Foreign Threat

by Mitchell Goldstein

  Jake demonstrated exactly what he meant. In doing so, Jake had the opportunity to have his hand in the abdomen first. He could not see much with all the stool that was in the cavity, but he quickly explored down in the pelvis and felt a soft but large mass.

  He briefly closed his eyes in case it was a bomb. Nothing happened, so he continued to feel it and tried to figure out

  what it could be.

  “What the hell” shouted Jake. “There is something growing inside this guy’s belly. Steve, why don’t you take a feel? But be gentle, I don’t want to disrupt this thing. He is from abroad, so for all we know, this could be a huge parasitic cyst. Let’s be careful.”

  Steve gently reached his hand into the patient’s abdomen and felt around. As he got toward the pelvis, he too felt the mass and said, “Oh, shit. This thing is huge.”

  Steve was still moving his hand around inside when Jake motioned for him to stop.

  “Alright, that is enough there, fellow. Let’s get this thing out, ship it over to Path, and head home.”

  “That sounds like a winner to me,” cheered A.J.

  Steve didn’t mind relinquishing responsibility for the surgery. He’d had the chance to open up and feel the abdomin-al contents. That was the most he had done yet in the OR, and he was ecstatic.

  “Steve, why don’t you take this Richardson retractor and pull up?” Jake placed the retractor inside the abdomen via the incision and under the muscle. He then pulled up as if to show Steve what he wanted him to do. “There you go, Carmichael. Now just keep that exposure, and we’ll try to get this mass out.”

  Jake placed both hands in the cavity and palpated around this mass. He continued to move his fingers around it in order to free it from any attachments that might have been made in the short while inside the body. Jake wanted to see the mass, so he did what no surgeon should do: he placed his head directly over the incision. The mass appeared to have a thick fibrinous layer of tissue covering it, so the doctor still could not tell what it actually was.

  Jake’s interest in identifying the mass was waning. He just wanted to collect the money and be done with it.

  After getting a good view of the thing, he then leaned back to his original position and again started to dissect the mass. Just as the mass was freed, he placed his left hand behind it and started to push it forward as if to get it out into the field and out of the abdomen. As he did so, he felt his index finger enter the mass.

  At first, he didn’t want to think it had really happened. He wasn’t sure what Thomas would think, but most likely, it would not be something that he was expecting. Jake reminded himself quickly that the most important thing right now was not to attract any attention to the hole. He squeezed his fingers together on that hand to occlude any material from escaping from the mass. He could feel his finger inside the mass. It felt like a soft material contained in a plastic bag, but he could not make out for sure what it was. He became paralyzed by the frightening thought of what it might be. He felt sweat eveloping on his forehead. The room started to spin around, and he was growing nauseous.

  “Dr. Douglas? Dr. Douglas! Are you alright?” Sue asked as she noticed Jake starting to sway.

  He didn’t reply, so Steve asked again, but louder, “Jake!

  Hey, are you okay in there? Is anybody home?”

  Jake glanced at Steve and then at Sue. “I think I had better take this over to Pathology myself. I’m not sure if anyone else should handle this.” As he was speaking, he pulled the mass out of the abdomen ever so slowly.

  Steve thought that Jake was having a difficult time with getting it out. “Here, let me help you-”

  “NO! Don’t touch it! I’m just fine. Don’t touch this thing. I am doing good. I just need to get it out carefully, and then

  I’ll walk it over to Path.”

  Sue wanted to protect the innocent as usual. “Alright, Jake. Let’s just take it easy on Steve. He was just trying to help out.” Everyone else froze. No one wanted to piss off Jake, thinking this was another moment when he might start acting like a complete asshole.

  “SHUT UP, SUE!” screamed Jake. “Just give me a moment, then you all can speak afterwards.”

  Sue was shocked. Jake Douglas almost always listened to her.

  The others stared at each other as if to question the abrupt change in Jake’s demeanor.

  Jake continued to slowly pull the mass toward himself and out of the field. He asked Sue for a basin to carry it.

  She hesitantly held the basin near the wound for him, still upset that he had been so rude to her and everyone in the room.

  When the object was free, Jake clamped his fingers even tighter so no one could see that his finger was inside the mass. He gently placed the specimen in the container, leaving his hand attached. Without changing gloves, he placed his right hand under the basin in order to stabilize the specimen inside the container. He turned around and quickly headed toward the door.

  Everyone else in the room held still for fear of the wrath of Jake Douglas. They waited silently for Jake to remove that thing.

  Steve had glanced down at the wound as the specimen was being meticulously removed. He thought he saw a trace of white powder trail behind the specimen. He wasn’t sure if his eyes were playing tricks on him, so he blinked twice and looked again at the wound. The phantom white substance had disappeared. As the specimen came out, a wave of blood filled

  the cavity.

  Jake was almost through the doors when he looked up at Steve and said, “Carmichael, pack the wound. I’ll be back in a

  moment, and we’ll look for an appendicial stump leak.”

  Everyone remained quiet after Jake departed. The doctor always had a way of creating a mood, and it was difficult to break.

  Steve grabbed a few lap pads from Sue and began packing the wound. Soon the blood stopped welling up in the wound.

  Finally, Sue broke the silence. “What an asshole.”

  Chapter 22

  Steve had a horrendous day on the floor taking care of patients. The work never seemed to stop: first a blood draw for cultures on a woman who developed fevers the night before, then a central line in an older man who had part of his colon removed for diverticulitis and needed intravenous nutrition, and then a young girl who’d had her appendix removed three days ago and was ready to go home but needed discharge planning to be completed. The list continued. Steve never had a boring day at the hospital, but he yearned for the day that his service was light enough to go to the library and read from his surgery text.

  Despite the great amount of work on this particular morning, Steve was able to keep up with the schedule. As always, Dr. Douglas was in surgery with a resident. Today he picked Sally to go to the operating room with him. Steve had determined that no one really bothered them with questions or gossip. The problem he had recently was that Jake hardly picked him to go to the OR. Since their encounter in the locker room and Jake getting in trouble with Dr. Rosberg, Steve hadn’t been invited back to the OR. Instead, he was responsible for all the scut work on the floor. He had to take care of all the admissions, all the discharges, and all the patient management. Steve reminded himself to use this to his advantage, learning about all the different issues surrounding his patients.

  Steve grew used to referring to the patients on the floor as his patients. After all, they were in his total care. Jake never bothered with many questions on rounds as long as the patients were flourishing. Steve took a great sense of personal satisfaction if his patients did well and would be just as disappointed if there were a problem that would develop with one of them. Jake evidently realized this pride that Steve had with his care of patients. The senior doctor would take advantage of this, knowing that Steve would take good care of the patients.

  Neither Jake nor Steve realized that Dr. Rosberg and the other attending staff also noticed the major accomplishments and excellent patient care that Steve was providing. Steve was always on the floor when a staff surgeon would com
e by to check on a patient. The comment would be, “Oh, Dr. Carmichael, are you out of the OR again? Weren’t you on the floor yesterday, too? Doesn’t Jake ever let you operate as part of your surgery residency?” Steve would just smile and shrug his shoulders. Then he would provide all the pertinent details to the staff about their patients, including morning lab values, events that occurred during the night, and the overall progress of them. The more Steve gathered information on complications like post-op pneumonia and atelectasis or deep vein thrombosis, the more the staff sensed his knowledge base and commitment to patient care. This built the staff surgeons’ trust in Dr. Carmichael to manage their patients. It would translate into more surgery time in the future as an upper level resident. The more a staff doctor trusted him with patients, the more he would get to do in the operating room. Retracting would be a thing of the past.

  It was nearly 3:30 in the afternoon before Steve finished the floor work. All of the patients who were supposed to be discharged had been discharged, and all the staff doctors had come by to do their rounds. Steve still had not heard from Jake or anyone else from the OR, so he took the opportunity to get some lunch. He knew it might be the only chance he had to eat for a while since he was on call overnight again. One of the first things he had learned as a surgery intern was that if you have a chance to eat, do it; you never knew what lurked ahead. You could only eat at reasonable hours for meals if you were at home on a day off or if you were attending a noon hour lecture with lunch provided.

  No sooner did Steve sit down with a cold sandwich from the refrigerator than his beeper went off. He swallowed the sandwich in just a few bites and grabbed his soda on his way to the nearest phone to answer his page. He knew it was not a true emergency, because as Erica had told him, the nurses would have paged him overhead to get his attention for something serious.

  He dialed the number and then heard the voice on the other end. “Uh huh…yep…okay. I’ll be right up.” Jake was done with surgery, finally, and wanted to make afternoon rounds.

  Sally was the one who had called Steve. From her tone in her voice, she sounded exhausted. On the way up to the ICU, Steve was thinking that the surgery took a long time and maybe there was a problem with the patient during surgery. He ought to know since he was on call and expected to manage the patient during the night. He arrived in the ICU to find the rest of his team in Room 4 going over Jake and Sally’s new post-op.

  Nurse Agusta Johnson was in the room admitting the patient to the ICU. She was busy trying to untangle several loops of IV tubing. “Well, Dr. Carmichael, looks as if we will be getting to know each other quite well tonight.” She was referring to how critical the post-op course would be during the night for the patient laying in the bed.

  Dr. Rosberg was standing nearby. “Not to disagree with

  you, Agusta, but I would rather you get to know Dr. Douglas tonight. Mr. Conrad will require a great deal of attention and TLC.” Dr. Rosberg looked over toward Steve. “Not that I don’t think you can handle managing this patient, Carmichael, because I know you can. I’ve seen what you do on the floor, but being on call for surgery as an intern will get you pulled in all sorts of different directions. Mr. Conrad needs a little more attention tonight, and it will be good for Jake to do some ICU monitoring and management with his patient. Isn’t that right, Dr. Douglas?”

  Jake looked down at his feet. “Yes, sir.”

  You see Dr. Carmichael,” Dr. Rosberg continued, “Drs. Douglas and Jenson were going to do a simple gastric ulcer resection for a persistent gastric ulcer. Unfortunately, no one seemed to think about getting some pertinent lab work such as white cell count or an amylase. So what was supposed to be a simple hour-long case turned out to be an eight-hour pancreticoduodenctomy. The pancreatic tumor appeared to be a stomach ulcer because it had eroded through the stomach wall. Steve, are you familiar with a Whipple procedure?”

  “Kind of,” he replied. “It’s when the pancreas, stomach, and duodenum are removed for a tumor in the head of the pancreas gland.”

  “Very good, Dr. Carmichael. Post operatively, these patients require a lot of attention. They have drains, feeding tubes, and gastrostomy tubes. Mr. Conrad will also need to be on the ventilator for a while as the case lasted a little longer than Dr. Douglas anticipated. Isn’t that right, Jake, my boy?”

  Jake kept his eyes aimed at the floor without responding Apparently Dr. Rosberg had already had a few words with

  Jake.

  Dr. Rosberg finished reviewing the initial vitals and then

  glanced at the labs. “Alright, Dr. Douglas, I expect you to stay around a few hours to make sure this patient is rock stable before you leave. Agusta, if Steve gets called away for a significant period of time during the night, please call Jake in, no matter what time it is, okay?”

  Agusta smiled devilishly. “That will be no problem, sir.”

  Rounds continued as painful as any other time that Jake had been in trouble. Dr. Douglas would make a concerted effort to be a know-it-all about every patient. However, Steve had become practiced in knowing most everything about all of his patients. He knew their history, past medical history and surgeries, their medications before surgery and their meds in the hospital, as well as any post-op problems and their complete lab work. He carried a notebook with everything written down to be sure he never failed. Jake would ask and ask, and Steve would answer with few hesitations.

  Rounds were almost done when Jake suggested that the whole team review the complete x-rays of every patient on their surgical service in the x-ray department. The doctors shook their heads in disgust but followed their leader to x-ray.

  On the way, Steve leaned over to Sally and asked, “Got in a lot of trouble today, huh?”

  Sally made sure to whisper so Jake would not hear. “Dr. Rosberg has reached his limit of tolerance for Jake. This case was the last straw. After finding out intraoperatively that we were dealing with a complete mess and had not been prepared for it, Jake had to confess to Rosberg that the preoperative work up was neither complete nor satisfactory. When Rosberg saw this tumor and reviewed the chart, he nearly strangled Jake. Then, well, you know: eight hours is a long time, so Rosberg began quizzing Jake on all the patients as if he were an intern again. Unfortunately, Jake didn’t know much about many of the patients, and it was obvious that he really didn’t pay too much attention on rounds. Then he made the idiotic mistake of trying to bullshit Rosberg about some lab values on one of his patients. Rosberg knew right away what Jake was doing and toyed him along for a few more lies. By then, Jake was swimming alone in shark-infested waters. Rosberg started to take bites out of him. First, they were small and painful, but then they got bigger and bigger. There was no sign of any rescue. I kind of think Rosberg enjoyed himself. Whatever. By the end of the attack, Rosberg threatened to ax Jake if he doesn’t get his shit together, and he meant it. I think that really scared Jake.”

  Steve stared at Sally with a dumbfounded expression. What a disappointment that would be to spend five to six years training and then to have it all pulled out from under you. It couldn’t happen to a nicer guy. Steve smiled to himself.

  When Jake was done going over every x-ray on every patient, he sent everyone home except for Roger. “You get to take call with Steve.” It was a common practice for med students to have the option to take call on surgery, but Jake had not enforced that before tonight. Jake, Steve and Roger went back up to the ICU and checked on Mr. Conrad. “Alright, Carmichael, why don’t you and Roger go and get dinner before the cafeteria closes? Check in with me when you’re done.”

  Steve looked with confusion at Roger and then back again

  at Jake, but he didn’t argue. They left the unit without another word.

  They returned to the ICU about an hour later. Jake was in Mr. Conrad’s room looking over vitals and checking his urine output.

  “Sorry, Jake, we got paged during dinner, and then I had

  to go to the ER for a perirectal abscess.” />
  “That sounds yummy. I hope you had a chance to eat before you drained the abscess.”

  Just then, Steve was paged overhead for a trauma code in the ER. He and Roger glanced at each other and left Jake in the

  dust.

  After Steve finished what felt like a late-night rush at a restaurant, he and Roger returned from the ER to the ICU. They found Jake sleeping in Mr. Conrad’s room.

  Steve nudged Jake. “Hey, wake up. It’s almost ten. Why don’t you head home now? I think things have slowed down for a while.”

  Jake groggily looked at his watch and then at Mr. Conrad and the ventilator. “Alright, I’ll head out, but don’t hesitate to call me.”

  Agusta leaned into the room and said, “Oh, don’t you worry about a silly little thing like that, Dr. Douglas. I’ll be sure to call you if we need you.” As she walked away, she whispered, “And even if I don’t.”

  Steve tried not to look at Jake after he heard that, but he saw Jake smile wryly.

  Just as Jake stood, his pager went off. He looked at the number. “Shit, the ER. Don’t they know I’m not on call?” He grabbed the phone off the wall and spoke to one of the doctors in the ER.

  The guy had such a loud voice Steve could hear the

  conversation across the room.

  “Sorry, Jake. I know you’re not on call, but there is this interesting looking guy with a funny accent who just came in with some pretty serious belly pain. He looks like shit but refuses to see anybody but you.”

  Jake looked like he had just seen a ghost. His face turned

  pale, and beads of sweat started to collect on his forehead. He looked down at his pager to review the last several pages.

  The ER doctor continued, “Apparently this guy came in several hours ago looking for you. The nurses said he had pretty serious abdominal pain, but he found out you were in surgery and said he would come back. Some kids just found him unconscious two blocks away, and EMS brought him back in. He woke up after a liter of LR, but he’s still terribly dehydrated with significant rebound. His belly is rock hard, probably perforated something. It looks as if he had recent surgery, but he says that was done elsewhere so we won’t have any records of his surgery. He refuses to see anyone else but you. Quite the following you have here, Jake. Already building up your private practice?”