Foreign Threat

by Mitchell Goldstein

  Steve was just as interested in the specimen sent for pathology. He thought that it would perhaps shed light on the reason the young kid coded the way he did. However, there was no way the Pathology Department would have the slides made up yet. Twelve hours had not even passed, and there was not a chance in hell that a pathologist would be at the hospital this early.

  Steve was wondering if the specimen would show cocaine or if the cocaine in his system was from drug use. The mass could have been just an abscess that collected after a severe appendicitis. It was not unusual to develop a collection of pus after a perforated appendicitis. Events occurred so quickly last night that Steve never had time to explore the abdomen, but the fact that there was so much stool in the abdomen meant there was a hole somewhere in the colon. Neither Steve nor Jake had time to explore the abdomen. Slowly, Steve realized that Jake went right away for this mass and never spent time exploring the abdomen.

  As Jake continued to get caught up on all the patients from

  Sally, Steve continued to reexamine the details of the surgery. The hole in the colon could have been from a variety of causes. One was that the appendiceal stump broke open and leaked stool. There could have been necrosis around the cecum, which would have caused a perforation. Another cause for the stool leak might have been an inadvertent injury to the bowel. Still, Steve was not sure why there was so much stool and why it even happened. He figured that the pathology report would answer some of his questions. He would check in with the Path Department later that day.

  “Steve, Steve! Hey, Carmichael! Where the hell are you, sport?” Sally was trying to get Steve’s attention while going over the day’s plan.

  “Sorry, Sally. I guess it was a long night. Where do you want me today?”

  “Well, Steve, let’s try doing what we have done for the last several weeks. That means the post call person gets to go to the OR. As far as I can remember, you were the one who was on call. Is any of this coming back to you now, or are you still sleeping?”

  “Yeah, right,” laughed Steve. “I am still a little tired after last night.”

  “So be it, Carmichael. I still need you to get your little ass over to the OR and scrub with your favorite chief resident.”

  Steve was half listening and half trying to replay the code last night. One thing was for sure: he didn’t need to be alongside Jake for the next four or five hours as he tried to figure things out. “Dr. Jenson, I am just not feeling well right now. Maybe someone else could scrub in this morning. After all, scrubbing for cases is a reward we earn as interns, and if I choose to relinquish that reward, that shouldn’t be a problem. I’m just too tired today.”

  “That’s okay, Steve,” joked Tom Formin. “We know surgery residency is tough and it’s not for everyone. So if you need to go to Mommy’s for some chicken noodle soup, well,

  that’s okay.”

  Tom Formin, the other junior resident, usually didn’t say much, but when he did, it was usually not very complimentary. He was rude to interns, students, and anybody who was underneath him on the totem pole. If an attending came by, however, he would shower them silly with admiration.

  “Fuck you, Formin.” Steve pulled out a tissue. “Here. Why don’t you wipe your nose? You got a little something there. Oh, wait a minute. What is that smell? Oh, I see, Formin. That is just a little shit left over from this morning’s session of kiss the attending’s butt!”

  The entire group laughed uncontrollably, including Sally. Even Tom smiled, but his face became redder and redder.

  “Alright, you two,” Sally said as she tried to regain her composure. “Tom, why don’t you go to the OR today? Steve, there are three discharges and two admits so far. Here is the list. Why don’t you give me a call when you have those done?”

  Although Steve was tired, the real issue was not fatigue. He was too preoccupied with the case from last night. He felt awake, but he had spent almost every minute thus far in the day rattling his brain about the code and why the young man died.

  Steve had the medical students go to the OR with Tom so he could get the work done and still try to figure out why the guy died last night. Work even went a little quicker without the burden of medical students asking questions about this and that.

  By about 1:30, Steve was done with all the floor work, including the admissions and discharges. He strolled into the cafeteria soon thereafter to sit down for a bite to eat. The place was almost empty except for the few people finishing their lunches. Steve paid little attention to the surroundings. He bought a sandwich and a Pepsi and then sat down to eat. As he chewed his food slowly, he seemed to be mesmerized by the lightly blowing trees.

  “Boo!” shouted Erica as Steve was looking off into outer space.

  “SHIT! What the hell are you trying to do, give me a heart attack? You must be bored today if you’re creating medical situations just so you can have a few more patients.”

  “Shut up, Carmichael. I’m far from being bored. But you look like either you are either bored or extra tired from last night.” She grinned. “I’m beginning to like you even more when you are sleep deprived.”

  Steve looked up and realized she was referring to this morning. He felt a sense of pleasure to know that she responded in such an accepting manner. He let her know with a slight smile.

  He leaned back and said, “Actually I’m not so much tired as I am puzzled as to why this young guy coded in the OR last night during surgery. He basically died as quickly as he arrived. I know he was sick prior to surgery, but he should have made it through surgery and even survived the code. Something doesn’t fit. I mean, this guy comes in from who-knows-where with a belly full of pus and shit, and then he dies. His tox screen is positive for coke, but he didn’t respond to anything last night.”

  “Yeah, I heard. It seems to be the talk of the day. You know what the medical fleas are saying about it, don’t you?”

  “Not really.”

  “Well, since you surgeons were having trouble with the medical code, you should have just called one of us. We prob-

  ably could have help save the guy’s life.”

  Steve looked at her and stared for about half a minute. Then he smiled and shook his head. “I’ll remember that next time I code a guy with a belly full of pus and all coked up. Thanks for the talk, but I need to get a few things done before I leave.” He stood up. “And about this morning, uh, I was really tired, but I think that definitely should be followed up with another dinner

  sometime.”

  Erica turned a deep shade of red and smiled. “That would be great.”

  Steve turned around with a satisfied look and left the cafeteria. Just before he was out the door, he glanced back at Erica and saw her still red and watching him. He smiled, waved to her, and headed to the surgical nurses station.

  On the way, he thought about asking Sally if he could leave early. He wasn’t so physically tired, but this preoccupation with the case had really worn him down. He figured she would have to OK it with Jake first, but after all that Steve had done last night, he hoped Jake would give him a break.

  Steve reached the station and logged onto the computer system to look up the pathology from last night.

  As he began working, Sally came up from behind him. “Boo!”

  “What the hell! Does everybody have it out for me or what? That is the second time today that somebody nearly gave me a heart attack!”

  “Sorry there, big boy. I didn’t realize it was such a popular thing to do. Are you looking up some labs?”

  “No. I already did that, and they all look fine. The guy in room 204 has a UTI and probably on his way to getting Urinary Septicemia. I put him on some Levaquin.” Steve continued, “No, what I need is to find that Path specimen from last night and see what the hell that mass was.”

  Steve pulled out a card from his pocket and began typing in the ID number for Ziamuddin. He waited a few minutes while the computer searched his file. Finally, a screen came up. “That’s
really weird. There is all his lab work but no path specimen.”

  “Steve, you sound really tired. I asked Jake at lunch, and he said it would be okay for you to head home after all your work

  is done. So scram, man!”

  Steve looked at Sally, wanting to give her a big hug. “Thanks a lot, Sally. I really appreciate that and will take you up on that offer. I’ll just call Pathology to see when the report will be complete from last night.”

  “That’s great, and then get some rest!” said Sally.

  Sally walked off, and Steve was even more perplexed. He reviewed the ID number that belonged to Ziamuddin and tried again to get his report on the path specimen. After several tries, Steve finally just called the Path Department and asked the receptionist to locate the abdominal mass from last night.

  After a few minutes away from the phone, she came back on and said they never received a specimen from this patient.

  “That’s impossible,” Steve said. “I took that out myself last night, and then Dr. Douglas ran it to the department. He took it right during the case, and then-”

  “I’m sorry, Dr. Carmichael, but I have no record of anything coming in last night.”

  “Maybe it came in late, but you must have it by now.”

  “I’m sorry again, doctor, but I do not have it on my in-shelf now, and there is no record of it coming in! You might want to check with Dr. Douglas himself.”

  “Alright, fine. Thanks a lot!” Steve couldn’t help the sarcasm dripping from his voice.

  He sat staring at the computer screen, trying to figure things out. He remembered without a doubt that Jake had walked out of the OR suite with the mass in his hands. After the guy coded and Steve was so busy, he didn’t actually see Jake come through the doors back into the OR. He just heard his voice. Maybe Jake didn’t have time to make it all the way to the Path Department. But as they were cleaning up after and closing the patient, Steve vividly remembered Jake leaving without any specimen.

  This was getting too weird. The more Steve thought about

  it, the more frustrated he got. Maybe Sally was right. Maybe he just needed some sleep. He signed himself out of the computer, collected his items from the call room, and left.

  As he walked out of the hospital, he was in such a daze trying to piece this all together that he failed to hear Erica say goodbye to him. By the time she ran to the doors, he was already almost to the parking lot. She watched Steve get into his car and drive away.

  Chapter 27

  Steve arrived home feeling totally exhausted. He went through the motions as always: first, he let Pudge out, then he let Pudge back in, fed Pudge, and then collapsed on the couch. The remote for the TV, though nearby, was not within hands’ reach and consequently too far away this time. Steve rested his head softly on the back of the couch and gazed up at the ceiling.

  He reviewed the last twenty-four hours, starting with when he had begged Jake to allow him to scrub on the case. After much pleading, he found himself in the OR operating on a guy no one knew anything about except that he was terribly sick. Jake seemed to be rather preoccupied himself. Although always cocky, there had been something strange about Jake’s demeanor last night. This mass inside a body that had recently had surgery made everything more confusing. Steve tried to remember exactly what the mass looked like. The events of the code seemed to mask everything else that happened prior to and after it.

  Steve went back to the thoughts about the mass. It was soft and compressible, but as he recalled pushing on it, no pus had come out of the mass itself. He remembered that the mass was covered with a thick layer of pus and stool and that the odor was horrific. As he tried to feel more of it, Jake pushed his own hands into the wound to quickly extract the mass. After that, Jake held on to it as if it was a favorite toy that he didn’t want to share with anyone else.

  Steve continued to reflect on the events of the day until he fell asleep on the sofa. He went quickly into a deep sleep with Pudge by his side. He slept for several hours until a beeping noise woke him up. He reluctantly opened his eyes, forcing one eye open and then slowly opening the other. He heard a beep again. He recognized the noise but was not sure from where it came. He had definitely been in a deep sleep because he initially thought he was waking up in the morning to head back to the hospital.

  When both eyes were opened and functioning, he noticed the clock in the kitchen. 12:30. Either he was very late or it was the middle of the night. As he lifted his body from the couch, he glanced out the window and saw a pitch-dark sky. With a sense of relief, he made his way to his computer. He finally recognized the beeping to be that from his email messenger.

  He opened his message board and found about ten messages from Sweetpea, all of them just saying hello or wondering why he hadn’t showed up for the daily chat in the last few days. That was odd, he thought, because they always communicated via a private chatroom. He didn’t recall giving her his email address. He always thought it would be the easier way to communicate with her but felt somewhat uncomfortable giving a stranger access to torment him. After so much communication with her, they had discussed exchanging email addresses and communicating via that route. But he was so tired now that he could not remember if he had actually given her his address.

  Nonetheless, he wrote back. “Sorry I have not talked to you for so long, but I have been really busy at work…as always. Last night I had this young guy die on the operating room table. It really has bothered me the entire day. I hope it will be the last time that ever happens to me again.”

  Sweetpea replied, “I’m so sorry about that. I’m sure that you did your best to help him out. That is all you can really expect of yourself. Don’t forget that you are human just like the rest of us. Sometimes you will have good outcomes, and unfortunately sometimes they will not be so good, but as long as you do your

  best, no one can ever fault you.”

  Steve always appreciated the way she made him feel okay even after a terrible day. Maybe that is why he chose to write back in the middle of the night. However, he was surprised to see her respond so quickly. It was as if she was waiting right there online to get the message and write back. Either way, she seemed to always find the right words to make him feel better. “I appreciate your kind comments. You always make me feel better. I knew there was a reason why I decided to write back in the middle of the night.”

  “Thanks. I don’t mind at all. Sounds as if your days are a little more stressed than mine. So was that jerk of a chief with you last night? If he was, I bet he didn’t really help matters much.”

  “Actually he was there, well, kind of. You see, we took out this mass from this kid and then Jake, my chief resident, took full responsibility to get the specimen over to pathology. It was while he was gone that the shit hit the fan and the young kid coded. He was really sick with a bad infection in his body, something we call sepsis. And then I think he went into septic shock and coded. I paged Jake back immediately, but we were well into reviving him – or at least trying to – when Jake came slamming back into the room.”

  Sweetpea was very interested. “It seems like this chief resident of yours is always evading his responsibilities. So what kind of mass was this? Was it like a tumor or cancer?”

  “I don’t really think so. The guy’d had surgery just a short while ago, and it looked as if it was an appendectomy. He probably had a leak after his appy and spilled stool into his belly after surgery. Things happened so fast that night because he was so sick that we don’t know where he had surgery or where he was from. He was foreign and didn’t seem to speak too much English. Anyway, I think it was an abscess. But Jake grabbed the thing as if it was his long lost favorite toy. He swept it away and ran off to the path department with it.”

  “That is kind of weird. What did it look like? I mean, was it hard or soft? Was there a lot of gunk on it?”

  “I can tell that you are not medically literate: GUNK? But to answer your question, it seemed somewhat soft
and did have a lot of pus around it. But Jake literally took over the case once I exposed it. He just darted his hands into the wound as if to get there first and then snatched it and ran off. I will say it was kind of weird. Right before the guy coded, I thought I saw white powder in the wound. But as quickly as I saw it, the blood and pus in the wound covered whatever was there. It was strange.”

  “That is really strange. Do you think it was just something from his stomach? I mean, if you thought there was a leak, then maybe that was just food particles, right?”

  “Actually if he leaked from where the appendix usually is connected to the colon, the food that he ingested was already digested once it reached the colon, so what leaked out was stool. And that is exactly what was in the belly, shit and a lot of it.” Steve continued typing. “But what was really odd is that after the guy coded and died, I was closing, and the anesthesiologist and I were talking about the cause of his death and why he didn’t respond to anything. I mean, he didn’t respond to fluids or to drugs. It was the strangest thing in the world. So I decided to get a tox screen even though Jake didn’t want me to.”

  “Why didn’t he want you to?”

  “I don’t really know, but A.J. and I thought it would help try to figure why this kid didn’t respond to any of the therapy. And as it turned out, he was full of coke…and it wasn’t diet either.”

  Sweetpea stressed her curiosity. “Well what did the path

  show? Did that report come back yet? That would probably shed some light on the matter.”

  “Exactly, it would probably give us a lot of information. The only problem is that the specimen is missing!”

  “WHAT?! Where did it go? How can you lose a large mass like that?”

  Steve tried to explain in his reply message. “I don’t recall the events after the code that well, but I know for a fact that Jake ran off with the specimen to the Path Department immediately after he got the mass out. Then all I remember is that he returned when the guy was coding. I don’t remember if he brought the specimen back with him to the OR suite. I need to ask him tomorrow. I just didn’t get a chance to ask him today. After I discovered the path specimen wasn’t in the computer system, I quickly called the Path Department, but they had no idea what I was talking about. They had absolutely no record of the specimen.”