressed 250 people in the hospital cafeteria en route to Maine to celebrate his father’s birthday. Although Tanner did not get to buttonhole Bush to convey his own policy proposals, he found the visit satisfying. “It tied public policy to a real hospital.”

The region’s bad economy has touched Tanner personally: his wife, Janice Ann Piazza, recently lost her job as a manufacturer’s website developer. “She was outsourced and downsized,” he says wryly.

When he feels overwhelmed, Tanner visits the neonatal icu. There he likes to watch the premature babies “and see them thrive.” Visiting the newborns provides an antidote to the “daunting process” of running a hospital with shrinking resources. “It’s a frustrating process and in some cases a depressing process,” says Tanner. “In some ways it’s also an invigorating process. When you have a small victory, it’s a victory. You know that what you’re doing is benefiting people. There’s somebody out there who’s getting a service that they wouldn’t otherwise get.”

—Cathy Shufro


			Originally published in Yale Medicine, Autumn 2003. Copyright © 2003 Yale University School of Medicine. All rights reserved.