“Before we hear case presentations, I want to welcome fourth year student Carlos Vega to our team. Carlos just completed his sub-I in flower-arranging…I mean family medicine. Let’s all show him what real medicine is, shall we? Carlos, since you’ve been working…say…three hours a day for the past 2 months? We don’t want to tax you too much while we get you up to speed. So, we’re going to start you with mainly post-op patients. This will allow you to review the histories of complicated trauma patients who are in the recovery phase while you get your feet wet. You will be expected to know everything that happened to them from the moment of their mishap to the time you present them. I want to know how many times they farted on the way to physical therapy, is that clear? When you have mastered that, you will be given progressively more challenging decision-making responsibilities with the appropriate monitoring from a resident. Do you have any questions?”
Minus the condescending language, this was about what I expected. “No, Sir,” I replied.
“Good. After morning report, see Dr. Althea Johnson for your patient list. I have custom compiled it for your special skills,” was it just me or was there a twisted evil grin on his face?
I listened to the war stories of the interns and residents of Team Three. Those who had been on call overnight presented pretty grim stories of car accidents, gunshot wounds, stabbings and other assorted tasty morsels of trauma for an audience of doctors in various stages of training. Each presenting physician was quick to point out in the driest terms possible how completely gruesome the situation was. Each was equally eager to nonchalantly highlight how his or her cool mastery of the situation had led to the best possible outcome. Occasionally, a good outcome was not possible and when that was the case, the presenter was obligated to make it clear that God Himself could not have saved the unfortunate victim. The senior staff equally delightedly attempted to poke holes in the narratives of the presenters—either to suggest that a simpler more elegant solution was available or that the answer could have been arrived at more quickly. This was a game I had seen played at medical rounds countless times before, but it seemed that these players considered it blood sport—no pun intended.
I walked out of the room an hour later sweating—and I had not even had to present a patient! I was glad it wasn’t me at the podium waiting for someone to rip my carefully prepared presentation to smithereens. Dr. Johnson handed me a computer printout of my patients.
“Carlos,” Dr. Johnson said, “Watch out for Royce Cunningham. He’s not as warm and fuzzy as he seems.” She raised her right eyebrow, which I later learned was her equivalent of an ironic smile, and continued,
“One other piece of advice: The last patient on your list is an HIV positive heroin addict named Wasserstein who was in a car wreck two days ago. He did pretty well in surgery, although he lost his spleen and they thought he might have a bowel perforation but he didn’t. Today in addition to any other problems, he is jittery, nauseated, anxious…you know the drill. The nurses have him on withdrawal precautions but you need to keep a close eye on him.”
“Thanks for the heads-up, Dr. Johnson.”
I looked at the list and logged onto the hospital computer to review the latest data on all of them, taking notes as I went. I made a judgment call. The Wasserstein dude was clearly potentially the most ill of the bunch. In my third year rotations the rule of thumb was, “see the sickest and the quickest first”. That meant you went to the ICU first because those patients were most likely to be changing for the worse. Then you discharged the patients that you knew were ready to go home—this made room for new admissions and that made the hospital administrators happy. After that you saw everyone else last.
Wasserstein was the most likely to crump (translation: go down the tubes in a hurry without warning) so I went straight to his floor.
When I arrived to see my newest and sickest patient, things at first didn’t seem so bad. I wasn’t surprised that his pulse was a bit fast or that his breathing rate was higher than normal because, after all, I had been told that he was in narcotic withdrawal. He had a low grade fever and that, too, wasn’t uncommon in the first days after surgery because of a phenomenon in which the lungs don’t completely expand and give rise to a mildly elevated temperature. I went into the room and started to ask him a few questions.
“Mr. Wasserstein?” I began, “I am Carlos Vega, a student doctor with Trauma Team Three. How are you feeling today?”
It was then that I noticed that he was very sweaty and pale and not focusing on me as he spoke.
“Who the fuck are you, man? I don’t know who you are but you need to keep the people with the black masks from looking in at me through the window.”
At first, I thought he was referring to the observation window from the hospital hallway and maybe he was just sick of the every 15 minute neurologic checks that came with someone on withdrawal precautions. However, it quickly became apparent that he was referring to the outside window which not only looked over an alley but was nine stories up.
I did a quick exam but something was clearly wrong here. I thought about what Dr. Greco would have said.
Hold on a minute. Do it from the beginning. Use the fundamentals. Don’t take anything for granted.
I called Dr. Johnson immediately.
“Dr. Johnson, I’m sorry to bother you. I know everyone thinks Wasserstein is acting oddly because he’s withdrawing from narcs but I think it could be from infection. I think he’s septic”. I gave a fast summary of my findings.
The reply came back rapid-fire, “Vega, you’re the doctor now, order the tests you think need to be done and I’ll co-sign.”
The test results I needed came back STAT and confirmed my suspicions. Wasserstein was an addict but he also had an infection that had gotten into his blood. I ordered antibiotics to cover the two most common groups of intestinal bacteria given his history of possible bowel perforation since his chest xray and urine tests ruled out pneumonia and urinary tract infection. He was transferred to the intensive care unit and had further evaluation to see if more surgery might be needed.
I then finished the transfer orders to the ICU and quietly faded into the background. This was no longer my problem and I had other post-op patients to take care of. My ICU colleagues took over care of Mr. Wasserstein. I was too concerned about making sure I finished my other duties to give the episode another thought.
Chapter 28
The day after the Wasserstein incident, I arrived early to make sure I knew everything about my remaining patients. I looked up Wasserstein and noted that he had been stabilized in the ICU and was doing better now. I dutifully collected every scrap of information and counted every fart from my post-op patients and prepared to be grilled to my eternal humiliation by Royce Cunningham.
When I got to morning report, many of the residents were looking at me and nodding. Ohmigod, I was sure my fart count was completely inaccurate. Sweat poured down my back. Royce Cunningham ascended the podium and looked directly at me with an inscrutable gaze and then addressed the room.
“Yesterday, I introduced our newest team member and gave him a bit of a hard time. I assumed because he had been getting massages and pedicures on the family medicine rotation that he might not know how to do real medicine.”
He looked at me and actually smiled. Well, it was kind of a smile. I don’t think he really knew how to smile. Maybe he looked it up in the Journal of Facial Musculature. Anyway, that was what he was trying to do.
“Well, my fellow surgeons and wannabes, I may have been premature in my judgment. Dr. Vega here evaluated a patient that everyone had assumed to be withdrawing from narcs and instead figured out the guy was septic. He ordered the right tests, chose the right antibiotics and transferred the patient to ICU. From now on, Vega, you better be ready to chip those manicured nails and skip those massages. We’re going to start you on your way to learning to be a trauma surgeon.”
Now it was my turn to look nonchalant-even if inside m
e a little voice was saying ididitididitididit!
Chapter 29
My first full day of clinical duties completed, I knew that there were two women who needed to hear from me ASAP. I started by calling the one whose wrath was mightier.
“Abuela, how are you doing?” I asked as meekly as possible.
“Don’t ‘how are you doing’ with me young man,” came the reply. “Now that you are Doctor big hero doing fancy operations and riding helicopters and forgetting your old abuela…”
“Untrue,” I countered, “I have not ridden a single helicopter since I got here.”
“Hmph,” she muttered in a less severe tone, as if my lack of opportunity to leave the earth’s surface made my transgression less heinous. “Well, have you saved any lives yet?”
“Not exactly,” I replied, “but I did diagnose an infection that everyone else seemed to think was withdrawal from heroin.”
“That’s my Carlito,” it was amazing how quickly she could go from angry at me to proud of me, “and what about that nice young lady you met in Maryland?”
“I haven’t even had a chance to call her yet. I called you first, Abuela.”
“Are you loco?” she erupted, “You are on the phone with an old woman when that lovely girl is waiting for you, where are your priorities, Carlito? Get off the phone at once! Call me tomorrow.” And she hung up.
The second phone call was trickier. Jillian and I still hadn’t worked out this long-distance relationship thing. We were only 90 minutes apart by car, but our chances of seeing each other seemed remote for the next month and a half. Jillian was intensively working on her senior recital and preparing auditions for the next step in her career. We talked for about 15 minutes while she was between rehearsals. I hung on every word and every inflection, trying not to over-interpret each nuance of what she was saying. She was her usual self. Yet I couldn’t help worrying. I hoped that didn’t come through in what I was saying.
What if she meets someone else?
Chapter 30
It’s amazing how something random can set the tone for an entire piece of your life. What if Royce Cunningham hadn’t decided to give me a patient he felt would be a useless waste of my time? What if I hadn’t taken a few extra seconds to question the diagnosis someone else had made? What if I had just been viewed as the usual surgical subintern instead of someone who had been lounging in family medicine for the previous two months? Then I might have anonymously gone through Metro Health Shock Trauma, done my time and had an adequate but uninspiring experience.
Instead, after the Wasserstein incident, it was as if everyone put out the red carpet for me. I don’t mean they made things easy for me—in fact, they continued to test me all the time. It’s just that the residents and staff had made a quick judgment—and they had decided that I was someone who belonged and therefore could be included in some of the best experiences at Metro.
So as the rotation progressed, I felt as if someone was always tugging on my arm to show me something they thought was clinically cool. And I made the most of it. I helped out with burn care, spent days at the wound clinic, got an awesome tutorial at the hyperbaric chamber (where very high concentrations of oxygen are used to help heal wounds among other things) and in general got pulled to every type of trauma situation anyone could find for me to see and participate in.
Unfortunately, this meant I was almost always at the hospital, even when I was not officially on-duty. Visits to Abuela were out of the question. Jillian did her best to understand my situation but one day she called me and I knew it wasn’t going to be good.
“Carlos?” she said in a voice that I knew was wavering with tears, “my grandfather died this morning.”
“Oh, Jillian, I’m so sorry…”
“You know how close we were, but also that he inspired my love of music—and especially the violin.”
“Sure, you’ve said that many times,” I agreed.
“Well, his funeral will be Saturday…can you please…come be with me?”
I wonder what Royce Cunningham would say to this one?
“Jillian, I will be there.”
“Thank you so much, Carlos. And…I can’t believe I’m saying this…but there is one more favor I need to ask. My first big recital is Sunday. With Grandfather gone, I’m going to be a mess. But if I don’t play well, I’ll be third chair at the East Nowhere Symphony. Would it be possible for you to attend the recital…you know, for moral support?”
I no longer wonder what Royce Cunningham would say—something about “whipped”.
“Can I get an autographed program?” I said with a twinkle in my eye that I wished she could see.
Chapter 31
Getting permission to miss a day of a sub-internship would require an act of congress. Asking to miss two consecutive days might involve a human sacrifice at the altar of Royce Cunningham. I just didn’t want that human to be me.
I decided to talk first with Dr. Johnson. She seemed very helpful and encouraging.
“You want to what? You pulled off the coup of the century by impressing his imperial majesty Cunningham the First on your second day here and now you want to turn all that goodwill to crap in a single act of desperation for a girl?”
Actually, two acts of desperation but who’s counting?
“Look at it this way,” I offered hopefully, “This is a former patient’s funeral and then I’m going to console a family member by attending her recital. Isn’t that just good medicine? A kind of closure thing?”
Dr. Johnson looked at me like I had grown three heads and lost the minds of all of them.
“Vega, please don’t load up all that family practice bullshit like you think Cunningham’s gonna buy it ‘cause you know he’s not. Tell you what, I’m going to tell him I overheard your phone conversation and that you said you couldn’t possibly come there but that I convinced you to go. After all, I’m a woman and he already thinks I’m chromosomally weak.”
“Dr. Johnson, you do not have to do that…”
“I know I don’t have to do it, Vega, but I’ll be damned if I’ll let Cunningham wreck a perfectly good sub-intern who has real potential in this specialty. Now get your sorry ass out of here before I change my mind!”
“I owe you big-time Dr. Johnson” I yelled as I ran from the room.
I could have sworn I heard her mutter, you bet your sweet ass,you do.
Chapter 32
On the drive to the Weinkopf house, I thought a lot about the last months of the life of Norman Weinkopf. I hoped they had been happy and peaceful. But I couldn’t help but wonder if the medication we had given him to help his agitation might have hastened his demise. He was eighty-six years old and had multiple medical problems including high blood pressure and high cholesterol, so dying of a heart attack or simple old age was not out of the question. Yet it was impossible not to worry about the studies that showed a trend to increased mortality rates in elderly patients who took those medications.
I parked in front of Jillian’s house and started up the front walkway but she met me halfway before I could even reach the door. She ran to greet me, gave me a tight hug and pulled me by the hand,
“Can we take a walk before we go in to meet everybody?” she asked.
I was a little curious who “everybody” was, but I was definitely up for a walk so I agreed and off we went.
We spent some time catching up and before long she found a way to reassure my insecurity about her grandfather’s death.
“Carlos, I know we haven’t known each other long but there’s one thing I’m pretty sure about and that is that you’re worried that the medicine you gave Grandfather might have contributed to his death. First of all, my whole family is in agreement that he was a very old man and it was just his time to go. Second, the past few months were really great. He was playing the violin almost every day, he could sleep, he had a great appetite and he was seeing his friends. He was at peace, Carlos. He was at the dinner table with my moth
er and father every night and he didn’t have to be in some nursing home. So if you are worried about whether you did the right thing by recommending that medicine, please don’t, okay? ”
I tried not to make my sigh of relief too obvious and then observed, “How is it that I am supposed to be here to comfort you and the first thing that happens is that you reassure me?”
One of those unbelievable smiles that I was falling in love with flickered across her lips and she said,
“I guess you’ll have to keep hanging out with me to find out, won’t you? We better go in the house now or everyone will think we’re making out in the car.”
Not a terrible idea at that but I suppose we should be sociable.
We walked in the front door, through the front hallway and to the left into the dining room where a surprisingly large group of people sat. There were plates with the last bites of chocolate cake and dark blue ceramic cups of coffee. In addition to Jillian’s parents, Martin and Annette, there were two other couples whom I did not recognize.
“Everyone,” Jillian began, “This is my friend Carlos. Carlos, you know my parents. On the left is my sister Morgan and her husband Jim. On the right is my sister Regan and her husband Brad. Regan and Brad have a son Daniel who is 2 years old and is asleep with his favorite teddy bear right now.”
The two husbands stood and gave typical broad masculine smiles and shook my hand. I was offered cake and coffee which I gratefully accepted. Once everyone had exchanged a few pleasantries, the conversation turned to memories of Norman Weinkopf. It seemed that everyone had a story that was by turns hilarious or heart-warming.
“Why don’t you share your story, Regan?” asked her father from the end of the table.