by Harry Kraus
Basil lifted a pack of crackers from his white coat pocket. “Eat when you can.”
Overby lifted a second finger.
Claire joined with the group in a jumbled unison, “Everyone teaches a tern.”
The chief resident held up three fingers.
“If you don’t know, ask.”
Overby grinned. “And four?”
Claire felt the color rising in her cheeks. She waited for the response. No one volunteered. Rick laughed. Sally shuffled her notes for rounds.
Dan made a clicking noise with his cheek. “Come now, class. You remember.” His eyes rested on Claire. “Keep the fleas …,” he prompted, his grin widening.
“Away from my patients!” The group’s response was enthusiastic, but hardly in unison, as they stumbled over the exact wording.
Claire tried to focus on her patient cards. She forced a chuckle. “Ha, ha,” she mumbled. “Ha, ha.” I can be a good sport, guys, but excuse me if I don’t laugh all day.
Claire forged her way through the day’s work with renewed determination. She was a tern. She was there to learn. She would accept criticism and use it to get better. She wouldn’t make the same mistake twice.
And, as she worked, she mulled over her own situation as a lonely intern in a powerful surgery program. The way to survive, she convinced herself, was to become a team player. Support the residents above her, teach the students below, and link arms with the interns around her. She wouldn’t be the one to back-stab the other interns. If she couldn’t be a compassionate friend to the other terns, the year was destined for pure torture. Isolate yourself and die. Forge friendships with the other interns, and you’ll have a chance.
She’d decided yesterday, during her soul-searching at Foster Park, to reach out to Bea Hayes. It was a no-brainer. The only two women in the intern group should be friends. Claire would lay aside her first impressions and make an honest attempt to see things through Bea’s eyes. She could rise above her own competitive impulses and help Bea to make it, too.
After morning rounds, there were X-ray and lab reports to gather, two chest tubes to pull, and six discharge summaries to dictate. Claire and Beatrice split the work and finished just before rounds with the attending on call, Dr. Stan Fowler. Pulling together, the two women seemed to make an efficient team.
Dr. Fowler was forty, nearly bald, and enjoyed his reputation as a pit bull. The interns had all been warned: He never lets go except to get a bigger bite.
The team walked into the ICU in pecking order. Dr. Fowler led the way, with the chief resident, Dan Overby, on his heels. The second-year resident, Basil Roberts, was next, followed by the interns, Beatrice Hayes and Claire. The students, Josef Cohen and Glen Mattingly, brought up the rear.
They approached the first bed, occupied by Sid Johnson, a twenty-two-year-old male, five days out from a gunshot wound to the abdomen. He was Josef’s patient, so he started the presentation. “Mr. Johnson is five days status post small bowel resection, splenectomy, left nephrectomy, and colostomy for injuries sustained in a gunshot wound to the abdomen. Over the last twenty-four hours, his T-max has been 101.6 Fahrenheit. His other vital signs have been stable. He has been—”
Dr. Fowler interrupted. “What are the most common causes for postoperative fever?” His eyes darted around the group. The chief resident was calm. This was clearly not a chief level question, at least not yet. Typically, the attending starts at the bottom of the pecking order. He squinted at the name tag of the blond student at his right. “Dr. Mattingly?” All were aware that he was according the students a special honor to address them as doctor.
“Infection.”
Fowler nodded. “What type?”
The student shrugged and offered, “Infection in the surgical wound.”
“I’ll accept that, but what’s the most common postoperative infection?”
Glenn stayed quiet. The attending looked at Josef. “What would you say, Dr. Cohen?”
“Pneumonia.”
“Wrong. That’s another possibility, but not the most common.” He looked at Beatrice. “Enlighten the students, Dr. Hayes.”
“Urinary tract infection.”
“Correct.”
Beatrice smiled.
“Why don’t you explain the most common causes of fever in the surgical patient, starting with the first day post-op?”
As Beatrice answered the question, Claire reviewed all the possible causes of post-op fever. Eventually, the question would be bumped to her, if the other intern failed. After a few moments, Beatrice paused.
The attending surgeon prompted, “Any other causes?”
Beatrice hesitated, looking at the floor.
Claire jumped in to assist. “I can think of two more, both possibilities caused by our interventions. One is line sepsis. The other is drug fever.”
Fowler nodded. “Very good.”
Claire relaxed a notch—until she caught the expression on Bea’s face. Her teeth were clenched and her eyes bore in on Claire’s. After Josef was allowed to continue his presentation, the attending examined the patient and gave instructions for the team. As they moved to the next bed, Claire felt a tug on the back of her lab coat. She turned to see Bea’s reddened face.
Bea motioned her to move away a few steps, then spoke with quiet tension. “Try not to interrupt, Claire. That was my question.”
Claire shrugged and returned a whisper. “I was only trying to help. I thought you were done.”
Bea rolled her eyes. “Don’t try to be so helpful. Try keeping your mouth shut.”
Claire watched as the team moved on toward the next patient. She stood by herself momentarily, stunned by the reproach. She choked back an uncivil response and shook her head.
So much for camaraderie in the trenches.
In general, Claire learned, the chief residents were classified as either “walls” or “sieves.” A “wall” is a resident who refuses patient admissions. Patients have to be critically sick or dying to deserve an inpatient spot on a wall’s service. The patients, if they are admitted at all, will be “turfed” to another service. A “sieve” is a resident who admits all comers, regardless of the nature of the patient complaints.
For an intern, having a wall above them means a certain amount of protection from being overworked. A sieve above you almost guaranteed countless hours of scut work and sleep deprivation.
Dan Overby was a classic sieve. His extreme level of competence in internal medicine made him a ready target for patient transfers from other medical services. His pride in his own ability prevented him from ever saying no to a patient admission, even one that seemed nonsurgical. Every area of medicine seemed to fall under the umbrella of the O-man’s expertise.
The attending physicians loved him.
The interns endured him. On the nights when the trauma service had a moment to breathe, Dan would surf the ER, looking for general surgery cases.
By eleven P.M., after eighteen hours of call, Claire was beginning to think she might see the inside of a call room. She was just leaving the ER when she heard his voice.
“Hey, Claire.”
She turned to see the chief resident with his finger pointing to a name on a large washable marker board. He picked up a chart from the rack. “I smell a case.” He smiled. “An intern case.”
She walked toward him and held out her hand. She was tired, but never too tired for a chance to operate. “What’ve you got?”
“Thirteen-year-old boy with right lower quadrant pain.”
She brightened. “Appendicitis?”
“You decide. You’re the doctor.” He lowered his voice. “If you wait for the new intern on ER call, you may have to wait another two hours before they figure this out. If you help them out by seeing a patient before they ask, they’ll look out for you.”
Claire accepted the chart and walked to the ninth cubicle. She knocked on the door and entered. Inside, a young man reclined on a stretcher, surrounded by what Claire assum
ed was his family. She counted three adults and two more children in the cramped examining room. She made eye contact with a woman sitting on a stool beside the patient. “Hi. I’m Dr. McCall, with the department of surgery.” She held out her hand.
The woman, wearing a Boston College sweatshirt and blue jeans, took Claire’s hand. “Surgery? Does Jeremy need surgery?”
“That’s what I’m here to find out.” She looked at the boy on the stretcher. His eyes were wide and his hands were resting over his lower abdomen.
“When did you get sick, Jeremy?”
He looked at his mother before answering. “Yesterday.”
“Does your stomach hurt?”
He nodded without speaking.
Claire could feel every eye in the room watching. She tried a more open-ended question, attempting to get more than a word out of the boy.
“Tell me in your own words what has been going on.”
He looked at his mother again.
“Go ahead, Jeremy. The doctor needs to know,” his mother coached.
“I got sick at school, after lunch. I think it was the pizza.”
Claire studied him for a moment. Open-ended questions obviously weren’t designed for this thirteen-year-old boy. “Where did the pain start? Can you show me?” She lifted his shirt to expose his abdomen.
“Here.” He pointed to his navel.
“Has it moved? Point with one finger to the spot it hurts the most.”
He moved his finger down, pressing and wincing as he looked for the worst location. He stopped in his right lower abdomen and pointed. “Here.”
Claire recognized the spot as “McBurney’s point,” from the classic description of appendicitis. She pressed gently on the spot and watched his face. She quickly lifted her hand.
Jeremy grabbed her hand. “Ow!”
“What’s your favorite food, Jeremy?”
“Ice cream.”
“If I could get you a bowl of ice cream right now, would you want it?”
He shook his head. “I’m not hungry.”
Claire suppressed the urge to smile. So far this boy was textbook. She was about to reel in her first abdominal surgery case.
She completed the interview and the exam and ordered a complete blood count and a urinalysis. If his white blood count was high, she would call the O-man and lay claim to her first appendix.
She felt her heart quicken as she slipped a small book from her lab-coat pocket. She opened The Surgical Resident’s Companion to a section on appendicitis and reviewed the operative procedure.
Thirty minutes later, armed with the lab work to confirm her suspicions of the need for surgery, she presented the case to Dan. He, in turn, examined the patient, and called the attending on call, Stan Fowler.
Dan hung up the phone and looked at Claire. “Dr. Fowler will be in to help do the case. He always scrubs in with the interns. And he likes to ask questions.”
She thought about rounds. “So I’ve seen.”
“I was just at the OR a few minutes ago. You’ll probably get to do the case right after the neuro boys finish up with their crainy.” Dan squinted to the back corner of the emergency room.
Claire followed his eyes. A man wearing a large bandage around his head stumbled forward toward a stretcher following Beatrice Hayes. The student, Glen Mattingly, appeared to be wrestling with the man, coaxing him forward.
She immediately recognized the wide-based walk, so characteristic of her father. The man’s arms seemed to flail randomly into the sky. Glen ducked and put his arm around the patient’s waist.
Dan tilted his head toward the action. “Why don’t you give ‘em a hand. Looks like they got themselves a winner.”
The last thing Claire felt like doing was lending a helping hand to Bea. She clenched her jaw. “Sure,” she responded, choking back her feelings. “On my way.”
As she approached, Bea pointed at the stretcher and raised her voice. “Okay, Mr. Davis. Get on the stretcher and lie down.”
The man appeared to be shaking his head. His left arm flung forward as he fell onto the stretcher. His hand struck Bea’s buttocks.
Bea’s eyes flared. “Watch it, buster!”
The patient’s speech was slurred. “Sh—sorry.”
Claire stepped forward. “Can I help?”
Bea looked up and groaned. “Just another of Lafayette’s finest.”
Claire put on a pair of gloves and began to unwrap the bloody bandage from the patient’s forehead.
Bea began opening up a sterile suture tray. “The ER resident said he has a long scalp laceration.” She looked at the medical student. “Draw his blood. I want to send off a blood alcohol level.”
The patient’s head continued to bob. His words were slurred, but understandable. “I—I don’t drink.”
Bea rolled her eyes. “And I’m Oprah Winfrey.” She pointed to Glen. “Draw the alcohol level.”
Glen nodded. “Did you see the size of his chart? Looks like this isn’t his first visit.”
“A repeat offender.”
Claire finished taking off the bandage. The deep laceration ran from the middle of his forehead back into his hair.
Glen put a tourniquet around the patient’s upper arm and jabbed a needle into his vein. He deftly drew the blood and put it into a vacuum tube. “The way he looked when he stumbled in here, I’ll bet his alcohol level is way over the legal limit.”
Claire frowned. “Was he driving?”
“No. He slipped and hit his head on the edge of the coffee table.” Bea pursed her lips. “At least that’s his story.” She pushed the patient’s cheek to the left. “Hold still so I can get a better look.”
Mr. Davis’s head continued to weave. He appeared to be keeping time to an unheard song.
Bea shoved his head down onto the stretcher. “Hold still!” She looked at the med student. “Hold him down. I’ll never get this sewn up with him jerking all over the place!”
Glen attempted to hold Mr. Davis’s head. While Bea was prepping the scalp with some iodine solution, the patient’s arm swung wide and knocked the edge of the sterile tray, sending the instruments to the floor with a clatter.
Bea cursed and looked at Claire. “Hold his arms!” She looked at her sterile field, now contaminated by the patient’s arm, and shook her head. “No, better yet,” Bea added, looking at the medical student, “just wrap this guy’s head up like it is. If he won’t cooperate, he can just live with a big ugly scar for all I care.”
Claire watched Bea stomp off in disgust, then turned back toward the patient. There, instead of Mr. Davis, she saw her father. She sighed. “Glen, we can’t just wrap this up. It’s gaping so widely, it’ll take weeks to heal without sutures.”
Glen nodded.
“Go get Josef. I’ll set up another sterile suture tray. Between the three of us, we can get this fixed up.”
Forty-five minutes later, Claire looked up from her work and smiled. The laceration, once jagged edged and oozing, was now closed with a neat row of nylon sutures. Josef and Glen were happier than she was to have the job completed.
Josef rotated his shoulders and groaned. “Man, he may be small, but he’s strong. I could barely keep his hands from jerking free.”
“I couldn’t have done it without you.” She looked at her watch. “I need to check with the OR to see if my appendectomy patient is ready.”
Glen looked at Mr. Davis. “Nice job, Dr. McCall.”
“Could you make sure he’s up-to-date on tetanus? And don’t let him leave without being sure someone else is behind the wheel.”
Claire walked away, a knot tightening in her stomach when she passed the ninth cubicle where her appendicitis patient had been. The space, once occupied by her patient and his family, was now empty. Could he have already been taken to surgery?
She jogged toward the elevator. She couldn’t afford to be late to the OR for her first opportunity to do a real case. First impressions with the attendings were too importan
t. Dr. Overby had mentioned that her case would likely follow the craniotomy. Certainly they wouldn’t have finished with that by now.
She took the elevator to the fourth floor and strode through the OR door. Donna Pritchard, an OR nurse, sat behind the main desk alone, intent on the computer screen in front of her. “Have they completed the crainy yet?”
“Oh goodness, yes. They’ve been finished for at least thirty minutes.”
“Have they brought the appendectomy patient up?”
Donna tucked a strand of hair beneath her OR cap. “Check room three. They should be about done by now.”
“Done? That was my case.”
Donna shook her head. “You can’t keep Dr. Fowler waiting. He’ll go right ahead if the resident isn’t present.”
Claire grabbed a mask and OR cap and hurried down the hall. There, looking over the scrub sink through the window into room four, she saw Dr. Fowler operating, standing opposite another assistant, who stood with her back to Claire.
Claire squinted in disbelief. It was Bea! She was operating on Claire’s patient!
Slowly, while clenching her teeth behind her mask, Claire pushed the door open. Dr. Fowler looked up. His tone was as sharp as a surgical scalpel. “Dr. McCall, nice of you to join us. If you work up a case in the future, I expect you to be on time. Fortunately for you, Dr. Hayes was kind enough to step in. Yessiree, and she did a bang-up job of it, too. Her first hot appendix.” He stepped back from the table and pulled off his gown. He looked at Bea. “Put in a subcuticular stitch to close. Do you know how to do that?”
“Sure thing, Dr. Fowler.”
She was kind enough to step in? She stole my first case while I sewed up her patient in the ER! Claire cleared her throat. “Dr. Fowler,” she began timidly, “I was repairing a scalp laceration in the ER. I didn’t know they’d brought my patient to the OR.”
The attending nodded. “Scalp lacerations can be handled by the med students.”
“Not this one, sir. It took two students just to hold the man down.”
Dr. Fowler grunted. “Nonetheless, Dr. McCall, your primary responsibility was to your appendicitis patient.” He paused. “If you want to be a surgeon, you have to do cases. It’s the only way to learn.” With that, he balled up his disposable gown and slam-dunked it into a large red garbage bag.