Foreign Threat

by Mitchell Goldstein

  “Well still,” typed Sweetpea. “They should cut you guys a little slack the first couple of weeks.”

  Steve didn’t want to explain the surgery hierarchy tonight.

  There were too many other things on his mind. “Yeah, you’re right.”

  He rambled about his day, including the boring start with orientation and then about his surgery service. He didn’t bother her with the details of meeting Erica. Tonight probably was not a good time to discuss other women, whether they were online or not.

  Steve saved the most exciting for last. “And just as I was getting off the elevator and arriving on the surgery floor, there was a code called in our hospital wing. Unfortunately, it was a patient from our service. We coded him a long time but were unsuccessful. I had to do CPR and shock him. My poor resident felt really bad as she did all his surgery and postoperative care…” He paused for a moment again and thought how sick it was that what was a terrible event for a family was his most exciting part of the day. “I know it is kind of sick to think that my most exciting experience of the day had to be somebody else’s misfortune. But I was able to participate in the thing that made me the most anxious about starting my internship: a code.” He stopped typing and waited for a response.

  After a short while came a response. “It must have been

  difficult for you and your resident to attempt to save the life of another person. I’m sure you will lay awake tonight in bed and sort out your emotions. You will probably replay the code minute by minute and realize the excitement of the entire event. And after you have gone through the code and all its details, you will encounter two issues. One, in order to learn to be an excellent doctor you will have to take care of and manage many patients. Some will not do well and continue to be very sick, and some will do fine, but you will definitely learn medicine from both groups of patients. Second, you will learn from very unpleasant situations. Like tonight, you learned to be involved with a code, and you found out that when put in a certain stressful position you can still function and provide excellent medical care…at least to your ability. You learned this tonight at the expense of a patient’s life. But the experience will hopefully provide you with some new knowledge so that the next time you’re in a code situation you will have gained new insight so that the outcome will be different. Most importantly while you’re lying in bed tonight thinking about that gentleman’s family, don’t get too sad because it sounds as if you and your resident did everything you guys could do. Just the fact that you were thinking about the unfortunate fate of the patient while you were learning shows me that you have great sensitivity…which I already knew. Don’t lose that… that sincere sensitivity and wealth of medical knowledge will make you an all-around excellent physician. I need to go, Steve. It’s late and I need to work tomorrow too. I’m glad you had an exciting day and learned a lot. When you’re seeing your patients tomorrow, don’t forget about the person inside. See ya, Sweetpea.”

  Wow, thought Steve. That was exactly why he loved talking to her. She always knew the right things to say to make him feel better. “Thanks for your warm thoughts,” he typed. “You always know what to say. Talk to you tomorrow, Steve.” He

  signed off thinking about all the comments Sweetpea had made.

  After letting the dog out, he got ready for bed. As he lay in bed for a while, he did think about the day’s events and everything that happened. Then he thought how lucky he was to have a friend like Sweetpea.

  Chapter 8

  The music from the radio seemed to be at concert decibels. At 4:30 in the morning in the middle of a good dream, it was bound to catch anyone’s attention. Steve rolled over, saw the time, and thought for a moment there was some mistake, like maybe he was supposed to get up at eight to round at nine or ten in the morning.

  But there was no mistake. His plan was to preround on all of the patients on Dr. Douglas’s service. If he had a chance to see all the patients before they started their formal rounds, then he would know about any problems that had occurred during the night. The more he knew for rounds, the better the chance he would get to operate.

  Steve had been awake several times during his short night. He had too much nervous energy and lay in bed at times thinking about the day before and the day ahead. He thought about Sweetpea and Erica. He thought about Dennis Burrows, the new friend he had made in orientation, and wondered if he had just as much anxiety as Steve. He thought about Sally and Tom and wondered what time they got up to round. He thought about the medical students, Mike and Roger, and remembered how it felt to be at the bottom of the hierarchy. He thought… and thought… and thought… and only slept occasionally between his moments of insomnia.

  He lifted his lean body from the mattress, but just as he was about to stand, he slumped back down into the nice warm, cozy blankets. Just a few more minutes, he thought to himself. Then he could rush his shower and still make it on time. But as his eyelids began to gently fall closed, he jumped out of bed. He definitely did not want to be late, at least not the first week.

  There were stories about residents who were fired for being late

  continuously, but it only took one morning to start a bad habit.

  He took a quick shower and made a light breakfast. He let Pudge out, made his bed, and tidied the house. It was pitch dark outside as he locked his apartment and made his way to his car. As he reached for the door handle, he heard a familiar, distressed noise. “Oh shit, Pudge!” Steve ran back up the stairs into his house and let the barking dog inside. “Sorry, pal.” He only paused a moment to pet Pudge before leaving for the hospital.

  The hallways of the hospital at 5:30 in the morning felt lonely. Few other people were walking around. The nurses on the night shift were finishing patient baths or charting their notes for the shift. A single resident must have been on call; he walked down the corridor with a large cup of coffee in his hand. Other than that, no other residents were visible.

  Steve started in the ICU, visiting Mr. Gordon first. His head was buried in the flow sheet when he heard a voice over his left shoulder.

  “Hey, top of the morning to you.”

  Steve swung around to find Dennis standing behind him. “What are you doing here so early?” he asked.

  Dennis shrugged. “I thought I would follow your footsteps as a good surgery intern and pre-round on all of our patients on the surgery service.”

  “Hey, that’s what I’m doing, but it looks like I’ll only get through the ICU patients,” said Steve. “So how was your first day? Did you get some assholes for residents?”

  “I actually think I have a great team. My chief, Linda Kaplan, seems really cool. She didn’t yell at all yesterday and was even nice to the students and let them leave early. Maybe it was just show for the first day, but that’s ok. I’ll take whatever

  I can.”

  “Yeah, you’re pretty lucky. I remember her from last year.

  One of my friends had her as a senior resident. She was very cool last year too. I think she is a civil person in general. I wonder what she is doing in surgery!”

  They both laughed.

  Steve and Dennis lost track of time as they compared their first day on the job. Just as Steve mentioned the code, a voice boomed from behind him.

  “Come on, Carmichael, we don’t have time to wait for you while you get a date for Saturday!” Tom Formin yelled across the ICU. If there was any doubt, it was gone: Tom was a dick like the rest of them.

  Steve turned and looked at Dennis, “I guess my residents have a civil nature about themselves as well. I’ll see you later, Dennis.”

  “Hang in there. I’ll talk to you later.”

  “Alright, Carmichael, you write the notes while one of the students does the exam,” said Tom. “Let’s get started. I don’t know where Sally or Jake are, but if we don’t move along, we’ll never finish before the operating room starts.” Tom looked over the flow sheet and noticed that Mr. Gordon had a slight temperature last night. “Shit,
Mr. Gordon spiked a temp last night.”

  “Yeah, but it was only a low-grade temp, and his white count was still normal at 9900,” responded Steve.

  Tom looked in amazement at Steve. “So you were doing more than getting a date for Saturday. Good job, Carmichael! That should land you in the OR today. At least hat would be my decision, but we both know that I’m not the commander in chief of this service.”

  While they were laughing, Sally approached from behind.

  Somewhat short of breath, she pleaded her case. “Sorry I was

  late. First my alarm clock didn’t go off and then I couldn’t find my notes for the Morbidity and Mortality conference so I can discuss Mr. Springer and then…”

  “It’s okay, Sally,” said Tom. “It’s just us. Remember that we’re on your side. The enemy has not arrived yet. Actually, Jake is late, too.”

  “Yeah, and when he does get here, he better have a good excuse why his ass was so late,” said Steve in a stern voice.

  Tom, Sally, and the students looked at Steve, shocked by his comment.

  He added with a straight face, “What? Jake should have to answer to somebody. We do. And from now on, Jake Douglas will have to answer to me when his sorry ass is late!” Steve could no longer keep his composure and began laughing, the rest of the team added to the laughter.

  After a few seconds of fun, Sally broke in and said, “Jake is not late, at least not late for making it to the hospital. He is outside the ICU talking to some lawyer. So how is Mr. Gordon doing this morning?”

  Tom explained that he and Steve had noticed low-grade temps from during the night, plus the normal WBC.

  Sally walked over to the patient and drew out her stethoscope while she listened to their report. She examined the patient herself while Tom spoke. He stopped when Dr. Jenson listened to Mr. Gordon’s lungs, heart, and abdomen.

  When she was done, she turned around and asked who had examined the patient.

  Mike, looking as if he had done something wrong, answered, “I did.”

  “What did you find? Any abnormalities or was every-

  thing the way you would want for your mother?” Sally smiled.

  “Actually, I thought his lungs were clear and his heart was sinus. I didn’t appreciate any murmur.”

  “Would you expect to hear a heart murmur in a post trauma patient if they didn’t come in with a murmur?”

  Mike was beginning to feel warm, “Uhh, I don’t think so.”

  Sally continued teaching rounds. “Are you sure? Are you absolutely sure? This is your mother we’re talking about now. Why don’t you listen again just to make yourself absolutely certain?”

  Mike grabbed his stethoscope and placed it on Mr. Gordon’s chest. The ventilator continued to make his chest move twelve times a minute, but in between the movements, Mike listened carefully. The distraction of the vent made it difficult to hear clearly, but he was certain there were no murmurs. He moved back from the bed shaking his head as he removed the stethoscope from his ears. “No, definitely not. No murmurs.”

  “How about his lungs? Any findings on his lung exam?” continued Sally.

  “No, I think the exam was just as I stated at first.”

  “Well, that is a very confident statement, especially for a third year medical student.”

  Mike looked down at his feet as if he had just been scolded.

  “As a matter of fact, I agree,” stated Sally.

  Mike looked up and produced a slight smile of relief.

  “Now, Dr. Carmichael, in the face of a life threatening trauma, do you think Mr. Gordon had a thorough exam when he came in to the trauma room? I mean, most likely this guy was about dead when he arrived, and tubes, IVs, catheters, and fingers were already going into his body. Most likely, a medic-

  al student at best put a stethoscope to this guy’s body. Do you think the exam would have been accurate?”

  “No, but if there was a murmur, I think it probably would have been noticed.”

  “Really? You think above all that commotion and noise someone with the best set of ears could hear a murmur? Carmichael, grab your scope and listen to my chest. Now! We

  don’t have all day.”

  Steve timidly walked toward Dr. Jenson and hesitantly pulled out his stethoscope. He wondered at first if she was joking, but Sally did not even hint a smile. He placed the scope over her heart and began to listen. Sally grabbed the scope off her chest. With his ears ringing from the amplified crash on his stethoscope Steve took off the scope.

  “Do you always do your heart exam through someone’s clothes? That is a sure way to miss a finding.” Sally unbuttoned the top three buttons of her blouse.

  Steve, now totally embarrassed, had to put his stethoscope on the upper part of her bare breast. He could feel his skin warm up quickly, but he listened carefully. After what seemed to be an eternity, he removed his scope.

  “Well what did you hear?” asked Sally impatiently.

  “I heard a normal sinus rhythm with a normal S1 and S2 and no murmurs.”

  “You sure? Absolutely sure just as if your mother’s care depended on it?”

  “Yes. I didn’t hear any murmurs.”

  “Well, how about that, Mr. Know-it-all. During a trauma code you missed a grade1 murmur from a mitral valve prolapse!” As Sally buttoned her blouse she asked, “So how does that affect your assessment of Mr. Gordon this morning,

  Steve?”

  Steve was not sure where to go with the question and he stared at her with a blank look on his face.

  Sally helped out. “Let’s say this guy is indeed the druggie that he was made out to be. Then he probably uses too, right?” Sally waited for a response after her large hint.

  “There is a small chance that he might have a vegetation on one of his heart valves.”

  “A small chance? I’m not sure that it is necessarily a small

  l or a large chance, but doing IV drugs certainly increase the chance that vegetation could develop on a heart valve and cause a bacteremia. That would certainly cause a low grade temp.”

  Continuing the role of chief resident, Sally turned her attention to Dr. Formin. “So Tom, since you were the highest in ranking here this morning, what did you attribute this low grade temp to?”

  Tom searched for the right answer. “Well, as you mentioned, he could have bacterial endocarditis-”

  “Very original Tom, but your astute medical student tells you that there is no heart murmur, and I agree.”

  Mike let out another proud smile, also revealing gratitude that the grilling was not directed at him any longer.

  Tom continued. “Since he is only a day out of surgery, he might have developed some atelectasis in his lungs. That small amount of lung collapse could certainly cause his low grade temp.”

  “Very good.” said Sally, “Keep going.”

  “Uhh, he could have, uhh…”

  “Dr. Formin, before you get into another ‘uhh’ fit, review the exam that you recorded in his progress note.”

  Tom reviewed the note that Steve had written but could not find any culprits that would cause the temp. Finally, Tom looked up, shook his head, and said, “I just can’t find another reason for his temp.”

  “That’s it? You just stop there and accept the fact that he

  has a low grade temp that could develop into a major septic episode?”

  Tom stared at Sally.

  Glancing at her watch, Sally realized the time was getting short and she had to wrap up teaching rounds. “Tom, what did the wound look like?”

  “I’m not sure.”

  “Why is the wound important, Dr. Carmichael? Does it make a difference the first few days out of surgery?”

  Steve had assumed that his grilling was done, but now he realized that he had a few more years to suffer the unusual teaching method. “It is my understanding that it usually takes up to a week to develop a wound infection, but there are a few organisms that may cause a wound to get infected
the first couple of days after surgery.”

  “Very good, and what would those bugs be?” demanded Sally.

  “I think Clostridium and Streptococcus could cause an early wound infection.”

  “Good. So should we look at the wound today, guys?”

  Steve walked over to the bedside, put a pair of gloves on his hands, and removed the dressing. The wound looked fine, without any redness or warmth over it.

  “Ok,” said Sally. “The wound looks good. We need to wrap this up. Mike or Roger, could you two think of any reason why Mr. Gordon has a temp?”

  The two students looked at each other and shook their

  heads no.

  Sally turned toward Steve again.

  “It’s probably too early for a urinary tract infection, but that could be a possibility,” he said.

  “Doubtful,” replied Sally. She finally looked at Tom, but he

  didn’t have the answer. “What is he scheduled for today?”

  Suddenly Tom and Steve knew where Sally was headed with her questioning.

  “The packs could be a source for the temp,” Steve blurted out.

  Sally nodded dramatically. “You’ve had a foreign material stuck in this guy’s belly for 24 hours, not to mention his trauma and hypotension. What more do you want? We need to get the packing out today. His WBC is okay, but what about his diff? Is his differential abnormal? Are there any bands?”

  Steve looked at his notes and then at the lab sheet, “No, that was all fine.”

  “Good. He will probably do fine. Let’s make sure he is typed and crossed before he goes to the OR. Steve, please order that. All right, that’s enough teaching for this morning. We need to fly to get through the rest of these patients.”