Bellevue

Chapter 16

Wednesday, July 3, 10:45 a.m.

Mitt surreptitiously arched his back and hunched his shoulders to try to help his stiff muscles, which were mildly complaining about his lack of movement over the last hour. He was a second assistant for an attending surgeon named Dr. Abraham Goldstein on his second case of the morning, the breast biopsy of Latonya Walker. The first assistant was Dr. Kevin Singleton, the other fourth-year resident besides Dr. Geraldo Rodriguez. So far the case had progressed perfectly smoothly.

Mitt had done a small amount of retraction assistance in the beginning of the case for the lumpectomy portion, meaning the removal of the questionable tissue from the patient’s breast, but the little help that had been needed had been mostly provided by Dr. Singleton. Later, after Surgical Pathology had reported the biopsy to be positive for grade 1 breast cancer, Mitt was required to provide a bit more help when several sentinel lymph nodes were removed from the woman’s armpit. These nodes had been sent off to Surgical Pathology to see if there was any microscopic evidence of cancer spread. The results would determine just how much more surgery was necessary.

“Dr. Fuller is one of our very new first-year residents,” Dr. Singleton announced to Dr. Goldstein as they waited for the second biopsy results. “Today is his third day.”

Mitt had had a favorable opinion of Dr. Singleton from the moment the man took it upon himself to approach him in the surgical locker room and introduce himself. He was a tall, thin man in his early thirties with a boney face but warm eyes and pleasant demeanor. Andrea had obviously been equally impressed with him. She’d worked with him the first two days just as Mitt had worked with Dr. Rodriguez. Now they’d switched. Andrea was helping Dr. Rodriguez and Mitt was scheduled to be with Dr. Singleton for all three of his cases that day.

“Well! Welcome to Bellevue,” Dr. Goldstein said. He eyed Mitt, who was on the other side of the patient, standing between Dr. Singleton and the anesthesia screen since the operation was on the left breast. “You must have done rather well in medical school. It’s not easy getting accepted into our program.”

“I did okay,” Mitt admitted vaguely when it became obvious that Dr. Goldstein was waiting for a reply even though he’d not specifically asked a question.

“I’m sure you did more than okay,” Dr. Goldstein added with a knowing nod. “I did my residency here, as you might have guessed, and I was in the top ten percent in my class. I had to be. Maybe it was the top five percent. I don’t remember exactly.”

Mitt nodded in return, as he didn’t know how else to respond. He was getting the impression that practicing surgeons, at least the male attending surgeons at Bellevue Hospital, were on the positive side of the narcissistic spectrum.

“What do you know about oncological breast surgery?” Dr. Goldstein asked.

“Not a lot,” Mitt admitted. He’d had several lectures on breast surgery in his third-year surgery course and had done well on the final exam, so he wasn’t completely devoid of resources, but he’d also learned in medical school that it was far safer to encourage a lecture than try to answer questions when dealing with an attending.

“Do you know who is considered the father of breast surgery for cancer? I’ll give you a hint: It was someone who operated here at Bellevue.”

Mitt was tempted to say Dr. Otto Fuller because that was what he’d been told by his father, but he knew that history reserved the credit for Dr. William Halsted, whose life was significantly more colorful than Mitt’s ancestor’s, especially after Halsted’s very public move from Bellevue to Johns Hopkins, where he became one of the four founding fathers of the medical school and hospital.

“Was it Dr. Halsted?” Mitt said, careful to put his answer in the form of a question. When that was done properly, it, too, invariably stimulated a lecture rather than another question that you might not be able to answer.

“You got that right,” Dr. Goldstein said. And true to form he added: “And I’ll tell you what else he advocated. First of all, he insisted on strict antisepsis similar to what we adhere to in this day and age. Second, he encouraged very delicate handling of tissue just like we’ve been doing today. And third, he urged careful hemostasis, which we’ve also done.”

Mitt was tempted to ask Dr. Goldstein if he’d ever heard of Dr. Otto Fuller, but he was reluctant for obvious reasons. Luckily, Mitt didn’t have to wrestle with the urge very long. At that exact moment, the circulating nurse reappeared to say that one of the sentinel lymph nodes was positive.

“Okay, team, let’s go to work!” Dr. Goldstein ordered. “But before we do, I have one more question for our first-year resident. Does finding cancer in a sentinel node mean we need to do a Halsted radical mastectomy?”

Mitt struggled to think of a way to answer the final question with a question, but nothing came to mind. Fortunately, he did remember the lectures. “I believe nowadays we can get the same prognosis and a significantly better cosmetic result with less surgery.”

“Right on!” Dr. Goldstein said, flashing Mitt a quick thumbs-up. “I’m getting the impression you were indeed high in your class, similar to me. As for this current operation, we’ll be doing a rather extensive lymphatic dissection, but we aren’t going to remove any pectoralis muscles, so the result will be far less disfiguring. In fact, it will be damn good, if I say so myself.” Then, turning to the scrub nurse, he said: “Scalpel, please!”

From that point on, Mitt did do a significant amount of retracting as Dr. Goldstein created a large skin flap and proceeded with the lymphatic dissection on the left chest wall and up in the axilla. The surgeon also concentrated on what he was doing, which ended his mild efforts at teaching, if that was what it had been. Mitt was uncertain.

After fifteen or twenty minutes had passed, Mitt began to wonder why Dr. Singleton was even there since, as a fourth-year resident, he was almost finished with his training, and currently he wasn’t doing much beyond anticipating Dr. Goldstein’s actions and helping when he could. The only conclusion that occurred to Mitt was that perhaps Dr. Singleton, like Dr. Rodriguez for the first two days, was there really for his benefit, to make sure his experience during the first week of surgery was as it should be. It made sense from a pedagogical standpoint. The problem with that plan, if it was the plan, was that Mitt’s patients hadn’t been chosen very well, with all four so far turning out to be clinical disasters.

After another ten minutes of the tedious lymphatic dissection and silence in the operating room, where the only noise was the metronomic sound of the respirator, Mitt’s general fatigue began to weigh him down. Seven hours of sleep marred by a recurring restless nightmare had not been nearly as rejuvenating as he’d hoped. Multiple alterations of his posture and tensing his spinal muscles helped, but only for short bursts of time. The very last thing he wanted to do on his third day of surgery was fall asleep and then jerk when he awakened, which had happened to him during first-year anatomy lab after staying up the night prior studying.

To keep himself awake, Mitt replayed in his mind his first case that morning, the vein stripping on Elena Aguilar. In contrast to all the other surgeries that Mitt had witnessed so far at Bellevue, Elena’s surgery itself went relatively smoothly despite her close-to-four-hundred-pound body, which presented a care challenge in getting her from the gurney onto the operating table. The challenge she presented to anesthesia had been another story.

Initially Elena’s case had been scheduled to be done under spinal with the thinking that it would be safer than general anesthesia, but getting the spinal in place turned out to be nearly impossible. Since Mitt had never done a spinal tap, he couldn’t really appreciate the problems the patient presented besides watching the difficulty of getting her positioned on her side on the narrow operating table.

Although several anesthesiologists had given it their best effort, even one nurse anesthetist who was reputedly the best in the department at placing spinal needles, no one was able to do it, and eventually they decided to use general anesthesia. Once that decision had been made and the patient put to sleep, the operation was able to commence.

The patient’s size made Mitt feel that he’d truly been needed to provide exposure to the veins, particularly in the woman’s groin. The attending physician’s name was Dr. Winona Benally — a particularly talkative and diminutive woman who needed a stool like the scrub nurse. During the forty-five minutes the actual operation took, Mitt learned more about vein stripping than he ever realized there was to learn, meaning from his perspective the operation was probably the best so far of his Bellevue career. The only blip in the procedure was another strange forceps incident. Just when Dr. Benally was about to tie off the saphenous vein on the right side, a pair of forceps fell directly into the incision that Mitt and Dr. Singleton were struggling to keep open.

“Hmmm,” Dr. Benally voiced questioningly but calmly. She put down the needle holder she held on the drapes and rescued the forceps. Holding them up, she turned to the scrub nurse. “Where did this come from?” she asked in a pleasant but obviously confused tone.

The scrub nurse, who’d been busy opening additional suture packets she’d just gotten from the circulating nurse, leaned toward the surgeon, looked at the forceps, and said: “I have no idea.” She took the instrument, examined it more closely, and, with a shrug, returned it to the instrument tray.

Dr. Benally directed her attention across the patient to look at Mitt and Dr. Singleton. “Did either of you see where those forceps came from?”

Dr. Singleton said no. Mitt merely shook his head. He was tempted to describe similar forceps anomalies that had occurred in surgery the day before and the day before that, but he hesitated. It sounded too weird, so weird he wondered if he’d imagined it. Yet, wasn’t this another similar event?

“No matter,” Dr. Benally said with a gesture of indifference. “Let’s get on with this.” She picked up her needle holder and went back to work. About twenty minutes later, the operation was completed. After the drapes had been removed, everyone helped wrap the woman’s legs in Ace bandages while the anesthesiologist began to revive the patient, but a problem quickly developed. The anesthesiologist wasn’t able to wean the patient off the ventilator, seemingly because the patient wasn’t able to adequately breathe on her own, presumably because the weight of the adipose tissue of her breasts and upper chest prevented her from doing so.

The moment Mitt became aware of this situation, he began to feel progressively nervous. Elena Aguilar was his fifth surgical patient, and it now seemed she was having difficulties, certainly not as bad as the others, but worrisome nonetheless. The disturbing question in his mind was whether something bad was going to happen to her. When he asked the anesthesiologist what she thought, he was relieved to hear she fully expected it was not going to be a problem. She thought the patient might have to stay in the PACU a little longer than usual, but otherwise everything would be fine.

“All right, that’s that!” Dr. Goldstein said, breaking into Mitt’s reverie. The surgeon handed off the instruments he’d been using to the scrub nurse and stretched his back after having been bent over doing the lymph node dissection up in the patient’s axilla. “Obviously, we’ve cleaned everything out superbly. Now it will be up to the radiologists and oncologists. One thing I’ve definitely learned in my career is that treating breast cancer is truly a multidisciplinary activity.”

Mitt relaxed the hold he had on the retractor, and Dr. Singleton took it out of his hand. Mitt stretched his own back and then his neck muscles.

“Okay, let’s begin the breast reconstruction!” Dr. Goldstein said as much to himself as to the others. But then he added for their benefit: “The last thing I want for any of my breast cancer patients is for them to suffer needless psychological morbidity.”

Mitt was impressed with the job Dr. Goldstein did reconstituting the breast’s contours with the closure of the flap he’d created for the axillary lymphadenectomy — although he could have done without Goldstein bragging about his year’s fellowship in plastic surgery. At that point and with Dr. Singleton’s encouragement, Mitt was included in placing and tying some of the subcutaneous sutures as well as some of the skin sutures under Dr. Goldstein’s watchful eye.

When the case was done, the drapes removed, and a pressure bandage had been applied, Dr. Goldstein stepped back from the operating table to remove his gown and gloves. “Well done, gentlemen,” he said. “I trust that you two will see to the postop orders and the dictation.”

“Dr. Fuller and I will see to it together,” Dr. Singleton assured him.

“Thank you, everyone,” Dr. Goldstein called while waving goodbye over his shoulder as he pushed out into the hall and disappeared.

To Mitt’s relief, Latonya Walker recovered from her anesthesia quickly. She was even lucid enough to cooperate in moving her from the operating table onto a gurney.

As Mitt walked along the hospital corridor with Dr. Singleton, following Latonya’s gurney to the recovery room, or PACU, he felt better than he had when he’d followed Elena Aguilar. At least Latonya was doing okay and her surgery — despite being significantly longer — had gone smoothly. Yet Mitt still felt nervous, remembering that Bianca Perez’s surgery the previous day had also gone without a hitch. If something truly bad was to befall either of today’s patients, and unfortunately Elena was already knocking on that door, his sense of responsibility was going to skyrocket.

“Your knot tying isn’t bad for it being your first week,” Dr. Singleton said graciously.

“Thank you, but it needs a lot of work,” Mitt responded. He thought the fourth-year resident was just being kind, because from Mitt’s own perspective he’d been all thumbs under the attending’s attentive gaze.

“There’s some knot-tying setups in the simulation lab,” Dr. Singleton said. “It’s good practice for someone just starting out like yourself.”

“That’s a good suggestion,” Mitt said. What he didn’t say was, When the hell am I going to find the time? Then he remembered he was scheduled to be off the following day and realized coming in to utilize the simulation lab might be a good way to spend at least part of the day. He could also do the admissions for his Friday surgeries then.

Once in the PACU, Mitt and Dr. Singleton sat behind the counter of the central desk to use one of the monitors. With the fourth-year resident looking over his shoulder and making suggestions, Mitt wrote out Latonya Walker’s postoperative orders just as he’d done for Elena Aguilar earlier that morning. While they were busy doing that, the PACU nurses went through the admitting procedure for Walker with the help of the anesthesiologist. Mitt had learned that the PACU was organized in a similar fashion to the ICU, with separate nurses for each patient, at least until the patients were stable and ready to be transported back to their hospital rooms.

When the postoperative orders were completed to Dr. Singleton’s satisfaction, Mitt used a recording line to dictate the details of Walker’s operation, again with Dr. Singleton’s guidance.

“Okay,” Dr. Singleton said, standing and stretching once they were done. “We have a good fifteen or twenty minutes before Diego Ortiz’s thyroidectomy, which might turn out to be a relatively long procedure. With that in mind, I recommend you make a pit stop if you are at all inclined.”

“Thanks for the suggestion,” Mitt said. “I certainly will. But I’d first like to ask a question, if I may.”

“Of course,” Dr. Singleton said. “What’s on your mind?” He sat back down.

“I’m a little confused, Dr. Singleton,” Mitt began hesitantly. “I’m wondering if Andrea Intiso and myself are being purposefully teamed up with either you or Dr. Rodriguez for some specific reason. Particularly today, it didn’t seem necessary for an experienced fourth-year resident like yourself to be assisting on a vein stripping or a breast biopsy.”

Dr. Singleton smiled. “First of all, you can call me Kevin. Second of all, yes, it was Dr. Kumar’s idea that at least for your first week, Geraldo and I would make sure you were introduced to your surgical residency appropriately, with a wide variety of cases and attendings, some of whom are better than others when it comes to teaching. We were also tasked with evaluating your technical skills, since residents arrive here with a wide variety of experience.”

“I see,” Mitt said. It did make pedagogical sense. He then glanced across the room at Elena Aguilar. He could see there hadn’t been any change. To his chagrin, she was still intubated and on a ventilator. He’d hoped she’d be off by now and the longer she stayed on, the more worried he became, as much for his own peace of mind as for the patient. At that point, she’d been in the PACU for more than two hours. “What are your thoughts about our first patient? Are you concerned?”

Kevin glanced across the room. “I guess,” he said somewhat vaguely. “Why don’t we go over and have a chat with the nurse? The PACU nurses know their stuff. Let’s get her take.”

Relieved that Kevin was taking an interest, Mitt eagerly followed him over to Elena’s bed. As they arrived, the assigned nurse was making a slight adjustment to the ventilator.

“What’s the good word?” Kevin asked.

“Not so good, unfortunately,” the nurse responded. “She’s not fighting the ventilator like she was earlier.”

“Uh-oh! That’s not what we’d like to hear,” Kevin said. “Has the anesthesiologist been by?”

“Certainly, a number of times. She also called for a Pulmonary consult because the patient’s oxygen saturation started to inch downward. And there was also a Cardiology consult.”

“Cardiology? Why Cardiology?”

“She started having episodes of premature ventricular contractions. Cardiology started a beta-blocker and ordered a stat electrolyte test. Surprisingly, her electrolytes were totally out of whack, which required immediate adjustments. At the moment they are all fine, but I tell you, it’s been an ongoing challenge.”

Mitt felt a general chill as well as some pins and needles on the insides of his arms while he listened to what the nurse was saying. As he looked down at the patient, he sensed that a worst-case scenario was relentlessly underway. The patient was mysteriously going downhill and it would continue, all of which made his concern that he was in some way responsible rocket skyward. He felt all this despite his rational sense trying to convince him of the opposite, namely that everything was happening by chance and chance alone.