“B-but sir, I’m improving, sir.” She clasped her hands and began to wring them. “M-most of those were early on. It’s been a rough year, sir.” She looked up and made her first direct eye contact with him. Her eyes were pleading.
“Ah, yes. A rough year, indeed.” Marshall sat forward in his chair suddenly, elbows landing on the desk, and fixed her with a hard stare. His tone changed abruptly from concerned professor to Gestapo interrogator. “You neglected to mention on your application that you had a baby!” He slammed his fists on the desk and the phone handset rattled in its cradle. A hint of a smile surfaced on his face, but he quickly suppressed it.
She let out a muffled cry of surprise and tears began to roll down her flushed cheeks. “How did . . . ? Who told . . . ?” Her lithe body trembled, and she swayed back and forth slightly.
Much better, he thought. Now we’re getting somewhere. His plan was paying off. Marshall reflected back to his first meeting with Karen. He had known early on that she had lied on her application about the out-of-wedlock baby. He was well connected and had his sources. Normally, this would have doomed any chance of admission to the rigidly Catholic Mercy Hospital. But he had intervened on her behalf; he had chosen not to reveal her secret to the committee. He said he saw real promise in her, and in this, he had been quite honest. “It would be such a shame if the hospital found out about the baby. Why, they’d have no choice but to expel you.” Marshall turned both palms upward in a helpless gesture as he let this sink in.
“I need this job,” she said meekly. “My baby—”
“I know you do, Karen. I know you do.” His soothing voice continued, “I understand perfectly. I want to help you.” Hope flickered across her face. Marshall felt a stab of remorse as she gazed at him imploringly with her doe eyes. He broke eye contact, but like a moth to light, his gaze soon returned to her breasts. His hands had taken a preliminary measure of them moments earlier and had discovered they were much larger than her baggy scrub suit had let on. This excited him immensely and served to obliterate his hesitation. Nothing would deny him now. “Remember what I said about the department being family? Well, family members help each other, don’t they? But help is a two-way street, isn’t it Karen?”
“W-what do you want?” she asked, although he could see from her anguished expression she understood.
“Nothing you haven’t done before, I assure you,” he said and stood up from his chair. The panicked look returned to her face.
“I can’t,” she said, and then bolted for the door. She grabbed the knob with both hands, yanking it hard. When she realized it was locked, she froze, still facing the door. Her shoulders collapsed and soon began to bob up and down as fresh tears came.
Marshall closed the gap between them. Being so close to her again, seeing her tightly curled, strawberry hair peek out from the surgical cap, breathing in her clean, young woman smell, he found it hard to concentrate. He reached out and took off her surgical cap. Her hair seemed to expand as if spring-loaded and tumbled down to just below her shoulders. He was amazed that it had all fit into her cap. He turned her gently to face him. Her limbs moved waxily as she released the doorknob; she wore a blank, resigned expression. She looked past him toward the shelves of books and journals, but appeared to focus on nothing. Marshall put his arms around her, drew her close to him and ran his fingers through her coppery mane. He towered over her, his chin resting on the top of her head.
“There, there now, Karen. No need for tears.” He selected a kindly, fatherly tone as he continued to stroke her hair. “I’m not the uncaring ogre that you imagine me to be. I don’t want to have to throw you and your baby out on the street all because of some bad grades and a little lie.”
All she could manage in response were muted sobs.
Marshall caressed her body and nuzzled her. “Don’t make me do that, Karen,” he said in a husky voice. “I want to help you. I need you to help me.” He slid his hand under her scrub top. He felt her shudder, but she offered no resistance. “And call me Daddy.”
The twenty-five-year-old memory, one of his favorites, still held considerable power and never failed to excite him. His heart was thumping rapidly and his breathing was uneven as he put the photographs back and locked up. Poor Karen, he thought. Such a pity.
CHAPTER FOUR
At 5:30 a.m. Wednesday morning, Doug’s clock radio alarm did its best electronic impression of a screech owl. God, he hated that noise. Doug had already been awake for ten minutes and was resting comfortably waiting for the alarm. He had the uncanny ability to know what time it was anytime at night. After twelve years of getting called at all hours, he could gauge the time by how fatigued he felt. He liked to get seven hours of sleep, but his brain had carefully cataloged the different feelings of one hour of sleep, two hours, three hours, and so on up to seven. He actually enjoyed waking shortly before his alarm, so he could savor the relaxation of his bed, rather than be oblivious to it in sleep.
He got up, shut off the alarm, and headed for the shower. He rarely utilized the snooze button, regarding this as a moral weakness. His morning routine was timed down to the minute. Surgeons did not tolerate late starts.
Doug’s mind wandered back to last night’s meeting as the hot water pulsed across his body. He had set the adjustable shower massage head to hard pulse; his seven-year-old son, Steven, called this setting “bombs.” It helped him wake up and relieved some of his morning stiffness.
Would the hospital really get rid of us? He would’ve thought it impossible a couple years ago, but now in the era of health care reform and managed care all bets were off. Surely, even if Pinnacle came in, they would offer positions to some of them. He began to mentally dissect his own group, Keystone Anesthesia.
He smiled when he thought of the large differences between the members of his group. Just as in every walk of life, some people are particularly well suited to their jobs and some are not. Doug was often amazed by how much effort some patients would expend to select a surgeon, only to leave the choice of the anesthesiologist to potluck. He knew that in many operations the two are equally important in determining the outcome of the procedure.
Doug cringed when he thought of two members of his own group. Omar Ayash was in his late fifties and had a bad habit of falling asleep in the OR while administering anesthesia. Sometimes he would nod off for a few seconds, and the circulating nurse would have to shake him to rouse him. He had been written up numerous times, and his personnel file was replete with incriminating reports, but somehow they couldn’t get rid of him. The hospital didn’t want to get entangled with disciplining a physician and felt the responsibility lay with the anesthesia group. Keystone was loath to fire him, as he had already threatened lawsuits for age and nationality discrimination. Doug couldn’t wait for him to retire.
Then there was Joe Raskin, a strange mix of a man. He was in his mid-fifties and aging poorly. He was barely 5’ 7” and unable to convince anyone that the 260 pounds packed on his frame belonged there. He was dark complected and sported a thick, unkempt black beard generously streaked with gray. His beard was so heavy that Doug figured Raskin needed to trim the upper portion if he wanted to see. He had intense, dark brown eyes and a broad nose smeared over the center of his face.
Doug reflected that Raskin was one of those guys that every place is obliged to have: a great talker. He could sure talk the talk, but stumbled when walking the walk. Raskin’s story was actually tragic; he had fallen into one of the common pitfalls of anesthesia practice. Doug recalled bits of one of their earliest conversations twelve years ago, when they had first met.
“Where did you train?” Doug asked.
“Mass General,” replied Raskin, his voice caressing the name in reverence.
Doug couldn’t help but be impressed. It was one of the premier anesthesia training centers. “When did you finish?”
“Sixty-nine.”
“Was Mercy even open then?” Doug asked.
“Yeah, sure.
It opened in sixty-eight. Bryan Marshall started the department. I came six months later.”
“But why Mercy? It couldn’t have been much more than a clinic back then. You probably could’ve gone anywhere.”
“You got that right, Doug.” Raskin paused and seemed to recall memories, possibly of his forgotten youth. “I was hot shit back then. They didn’t come any better trained. I coulda written my own ticket.”
“Yeah, but why Mercy?” Doug persisted. “Why not Penn or Columbia or Cornell?”
“I was hot shit.”
Raskin never did answer the question, but Doug finally figured it out over the years: laziness. Raskin had opted for the easy life when he took the job at the shiny new Our Lady of Mercy hospital. It was a nice posh job in a sleepy community hospital, complete with nurse anesthetists (CRNAs) to do the work. He couldn’t pass it up.
Therein lay the trap. Raskin’s job consisted of supervising the CRNAs. This was supposed to mean an intimate involvement in the cases, helping with the critical induction and emergence phases, and troubleshooting any problems. Probably Raskin started out that way, but eventually the money and his laziness must’ve gotten in the way.
Raskin worked during the heydays of anesthesia. He and his early partners (Omar Ayash joined in 1972) made a fortune supervising thousands of cases. They ran three or four rooms with low-paid CRNAs, and billed the fledgling insurance companies full freight decades before the days of cost-containment and the powerful HMOs.
Somehow, Raskin’s supervision evolved until it looked like what it did now. Raskin no longer bothered to set foot in any of the ORs. He spent most of the day on the phone to his various brokers keeping tabs on his several million dollars in pension, profit-sharing, and personal accounts. He walked up and down the corridors of the OR complex rubbing his hands together, and signaled the “girls,” as he referred to the CRNAs, to proceed. He gave them a peculiar hand sign, a cross between a military salute and a traffic cop gesture, through the window in the OR doors.
The essential drawback to this technique, Doug figured, besides having the CRNAs make fun of Raskin behind his back, was that his skills, his actual hands on procedures, deteriorated badly.
This might have been okay; Raskin might have been able to slide by until his retirement except for several gigantic unforeseen changes that swept over the anesthesia field in the late 1980’s. First, CRNA salaries skyrocketed, doubling or even tripling in a five-year period. Second, the supply of well-trained anesthesiology residents was at an all-time high. Third, because of the advances in surgery and anesthesia, many more complicated procedures were being done on older and sicker patients. What this all translated into was that many anesthesia groups were leaning toward more physicians and fewer CRNAs to run their departments. This meant less supervision and more personally administered anesthetics by the physicians themselves.
Doug remembered very well when this change had come to Keystone Anesthesia Associates. Early in his employment, the group had voted on more physician anesthesia and less supervision. He had been thrilled. After just two years of supervising CRNAs at Mercy, he could easily make the transition back to administering his own cases. To someone like Raskin, however, this must have been his worst nightmare.
Raskin was a very intelligent man and surely realized what was happening. But again, Raskin’s innate laziness prevailed and prevented him from taking any meaningful steps to remedy his situation. It must’ve been just easier to let someone else do all the work, and deceive himself into thinking that he could’ve done it himself.
Doug often wondered how much Raskin actually realized. Did he understand the depth of his fears and incompetence? Or had he, after lying to himself for so many years, come to believe his own lies?
Doug felt uncomfortable with his own skills when he took a two-week vacation. When he came back, the first day he was a bit rusty and might blow an IV or something before getting back into the swing of things. He couldn’t imagine a twenty-year vacation.
The real irony of the situation was that Joe set foot in the ORs only when he was summoned to help out in an emergency. Doug thought this was especially ridiculous. How is the guy who hasn’t intubated anyone in a year going to waltz in and do the one the experienced CRNA cannot? Invariably, the answer was he could not. So another anesthesiologist, frequently Raskin’s friend, Bryan Marshall, came in and bailed him out.
In addition to losing skills he’d once possessed, Raskin also became deficient in techniques that hadn’t even existed when he’d trained. All branches of medicine progressed rapidly, and the highly technical field of anesthesia was no exception. New procedures, techniques, and monitors were constantly coming on the scene with the rapid growth of microchip technology. New drugs were also constantly appearing. Doug knew that the anesthetic of 1999 bore little resemblance to an anesthetic of the 1970s.
Raskin’s knowledge didn’t actually become obsolete. Raskin prided himself on keeping up with all the latest, through reading extensively in journals and attending numerous meetings. Raskin could carry on a wonderful discussion of any of the cutting-edge techniques or pharmacodynamics of modern day anesthesia. This was where the talk the talk part came in and served as a highly effective smokescreen.
What Raskin really lacked was the technical expertise, gained only from hands-on experience, to apply the new technology. But more than that, Doug surmised, what he really suffered from was fear, a deep-seated fear, approaching phobic proportions. He avoided any hi-tech, complicated case like the plague.
Doug often speculated on the enormous effort Raskin expended manipulating the schedule. Wouldn’t it just have been easier to learn the newer techniques and do the cases, then to constantly avoid them and live in perpetual fear that he would be assigned to one that he couldn’t weasel out of? The constant fear surely took its toll. He became meaner and nastier, prone to temper tantrums and displays of rage. His interaction with the patients and the nursing staff suffered. Whereas Omar Ayash’s file was thick with reports of incompetence, Raskin’s file was filled with patient and staff complaints.
As hard as Raskin’s predicament was to understand, what was even more difficult to comprehend was why Bryan Marshall put up with Raskin. Marshall didn’t suffer anyone lightly. Did having a yes-man for all occasions justify his forbearance? Doug had gnawed on this one for years but had never come up with a truly satisfactory explanation.
Doug turned off the water and stepped out of the shower. He toweled off his six-foot-two-inch frame, wrapped the towel around his waist, and got ready to shave. He studied his image in the steamy mirror for a moment. He was comfortable with what he saw, but he chuckled when he thought it had not always been so. Throughout his teens and early twenties, Doug had believed his nose was too big and chin too small. But over the years he had come to accept that maybe his initial assessment, perhaps skewed by his shyness, had been harsh. It seemed that women were indeed attracted to his features. His wife, Laura, insisted he was handsome. He still didn’t quite get it, but had moved beyond the questioning state.
The steam did a good job hiding the gray sneaking in at his temples and the bags developing under his eyes. He knew his looks and youth were following the well-worn trail to middle age. He couldn’t quite figure out how much it bothered him.
He walked into the bedroom where Laura was still sound asleep. She looked especially pretty; her face was so peaceful, framed by her long black hair. Snuggled up next to her was Anthony, their three-year-old little boy, vigorously sucking his thumb. He was the youngest of their three sons. Anthony had a habit of climbing into their bed early in the morning. Doug smiled as he remembered twelve years ago, when their first son, Teddy, was a baby. They had discouraged him from sleeping in their bed, believing that their marriage bed was no place for little children. It might foster hard-to-break habits of dependency likely to warp a child’s development. Being first time parents was not easy. Now, he looked forward to Anthony snuggling with them and believed this sen
se of comfort and protection would only help the child in later life.
Doug loved to take Anthony out to breakfast after being on call. The older boys were in school, and Laura appreciated the opportunity to get some housework done unimpeded. The two generally gravitated to the Country Oven, a little coffee shop just down the road off the interstate. Anthony especially liked to retrieve the USA Today from the “slamming door,” and to sit on the stools at the counter rather than at the booths or tables. He also enjoyed taking his toy-du-jour to show the waitress and paying the bill with Dad’s help.
At times like these, when the house was so quiet and everyone was still asleep, Doug was overwhelmed with love, thankfulness, and serenity. Sadly, guilt also surfaced. Just this past weekend, Laura and he had had another monster fight, this time over something really critical, like did he have time to go the gym. Strange how minor issues could explode into nasty fights so easily. This worried Doug almost as much as the fact their fights had become more frequent. What was happening?
Doug shook off this worry only to have uglier thoughts replace it. Would someone die today at his hands? Would this be the day the sleeping serpent reared its ugly head and sank its fangs into him? Strange thoughts for the Iceman. Doug smiled briefly. He didn’t believe he was as cool as they thought he was. He wasn’t sure anyone really could be. He was thankful for his experience and knew he was stronger for it, but he could never be absolutely sure of himself. How’s that expression go? Past performance is no guarantee of future results.
Over the years he had dealt well with these fears, banishing them quickly whenever they appeared. They barely grazed his consciousness, as he kept them imprisoned in the subterranean depths of his subconscious. However, because of Mike’s unfortunate case Monday, his fears were launching a bolder assault.
Doug arrived at the hospital at 7:05 a.m., the same time he always did. He slid his plastic card into the slot to activate the security gate into the doctor’s parking lot. To this day, he was slightly embarrassed to park in this special lot. One of the OR nurses said that as long as they had Doctors’ parking lots, it would be hard to have much sympathy for all the doctors’ whining about dwindling reimbursement. She was referring of course to all the shiny new Mercedes, BMWs, and Lexus’s that inhabited this particular lot. She had a good point.
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