by Allen Wyler
My flock? Alex realized the thing he resented most was Clarence’s smug self-assuredness. In spite of Alex’s ability to control the residents, Clarence knew he could proselytize whenever and wherever he wished. And at the moment, he appeared to savor his ability to rub Alex’s nose in it. The patient comes first, Alex reminded himself. Forget it. Let this pass. It’s a stressful time for them. He could think of nothing to do but smile. “Roland’s fine. I was able to remove a hundred percent of the tumor. He’s in the recovery room and should be waking up soon. Once he does, I’ll move him to the intensive care unit for overnight observation. I expect he’ll be back to his room tomorrow morning.”
Clarence smiled at his flock and lifted his hands like a priest at the altar. “Praise be to God!” The family echoed his words. Alex turned and left. What goes around comes around, Clarence. Count on it.
43
“Best way to deal with those rag-heads is to just nuke the hell out of Baghdad,” Brett Johnson said. “Drop a big one and turn that damn place into glass. Launch a hundred cruise missiles, that ought to do it.”
Alex stopped operating to look at the young man. “Don’t joke about that.”
Johnson recoiled. “Hell, I ain’t joking. I’m serious as a damn heart attack. The Koran tells the Arabs to slaughter all infidels—meaning anyone who’s not Muslim. We just need to wipe out all them rag-heads before they get the chance and settle the issue.”
Alex handed Chuck his instruments and turned to look at the resident. “Where’d you come up with that business about the Koran?” Alex glanced over the surgical drape at Cole. Cole looked up from the latest issue of Car and Driver he was reading and nodded, letting him know he was listening.
“Everybody knows that,” Brett said dismissively.
“News to me. Then again, I guess I’m not everybody. So tell me, did you personally read those words in the Koran, or is this something you heard from a friend?” The only sounds in the room now were the soft hiss of the suction and the wheeze of the anesthesia machine. The circulator, Chuck, and Cole were all listening. Cole turned down the cardiac monitor to a barely perceptible volume.
Johnson dropped his eyes to the surgical field. “You mean me personally? No, I don’t read that Arab shit. But I have it on good authority.”
Alex seldom stopped a case to talk, but he wasn’t going to let the remark pass unchallenged. “What good authority?”
“Oh hell, I don’t remember.”
“Have you read any of the Koran?”
Johnson gave a derisive snort. “Hell no. Why should I do something like that?”
“Doctor Johnson?” A circulating nurse stuck her head in the door. “You on call today?”
“I am.” He sounded relieved to have a distraction.
“Just got called by the ER. They need a resident to come see a patient.”
Johnson waved her away. “Tell them I’m busy. Call someone else.”
Alex jumped on it. “Wait, don’t do that.” He looked at Johnson. “You’re not really doing much at the moment, and this dissection’s going to take me”—he glanced at the wall clock—“another couple hours. Go ahead, scrub out. I’ll muddle on without you.”
Johnson slapped his sucker onto the overhead table in a snit. “Whatever.”
“Doctor Cutter,” the circulator said, breaking his concentration, “we just got called again by the ER. Seems they’re still waiting on a resident to come see the patient.”
Alex handed off the Malis—a forceps capable of cauterizing tissue—to Chuck and rocked his neck side to side, working out kinks. He stood up from the rolling stool and backed away from the microscope so he could flex and extend his spine in an attempt to loosen up the tight, aching muscles. The clock showed him he’d been sitting in the same position for three straight hours.
“Bob, Chuck, please note the time.” Then he told the circulator, “Call the lounge and find out which resident is free at the moment. Ask him to come see me. If we don’t have one available, find one who’s scrubbed.”
“You call, Boss?”
Ah, Steve Stein. Perfect. “I did. There’s a patient in the ER who needs to be seen. Pop on down there, take care of it, and report back as soon as you’re done. Got it?” If Johnson was lying to him—which he strongly suspected—this might be the perfect opportunity to document it.
“I’m on it.”
“Note the time?” he asked the moment Stein was out of the room.
Both Cole and Chuck said they had.
“Routine migraine,” Stein explained thirty minutes later. “Took care of it and discharged her with instructions to schedule a follow-up with you next week. Anything else?”
Alex thought about it a moment and decided he needed to keep a lid on this incident until he had a chance to sort out all the facts. “Yes. Keep this just between us. Understood?”
After a questioning look, Stein nodded and pushed through the heavy OR doors into the hall.
“Bob, please note the time.”
Thirty minutes later Johnson sauntered in, tying his mask in place. “All taken care of.”
Alex handed his instruments to Chuck and stood, grateful for another excuse to stretch. This should be interesting. “What was the problem?” He tried to sound neutral.
“Routine rear-end collision. Driver was complaining of neck pain. The only reason I needed to be gone so long was I had to get X-rays, and Radiology was backed up as usual. I’ll scrub back in.” He turned toward the door to the scrub sinks.
“Hold on. Before you do, jot down the patient’s name so I can sign the chart when I finish up here.”
Johnson appeared at a loss for words. “Uh … that’s not necessary.”
“Oh? Why not? You signed the chart as my resident, right?” If so, Alex would be required to countersign.
Johnson shuffled his feet. “Not exactly. Thing is, uh, Friedman came in about the time I was finishing up, so I asked if he’d sign the orders. I know he’s not on the rotation but thought I’d save you the hassle. So you see, there’s no need to bother.”
A wave of sadness descended over Alex. Why lie? What could he possibly think he’d gain? Didn’t he realize he’d eventually be caught? “It’s no bother because I do want to review the chart. Consider it part of resident quality control.”
Johnson nodded agreement. “Okay. I’ll do it after the case is over.”
Alex caught Chuck rolling his eyes. “No, Brett, write down the patient’s name now. I’m closing anyway. It’ll be done before you can finish a scrub. Leave the name on my loupes case. Okay?”
Johnson shrugged. “Whatever.”
Alex watched the circulator hand him a progress note to write on. Johnson glanced back over his shoulder at Alex, shrugged again, and wrote something on the paper before slinking out the door.
“Hey, Johnson,” Alex called after him. “Two things.”
“What?”
“First of all, leave the paper.”
“Oh.” Johnson reluctantly handed the sheet to the circulator. “What else?”
“What would you say if I told you Humpty Dumpty was pushed?”
As Johnson shouldered his way out the door, he called over his shoulder, “He was probably an asshole and deserved it.”
With Johnson gone, Alex asked Cole and Chuck, “You guys catch all this?”
“Hard to miss,” Cole said.
“Good. I’d appreciate it if none of this leaves this room. At some later time it may be necessary for you to verify what just happened.”
“Uh, uh, uh, Lord have mercy,” Chuck muttered. “That boy’s in a world of hurt.”
With the wound dressed and the patient on his way to the recovery room, Alex—still wearing scrubs—dropped down three flights of stairs to the Emergency Room. Luckily, the nurse who initially called for the consult was finishing up his end-of-shift paperwork.
“The patient you called about, which resident took it?”
“Just a second, let me have
a look.” The nurse began thumbing through a handful of charts in the “Out” bin. A moment later he slid one from the stack. “Here we go. Let’s see … a migraine. Looks like your man Stein took care of it. Why?”
“Brett Johnson show up to see anyone?”
The nurse reached for a log of all the patients seen during the day and by whom, and ran a finger down the list. “Nope. Doesn’t look like Johnson’s been here today. The list runs from midnight till now. Want me to check yesterday’s records?”
“No, that’s not necessary. Has a whiplash patient been seen today?”
He checked the log again. “Doesn’t look like it.”
“Friedman been here to see anyone in the past two to three hours?”
This time he didn’t need to check. “Nope.”
“Final question: Know of any problems getting Johnson to respond to calls?”
With a sigh, the nurse glanced away, perhaps searching for a diplomatic answer. “Let me put it this way: we’ve had our issues.”
“What sort of issues?”
“Pretty much exactly what we’re discussing. Not answering pages. And when he does, he doesn’t always come in. Which obviously puts us in a bind, because we then have to turn around and call around for someone else to come see the patient. There’ve been times when your boys are tied up over at the trauma center so we had to call in one of the private surgeons. They’re not thrilled about the idea of backstopping your guys.”
Alex closed his eyes and squeezed the bridge of his nose, trying to lessen an impending headache. “Why am I just hearing about this?”
“Supposedly Doctor Reynolds was told about it a while ago, but nothing’s been done. Least nothing we’ve been able to see.”
Reynolds was probably too busy at the time and simply forgot. Alex jotted down the nurse’s name and other particulars about the incident. “I may need to have you recount this conversation under more formal conditions. Any problem with that?”
The nurse seemed relieved to have the story out. “None at all.”
44
“Excuse me, Doctor Stein,” Alex interrupted, stopping Steve Stein in the middle of presenting an X-ray during the Monday teaching conference. “I that see Dr. Johnson has elected to join us.” The time was 4:16 p.m. All eyes went from Stein to Johnson, who was halfway down the auditorium aisle.
“Dr. Johnson,” Alex called, “please tell the group what kept you from being here at the start of conference.”
Several residents exchanged knowing glances while Johnson awkwardly slipped into an empty seat behind the group. “Sorry, sir, I was taking care of a post-op.”
“Right, patient care comes first.” Alex stood up and pulled a blank index card and pen from his lab coat breast pocket. “What’s the patient’s name?”
More furtive glances between residents.
“The patient’s name?” Johnson asked lamely.
“Yes, the patient’s name.”
“Oh, man … right on the tip of my tongue … give me a second; it’ll come. Go ahead, don’t hold things up on account of me.”
“Okay. After conference you stay and we’ll discuss it.”
“I’d love to, Doctor Cutter, but I need to get back to my patient soon as we finish. In fact, if my beeper goes off, I may have to leave early.”
Alex knew the old beeper trick all too well. Trigger it yourself or have a buddy call you. Who can say you shouldn’t leave whatever you’re doing to answer the page? Convenient.
“No, you don’t. You stay right there,” he snapped. “You will stay and we will discuss this.” He addressed the group. “Conference adjourned. Everybody out except for Doctor Stein. Steve, come here please.” Alex kept an eye on Johnson as the rest of the residents set a new world record for how fast they filed out of the auditorium.
Stein began quickly repacking the CT scans into a large green Radiology envelope, the green color identifying the films as loaners. Now finished, Stein approached Alex. “Yes, Boss?”
“Wait in the lobby.”
Stein glanced from Alex to Johnson, back again. “You bet,” he said before high-tailing it out of the room.
Alex approached Johnson, who stood, licked his lips, and started rubbing his thumb and fingertips together, a nervous habit of his frequently displayed when presenting a case at conference. “Okay, Brett, let’s go see your post-op.”
Suddenly, Johnson went all hangdog on him, shifting his weight, hemming and hawing as he got his act together. He inhaled audibly. “Sorry, sir, but I lied. There is no post-op patient. Actually, I was on the phone to my mother. She’s just been diagnosed with breast cancer, and I was trying to talk her through the treatment options. She doesn’t understand medical things very well and is frightened to death.”
Ah, Jesus. The dying mother routine. Only slightly more believable than the dog-ate-my-homework excuse. “Sorry to hear that.” Alex mimed a thoughtful pose. “You know, I bet I could help with that. Why don’t we go to my office and call her, put her on speaker phone. I’ll be more than happy to explain things to her. C’mon, let’s go.” Alex motioned to the aisle.
Johnson looked even more pathetic now, complete with a bit of foot shuffling. Another shake of his head. “Aw man … Aw shit … Look, I’m sorry, but that was a lie too. Because, see, I’m too embarrassed to admit the truth. We’re having marital problems. My wife … she doesn’t understand why I have to spend so much time at the hospital. I was on the phone to her and, well, it’s overwhelming … the thought of losing her.”
Alex relaxed his fists and extended his fingers, loosening them. “Enough! You just lied twice in less than thirty seconds, and I know you’ve lied to me in the past.” His voice wavered on the cusp of anger.
Johnson snapped from hangdog to righteous indignation. “Lied in the past? Never!”
Alex sliced his palm through the air. “Stop it! I don’t want to hear any more bullshit. It’s all been documented.”
Johnson stiffened. “And just what do you think you’ve documented?” He sounded confident now, as if calling a poker bluff with four aces in hand.
“Fair enough.” Alex nodded and withdrew a card from his white coat. “Let’s start with Friday. You scrubbed out to answer an ER call. I checked on it after I finished my case. You never got within a hundred feet of the place. I ended up sending Stein to cover for you. Then you had the nerve to look me straight in the eye and lie about it. This has been going on all year.” Alex held out his hand. “Hand over your ID card. You’re fired.”
Shocked and stunned, Johnson stared back. “No, don’t do this. Please. I’m serious about my wife. Fire me and she’ll leave me for sure. Please, Doctor Cutter, sir, don’t do this to my marriage and family.”
Alex motioned again for Johnson’s ID. “I’m not doing a thing to you. You did it to you. Card, Johnson. I want it now.”
“But … I’m on call.”
“No, you’re not. That’s already been taken care of. The paging operators have been notified. You’ve already been removed from the residency roster, and your hospital privileges are revoked.”
They walked from the auditorium, Alex turning right and—to his relief—Johnson veering left, Alex wanting as much distance from him as possible. It’d been harder than he imagined to fire the kid. Stein stood in the main lobby, still holding the green folder of CT scans.
“Steve, sorry for this imposition, but you’re taking Johnson’s call tonight,” Alex said. Of all the residents in the program, he trusted Stein most, probably because of their relationship prior to relocating here. He and Stein had shared confidential information, so he knew the kid could keep a secret.
“Figured that was what had happened when I got called for a problem on Seven Madison.”
“Good. I’ll leave it to you and the others to revise the call schedule.”
45
“What’s the biggest risk of operating with this position?” Alex asked Steve Stein as they opened the bone flap for a craniotom
y. Alex had the patient positioned on his left side, the table incline placing the feet a few inches lower than the head.
“Blood loss?”
Alex made the “wrong answer” buzzer sound. “Nope. Try again.” Then to Chuck, “Bone wax.” Quickly, with the piece of bone detached from the skull and safely wrapped in a saline-soaked sterile towel, Alex began pushing wax into the marrow space of the skull edges. “Why am I using bone wax?” The sterile wax would seal the space, making it airtight.
Steve moved the sucker closer to where Alex worked, clearing away the oozing blood. “To stop bleeding.”
Alex packed the last spot, then used a wet cotton sponge to wipe the remaining wax off his gloves. “True, but what else? Why not simply cauterize the space?”
“Don’t know. Because cautery doesn’t work well with bone?”
Alex placed the unused glob of wax back on the overhead tray. “We want to prevent air from being sucked into the venous system. Doesn’t have to be much at any one time, but over time it can add up.” He looked to Chuck. “Irrigation.”
Chuck placed a blue rubber ball with a short nozzle in Alex’s hand. He used this to squirt sterile saline over the exposed dura and bone edges, washing away residual bone dust and blood before proceeding to the next stage of the opening. “Same goes for when we open the dura. We have a major venous sinus running along here,” he said, pointing along the midline of the brain surface. “We need to be extremely careful to keep from getting an air embolism. That, Doctor Stein, is our most serious concern right now. And what’s the name of this sinus we’re trying to avoid?”
“Superior saggital sinus.”
“Exactly.”
A few minutes later, Alex stopped Stein as he carefully cut open a three-sided flap of dura hinged along the sinus. “Hold on. You’re close to the edge of the sinus now. It’s not safe to cut any closer. Let me take it from here.” Alex stepped over to the wall-mounted X-ray box for a closer look at the CT scans to gauge the sinus width. He heard Stein ask for a pair of surgical scissors and started to turn to tell him again to stop, when, to his horror, blood gushed from the wound. Stein froze.
