Cutter's Trial

by Allen Wyler

  Ellen Bowen, a plump, cherub-faced woman in scrubs, had her brown hair tucked into a bouffant surgical hat. She sat at her desk in a small, glass-enclosed office at the intersection of two halls. Garrison explained that the two dedicated neurosurgery operating rooms were opposite one another at the far end of the hall. ORs dedicated to single specialties provided numerous advantages, including greater flexibility in case scheduling.

  Soon as Ellen saw them approach, she stood and opened the door. “Come on in, Doctor Cutter. Oh, you’re allowed to join us too, Doctor Majors,” she said, obviously joking. “Have a seat.”

  The cramped office held one desk and two chairs with barely enough room to keep your knees from banging into something. The adjoining glass walls provided a panoramic of the intersecting corridors and a straight shot down the hall to their ORs. Alex noticed the office bookshelves were stocked with three-ring binders from suppliers of various surgical instruments as well as the Baptist Hospital Procedure Manual.

  “Getting settled in?” she asked when they were seated.

  “Pretty much. Still unpacking, but we have it well under control, enough to get by, anyway. The other stuff isn’t essential. Looking forward to starting work.”

  “And we’re looking forward to having you here.” She smiled.

  Garrison stood. “I’ll let you two talk business while I go finish clinic. You can find your way out?”

  “I’ll show him,” Ellen offered.

  With Garrison gone, she launched into business. “Reason I wanted to talk is to finalize your card.” A surgeon’s “card” listed preferences for routine instruments used in various types of cases: glove size, preferred sutures, routine instrument, and so forth. “Roberta was kind enough to fax me a copy of your craniotomy tray.” Roberta, Ellen’s counterpart from his old job, sent her a list of the instruments routinely used for opening a head. “So I believe we have that under control. There are a few other items I’d like to nail down. What’s your glove size?”

  Requesting this level of detail was impressive and not something done at the university hospital he left. “Seven and a half.”

  “Regulars or browns?” she asked, referring to the dark brown hypoallergenic gloves favored by some surgeons.

  “Browns.”

  Alex realized being catered to with such deference was strangely refreshing, especially having spent his career thus far in the shadows of others. Yet he also found it somewhat embarrassing and the allure of being accustomed to such treatment frightening. Too much of this could transform a well-intended person into the stereotypical prima donna personality screenwriters loved to portray: megalomaniacs prone to throwing OR hissy fits while expecting red-carpet privileges at all times.

  They had just about finished with Ellen’s checklist when a thin, scrub-clad male tapped the window. Ellen motioned him in, explaining, “This here’s Chuck Steven. Asked him to drop in, schedule permitting. Chuck is our neuro specialist. Chuck, this is Doctor Cutter.”

  Alex stood to shake hands. The scrub tech appeared to be in his mid-thirties with sun-damaged, acne-scarred cheeks and a face that managed to look serious and affable at the same time. A surgery cap covered his hair and a mask dangled from his neck.

  Chuck launched straight into a Q&A session. “Any particular preference on how you want your cases handled, Doc?”

  “Not really, other than I’m a stickler for maintaining sterile technique,” Alex said. “My only real ‘quirk,’” he said with finger quotes, “is to double glove during the openings. Then, soon as the bone flap’s out, I re-glove and use a wet lap pad for wiping down the new one. Oh, and I use a ton of irrigation during cases.” Although double gloving restricted finger movement slightly, the highest chance of breaking sterility occurred while opening the head.

  After five more minutes of chitchat, they finished. Chuck needed to set up his next case, and Alex was anxious to find his way back to his pizza-oven car. Several projects still needed completion, especially refurbishing the grill since Lisa was expecting him to grill steaks for dinner.

  As he worked his way to the second floor and the sky bridge back to the office building and parking lot, he paused to savor this new sense of professional happiness. Finally, after years of training and a stint in professional no man’s land, he’d become his own man. No doubt Dick Weiner used and manipulated him, then discarded him. But if there could ever be a happy ending to that story, this might just be it. He hoped Lisa would adapt as well.

  25

  “Good morning, I’m Doctor Cutter,” Alex said, entering the small exam room furnished with one exam table, two rolling stools, and a wall-mounted, fold-down charting desk. A man in his late fifties or early sixties sat in the chair opposite the desk.

  “Hi, Doc, Bart Jorgenson.” The man offered a meaty hand but didn’t rise from the chair.

  After shaking hands, Alex set the patient’s chart—a manila folder only a few pages thick—on the chart desk and took a seat on the remaining rolling stool. “What brings you in today?” This was his fourth Any Doctor patient for the morning.

  “Well, got me this dang prickly numbness,” he answered, pointing to his feet.

  Alex opened the manila chart to check the man’s age on the front sheet. Yep. Sixty-two, pretty much the age he appeared to be. Alex tore a sheet of clinic notes from a tablet and jotted “CC-feet numbness,” the CC standing for “chief complaint.”

  “Both feet or just one?” An important first step to narrowing the problem.

  “Both.”

  Alex made a note of this. “Have any pain with the numbness?”

  “Nope. Just burning numbness. Doggone thing bothers the heck outta me, ’cause when I rub it, I don’t get no satisfaction.” These last words brought a faint smile to the man’s lips.

  “Rolling Stones fan, huh?” Alex said, making another note. “How long’s it been bothering you?”

  “’Bout six months, give or take. Sorta hard to know for sure on account of it coming on so doggone slow.”

  The symptoms reminded Alex of peripheral neuropathy, a disorder affecting the nerves. “Any other medical problems you’re being treated for? Diabetes, vascular problems?” Both were commonly associated with neuropathy.

  The patient shook his head. “Nope.”

  Alex continued to take the man’s history, the whole time thinking, Naw, couldn’t be. But with each new detail, one specific diagnosis stood out as the top contender of all possible causes. History finished, Alex started in on the physical exam, testing the man’s ability to feel pinpricks, light touch, and vibration from his toes to his thighs. The sensory loss appeared in a classic “stocking distribution” over both of the patient’s feet and ankles, another telltale sign of peripheral neuropathy. His next job would be to find the root cause of the problem. Most peripheral neuropathies, he knew, were secondary to metabolic problems.

  Alex handed the man his shoes and socks, then busied himself checking off various blood studies on a pink lab sheet.

  “What you reckon is my problem, Doc?” The man pulled on a sock.

  “I need some tests to be certain, but after we draw your blood, I’m going to have the nurse give you a shot of vitamin B12.”

  He stopped tying his shoelaces to look questioningly at Alex. “Vitamins? You’re going to treat me with vitamins? Hell’s bells, I can just pick me up some a’ them at a Rite Aid an’ save money.”

  Alex shook his head. “It needs to be a shot to make certain the vitamins get into your system. You might not be absorbing as much B12 as you need.”

  Minutes later he led the patient to the nurses’ desk and handed the paperwork to the first available nurse. “Mr. Jorgensen needs this blood draw, and then give him three hundred micrograms of B12 IM. But in that specific order.” It wouldn’t do to give him the B12 first.

  Before seeing the next Any Doctor, he detoured to his office to dictate a note, confident for having diagnosed his first case of peripheral neuropathy secondary to vitamin
B12 deficiency, a condition he’d read about but never actually seen. Ironically, this was the same problem he faced in his oral boards. If the lab work confirmed the diagnosis, he’d ask a gastroenterologist to work up the reason for the B12 deficiency. Once these issues were settled, he’d send the patient back to his primary care physician with a treatment plan.

  For a moment he savored the impact a correct diagnosis would have on the patient and his family, mildly amazed at this feeling of satisfaction for having diagnosed the problem. He hadn’t really experienced this at his old job and was struck by how much more significant and personal it felt in contrast to chronicling another data point in the lab. Lab research seemed so detached and sterile in comparison. Not that clinical medicine lessened his drive for research, but it brought a different type of professional joy. Hopefully he’d just altered the course of a disease in another human. With renewed vigor he picked up the next Any Doctor chart.

  That afternoon Alex purposely arrived at the auditorium five minutes in front of the 4:00 p.m. conference, his first teaching conference as vice program director of the residency. He intended to lead by example. A handful of residents were already chatting in the first two rows when he slid into his front row place, leaving the aisle seat on his right for Reynolds. Now with a say as to how these conferences ran, he intended to make sure they began and finished on time. He wanted the residents to consider them a high priority and believed that teachers who arrived late for conferences set a bad example, demeaning the importance of teaching.

  At precisely 4:00 p.m.—in spite of Reynolds’s absence—he announced, “Four o’clock, time to get going. But before we hear the first case, I have an announcement. I’m instituting journal club. It’ll be held the first Wednesday of each month at my home, seven p.m. Snacks will be provided so that those of you who don’t have time to grab dinner won’t die of starvation. You can expect to receive your assigned articles in the next few days. Okay, who’s got the first case?”

  A midlevel resident approached the view box and illuminated a CT scan. “First case is a,…”

  Alex settled in, listening closely to the presentation. As the professor, he was expected to solve any case a resident might throw his way, and with a program having this much clinical activity, curveballs and doozies were probably common.

  Five minutes later, Reynolds slipped silently into his seat. Alex glanced at him, worried he might have offended him by starting conference before he arrived. Reynolds smiled with a nod, as if to say, “Perfect.” A wave of relief swept over Alex.

  Halfway through conference Alex surveyed the group again, realized all the residents were now present, and took the opportunity to announce, “I want to chat with the seniors after conference, so please stick around.” He nodded for the resident to continue.

  Reynolds glanced at his watch. “Don’t believe we have time for another case. Conference adjourned.”

  Alex stood and caught Reynolds’s eye. “Want to stick around, hear what I have to say to the residents?” The last thing he needed was for Reynolds to suspect he was working with the residents behind his back. This thought made him realize just how gun-shy and paranoid the ordeal with Weiner had left him.

  “Naw, y’all go on. Need to get on back to the farm. Victoria’s got some honey-dos waiting on me.” Reynolds clapped Alex on his shoulder. “This have to do with what we discussed last week?”

  “Exactly.”

  Reynolds winked and gave Alex a collegial punch to the shoulder. “Atta boy!”

  With no other meeting scheduled to follow in the auditorium, Alex and the four seniors decided to stay put.

  “I want to hear,” Alex began, “how you guys view the teaching in this program. What do you see as strengths and weaknesses? Anything you tell me remains absolutely confidential.” He made direct eye contact with each of them as he spoke. “Mark, why don’t you start?” Alex picked him for no other reason than he remembered his name. He’d learn the others’ names in time.

  Mark glanced at the other three, obviously uncertain or uneasy about how much to divulge—a sure sign they still considered Alex an outsider. Hesitantly, Mark said, “The amount of call sucks.”

  Alex laughed. “That’s par for the course. I’m asking about the teaching.”

  The others seemed content with continuing to let Mark be the group spokesman. “What teaching?”

  The others snickered.

  “Okay, let me be specific. How much teaching you guys get in the OR and on rounds? How well do the attendings educate you? Where do you see need for improvement?”

  Another round of glances were exchanged.

  “Reynolds tries,” Mark answered tentatively. “But he’s gone so much of the time … and when he’s here, he’s so busy. The only time we actually learn from him is during our chief-year rotation on his service. There’s the Monday conference, but that’s not one-on-one. Garrison tries, I guess, but he’s so busy running the clinic and operating that he’s not around or available all that much.”

  The other three residents nodded agreement.

  “How about other faculty?” This was the point Alex was really interested in. Someone would lose resident coverage, and Alex wanted to cut the least effective teacher.

  “They’re a joke,” another resident said. “All they want’s a warm body to hold a retractor or suck during a case. Only teaching we hear is, ‘retract here’ or ‘suck here.’ That’s not teaching.”

  Pretty much what Alex expected. Nonacademic programs often suffered from a dearth of structured teaching. Larger surgical throughput counterbalanced that to an extent, but volume could only be effective if residents actually learned from those cases.

  “Let’s talk about the OR then. How much they let you do?”

  “Depends on the surgeon,” another resident offered, the group becoming more responsive now. “Some let us do a lot, others don’t even let us open or close. Most of the time we’re nothing but slave labor.”

  Another resident muttered, “Tote them bales, boy.” The others laughed. Alex took a blank piece of clinic notepaper from his white coat and a pen from his breast pocket. “Let’s go through the attending you cover and grade them.” He’d suggested this approach to Reynolds during their talk last week. Reynolds liked the idea of making the residents responsible for determining which two private surgeons would be weeded from coverage. His actions, Alex realized, would generate resentment from the affected surgeons. But hey, you couldn’t please everyone all the time.

  26

  Alex stood at his desk dictating a note on a patient when Dave Ray knocked on the doorjamb and walked in. Alex held up a just-a-minute finger while finishing his clinic note. He popped the cassette from the small, black Sony recorder and replaced it with a clean one. Instead of piling up a day’s worth of dictation for his secretary, Kasey, he kept a supply of clean tapes in a bin on the desk, handing off a dictated clinic note after each patient. Once Kasey transcribed the tape, she rewound and degaussed it and dumped it on back in the bin. An advantage to this method was that it allowed Kasey to ask questions while the visit was still fresh in his memory.

  “What’s up?” Alex asked.

  “Since you’re not at full speed yet, thought we might be able to get us some tennis time in this afternoon, say five o’clock?” Then as an afterthought, “You do play, don’t you?”

  Alex glanced at the remaining schedule. “Five thirty too late for you?”

  Dave smiled. “Naw, that works. There’s a set of courts out on Poplar ’bout two miles north of your place. We can meet there. Think you can find it okay?”

  He vaguely remembered noticing the courts during one of his exploratory drives through the areas adjacent The Gardens. “Should be able to.”

  “You seem to be settling in just fine. Like working at the clinic?”

  Alex loaded a new tape into his recorder. “Things are running great. Much more efficient than my old job.” Which was unbelievably true. The difference in effic
iency between the university and clinic was mind-boggling.

  Dave glanced at the degrees Alex had placed on the wall during the weekend. “Getting enough support? Lacking for anything?”

  “No, I’m good. Have everything I need, except for surgical cases. I suspect those will come in time.”

  Dave nodded vigorously. “Count on it. A couple more months and you’ll be so busy you won’t have the luxury of afternoon tennis. You need anything, let me know. Got us a good set-up here. Those of us in administration do everything possible so the docs do what y’all do best, which is take care of patients. It frees you guys from doing what we do best, which is run the clinic. Makes for a win-win relationship.” He knitted his fingers together in a sign of symbiosis.

  Curious statement. “All right then, see you there.”

  “Oh, one other thing. You hear about Robert?”

  Alex still hadn’t learned all the partners’ names well enough to flash on who Dave referred to. “Who?”

  “Robert Sands. Does our pediatrics.”

  Alex vaguely remembered meeting him. Because Robert spent his time at the children’s hospital, Alex saw him only at clinic meetings. “No. What?”

  “Aw man … really a sad situation. Man can’t do surgery anymore. Ever. In fact, we’re thinking we’re gonna have to stop him from seeing patients. Essentially, he’s finished. Forced retirement.”

  Alex was shocked. The man he remembered was approximately his age. “Why? What happened?”

  “Guess that means you ain’t seen him lately. Man’s low sick with a bad case of hep C. We’re all figuring it’s from sticking himself with a needle last month while working on a kid over at the trauma center.” Dave shook his head in sorrow. “Damn shame, real damn shame. Man’s a world-class surgeon.”

  Once infected with the hepatitis virus, always infected, just like HIV. “Jesus, he’s young, too. Right?”