See One, Do One, Teach One: How I passed out doing my first spinal tap in the King's County Prison Ward

That day, I had gone down to the prison ward with my senior resident, Dr. Kitakihka. The House Staff in Internal Medicine at Kings County Hospital back then were all foreign medical school graduates; and a good many of these practicing physicians from other countries who were once again going through the same old shit in order to obtain medical licenses and board certifications in the United States. Dr. Kitakihka, in retrospect, was one of the best doctors I had ever worked with: Cheerful, laid back, and smart as a whip. And he never wore gloves. Did for our spinal tap, but otherwise had some kind of existential issue regarding exposure to blood bourne pathogens. Emerging from AIDS ravaged Uganda at the time, he had practiced an unfathomable style of medicine; to him, Kings County could have been the Mayo Clinic. Very respectful, he had trained under the British System, and would laugh at matters we Americans perceived as being "difficult."

One took a big freight elevator specifically designated to access the prison facility; its door opened onto a small cube facing this foreboding reinforced concrete door. As you stood holding your 23 gauge butterfly needle,  hand trembling, and NYPD guard ogled you through a smoky little window. When satisfied, the door began to slide across, taking thirty seconds to complete its travel. The next space entered comprised a hybrid nursing station, to the left an elevated room protected by reinforced glass, from which the guards rarely emerged. Straight ahead was a little kitchen with one or two chairs, medical cabinets, and a desk. The nurse sitting there was like most of the others. They didn't so much as glance at medical students; you needed to have an alien emerging from your abdomen to get any kind of response. And even then, the stare suggested a nihilism acquired through service within a gulag concentration camp. I had the greatest respect for their judgement: As I came to understand, they knew precisely when it was "time to panic," which was almost never. Another reinforced door had to be opened in order to enter the sixteen bed prison ward.

Kings County in the early 90s still had open wards. What I mean by that suggests a very specific working environment that is not seen in other American Hospitals. The Medicine floor for instance, I think it was on six, housed people in florid renal failure, with end stage cancers, trachs, Wernicke Encephalopathies, infectious diarrhea, PCP pneumonia, the usual menu, all laying there, in Central Brooklyn's 100% humidity, like kids in a Camp Minniehowhow bunkhouse with one teenage counselor. They'd shut the windows and turn on the air conditioner only if temperatures rose over one hundred and fuck off to anyone who'd tell you otherwise.

Recall the Kings County Hospital renovation of the 90's when an incredible sum of money vanished between the eleven contractors hired: "This month, 10 years and more than $100 million into a building plan that would largely replace the hospital, Mayor Rudolph W. Giuliani halted the project, expressing concern that it had been badly mismanaged." New York Times Feb 28, 1994 (Elisabeth Rosenthal)

So here we came, the Downstate Medical students, in our white waist coats, carrying clip boards and calculators. We were the ancillary hospital staff, the phlebotomists, essentially what they used to call "orderlies." But there was no better education in becoming a "real doctor."

The day had been another barbecue on the Kalahari, the prison ward an oven. The inmates were straddled on their beds, staring at us. There was not much cause for concern as these guys were all sick, some of them would have even fulfilled admission criteria for an Intensive Care Unit bed in other hospitals.

As this was my first spinal tap, Dr. Kitakule had accompanied me. A short partition was erected around the prisoner, a latino dude with suspected meningitis related to his HIV status. Three quarters of the inmates on the prison ward were HIV positive with low CD4 counts, expressing the gamut of what today would be considered rarer manifestations of AIDS related illness. This guy had been diagnosed with Cryptococcus Chorioretinitis. I'd been down the day before to look into his eyes, making note of the characteristics yellow spots cause by an opportunistic fungus that can work its way into the central nervous system, a real shit. The guy wasn't doing too good.

I had to poke the man several times with the long needle. He started writhing from the get go, moaning loudly. Another prisoner had been peering around the partition murmuring Oh my God, Oh my God; moaning along with him.

As an EMT I had passed out once pulling traction on a severely fractured forearm. The bones moved, made a loud grinding sound and the patient screamed. Lights dimmed from my periphery inward then extinguished altogether. I was revived laying on top of the woman, her broken arm pinned under my chest. Luckily, she had a sense of humor. Later on in my career, I worked in a Public Health Service stand-alone ER in the Southwest, doing all my own closed reductions of similar forearm fractures without passing out. These were my years of acclimatization. I wasn't alone though. My all time favorite was a face plant into a pelvic cavity during an open hysterectomy. And that particular medical student was planning on specializing in Gynecology.

A drop of clear fluid finally emerged from my spinal catheter but the process had already commenced. I thought I could tough it out so I didn't mention to Dr. Kitakihka that I felt I was viewing everything through the wrong end of a telescope. I only recall standing up suddenly and remarking:

"I think you'd better take over."

There was a clatter and the next thing I knew, an NYPD officer, holding both my wrists, was dragging me across the prison ward floor. They gave me orange juice at the nursing station and I think that nurse even asked me how I felt.

When it came my turn to present the spinal fluid results at the next morning report, our battle hardened attending, a Pulmonary Intensivist, said:

"So, Dr. Knott. word has it you're going into psychiatry." There was a pause. He turned to Dr. Kitaihla. "Make sure Dr. Knott does the next fucking lumbar puncture and the one after that."

I did three in a row that Saturday night. They left me alone in the ER on the adult medicine side to set up my own sterile field between gurneys, as we all did, and try to remember what Dr. Kitaihla had showed me.

"You OK with this?" the resident had asked before leaving. "I have an admission."

"Yeah, fine."