by Allen Wyler
“How do you like being back at the clinic?” Alex asked. Not that he gave a rat’s ass; it just seemed to be the right thing to say.
“I’m blessed, truly blessed to be given an opportunity to return home. How ’bout you? You like it here?” Wiry black hairs sprouted over the neck of Clarence’s scrub shirt, giving him a feral appearance.
“Love it here.”
Uneasy silence followed. Alex waited to hear what Clarence had to say. A moment later Clarence cleared his throat. “I understand you run a journal club.”
Ah … “Yes. Faculty are invited, so feel free to attend.”
Clarence shifted weight from one to the other foot. “That’s what I wanted to talk about. Why did you choose Wednesday evenings?”
Clarence’s tone carried a challenging vibe that put Alex on guard. “Seemed the best choice, is all. Why?”
“But why Wednesday? Why not Tuesday or Thursday?”
Obviously, Clarence had an issue with Wednesday. What could it be? How could it make a damn bit of difference? Why was he sounding so accusatory?
“Have to think about that a moment. Let’s see … Monday is conference day, so that’s out. Fridays are the start of the weekend, so that’s out.” Alex shrugged. “Wednesdays just seemed to be the best option.”
Clarence leaned forward, eyes boring intensely into Alex. “A righteous person would never choose Wednesday. A righteous person would know the difference between right and wrong. This leads me to conclude you’re a godless person.”
Whoa! His first impulse—to say “fuck off”—was immediately trumped by curiosity. What the hell was he talking about? Calmly, he said, “Excuse me, Clarence, but I have no idea what you’re talking about.”
“No, of course not. I didn’t expect you would, considering where you come from.”
That pissed him off. “And where’s that?”
“The West Coast.” Clarence was standing straight now, white balls of knuckles at his sides.
Alex signaled “time out.” “Hey, take a deep breath and explain what it is you’re talking about. I’m totally lost.”
Glaring, Clarence actually did take a deep breath while shrug-adjusting his white coat. “Folks around here are God-fearing Christians. You understand that much, don’t you?”
“Some are, some aren’t. Not everyone is Christian.”
“That’s not the point. Point is, Wednesday evenings are for Bible study. Everybody knows that. You can’t just go ’round ignoring these things. That’s why I’m telling you to change it to another night. Tuesday’s what I think it should be, but Thursday’s fine with me, too.”
“Fine with you, huh?” Alex mind buzzed with sarcastic replies.
Clarence nodded.
“Tell me something: What happens if I keep things as is?”
“That’s your option, but don’t expect the residents to be there,” he said quickly. “As of this week, I’m requiring the residents to come to my home for Bible study and fellowship.”
Alex struggled to control his anger. Clarence had finally crossed a defensible line. “Sorry Clarence, there’s no way in hell you can force residents to attend. I won’t allow it. This is a neurosurgery residency, not the First Church of Clarence Hill.”
Clarence stabbed a finger at his chest. “We’ll see about this. Doctor Majors made a commitment to me to attend. He’ll be there every week.”
Garrison would probably walk on red-hot coals to get away from Anne for an evening.
“Well, have fun. Just don’t expect any residents to attend.”
Clarence’s face was red with rage. “We’ll see about that.”
“Before you go, let me ask you something.”
Clarence cast a wary glance.
“What would you say if I told you Humpty Dumpty was pushed?”
Clarence side-stepped toward the door. “I’m not going to give you the satisfaction of playing your silly games.” He wheeled around and stormed from the office.
Fuck!
Pulse pounding his temples, Alex dropped into his desk chair to think. Had there been a better way to handle Clarence? Probably. But the bastard pushed so many hot buttons so rapidly it was impossible to not lose his temper.
Learn to exercise more caution, be more circumspect before reacting. Making clinic enemies will only make your job more problematic.
Sounded good, but realistically, he knew that in an organization this complex it would be impossible to avoid getting into polarizing politics. Besides, for whatever reason, there had been no love between them from the moment of their first encounter. The problem with the present situation was, Clarence Hill seemed too closely allied with Garrison, a person Alex couldn’t afford to alienate. On the other hand, he didn’t seriously believe Clarence would try to escalate this particular issue beyond their private discussion. Instead, Clarence would be constantly searching for any and every opportunity to subtly erode Alex’s cachet within the clinic. In Alex’s favor was the fact he was now one of the clinic’s top revenue producers, second only to Martin, a point that assured him a layer of political Kevlar in spite of how distasteful Alex found this dynamic. He would prefer clinic stature to be based on more relevant attributes like ethics, decision-making, and patient outcome. Yet he knew this desire was too Pollyanna, too unrealistic. He found it equally discouraging to know this confrontation likely marked the beginning of an escalating power struggle between Garrison’s and Reynolds’s successors. He hated the thought.
41
The phone rattled Alex awake on the couch. After knuckling his eyes, he checked the clock. 12:03 a.m. Last he remembered, he was sitting there reading a medical journal. Most lights were off, so Lisa had long since gone to bed. He picked up the cordless phone. “Cutter here.”
“Doctor Cutter, Harvey Leventhal. Got a GSW to the head over here at the trauma center. Tangential right hemisphere. We’re scanning him now, but I’m taking him to the OR soon as he’s off the table.”
“Be right in.” Leventhal was an extremely competent senior resident who Alex predicted would become a dynamite chief resident next year, so there was no need to rush.
He caught up with Leventhal in OR One just as the anesthesiologist finished taping the patient’s endotracheal tube securely in place. Leventhal was arranging CTs on the view box, the scrub and circulating nurses flying about in the hurriedly orchestrated pace of an emergency case.
“Got a tangential furrow through the fronto-parietal bone, driving in bone frags here, here, and here,” the resident said, tapping obvious bone fragments on the scan.
“What’s your plan?” Alex asked rhetorically. He heard the sudden hiss of steam escaping from the autoclave as the circulator unlocked the thick, reinforced stainless-steel door.
“GSW 101. Debride the wound, close the dura, and then play hockey.”
Alex laughed. “Yeah, get the puck out of there. Gotcha. Good plan. Let’s go scrub up.”
At the scrub sink, Leventhal said, “I put in a call for the Baptist resident, but he’s tied up at the moment. Soon as he gets here you can head on back if you want.” At that point, Alex would have fulfilled his oversight requirements. If he left the OR when Leventhal’s assistant arrived, it would signal a vote of confidence in the resident’s abilities.
Alex assisted Leventhal by squirting irrigation over the ragged wound edges while he worked at controlling the bleeding. Tangential wounds were often hard to close because the bullet blows out a furrow of skin, producing ragged damaged edges that have to be removed to produce a clean, even closure. This results in less scalp available to cover the same area of skull, making the closure tricky. And unlike a clean surgical wound, these were often grossly contaminated from hair and small bits of skin and other debris. Once the wound edges were cleaned up and the bleeding controlled, Leventhal began carefully picking out bits of contaminants, flicking them off the tips of the forceps onto the floor to keep the operating area sterile. Alex squirted more saline into the field, assisti
ng in the cleaning process as Leventhal worked.
With the superficial areas now debrided, Leventhal placed a self-retaining retractor to spread open the wound so he could get a better estimate of the underlying skull damage. The bullet had made a linear groove high along the left temple, pushing bone fragments through the dura into the brain. Luckily, because the bullet struck tangentially, most of the force had been expended along the bullet trajectory instead of radially into the brain substance. One by one, Leventhal picked out the bone chips with a hemostat. Because the fragments were contaminated with hair and bits of skin, and because bone can’t be autoclaved without killing it, he dropped these pieces into a bucket on the floor at their feet. In six months or so, if the wound healed without signs of infection, the scar could be opened and acrylic used to fill in the skull defect for a better cosmetic result.
The junior resident finally walked into the OR just as Leventhal was getting ready to patch the dura and close.
“Go ahead and scrub,” Alex told him. “Leventhal, think you can handle the dura?”
“Figure I’ll patch it with temporalis fascia,” he replied, referring to the heavy connective tissue encasing the muscle to the jaw.
“Perfect.” Alex stripped off his gloves. “I’ll write an op note.”
In the darkened bedroom, Alex carefully slid between the sheets without awakening Lisa, the glowing clock radio now showing 3:41. Sleep would most likely be impossible now, yet he rolled onto his left side to begin his relaxation exercises, hoping to be surprised in the morning by the alarm. He thought about his life, about how differently he lived from the patient just operated on: an unidentified African American male, perhaps mid-twenties, literally pushed out of a moving car in the Emergency Room parking lot, the only witness to the drop too confused and shocked to note even the make of the car, much less who drove or anything else of importance to the police. The kid, of course, had been stripped of all identification. Might be gang related and likely was drug related. No one knew any particulars, not that that information was medically relevant. But the thing was, the patient’s history was important because victims of street crimes typically were at higher risk for AIDS and hepatitis, two diseases readily transmitted to a surgeon from an accidental needle stick, especially during a rushed emergency surgery. Alex thought back to Robert Sands, the pediatric neurosurgeon who had been forced into early retirement for exactly this reason. And guess what? In spite of these increased risks, the clinic was likely to receive no reimbursement for this surgery. Or cases like it. The gangbangers and petty criminals, usual patients in the trauma center, didn’t carry Blue Cross cards. Although he didn’t enter medical school with the goal of making money, he did believe he should be compensated for his services.
Tossing and turning, he watched the glowing digits increment minute by minute. At 4:45, still unable to sleep, he slipped silently into the bathroom and shut the door to begin preparing for another day, another month, another 5:30 clinic business meeting. Thank God he had clinic instead of surgery that day.
42
“Jesus, that one looked close,” Cole said, referring to a missile explosion lighting up the Baghdad night sky on CNN. They sat on a couch in the surgeon’s lounge, watching Wolf Blitzer report live from Baghdad as they enjoyed a cup of coffee before they started the first of two cases. Cole was now routinely assigned to Alex’s cases. To Alex, Cole and Chuck Stevens were as intimate as family. Residents came and went, but the core group remained intact, each day learning more about each other’s lives, tastes, insecurities, and desires.
“Wonder if he gets hazardous duty pay for being there,” said Alex.
“Uh-oh, here comes your friend.” Cole nudged him.
Alex glanced up just as the TV segued from Blitzer to General Schwarzkopf. Gene Roux, the morbidly obese hematologist, stood at the counter stirring a packet of sugar into a steaming Styrofoam cup. Just one more routine in Alex’s life—watching Roux wash down the morning maple bars with sugary, creamy coffee. He watched this little drama with a mixture of morbid fascination and disgust. The guy was killing himself. Surely he must know that.
“There he goes. Maple bar number one,” muttered Cole.
Roux’s sausage-link fingers made the maple bar seem small and delicate, about the right size for the three bites Roux required to devour it. A lick of his fingers, followed by a second bar, then one more cup of coffee for the road. Done, Roux rinsed off his fingers and left the room.
“Watching this makes me sick,” Alex said.
“Yeah, but if you ever need a hematologist, he’s your man.”
“Assuming he’s still alive. I can’t imagine what his coronaries must look like. To say nothing of his blood sugar.”
“Doctor Cole, patient’s ready,” a nurse said from the doorway.
Cole slapped his thighs to stand. “We should be ready for you in ten, but feel free to mosey down earlier to select your music. Have a few new CDs for you. You heard the Les McCann and Eddie Harris at Montreaux disc? ‘Compared To What’ is my favorite on it.”
“Know the song, just not that version. It’s pretty good?”
Cole was tying his mask in place. “Just wait.”
“Doctor Cutter?”
Alex stopped working to peer around the overhead table. Ellen stood just inside the swinging doors, mask held over her mouth and nose.
“Yep?”
“Doctor Reynolds asked if you could drop by his office when you finish this case. Said he wants a few words. Let me know if you want us to hold on your second case.”
He shook his head. “No, go ahead and flip the room. Second one’s going to take a while, and I want to get done at a reasonable hour today. Whatever it is Reynolds wants to talk about can’t take that long. Thanks.”
“What’s up, Jim?” Alex entered Reynolds’s office. Claude wasn’t at her desk but had left Reynolds’s door ajar, probably out taking a cigarette break now that the university was cracking down on in-office smoking.
Reynolds set down his pen. “Couple things.” He pointed to one of the chairs in front of his desk. “Have a seat.”
Alex sat.
“Two things for discussion, both important. Y’all got a second case waiting?”
Uh-oh. Sounded serious. “I do.”
“All right then, I’ll make it short. But before I begin, I just want to say how pleased we all are with your practice. Figured you’d be a success, but never imagined it’d be this successful. I was bragging on you the other day to some friends at the Senior Society,” he said, referring to an exclusive neurosurgical organization of program directors and their seconds-in-command. “We should get you into that organization, by the way.”
“Thanks.” Alex realized how much his priorities had shifted since moving here. Two years ago he would’ve jumped at the chance to advance his academic career, but that was no longer the case. What’s happening to me?
Reynolds began polishing his glasses on his white coat. “I received orders to report to Bethesda on account of this Desert Storm business. Don’t know how long it’s going take, but the way they’re talking, it won’t be all that long. While I’m gone you’re in total charge of the department, which makes me even more thankful for bringing you on. I got the utmost faith in your judgment, but if something comes up and you reckon you need to talk to me, call. Soon’s I get there I’ll let Claude know how to reach me. Damn! Never reckoned on getting called up, especially at my age, but all’s I’ll be doing is shuffling some papers behind a desk.”
Alex waited, but when Reynolds didn’t say anything else, he spoke up. “You mentioned two things. What’s the other?”
“That’s it. Residency and department. You got ’em both starting tomorrow morning.” He seemed to reconsider. “On second thought, we might oughta make that starting at six tonight. Have a problem with this?”
“No problems, but if we’re done with this issue, I have something to run by you. Brett Johnson. Heard any rumblings about him f
rom the residents?”
Reynolds haphazardly replaced his glasses and started tapping his steepled fingers together. “Rumblings. Huh. Damn good word for it. Yes, I have. Why d’you ask?”
“He’s been late for cases. When I question him, I get the feeling he’s lying. I’ve had a few complaints from the residents about him—not answering pages some nights, forcing them to cover for him. Things to that effect.”
This last statement raised Reynolds’s eyebrows. “Know this for fact, or is this only just grumblings?”
“Nothing for fact. He’s on my service now, so if he is lying to me, I plan to find out soon enough.”
Reynolds sucked a tooth. “What you think we oughta do about it?”
Alex hated what he was about to say. “There’s no room in the program for liars. If I catch him in a blatant one, he needs to be out of here. I can’t believe it would be a one-time event.”
Reynolds nodded. “Agreed. Whatever you do, I want to be damn sure we got us ironclad documentation of wrongdoing. I want it in our files. Can’t have him coming back at us with some wild-ass wrongful termination suit. In other words, you catch him in a lie that’s cause for termination, you better have enough evidence to prove it in a court of law. Understand?”
“Yes sir.”
“You get that evidence, you fire his ass. It’ll stress the rotation some, but the boys will understand.”
Alex checked his beeper. “They’re ready for my second case. We good here?”
Reynolds nodded, his attention already back to the paperwork in front of him. “We are.”
“… and protect us from harm. Amen.”
Alex stopped halfway through the door to one of the small private rooms in the surgery waiting area reserved for families. Clarence Hill stood in the center of room, the family of Alex’s patient clustered around him. Taken aback, Alex asked, “What are you doing here?”
Clarence stood with arms outstretched in a pose resembling Christ on the cross. “Leading my brothers and sisters in a prayer for God’s benevolent healing. These folk are members of my flock. How’s Brother Roland doing?”