Necessary Medicine

by M. K. York

  “It’s a damn stupid—”

  “It is not. I know it doesn’t mean much to you—” Eli hunched farther over the steering wheel “—but reputation matters. If people get the idea that I don’t respect boundaries, it makes it harder on my residents. People start wondering whether they got a leg up the ladder by getting a leg up on the boss. And maybe their next attending thinks they can get away with something, because they heard the last one did.”

  “I’m not in your department. And I told you, it doesn’t need to be public—”

  “Because that looks so much better, when it inevitably gets out.”

  Neil sighed in frustration. “You don’t—how are you so cold about this?”

  Eli’s hands tightened around the wheel, knuckles going white for a second before he answered, sharply, “Years of practice.”

  “I don’t understand how you can do this.” Neil had to blink, hard. “It’s killing me.”

  They were both quiet for a few blocks after that. They found a parking spot, Neil gesturing wordlessly to Eli, who pulled into it.

  After he killed the engine, Eli sat in silence for a moment and then said, “Me too,” like a confession, into the dark.

  They were both subdued when they walked into the restaurant and found Pete, who’d gotten them a booth.

  “After you.” Neil stood between Eli and Pete’s side of the booth. Eli shot him a suspicious look but slid in across from Pete, and Neil followed, crowding against him before settling back onto his side. Eli let out a soft little exhalation between his teeth.

  They ordered their food—the owner giving them the kind of suspicious glances patrons coming into a restaurant less than two hours before close might deserve—and ate in amiable enough silence, though once or twice Neil deliberately pressed his leg against Eli’s, eliciting a quick cough or choke.

  “You know next week is Beer Week?” asked Pete, over his pad thai as he pushed the last few bits together. “A bunch of places are in on it.”

  Eli rolled his eyes. “Let me guess. You want to go?”

  “Beer, Eli. As far as the eye can see.”

  “You know it’s not good for your heartburn.”

  Pete made a face. “Thanks, dear. Are you interested or not?”

  Eli leaned back, thinking. “I guess I’m free on Saturday.”

  “Neil?” asked Pete.

  “I have Saturday off. I could go out, but I have to be back early so I can sleep before Sunday.”

  “One yeah vote from Mr. Boring. Great, I’ll pick a place.”

  Neil gently nudged Eli’s ankle with his foot. Eli’s back stiffened, and he smiled overly brightly. “That sounds great.”

  When they left, Eli and Neil headed toward Eli’s car by unspoken mutual agreement, Pete waving at them as he walked back to his car.

  “You have got to knock it off,” said Eli under his breath.

  “I have no idea what you’re talking about.” Neil put his nose in the air. “We’re just hanging out. Like a couple of guys do.”

  Eli shot him a sidelong look full of annoyance, tempered by something softer.

  “Pete’s not an idiot, you know,” Eli said after a minute.

  “You want me to stop leaving him bread crumbs?” Neil shrugged. “He asked me a lot of questions. I told him it was personal.”

  “If you keep playing—footsie with me, he’s going to figure it out.”

  “Fine. No footsie in front of Pete. Got it.”

  They climbed into the car, Eli blowing on his hands for a moment to warm them. Neil just watched Eli’s hands, thought, I could warm those up for you, but didn’t say it.

  Eli drove him home, the stereo turned off, just the sound of the road.

  “Any interesting cases lately?” asked Neil after a while.

  “I’ve got a woman with HOCM in the hospital right now. She was in for a procedure to ablate some of the hypertrophic tissue.”

  “That’s pretty cool.”

  Eli nodded. “I don’t see a lot of HOCM, although I would guess I see more than my fair share. I’m co-managing with Wei.”

  “That must be fun.”

  “Oh, he’s a charmer. But he’s good. How about you? Any good surgeries?”

  “I’m starting colorectal. So, it could be better, could be worse.”

  “What are you going to do for your elective block?”

  “Hepatobiliary. It’s really applicable to gen surg practice.”

  “So you’re still thinking general surgery?”

  “Yeah, at least nominally. I’m getting the feeling I’ll end up doing mostly HPB, but I’ve got the numbers now to do most of the surgeries I’m interested in.”

  Eli hesitated before saying, “Have you started looking at jobs?”

  “Yeah.” Neil drummed his fingers on the car door.

  “Anywhere in particular?”

  Neil shook his head. “I started getting recruiters calling in fourth year. They’re getting more persistent. Lot of different places.”

  “I see.”

  “I’m thinking about starting out locum tenens. See what seems like a good fit before I commit.”

  “That can be rough. Looking to spend some time in the sticks?”

  “Maybe. I’m still thinking about it.”

  They rode in silence the rest of the way.

  * * *

  Eli started texting him again. In fits and starts, but he got a comment on the place Pete had picked for them to meet up for the Beer Week night out, and then, Do you think Mark would like to come?

  Which was a good question. He asked Mark—tracked him down taking a lunchtime catnap in the call room.

  “Hey,” Neil said as Mark lifted his head from where he was browsing his phone instead of sleeping. “Do you want to come with me and Pete and Eli to Beer Week?”

  “An entire week of beer?” Mark looked like he was seriously considering it for a minute, and then shook his head. “I’ve been bushed lately. I need to sleep.”

  Neil pulled the rickety folding chair out from the wall and sat down next to the bed. “How are you doing?”

  Mark sighed, setting his phone down. “I’m fine.”

  “You look like shit.”

  “I feel like shit. But I’m fine.”

  “Any more thought to seeing somebody?”

  Mark shook his head a little, tightly. “I don’t want to talk about it.”

  “Okay.” Neil held up his hands, moving them back. “We don’t have to talk about it. Just, you know. If you ever want to. I’m here.”

  “Yeah, I know. I appreciate it, man. Seriously.”

  “Sure you don’t want to come out for beer?”

  “I’m sure. Sleep is just...man. I need it.”

  “Okay.”

  * * *

  Beer Week night turned out fun. He wasn’t sure what else he would have expected. If nothing else, Pete was fun. He was a big man with a booming voice, so he got them served in pretty short order, and where he couldn’t, Neil was tall enough to get almost anybody’s attention.

  Eli was sitting across from Neil and Pete at their third place—probably their last; it was starting to get late and Neil was feeling pleasantly fuzzy around the edges, the kind of tired that would mean he could drop into bed and sleep easily—leaning back in his chair, smiling over a glass of beer. Neil looked at Eli and felt his stomach drop, with the knowledge that this was good, but it wasn’t enough, he wanted to touch Eli, he wanted to kiss him again.

  Eli glanced over at him in the middle of the story Pete was telling about a patient in the ER with a massive retroperitoneal bleed, and he froze at whatever he saw on Neil’s face.

  The Uber dropped Neil off first that night. No time to talk with Eli.
Probably for the best.

  * * *

  Neil wasted some time looking up the university’s policy on—well, he tried “professionalism,” which led to “sexual harassment,” which finally got him to the policy on relationships.

  It wasn’t particularly encouraging. They’d kept it vague enough that he could read it as either forbidding or permitting. Lawyers always liked to leave wiggle room in their arguments.

  He had a feeling he knew which side of it Eli would come down on.

  Chapter Twenty-One

  February dawned clear and cold, the sunlight dazzling on Neil’s way into the medical center.

  The shift was going pretty well—no emergencies, nothing he couldn’t put a couple of junior residents on. He needed to draft their call schedule for the next block, anyway.

  So when he was just rolling into his night on call, the emergency that came in was a shock.

  The ER attending was yelling, and Neil couldn’t blame him, looking past him at the man on the gurney, white as a sheet and trying feebly to writhe in pain. “Forty-four-year-old male with what looks like a ruptured triple A! We need him on the table now!”

  They had the OR ready to go in record time, the Vascular Surgery attending on call dragged in along with the Vascular fellow who’d been trying to eat dinner in the hospital cafeteria. The abdominal aorta was about the third-worst place to burst an aneurysm; first was the thoracic aorta just off the heart, because the blood there was under high pressure and it was all the blood, and second had to be the brain, because overfilling a confined space meant the brain would be compressed. But this patient was going to lose a lot of blood, very quickly, no matter how fast they got into the abdomen.

  It took Vascular a while to get the bleeding under control. They sewed the new graft into him right there on the table, and that was when they called for Gen Surg, because it turned out he’d lost blood flow past the ruptured aneurysm long enough that his bowel had started to necrose.

  Neil came in to do the dirty work on that. The attending who’d handled the bulk of the emergency graft refused to leave the OR, even though he looked dead on his feet and the vascular portion of the surgery should be over. “I’m the only attending in this room,” he said grimly. “I’m not leaving.”

  What should have been simple—clip off the bowel, resect the necrotic section, resew—turned into a goddamn nightmare, because there was something wrong with the bowel itself. It was as fragile as tissue paper. “What do you think?” Neil asked the attending and fellow. “Marfan?”

  “Either Marfan or Ehlers-Danlos,” said the attending, naming the major collagen disorders that could leave tissue that flimsy. “Something like that, anyway. We’ll have to run genetics to be sure.”

  Neil carefully gathered up the now-raw edge of bowel. His first few attempts at stitches had pulled right back out of the weak tissue. “It’s just falling apart in my hands. Think I’ll switch to pledgeted sutures.”

  The attending nodded. “Good call. We used them for the graft.”

  “Still losing blood, though.”

  “We’ve got another unit coming.”

  “Good.” Neil leaned back over the incision. The hot, bright lights were just part of the scenery, except when he couldn’t get a good look at something. “Can you get me a little more light here? And cautery for this bleeder?”

  A nurse adjusted the light while the intern who was on cautery nipped another blood vessel.

  It took Neil twice as long as it should have to finish the surgery, because the bowel was so frail. But finally, finally, he had the intestines patched together, and he could start sewing up the surgical incision.

  “Aorta’s still looking good,” he reported to the Vascular attending, who was hovering at his elbow.

  “No mystery blood?”

  “No mystery blood. How far did the aneurysm extend? Iliacs?”

  “Common iliacs, yeah. We cut clear down to the bifurcations.”

  “Ouch.”

  “Well, it’s not like the rest of this isn’t going to have to go sooner or later.” The attending nodded in the general vicinity of the rest of the aorta. “It’s all going to fall apart on him. Best replace it while we can.”

  “For now, I’m just going to focus on getting him put back together. You can cut him open again later.”

  “Do you want me to close?” asked the intern.

  “No, this one’s tricky because the tissue is so friable. I’ll take it.”

  The intern nodded.

  Neil layered the muscles and then the skin back together. “How’s his aortic root look?”

  “Didn’t get a good look at it yet, we don’t have imaging on him. My money says it’s dilated, though.”

  “With this kind of widespread aneurysmal degeneration, it pretty much has to be, right?”

  “There are a couple other options, but that’s what I’d guess.”

  Neil hummed softly in agreement as he finished the closing sutures. “All right. Think we’ve got him about patched up for now.”

  Afterward, while he was washing his hands, the attending came up behind him and said, “We’re trying to get records on this guy ASAP, but we’ll need to take a look at his heart. I’m going to ask Newcombe to get in on this.”

  “Sounds good,” said Neil, ignoring the jolt that went through him. He’d thought he and Eli would never have another case together—he’d been wrong, after all.

  * * *

  The next morning, their new patient was on rounds, and the intern was clutching his outside medical records, faxed in long before any human being should be awake.

  “Tell me about this patient,” the attending, Dr. Murphy, said to the intern, who nodded, getting even more of a white-knuckle death grip on the records. God, it was February, the kid had been doing this for eight months; he needed to lighten up.

  As the intern was stuttering through the patient’s medical history—turned out he’d been diagnosed with Marfan a few years before but then had never gone back for follow-up or the surgery that would have saved him the experience of rupturing the biggest blood vessel in his body and almost bleeding out into his own abdominal cavity—Neil felt the hair on the back of his neck rise. A second later he placed familiar footsteps, and he turned to see Eli, standing in the doorway of the patient’s room.

  Eli smiled at him, and for a second it hurt to breathe.

  The intern glanced up and his gaze followed Neil’s. “Oh, uh, hello, Dr. Newcombe,” the intern said.

  “Don’t let me interrupt,” said Eli. “What were you saying about his follow-up?”

  “Uh, it was nonexistent. Sir. He was seen at a clinic a couple of times after that, and they tried to convince him to take his blood pressure meds, but without success.” The intern’s eyes flicked over to the patient, who at that moment was fast asleep, snoring faintly on each wheezy breath. He was still pale, but he looked a little less dead than he had the night before. “He ruptured—lucky for him, he’d come into the ER and was complaining of a ‘funny feeling’ in his stomach, so he ruptured here, and we got him into surgery immediately.”

  Eli nodded thoughtfully, cutting short the case presentation. “Do we have cardiac data on him yet?”

  “ECG’s a little funny but nothing definitive. Echo is scheduled for this morning.”

  “Planning on going TEE?”

  “Not unless we have to. He’s pretty fragile right now.”

  “Good. Mind if I have a listen?”

  The intern looked to Murphy, who nodded. “Go right ahead.”

  Eli pulled his stethoscope off his neck and went to the bedside. He didn’t even wake the patient up—just gently tucked the stethoscope head under the hospital gown and listened to the valves. Neil watched as his forehead creased in concentration.

>   He straightened back up. “Sounds like mitral regurg to me. He may need repair for that. I’ll give Wei a heads-up that we might need him on this, too.”

  The intern and Murphy nodded in unison.

  “How’d his surgery go?” asked Eli, turning to Neil and raising his eyebrows.

  “Complicated. Tissues are fragile. We’ll have to be on the alert for more bleeding if he rips out any sutures. And continuing to check the bowels for further necrosis.”

  “Good, good.” Eli turned back to consider the patient. “Hopefully we can get him healed up enough that when we discharge him, he can come back for his cardiac surgeries and any more aortic grafting he needs with a minimum of muss and fuss.”

  “Are you thinking about an elephant trunk?” asked Murphy.

  “Oh, that’s for Vascular to decide. I just want to make sure we get a good picture of his heart before we go cutting on it.”

  “Fair enough,” said Neil.

  Eli stuck around while Murphy and the intern hashed out the differential and the care plan, and then he said goodbye to Murphy. On the way out, he looked back into the room, and his eyes met Neil’s. He smiled again.

  Goddamn it, thought Neil.

  * * *

  The patient did rip out a suture, just after his echo that morning. They had to rush him back to the OR and open him up again. The graft had developed a leak and two of the bowel sutures had torn through.

  Neil was supposed to be off, but he was sticking around to see this one through. He’d crashed out in the call room for a couple of hours before coming back around to check on the patient and finding him gray faced in pain despite the opiates.

  It was a sweaty, nasty morning. After that surgery, Neil took a shower and just went back to nap in the call room.

  * * *

  The echo ended up showing mitral-valve prolapse—the whole thing was as floppy as a parachute, billowing out with every heartbeat. So the patient did need cardiothoracic surgery, in addition to the further aortic repair he was going to have to get sometime in the next couple of years.

  “Neil.” Eli stuck his head into the corner where Neil was working on his documentation. “Wei and I are going to have lunch and talk about our patient. Do you want to join us?”