Bellevue

Chapter 18

Wednesday, July 3, 3:05 p.m.

“Are you all right?” Dr. Smith demanded of Mitt in a concerned voice with his head cocked to the side. He and Dr. Singleton were staring at Mitt in shocked surprise. The attending surgeon had been interrupted in midsentence by Mitt’s sudden mumbled outburst.

Mitt’s line of sight shot over to Dr. Smith for a millisecond and then back to the girl and the crowd that he feared were about to storm into the operating room. But to his astonishment, the girl and her grisly cohorts had miraculously disappeared in literally the blink of an eye. In their place, the door seemed to be slowly but calmly settling back into its jamb, or was it? Mitt jumped as the door then did burst open in the next fraction of a second, and on this occasion, it banged open with a thud as its interior door handle hit up against the operating room’s tile wall.

“Surg-Path promised me we’ll have the results ASAP,” Juana called out to the team as she breezed into the OR from the sterilizer room, heading directly over to Marianna. Brandishing a package, she then added for Marianna’s benefit: “Here’s the three-zero Vicryl suture you asked for before I ran down to Pathology.” Being scrupulously careful to use sterile technique, she tore open the package and made certain the contained suture packet dropped untouched into Marianna’s open hand.

“What’s the matter, young fellow?” Dr. Smith prodded when Mitt didn’t immediately respond. The surgeon had not taken his eyes off Mitt.

“I don’t know,” Mitt stammered, trying to mentally orient himself after the shock. His mind was in a momentary jumble, questioning what he had truly seen. Once again, the question loomed: Was the fleeting and disturbing visual a product of his tired, overstimulated mind or had he briefly fallen asleep and experienced some kind of an instantaneous nightmare, all while standing up and otherwise functioning? He had no answers, nor did he have the time for any internal debate. Dr. Smith was expectantly staring directly at him, waiting for an answer.

“I’m sorry,” Mitt said, believing an apology was the way to start. He stuttered a bit, then pulled himself together, shaking his head. “I don’t know what came over me. Maybe I fell asleep for a second. I apologize. I’ve been under a bit of stress these first few days.”

“I know exactly what you mean,” Dr. Smith said in a fatherly tone. “I think all of us can relate to what you are saying about just starting out as a resident. Am I right, Dr. Singleton?”

“No doubt,” Dr. Singleton responded.

“Have you already been on call?”

“Yes,” Mitt said. “Monday night. It was my first night.”

“Well, there you go,” Dr. Smith said knowingly. “Did you get much rest?”

“Not a lot,” Mitt admitted.

“I can remember falling asleep in surgery my first week,” Dr. Smith said with a self-deprecating chuckle. “The night before I had gotten called in the wee hours of the morning to help with an emergency surgery where the surgeons were trying to save this guy’s leg that had been crushed by a garbage truck. My job was to stand down at the end of the operating table and hold the foot aloft while they tried to connect the vessels behind the knee. It went on for God knows how long, and I fell asleep standing up. I remember that incident to this day, especially because the two attending surgeons got really pissed.”

“Something similar happened to me,” Dr. Singleton said with a chuckle. He went on to describe his experience, but Mitt tuned him out. He’d gone back to agonizing about the hallucination he’d just experienced. Since he’d seen the girl before, she was at least familiar, even if scary. But that wasn’t the case with the others, which begged the question of why on earth his mind had conjured up such a horrid, disgusting ragtag group. It was as though patients who had been surgerized at Bellevue sometime in the distant past were returning en masse to exact revenge for what they had experienced and suffered.

Mitt inwardly shuddered when he recalled the image, some men and women holding amputated limbs while others held even more disgusting bloody organs. Could the whole idea have somehow originated from his skim-reading Pendleton’s unpublished article the night before? After all, it had been a shock to learn that his own medical forebearers had inexplicably eschewed anesthesia and antisepsis when the benefits were so glaringly obvious.

“Good news, everyone,” Juana called out, putting down her phone and interrupting Dr. Smith and Dr. Singleton, who had continued trading war stories, with each trying to outdo the other in how much they’d been overworked as a point of pride when they had been first-year surgical residents. “Frozen sections are all clean. No malignancy.”

“Perfect,” Dr. Smith said. He straightened up, pulling himself together. “Okay, let’s close up. But before we do, I want you to notice, Dr. Fuller, that our operative field is completely bloodless. I can’t emphasize enough that hemostasis is vitally important in thyroid surgery. That said, how would you rank yourself with suturing ability?”

“Amateur,” Mitt admitted.

“Well, I guess we’ll see,” Dr. Smith said. “Marianna, hand Dr. Fuller the three-oh Vicryl so he can close the strap muscles for us.”

To Mitt’s surprise, Marianna did hand him the loaded needle holder along with a pair of forceps while Dr. Smith removed all the retractors before approximating the strap muscles to the midline with a pair of forceps.

“Try to grab just the connective tissue of the two sides of the median raphe,” Dr. Smith instructed. He used the point of another pair of forceps to indicate exactly where he meant.

Mitt tried to concentrate, pushing the shock of the hallucination out of his mind with some difficulty. He was able to handle the needle holder as Dr. Wu had suggested, rolling his wrist to follow the curve of the needle point. He did the same on the opposite side of the median raphe.

“Not bad,” Dr. Smith said. “Now tie it so the tissue edges just touch.”

Mitt felt like all thumbs as he tried to tie the suture, and by the time he’d placed the second knot, the suture itself was loose. In a flash, a pair of scissors appeared and the mis-tied suture was gone.

“Try it again, but this time maintain adequate tension on the ends of the suture to maintain the position of the tissue edges, particularly as you run down the second knot.”

“I’ve advised him to spend some time in the simulation lab,” Dr. Singleton said.

“Very good advice,” Dr. Smith agreed. “Suturing is the bedrock of surgery.”

Mitt tried again, and the result was better. Then, after having placed three sutures, he began to feel a progressive confidence. Not long after, the strap muscles were back to the same position they had been in at the beginning of the case.

The skin closure took Mitt a bit longer, as he found the fine silk that was used more difficult to handle. Also, following the advice of Dr. Wu, he took the time to make sure that the skin edges didn’t roll in or pucker out. While that was being done, Dr. Smith gave a mini-lecture on why he didn’t use a drain with his thyroidectomies despite a number of surgeons doing so. Mitt listened with half an ear, concentrating on his suturing.

When the case was finished, Mitt thanked Dr. Smith with great sincerity. Except for the brief but disturbing hallucination episode, it had been the most positive experience he’d had in the operating room so far. There had been real teaching, the atmosphere had remained cordial and cooperative, and the instruments didn’t do any gymnastics. Mitt gave full credit to the attending, who seemed to take Mitt’s compliments to heart, and thanked him in return. He then made sure Dr. Singleton would see to the postoperative orders and the dictation, and left the OR.

Mitt and Dr. Singleton helped move Diego Ortiz from the operating table onto the gurney and then angle the gurney out into the hallway. With the anesthesiologist, Dr. Lenora Carpenter, at the head of the gurney and Mitt and Dr. Singleton at the foot, they began heading toward the PACU. “Thanks for the help, guys,” Dr. Carpenter said. “This gives me a chance to give you a heads-up when you write up the post-op orders. I did something a little out of the ordinary on this case. As a bit of background, I’d learned that this patient had been severely hypothyroid for some time and was taking a rather large daily dose of thyroxine. Since I’ve personally had a couple of bad anesthesia experiences with cases of severe hypothyroidism that resulted in a cardiac arrest made even worse by being difficult to resuscitate, I’ve hung a micro drip with a specific concentration of levothyroxine to piggyback his IV at ten drops a minute to avoid such a situation.” While she was pulling the gurney with one hand, she used the other to gesture toward the smaller IV setup next to the normal-sized one that hung from the IV pole at the head of the gurney. “My point is that the levothyroxine should be maintained at the rate I set until he can take it orally. To be doubly sure, I did check the TSH level, and it was normal. If you have a problem with this strategy, you could get a medical consult. But let me warn you: During the case he did throw a few extra heartbeats to keep my attention, so all this is not a hypothetical concern.”

“Sounds like a good plan to me,” Dr. Singleton said. “And this is certainly your area of expertise, not ours.”

They arrived at the PACU and pushed in through the double swinging doors. Mitt immediately hazarded a glance over to Elena Aguilar’s bed, and his heart missed a beat. She was gone! With everything else that had been happening, he took her absence as a very bad sign. Things were looking better when he looked in Latonya Walker’s direction. She was sitting up in bed sipping ice water through a straw. Her color was good. Mitt imagined she’d soon be heading back to 15 West.

While Dr. Singleton headed to the central desk, Mitt stayed with Mr. Ortiz along with Dr. Carpenter and the assigned PACU nurse to get the patient situated. Although fearful of what he was going to hear, the moment Mitt had an appropriate opportunity, he asked the nurse if she had any idea what had become of Elena Aguilar.

“Yes, I do,” the nurse said. “A bed opened up in the ICU, so she was transferred.”

“Was she doing better?” Mitt asked.

“I wouldn’t say better,” the nurse said. “Let’s just say not worse.”

“Okay, thanks,” Mitt said. He was partially relieved. Although he would have preferred to hear she’d been sent back to her room, at least she was still alive. The ICU wasn’t auspicious, especially since he found going in there so damn stressful, but as he already needed to go in there because of Bianca Perez, he tried to reassure himself it wasn’t all that bad.

A few minutes later, Mitt said a quick hello to Latonya Walker before joining Dr. Singleton at the central desk. Just as he’d done for the previous two patients, Mitt, with Dr. Singleton’s aid, typed Ortiz’s postoperative orders into the EHR. When he got to the end and was about to press Enter, Dr. Singleton tugged on his arm and reminded him about the levothyroxine.

“Oh, right!” Mitt said. “Sorry! What exactly should I put in here about that?”

“Just type in what Dr. Carpenter told us.”

Mitt did as he was told. When he was completely finished and they both stood up, he mentioned to Dr. Singleton that Elena Aguilar had been moved to the ICU.

“Good to know,” he said. “I’ll make it a point to check her out sometime this afternoon. Let’s hope the pulmonary and medical people can do some magic. At least she doesn’t have varicose veins any longer.” He gave a half laugh at his own stab at black humor.

Mitt tried to force a laugh but couldn’t quite manage it.

“I’ve got a pile of work, but before I take off,” Dr. Singleton said, lowering his voice and assuming a more serious tone, “did you want to say anything more about that little episode of yours back in the OR when we were waiting for the frozen section results? For a second there you appeared... I don’t know how to describe it, but maybe ‘terrified’ is the right word or something in that vein.”

Mitt stared at the fourth-year resident as his mind processed this surprising question. He intuitively liked this man and trusted him, and despite his suggesting he be addressed by his given name, Mitt saw him as a definite authority figure. So he hesitated. As much as he would have liked an experienced person to offer his opinion about what Mitt’s mind was conjuring up on occasion, he intuitively worried more about what Dr. Singleton might think, whether he might decide that Mitt was losing it and was a potential handicap for the program. Mitt was fully committed to becoming a surgeon, and he knew enough about the system to understand that if he got asked to leave NYU for having weird hallucinations, he’d probably not be able to get in elsewhere. All in all, it was too big a risk.

“All I can think of is that I momentarily fell asleep,” Mitt said, reiterating his previous explanation and trying to sound convincing. “There’d been a pause in the procedure, and maybe I kind of let myself relax too much or something along those lines.”

“Okay! You’re probably right,” Dr. Singleton said with a shrug. “And at least you didn’t violently jerk like I did when I fell asleep in surgery my first year. To make matters worse, at the time I was holding a retractor, which I ended up yanking out of the incision. Anyway, it’s water over the dam. Tell me! Are you on call tonight?”

“I am,” Mitt admitted.

“Well, I recommend you try to get as much rest as you can. Really! Get yourself to the on-call room early on and relax. If you are able to get some sleep in the beginning of the evening, it won’t be so bad if you end up being called to the floor in the wee hours. That was the trick that was so hard for me to get through my thick skull back when I was in your shoes. Too often I was out in the evening trying to scare up trouble. Well, not really trouble, but you know what I mean. I did spend a lot of time in the simulation lab when I should have been sleeping.”

“Good point! I’ll take your advice and try to get some sleep early on,” Mitt said, and meant it. The one helpful circumstance was that he wasn’t facing three admission H&Ps like he’d had on the first night he was on call. “And even if it is a busy night, at least I’ll be off tomorrow on the Fourth!”

“Oh, that’s right. It’s a holiday. Good for you. Enjoy it! Sleep all day if you can.”

“I will,” Mitt said, which was a lie. He fully intended to come into the hospital.

“We will have another day of surgery together on Friday,” Dr. Singleton continued. “You’ll be assigned three more cases, which I’m certain will be different from the cases you’ve had so far, since Dr. Van Dyke is making a concerted effort to give you a taste of the breadth of general surgery during your first week. As for today, let me compliment you. Your suturing technique is good for a beginner, but your knot tying needs some serious attention. I’m sure you know this, which is why I suggested you spend some time in the simulation lab.

“And one more thing: If you have any difficult management conundrums about the patients we operated on today while you are on call tonight, you’re welcome to call me directly no matter the hour. Walker and Ortiz should do perfectly fine, but Elena Aguilar is another story. I don’t know what it is with her, but there’s something going on we don’t understand. But medicine in general and surgery in particular can be like that. You do everything right and do it the same way you’ve done it successfully in the past, and some patients go south no matter what you try. Anyway, enough philosophizing. Good luck tonight and see you again on Friday.”

To Mitt’s surprise, Dr. Singleton stuck out his hand, and Mitt shook it. Dr. Singleton then tapped his surgical hat with the tips of his right-hand fingers in a kind of abbreviated form of a salute before heading toward the swinging doors. In the next moment he was gone.

Mitt turned and headed back toward Diego Ortiz’s bed as he was expected to, to make sure the attending nurse didn’t have any questions about or possible addendums to the postop orders. If all was copasetic, then Mitt would be able to get to the surgical locker room and prepare himself for the night on call. As he thought about the coming evening and night, his prognostic abilities sent him the unwelcome message that it was not going to be a picnic by any stretch of the imagination, especially as he could feel the hairs on the back of his neck rise as he thought it. What that meant, he had no idea and was pretty sure he didn’t want to guess.