Dead Still

by Barbara Ebel

  “An opportunity for all of us to grab lunch at the same time rarely presents itself,” Bob said, “so let’s do it.”

  They went to the call room where they automatically claimed their previous bunk beds. Ginny sat down and checked her phone for messages and Da’wan unpacked, even taking out a miniature flashlight to place alongside his textbooks beside the pillow, and slipped a pocket-sized surgery manual into his lab jacket. Annabel checked her white coat items and, using Da’wan’s example, tucked the same small study and reference guide in her lower left pocket; she should be studying at least as much as him, she thought.

  Da’wan, Bob, and Annabel waited silently as Ginny attentively scrolled through messages and emails. When she realized all eyes were on her, she jumped up.

  “Come on,” Bob said, “let’s pass by the office on the way to the cafeteria. I left my pocket manual on the desk and I want to have it with me like you two nerds. Instead of talking over lunch, we may be buried in them for our first test in two days.”

  “We sure lucked out,” Da’wan said. “Since we’re on call today and if we don’t get killed tonight, we’ll have most of tomorrow to study.”

  They let that sink in as they looked ahead and saw Robby coming the other way, Marlin Mack trailing him. Dr. Burk’s expression was far from pleasant and, although they could not hear his words, they knew he was angry from his tone of voice.

  In front, Annabel and Bob slowed their pace as Robby gesticulated for Marvin to follow him into the office. The door closed behind them with a thud.

  “Wow,” Bob said.

  “I’ve never seen him get mad,” Annabel said.

  “Bob, I don’t think you should get your book,” Da’wan said.

  “Neither do I,” Ginny piped in.

  They tentatively walked past the closed door. Annabel strained her ears to hear anything from the other side. In a raised tone, she heard Robby say, “I left it to you.”

  After they passed the door, Bob flicked his hand back and forth. “There are sparks flying in there,” he said. “I wonder what happened.”

  Annabel looked backwards. She’d never seen Robby look so upset and, for the second time today, he seemed annoyed at Dr. Mack.

  -----

  Robby Burk held the door open letting Marlin pass, then swung it closed. He put both hands on the side of his head as if a pain throbbed in his temples, walked to the desk, and spun around.

  “Glossypiboma!” Robby blurted out angrily.

  Marlin stared at him nervously. He had no idea what that meant or what Robby’s problem was. So far, the only other thing Robby had said was “I left it to you.” He was pissed off at something but Marlin hadn’t done anything out of the ordinary that he could think of except for not seeing patients before rounds that morning. And as far as he was concerned, that was water under the bridge.

  “Glossy what?” Marlin asked.

  “Glossypiboma. You have obviously never heard that word before. It refers to retained surgical sponges or instruments. Do you know why you don’t hear that word?”

  Marlin shook his head, stupefied.

  “Because the overall incidence is so rare!”

  Perplexed where Robby was going with this, Marlin didn’t know what to say.

  “Our hernia repair from last Friday - the landscaper, Mr. Simmons - is downstairs in the ER. He’s had increasing redness, swelling and pain at the site. The X-ray is conclusive enough to realize that there’s a retained small gauze pad inside. Maybe it’s even embedded with the mesh I sutured in. The poor man has an infection and now needs another surgery.” Robby took a deep breath and held his hand out to keep Marlin from responding.

  “I gave you the case to close up. God knows, you residents need the experience and chief residents have to increasingly let go of the reins. But this type of thing is a totally preventable cause of morbidity. It’s medical negligence, easily proven as a result of res ipsa loquitur.”

  Marlin stared at him, puzzled by another term.

  “The doctrine means ‘the thing speaks for itself.’ An object left in a space where it doesn’t belong becomes indefensible. It will depend on Mr. Simmons whether he is already at this moment dialing a medical malpractice attorney. I am not even out of my residency yet and may have to fight a lawsuit!”

  Since Robby had first mentioned the retained surgical pad, Marlin had begun scheming how to shift the blame away from himself. Granted, since he was the resident he’d have to take some heat, but that could be tampered down to a stovetop flame rather than a large bonfire. He could blame it on the medical student.

  “A lawsuit would be terrible!” Marlin countered. “I will treat Mr. Simmons so graciously and with such empathy, he will think it deplorable to even think about such a thing.”

  Robby waved his hand. “You don’t strike me as the empathetic kind,” he said, his tone softening just a tad.

  “More than you know,” Marlin said and then shook his head. “It’s just that it’s probably going to ruin any future for Dr. Tilson.”

  Robby tilted his head. “What do you mean?”

  “I may have mentioned it before. She’s been so damn interested in what’s going on across the blood-brain barrier at the head of the table, asking and learning about anesthesia from Wilbur Gill. She was the one responsible for dabbing blood at the repair mesh and the closure after you left. She left the foreign body inside the patient and I’m sorry I didn’t catch her doing so.”

  Robby lowered himself onto the edge of the desk. His facial expression relaxed into despair. “That’s not good ...,” He took a deep breath, shut his eyes for a moment, and finished his thought. “… I mean, her doing that.”

  “Yes, I know,” Marlin said. “And the nurses had already done a surgical sponge count at closure.”

  “I think someone was getting relieved when I left the OR. Who was it?”

  “Yes, I remember that. The scrub tech was relieved for a break near the end of the case. Their counts had been properly done.”

  “The Association of Perioperative Registered Nurses advises that sponge, sharps and other items be counted five times. One time is for when a scrub tech or circulating nurse is permanently relieved.”

  “Well, the scrub was only given a break but the case ended soon thereafter. Anyway, Annabel Tilson is a sore excuse of a student to be anywhere near a surgery ward.”

  Robby placed a hand back on his temple. This was too awful. Marlin was right. Annabel Tilson hadn’t upheld the unwritten oath to ‘do no harm.’ He would have to confront her with the entire problem as well as bring Mr. Simmons back to surgery. What a shame because she seemed like a nice young woman who had even given him encouragement about joining Global M.D.s.

  -----

  Dazzling sunlight streamed through the window as the four students began to chow down their lunch. Annabel took a bite of a catfish sandwich and washed it down with water.

  “Do you think we’re going to find out what Dr. Burk is so mad about?” Bob asked.

  “If it doesn’t involve us,” Da’wan said, “it probably doesn’t make a difference. We need to concentrate on our upcoming exam.”

  “If we get through today and tonight unscathed,” Annabel said, “and get out early tomorrow like we’re supposed to, I’m going to be cramming the rest of the day like crazy going over everything I’ve studied already.”

  “Does anyone want to study together?” Bob asked, glancing sideways at Annabel.

  “Not me,” Ginny said. “I need some time with Katie.”

  “I study alone,” Da’wan said, sprinkling salt and pepper on his steamed vegetables. “You don’t want to study with me anyway.”

  “That’s not true,” Bob said. “You could teach me a thing or two.” He looked again at Annabel.

  “Quit looking at me,” Annabel said. “But if we all pass, we should celebrate.”

  “Now we’re talking,” Bob said.

  Annabel was about to finish the last bite of her sandwich w
hen her pager went off. She sipped some water, put her napkin on the table, and went over to the phone.

  When she called the number, it was Marlin Mack. “You are not up for the first admission today,” he said. “However, since Mr. Simmons was your patient from last week, Dr. Burk wants you to follow him again for continuity. Wherever you are, come to the preop area to see him because we’re taking him to surgery again. He showed up in the ER with a groin infection.”

  “Okay,” she said. “That makes sense.”

  “It’s not up to you to say that Dr. Burk’s decision makes sense. It’s up to you to follow orders without question.”

  Marlin hung up and Annabel put down the phone with a bad feeling. She walked back to the table and slumped into the chair. “They’re taking Mr. Simmons, the hernia patient from last week, to surgery. He came into the ER.”

  “What for?” Da’wan asked.

  “I don’t really know,” she said, “except that he has an infection. I wonder if his admission had something to do with the tense atmosphere between Dr. Burk and Dr. Mack.”

  “No telling,” Bob said. “But I’m going to try to make myself scarce.”

  Da’wan nodded. “If I have free time, I’m going to hide in the call room.”

  “Me, too,” Ginny said.

  “Great,” Annabel said. “I hope I eventually get there whenever. But right now I have to go to the OR to scrub in. They are giving me this first admission since he was my patient to begin with.”

  She turned and headed upstairs without enthusiasm.

  “That’s bad luck for Annabel,” Bob said. “Especially since she has to scrub with the resident rat.”

  -----

  When Annabel arrived in the preop holding area, she didn’t see Dr. Burk or Dr. Mack. She spotted her patient in a hospital gown, the sheet drawn up to his abdomen and his right hand already sporting an IV. On the pole next to him hung a bag of fluids as well as a smaller bag of antibiotics.

  She walked quickly to the desk to read any previous notes the others would have written. The chart held the ER doctor’s evaluation first; Robby’s scribbled note followed and then Dr. Mack’s. Now she knew why Mr. Simmons had returned. Their ‘impressions’ were retained surgical pad and the plan was to take him to surgery. But he had a terrible infection at the site and Annabel felt sorry for him. If it weren’t for this complication, the man would be seeing a drastic improvement with healing and a lack of his previous symptoms.

  She walked over to his stretcher and greeted him with a slight smile. “Mr. Simmons, I can’t say I’m happy to see you here. Do you remember me? I’m Dr. Tilson, one of the medical students.”

  “I remember. I’m not happy to be here either. In essence, I’m steaming mad to know that one of you screwed up. Leaving a surgical item inside me makes me think I’m in one of those bizarre TV shows where the most unexplainable phenomena occur; it’s inexcusable. And I’m red as a beet down there and infected.”

  He took his weathered hand and pushed away the sheet and gown to show her the area. Not just red hot but swollen, the area stood out on the top of his lanky tanned leg. She grimaced and felt cornered in a discussion she didn’t know how to handle.

  Annabel looked back at his face, his cheeks sunken from his light weight and hard outdoor work due to his business. He was only fifty-three-years-old but looked older.

  “I am sorry you are going through this,” she said. “Dr. Burk is a very good surgeon. I would have him operate on me if I needed it. All of us will take very good care of you and I hope you are able to go home soon after this repeat surgery.” She eyed his expression, hoping he’d calm down. “In the meantime, may I listen to your heart and lungs?”

  He mumbled a “yes” and she took out her stethoscope, then asked him questions for her own history and physical.

  Wilbur Gill walked in holding a labeled syringe and nodded at Annabel. “We’re ready to take him back,” he said, inserting the needle into an IV port and pushing the end of the syringe.

  In a short time, Mr. Simmons rested his head back on the pillow. Then he closed his eyes. “That’s better,” he mumbled.

  “Midazolam,” Dr. Gill said.

  “So that sedates and causes amnesia?” Annabel asked.

  Wilbur smiled. “Nice, huh?”

  “Appears to be,” she said. “You got me out of a difficult encounter with him. He’s not a happy camper.”

  “In his shoes, neither would we be.”

  “If you have time, maybe you can continue to show me a few things from your side of the drapes. But subtly please … otherwise Dr. Mack may give me trouble later.”

  Chapter 15

  Annabel watched the resident and attending anesthesiologist put Mr. Simmons to sleep. She didn’t have an appreciation of everything they did nor did she understand why they did certain things, even like the attending putting fingers on the patient’s neck and applying pressure as Mr. Simmons went under. She was such a rookie but knew that, in the next two years, her clinical knowledge would soar like an infant’s developmental milestones.

  After Robby, Marlin and Annabel gowned and gloved, she stood between Marlin and the head of the table. But she felt tension in the air and Robby had not said one word to her. On the other hand, Marlin had a smirk on his face.

  “Where’s that hemostat I asked the OR to order?” Robby asked, looking at the instrument tray.

  “It’s on backorder,” the tech responded.

  “Is anything going to get done correctly with this patient?” Robby scowled.

  As he opened the patient’s previous sutures, there was a heavy silence. Even so, Annabel was very aware of Robby’s chemistry from across the table. Turning to her, Marlin broke the ice.

  “In case you weren’t paying any attention,” he said, “our tech just gave you another OR saying.”

  “What’s that?” she asked

  “It’s on backorder.”

  “Oh,” she said. For the time being, she decided not to interfere with Robby’s surgery by saying another word. It was obvious that he wasn’t letting Marlin touch the case except to assist him as, after a while, it was apparent the gauze left inside Mr. Simmons was adherent to the mesh Robby had used for the hernia repair; he had to take it all out and replace the mesh. When he paused, he looked over at Wilbur.

  “I thought the patient just moved a little bit. I can’t have that right now. Don’t you have him paralyzed?”

  “I do,” Dr. Gill said, “but I’ll recheck.”

  Both of the patient’s arms were out on boards and Wilbur pressed the button on the twitch device attached to the patient near his wrist. “He’s well blocked, Dr. Burk.”

  Annabel peered over to watch. Maybe the tense atmosphere coming from Dr. Burk was not conducive to asking questions but she was still a student and was there to learn. “Do you always paralyze patients during surgery?” she asked Wilbur.

  “During a general anesthetic, quite often,” he said. “The surgeon has much better operating conditions that way, especially if it’s something delicate like eye surgery or working on a major blood vessel. So, yes, and the patient must be well anesthetized; otherwise it would be hell to be conscious yet paralyzed.”

  Annabel thought about this interesting subject. Knowing that she had a smirky resident and a boiling mad chief resident, she decided not to go any further with the discussion and nodded at Wilbur. “I’m going to request anesthesia to fill in one of my two week elective slots,” she said.

  “You won’t learn much in two weeks,” Dr. Gill said, “but that would be a good initiation. Maybe enough to consider it as a specialty.”

  Annabel nodded and he gave her a thumbs up. Robby finished his repair which took longer than the first time and then he closed the inflamed skin.

  “I want to verify and watch your count,” Robby said to the tech and circulator as they began methodically accounting for all the gauze pads on the tray table from when they started. When the count was good, Robby looked at
Wilbur. “And the antibiotics went in before we made incision, correct?” he asked, sounding like a taskmaster.

  “Yes, sir,” Wilbur replied.

  “Okay, then. We’re finished here. Dr. Gill, he’s in your hands now.” He turned to Annabel. “In about twenty minutes, meet me in the office.” Robby and Marlin both stripped off their outer surgical garb and left.

  Annabel didn’t know what to do next. Her instincts told her that Robby was going to reprimand her and she had no idea why. He remained the best part of the rotation and if he turned on her, the wards would be like walking into a prison every day. She watched Wilbur hustle to reverse the anesthetic effects and decided to stay with their patient when Dr. Gill brought him to the recovery room, more commonly termed the PACU or post-anesthesia care unit.

  The anesthesia resident still injected medications into Mr. Simmons IV; when the patient stirred, slightly lifted his head, and gripped Wilbur’s hand on command, the resident took out the endotracheal tube and let him breathe oxygen through a mask.

  “Mr. Simmons, your surgery is over,” Wilbur said.

  “Hmm.”

  “We’re taking you to the PACU.”

  Annabel followed as the nurse and Wilbur pushed the stretcher to the PACU where the patient was hooked up to monitors and Dr. Gill gave a report.

  “Mr. Simmons just had a repeat inguinal hernia repair for a retained surgical pad,” Wilbur said. “Dr. Burk was the surgeon. The patient has no allergies, had negligible blood loss, and received a general anesthetic.”

  Annabel stepped away as Wilbur continued and Mr. Simmons adjusted the pulse oximeter probe they had placed on his finger. She might as well go face Dr. Burk’s music.

  When Annabel entered the office, she found Robby sitting at the desk. He faced the window and had two charts; she assumed they belonged to Mr. Simmons. When she approached, he was reading through Mr. Simmons’ last week’s admission information page by page.