by Allen Wyler
“About same age as you. Hired him six months before y’all.”
Kasey popped in as Dave was leaving and handed two sheets of striped lab results to Alex. “Thought you might like to see this. The patient you ordered the B12 shots for?”
He quickly scanned the sheets, one listing hematology results, the other listing blood chemistries, any abnormal values in bold font. Several abnormalities were obvious: the white cell nuclei were multi-lobed, and the size of the red cells was excessively large, both findings typical of pernicious anemia. The other sheet verified the suspected B12 deficiency as the cause. A tingling elation snaked through Alex. Nailed it!
“Kasey,” he said, handing the lab results back to her, “please have him scheduled to see a gastroenterologist. I’ll fill out a consult sheet.”
“Who you want him to see?”
Alex realized he had no idea. He glanced across the hall at Berger’s office, but Martin was out. “Ask Garrison’s secretary who he refers to. That should work.”
Before turning his attention to the next Any Doctor, he quickly filled out the GI consult. Sitting back in his chair, he momentarily savored the glow of hitting a home run in his first at-bat, how different this felt to the hypothetical case on his orals. That one had been just that: hypothetical. This one, however, was startlingly real. He’d caught the problem before it could cause irreparable damage. This was real medicine, not some abstract, detached mental exercise in a test tube or under the microscope. Then again, the comparison wasn’t really warranted. Practicing medicine and doing research were totally different endeavors, each yielding their own unique satisfaction. Which reminded him, he was behind on getting his lab activity running again.
He glanced at the half-written NIH application on his desk. Instead of tennis, he should be working on the grant. Call Dave and cancel? No, I deserve a break. The pace of clinic was faster than anything he had yet experienced, and certainly faster and denser than he’d expected.
Alex grabbed the phone before the second ring finished. He squinted at the bedside clock. 1:03 a.m. Rolling onto his left side, his back to Lisa, he said softly, “Alex Cutter.”
“Sorry to call so early in the morning, Doctor. This is the Baptist West paging operator. Dr. Singh on Six West would like to speak with you. May I connect you?”
“You on call this evening?”
Yeah, but it’s morning. “Yes.” Alex sat with his legs over the edge of the bed now, a ballpoint and notepad in hand.
“Have a patient needs seeing ASAP. How long before you can get here?” Singh’s words carried a tinge of panic.
Depends. “What’s the problem?”
“Nurse found my patient unresponsive about an hour ago and called me. I came in to evaluate him but don’t have a clue what’s going on or what to do for him. I need help.”
“Be there soon as I can.” Alex mentally ran a list of things Singh could do while he was in transit. “Any recent imaging on the patient?”
“No.”
“Then have them do a CT scan.” Having never set foot in the building, he wasn’t sure how long it would take to find them. “Which floor is the patient on?”
Years ago Alex discovered the comfort of wearing scrubs to bed. The nights he was on call, he brought a fresh set from the hospital and returned the old set the next morning. When he got called in for emergencies like this, it allowed him to get out the door a couple minutes faster.
He hung up the phone. Lisa—long since used to nighttime interruptions—was back asleep. He believed some of the calls no longer woke her. Noiselessly, he eased the bathroom door shut, rinsed his face, grabbed his electric razor, and headed for his car.
The empty streets allowed him to drive a bit above his usual speed as he headed west on Central, catching a long string of green traffic lights and even blowing through a red light after first checking for cops. Driving left-handed, he worked on knocking down his stubble with the electric razor. Not a perfect shave by any stretch, but at least he wouldn’t look quite so ratty.
Twenty minutes later he pulled into the parking lot outside the ER, killed the engine, and jumped out of the car, slipping on his white coat as he headed toward the automatic sliding glass doors. An armed security guard in the ER directed him to an elevator bank that would take him to the sixth floor.
He hurried down the dim hall toward the brightly lit nursing station where a middle-aged man with dark skin and gray hair stood talking in hushed tones to two nurses in blue scrubs. The man—literally wringing his hands—wore a tie-less white shirt, dark slacks, and a rumpled sports coat.
“Dr. Cutter?” the man asked with obvious relief. “Ajay Singh.”
After shaking hands, Alex wiped the sweat from Singh’s palm on his scrubs. “Tell me about your patient.”
“This way,” Singh said, pointing over Alex’s shoulder. “We can talk as we walk.” He started hurriedly down the hall. “I admitted him this afternoon from my office. He had a temp of 103, said he felt awful the night before. He looked dehydrated and sick enough that I decided to hospitalize him straightaway. I ordered codeine for his headache and some routine blood work and, because of the temp, the usual cultures. I started him on IV fluids, but in spite of it he seemed to get worse. When the nurses checked him”—he paused to look at his watch—“an hour and a half ago, they couldn’t arouse him.” As they entered a room, Singh pointed to a patient on his back, both eyes tightly shut.
Alex watched the patient for a few moments to get a gestalt impression. The man looked sick. The next thing he noticed was Cheyne-Stokes respirations, a waxing and waning breathing pattern indicative of decreased consciousness. This finding immediately decreased the odds of a psychological cause for the coma.
“What’s his first name?” Alex asked no one in particular.
“Ethan.”
Alex placed his hand on the man’s shoulder and immediately felt the heat. “Yikes, he’s burning up. Hey, Ethan!” he shouted, rocking the man’s shoulder. “Wake up!”
The patient grimaced, both arms flexing at the elbows, hands fisted, eyes clamped shut—a classic posture associated with organic coma. The limb symmetry indicated both sides of the brain were equally affected. At this point Alex knew any further attempt to assess the patient’s orientation would be impossible, so he turned to evaluating the cranial nerves. Normal eye function requires precise coordination of half of the twelve cranial nerves, making the eye exam the most important part of the neurological evaluation. Alex tried to open the upper lids, but the patient resisted. Alex tried harder. The patient responded again by flexing his limbs and clamping his eyelids together. Applying even more force, Alex was able to open the eyes enough to glimpse the pupils, equal in size. He tried to rock the head side to side, but the patient’s neck wouldn’t move. That gave Alex two critical findings: photophobia and nucal rigidity. In other words, light on the retina was painful, and his neck was stiff from irritation to the meninges. Together, these two pieces of information indicated bad news.
“Aw man,” Alex muttered. “He has meningitis.”
“What?” Singh asked anxiously.
“This whole picture,” Alex said with a nod at the patient, “indicates meningitis. At his age, most likely cause is subarachnoid hemorrhage. But the history of onset doesn’t fit.”
Could it possibly be? Just like that case at Coastal County?
Alex looked to the nurse. “We need to set up for an LP.” Then to Singh, he said, “He get the scan?”
He nodded. “He just returned when you arrived.”
“Good. Before we pop a needle in his back, I need to check the scan to make sure we’re not dealing with something weird like a mass up there,” he said, pointing to the patient’s head. A common mistake generalists made was to perform a lumbar puncture on a patient harboring a brain mass from a tumor or abscess, because removing spinal fluid lowers the lumbar spinal pressure, causing the increased cranial pressure to squeeze the brain out the base of the skull w
ith disastrous results. More than a few patients had been inadvertently killed as a result.
“What do you see?” Singh asked Alex.
This question always amazed Alex, because CT scans seemed self-evident, clearly showing the brain, its various cavities, and the skull. There was nothing subtle about the anatomy. Then again, he supposed he was used to reading them. He wondered how well he’d do looking at a CT of the abdomen.
“Good news, bad news. Good news is we’re not dealing with a mass, so we can probably get away with an LP. But the bad news is the brain’s tight as hell.” The entire brain appeared swollen from edema, the internal chambers collapsed, increasing the risk of a lumbar puncture.
Alex asked Singh, “You want to do it?” Offering Singh the chance to do the LP would allow him to bill for it. Alex suspected he wouldn’t want to touch it, shifting all the risk back on Alex.
Singh waved his hand. “No, no, please, you do it.”
“Better get going then.” Alex headed for the door, thinking about the radiologist who would read the scan later that day—perhaps while enjoying her cup of morning coffee—and then bill for an interpretation rendered hours after the information had been processed and acted upon. This sort of after-the-fact analysis irritated Alex. If the radiologists wanted to charge for those readings, they should have dragged their asses out of their warm, comfortable beds to provide the service when it really mattered.
While they were downstairs viewing the CT scan, the floor nurses had wisely called for backup so that by the time Alex and Singh returned, a male nurse was waiting in the room, ready to help. On the over-bed table, the blue plastic water jug and box of Kleenex had been replaced with a disposable LP tray in the unopened cardboard packing box. “What size gloves, Doctor?” the floor nurse asked.
“Seven and a half.”
“Prep solution?”
“Betadine.”
“Bed’s already flat,” the male nurse said from the opposite side of the bed.
Alex slipped the pillow from under the patient’s head and handed it to the male nurse who knew enough to fold it and place it between the patient’s knees. Alex moved a chair next to the bed, removed the clear plastic wrapper from the LP package, and slipped out the sterile wrapped tray. “Ready?” he asked the nurse.
“Yep.”
Alex motioned to Singh. “Get on the other side to help hold. He’s not going to like what I’m about to do.”
“Okay, on the count of three,” Alex said once everyone was in position. “One, two, three.” Using the draw sheet, Alex rolled the patient onto his right side then quickly pulled him toward the edge of the bed, positioning the patient’s back parallel to the edge. The nurse and Singh held the patient in this position. “Don’t move his legs until I’m ready, okay?”
“Roger that, sir.”
Another ex-corpsman. Carefully, Alex pulled off the coverings to expose the molded sterile plastic tray of disposable plastic parts. He opened the gloves and slipped them on as the floor nurse poured Betadine solution into the prep-tray compartment, saturating three sponges. Alex painted the lower spine area with the solution, dropping each contaminated sponge into the wastebasket rather than back in the sterile tray.
Alex placed the sterile paper drape over the man’s hips so the hole in the center was over the lower lumbar spine. Using the drape as a sterile barrier, he felt for the edge of the hip and adjusted the position of the hole slightly. As the Betadine continued to dry, he replaced the prep gloves with real surgical gloves for a better sense of feel.
With his left hand he felt for the space between spines, found what he wanted, and told the nurse, “Go ahead, curl him up with his knees as close to his chin as possible. We’re only going to get one shot at this.” Flexing the back opened up the space between the spines so the needle could pass more easily, but it would still be extremely painful.
“Get the head,” the nurse said to Singh as he wrapped his muscular arm behind the man’s pillowed knees. The nurse pulled the knees toward the head.
With his left thumb and forefinger straddling the desired space, Alex adjusted the angle of the long spinal needle to the correct trajectory, said, “Hold him,” and pushed the needle through the skin. Reacting to the pain, the man tried to straighten, but the nurse and Singh held him in position.
“No local?” the nurse asked, surprised.
“Hurts worse than what I just did. And takes longer.” With the long needle halfway in, Alex paused to sight along the patient’s spine once more, double-checking the trajectory, making sure it was perfectly perpendicular to the spine. Satisfied, he continued to slowly advance the needle deeper, feeling each level of resistance the tip encountered, mentally visualizing the anatomy as the bevel approached the spinal canal. The tip grazed bone as it moved deeper, suddenly unimpeded, meaning he just passed into the proper space and was only millimeters from the target. Next, he felt slight resistance and gently tapped the needle a millimeter farther. He felt a slight pop as the bevel punched through the tough dura and entered the spinal canal. A perfect pass.
Alex readied the manometer and stopcock, withdrew the needle stylus, and quickly attached the pressure-measuring device to the end. “Hold the top of the manometer, please.”
The floor nurse reached over Alex’s shoulder to hold the top.
Left hand holding everything snug in case the patient moved unexpectedly, Alex opened the stopcock. “We’ll do this slowly,” he said to no one in particular.
Ugly, grayish viscous fluid began to slowly fill the manometer. “Ah, Jesus,… will you look at this. Nothing but pus.” Fluid this thick would make an accurate pressure reading impossible.
“Call Infectious Disease,” he said to the floor nurse. “Tell them to get someone up here STAT because we have a flaming case of meningitis. Ask them for a list of all the cultures they want.” Most likely they were dealing with a bacterial infection, but you never could be sure. Whatever the problem, it looked like shit.
At this point Alex’s job was essentially done. With the pressure measurement useless, he simply drained several CCs of the viscous fluid into three sterile collection tubes before withdrawing the needle. “Okay, we’re done.”
At 3:37 a.m. Alex set the brake and killed the engine. He sat in the silent car decompressing from mixed emotions. On one hand he felt exhilaration from slam-dunking the diagnosis. Only once before had he actually seen fulminate infective meningitis—an unconscious street person brought to the county hospital without a history. That time he performed the LP because an astute senior resident ordered him to do so. On the other hand he felt sorry for the man at Baptist West who could end up permanently damaged from a terrible disease. He tried to buoy his spirits by reassuring himself things would definitely be worse if he hadn’t done the LP, but that helped only slightly.
Perhaps he’d been wrong about private practice. Diagnosing problems with life-saving implications brought such a different sense of satisfaction than research. Probably, he realized, because each case became a self-contained story with an obvious ending. Research seemed to have no such well-defined conclusions, most lab days simply generating more work and more questions. In comparison, these little case-by-case triumphs felt meaningfully tangible. In spite of being dead-dog tired, he decided to devote at least two hours the following evening to his grant submission.
He slipped from the car and made his way silently back to bed. Morning would come too soon.
27
“Got a moment?” Reynolds asked Alex as the Monday conference was breaking up.
Alex stood, waited for Reynolds to vacate the aisle seat. “Sure. What’s up?”
Reynolds motioned for him to continue up the aisle with him toward the exits. “Got a cerebellar tumor scheduled for the morning but just learned I need to fly up to Bethesda on Navy Reserve business. Mind taking it for me?”
Two weeks had passed and still no surgical cases. This would be Alex’s first surgery here, and he was anxious to b
egin this facet of practice. It seemed too long since his last case. “Yeah, sure. As long as your patient doesn’t mind.”
“Mind? Hell, that nigger’s not going to know any difference. Just walk in the room and tell her you’re the surgeon. Got her as a referral from a doc who doesn’t send me much, so I know he doesn’t give a lick either.”
Alex recoiled at the use of the word nigger but said nothing. He immediately felt ashamed for his silence. His hesitancy, he realized, was from still being gun-shy after the Weiner experience. Last thing he wanted to do was piss off his chairman.
Reynolds must have read his mind, for he punched Alex’s shoulder good-naturedly. “Don’t like the word nigger, huh? Alls I can tell y’all is to get used to it. Us southerners don’t mean nothing bad by it, ’cause niggers are niggers. Always have been, always will be. Hell, even niggers call each other niggers. It’s something y’all are just gonna have to learn to tolerate.”
Doubt it. Besides, a white man calling someone a nigger isn’t quite the same thing.
“What’s the patient’s name?”
“Latisha Alexander, East 715. Y’all have a 7:30 start. Appreciate you taking her for me. Hadn’t planned on this trip, just suddenly popped up is all.” They passed through the doors into the hospital lobby where a young African American male in scrubs and bouffant surgical cap hummed while steering a floor buffer back and forth across the marble.
Alex jotted her name on one of the three-by-five note cards he stored in his breast pocket for exactly this purpose. “Naval Reserve, huh? Didn’t know you served.”
“Yep. If I stick with it another four years—which I have every intention of doing—I’ll make admiral. Do that, figure I can retire. I can fix you up too if you want. Make some extra money while you’re at it. Easy money. University and the clinic are required by law to give you the time, so it’s one sweet deal. ’Sides, you don’t have to do a damn thing except your monthly weekends and a couple weeks a summer. Reckon you might oughta look into it.”
