Monday, September 16, 2013

Night Clinic and the Garden


“Dr. Barnes, how nice to see you again, it’s been too long,” Miss James remarked as I hung up my coat. “Residency been busy?”
“You have no idea, Nurse. I wish people would only get sick between the hours of 8:30 and 5. It’s so inconvenient when someone decides to have an MI at midnight. Personally, I wish my only night work was here at the Night Clinic.”
I leaned over to give her a kiss, but she turned her head away. I guess two months was too long a time to let pass without seeing, or calling, her. This could be a long shift, I thought, but one never knows what may transpire to bring people back together.
“Anyone waiting?” I inquired, hoping I could break down her icy veneer.
“High fever and a rash in two and vomiting in three. Room one needs to be cleaned. It seems the day shift never went to kindergarten and left One a bit messy.”
I picked up the chart outside room two. Owen Martin, thirty two, no previous medical problems, fever for three days, up to 103, and generalized rash. Here we go.
“Good evening, Mr. Martin, what brings you in here today?” I started my doctor banter.
“Bus,” he answered tersely.
It’s going to be one of those nights.
“I’m sorry,” I started over. “I mean, what’s the problem you’re having.”
“What’s the problem, doctor? Just look at me; you can see the problem.”
“That is quite a rash, no question. When did it start and where did you first notice it?”
“I first noticed it in the bathroom about a week ago.”
I raised an eyebrow at his response and then rephrased my question. “Where on your body did you first notice the rash?”
“Oh, sorry, doctor. It was on my stomach. It just spread each day and then I noticed the fever and some aching in my joints.”
“Been hiking in the woods recently; any bug bites?”
“I was hunting a couple of weeks ago. Didn’t manage to kill anything, though, except about a case of beer.”
Lyme disease popped into my head. “Did you get bitten by a tick? Let me check you. Go ahead and get undressed, here’s a gown for you. I’ll be back in a few minutes.”
I left Mr. Martin and went to room three. Sixty years old…hypertension…vomiting today, nothing much.  Probably a stomach bug. I noticed Miss James looking a bit frazzled as I opened the door.
“It’s going to be a busy night. There are about ten people in the waiting room already.”
I better pick it up.
“Good evening, Mr. Sanchez, what is the problem…”
I quickly dispatched him with a script for phenergan and follow up at the County Clinic in a few days and then went back to search for a tick.
“I’m back,” I announced as I returned to room two. You said the rash started on your stomach?”
That’s right, doctor,” Mr. Martin answered.
I started my search on his abdomen without any luck, moved to his groin and perineum, up and down, everywhere, but the nasty bug eluded me and my magnifying glass.
“What are you looking for, doctor?” my patient queried.
“A bug, a tick to be exact.”
“Oh,” he answered and then he became quiet. After another minute he spoke up. “I did find a little spider, maybe it was a tick, in my belly button. I killed it.”
“Let me look at your belly button,” I requested.
I pulled the skin apart to open it up and got up close and magnified the area. There was a tiny black speck that I pulled out. This could be part of a tick. I didn’t see anything else.
“Mr. Martin, I suspect you have Lyme disease. Here is a prescription for antibiotics, one pill twice a day. It shouldn’t be very expensive. Take it to the pharmacy over on sixteenth. It should only be four dollars. Here is a sample to get you started. And, this is the number for the Infectious Disease Clinic at the hospital. See them within the next week or so. Don’t forget to take the antibiotics and, here’s another script for your aching and itching. Any questions?”
“I’m not going to die, am I, Dr. Barnes? I always heard about Lyme disease and…”
“We caught it early, Owen. Just take the medication and keep your appointment and you should b fine.”
He shook my hand, clutching the prescriptions tightly in his other fist.
“Thanks, Dr. Barnes. I’ll call you if I don’t get better.”
“Go to the clinic if you don’t get better, but be sure to go.”
He left and I went out into the hall. All the rooms had charts on the door and I peeked out into the waiting room and saw about twenty more people seated. No one looked terribly ill until I saw her. She was a little girl sitting by herself in the corner, next to a fake potted plant. She sat with her hands across her knees, fidgeting.
Miss James came out of exam room one.
“Nurse,” I formally requested, “there’s a little girl sitting by herself in the corner out there. Please bring her back next. Thank you.”
“Of course, Dr. Barnes.”
I picked up the chart to room four. “Splinter in hand.”
I opened the door and greeted Mr. Billroth. “Good evening, Mr…”
I went through my usual spiel, but my thoughts kept drifting back to that little girl. Something about her demeanor was unsettling. I quickly removed the splinter from Mr. Billroth and sent him on his way. I ignored the patients who had been waiting in rooms one and two and went to three and the little girl.
Her chart was blank, no name, age or anything.
“Hello,” I said gently. ‘I’m Dr. Barnes. Can you tell me your name?”
She looked at me with her big brown eyes, but just sat there, clutching a raggedy doll to her chest. She couldn’t have been more than five years old. Long, curly brown hair fell around her shoulders and she was neatly dressed in a blue dress and pink tennis shoes. She didn’t have any of the grime I’d come to expect on “street orphans” which made me think that she had a home somewhere and she was probably lost or had just run away.
“I promise no one will hurt you.”
Miss James came in behind me.
“We just want to know who you are and where your parents are.”
“Daddy’s at the hospital. Mommy was there, but they took her away and now she’s in the garden. I saw her there today and I wanted to be with her, but she told me I had to leave.”
Miss James knelt beside the little girl.
“What’s your name, honey?” she asked while she slowly stroked her hair. The girl didn’t answer.
“Can you tell me your doll’s name?” I asked. “I’m sure she’s scared, too.”
The girl held up the doll, which looked worn and dirty.
“This is Peaches. Mommy gave her to me before she got sick and had to go to the hospital.”
“Can you tell me your name?” Miss James asked again. “If Peaches gets lost, I’ll know who you are and be able to bring her to you.”
“Jewel,” she answered. “My name is Jewel and I’m five years old. Please, I want to go back to the garden and be with Mommy.”
I took Miss James aside for a moment.
“Do you know of any garden near here? All I’ve ever seen is garbage and dirt and more garbage.”
She shook her head and went back to Jewel.
“Can you tell me about the garden?” she asked.
“It was wonderful, so beautiful and smelled so sweet and fresh. I saw Mommy there. I wanted to go with her, but I couldn’t.”
“Where is the garden? I asked.
“It wasn’t far from here. Mommy was at the hospital. She’s had to go there a lot. I was there with Daddy, but then they took Mommy away. I couldn’t stand it so I ran away to find her. And I did find her; in the garden.”
“Can you tell me about the garden, Jewel?”
“There were beautiful flowers and birds and even a lion. There was a river which sparkled in the sun and Mommy was sitting in the middle of it and she didn’t look sick at all. She looked happy and pretty and I wanted to go with her. I tried to run to her, but she told me I had to wait. Someday we would be together again, she said. Then she went away again and then I couldn’t find the garden anymore. But, I was standing right outside your door after Mommy left. Every other place looked dark and dirty, but it was light here, so I came inside. Please, can’t you go with me to find the garden again?”
I looked at Jewel and then at Miss James, but didn’t say anything. Finally, I told Jewel to wait in the exam room while Miss James and I talked about what to do.
“It’s obvious what’s happened. Her mother must have been sick and died at a hospital. When she learned that her mother had been taken away she ran away to find her and imagined her to be in a beautiful garden. Probably a pretty healthy defense mechanism for the little girl. I think that our task is to figure out which hospital her mother was in, which will help us find her father so we can get her home. Why don’t you start calling the hospitals and I’ll take care of the other patients.”
“Sounds like a reasonable plan, Dr. Barnes. I’ll keep Jewel with me,” Miss James replied.
We went to separate ends of the clinic. Miss James was in the back office while I saw a stream of patients with, luckily, minor complaints. Headaches, backaches, foot aches, neck aches, sore throats, sore ears, sore eyes they all came and went. It was four am when I finally had the clinic cleared out and I could check on Jewel and Miss James.
“Any luck?” I asked.
Jewel was sitting on the floor drawing, while Miss James was scribbling something on the pad.
“Mercy Hospital, Saucedo, you’ll contact her father. OK, but can you give me his contact information, thanks,” she finished her phone conversation and turned towards me. “Her name is Jewel Saucedo, she just turned five years old and her mother, Mary, just passed away. She had been battling ovarian cancer for a couple of years.”
“Do we know where the father is?”
“His cell phone is 906-100-1000. They called him while I was on the phone with them and he’s on his way here.”
“Good, good. At least I managed to clear out all those patients. I’m glad none of them were terribly sick,” I commented, then I turned towards Jewel. “Jewel, your dad is on his way…Jewel…JEW-EL.”
I was shouting because our little Jewel was gone. We called everywhere in the clinic, but she didn’t answer.  Only her drawing remained, a picture of green trees, colorful birds and a woman with long dark hair. Jewel’s Garden. I was starting to feel a bit frantic, first because a little girl was out alone in the night in what could be a dangerous part of town and second because her father was on his way and expecting to find his little girl safe at the clinic.
“Call the police and her father and tell them what’s going on. Close the Clinic for the rest of the night. I’m going out to find her. You wait here in case she comes back.”
I raced out into the night, shouting her name, “JEWEL, JEW-EL.”
I went from street to street. I saw police cars role by several times and stopped and talked to two of the officers. No luck so far.
If anything should happen to her…
But I couldn’t think anymore about that.
It was beginning to get lighter as I was becoming more discouraged. But, then I saw something unusual, extraordinary, wonderful. At first I thought it was the sunrise, but it was to the west and was too bright. A light shining in the distance. I ran towards it and when I saw it I froze.
There, across the wide boulevard was Jewel’s garden. In the middle of dark gray buildings, piles of unclaimed garbage, rats, winos and urban blight was the most beautiful garden I had ever seen. Lush green trees and plants, vibrant, bright flowers, birds with feathers of every color singing and calling; the most splendid beauty filled my eyes. I heard the rush of a swift river and then I saw them, sitting on the far side of the river, mother and daughter, Mary and Jewel, laughing together, happy, more than happy, joyful.
I started to cross the wide street and Jewel looked up at me and waved. As I stepped out in the street I heard the shrill wail of a car horn and stepped back as an eighteen wheeler rolled past. When I looked up, Mary, Jewel and the garden were gone. All that remained was Jewel’s worn, torn doll. I picked it up and trudged slowly across the street.
 I knew I would never find them again, but I also knew that little Jewel was where she belonged. I started to walk back to the clinic, slowly at first, but then I began to run. I was out of breath when I finally made it back, barely noticing the flashing lights as I went inside.
“MISS JAMES. MISS JAMES,” I shouted as I walked past the waiting room.
“I’m here,” she answered softly. Her eyes were filled with tears.
Before she could speak, I blurted out, “I saw, her, Jewel and her mother. And Jewel’s garden. And they were so happy, so peaceful…”
“SHE’S DEAD, JEWEL’S DEAD,” and Miss James broke down crying.
I held my assistant tightly and stroked her hair, not knowing what to say or do. At the same time her words didn’t surprise me. I suppose I already knew the truth, but after seeing her and her mother and their garden, I couldn’t feel sad. I left Miss James and went to speak to the police and a very distraught father.
“She was hit by a bus crossing Elm. Happened about an hour and half ago. The bus driver said he honked and tried to stop, but…”
“Is this her father?” I inquired. There was a man of about thirty, eyes bloodshot and sunken, weariness and anguish radiated from the center of his being.
“Leon Saucedo,” he whispered.
“May I speak to you in private?” I requested. He nodded his head.
I took him into one of the exam rooms and told him my story. I hoped it would provide a tiny amount of solace. He thanked me and went away, carrying Jewel’s ragged doll.
I filled in all the details for the police and they went away. Finally, we were alone. Only Miss James and I remained in the clinic. The next shift would be arriving in less than an hour. I went back to her and sat down on the floor next to her. She was crying, deep sobs and wails. I handed her a towel and then told her.
“You know, what Jewel told us, about the garden, was true. I saw it. It was all she said and more. It was like a glimpse into Heaven here on earth. And when you told me she was dead, I already knew it, But, I couldn’t, can’t,  feel sad, after seeing her in that place. As a matter of fact, I wished I could be with them. More than anything I wanted to be with them. I started to cross the street, and I felt such joy, but I had to stop when a truck came by and then it was too late. I suppose it wasn’t my time, wasn’t meant to be. I don’t know if it’s all good or bad, but I do know one thing. Among all the memorable and extraordinary days and nights I’ve lived as a doctor, in the hospital or here at the clinic, this is the most memorable and amazing of them all.”
Her cries stopped and she stared at me.
“Dr. Barnes, I don’t know what I would do without you. It’s never boring with you around; you most definitely brighten up my mundane life.”
She put her arm around me and gave me a light kiss on the cheek as we waited for our shift to end.

Sunday, September 8, 2013



One would never guess that a frequent activity in the OR is painting. I’m not referring to the application of paint to the walls of a room or house. The painting I’ve seen is limited to the patient and his or her body parts.

I suppose the first application of “paint” would be the initial scribble placed by the surgeon, marking the surgical site. This is a relatively new requirement and is so simple and makes so much sense I’m surprised anyone actually thought of it. The rationale behind this “signature” is that if the surgeon and the patient agree that the hernia, or fractured hip or lipoma is on the right or left or in a certain spot, then wrong site surgery will be eliminated. And, it really does work.

Beyond this, however, and in line with real painting is the OR prep, the act of applying antiseptic solution to the surgical site. This liquid, which goes by a variety of names which may sound antiseptic such as Chloraprep or Betadine, or magical like “Merlin” or perpetual such as “Duraprep” or merely utilitarian, Hibiclens, is applied by the circulating nurse before the patient is draped and the surgery commences. Its purpose is to kill all microorganism which may be residing on the patient’s skin and to continue its destructive ways as long as the case goes on.

Over the years the technique for applying this agent has evolved. In medical school I think the teaching was fairly well standardized. Every surgery I recall from those days started with a ten minute scrub of the site with Betadine soap. This was followed by the application of Betadine solution, which was different from the scrub. It did not contain any soap and was designed to stay on the patient for the entire case. It was always applied in standard regimented fashion.

The nurse would start in the middle of the surgical field and “paint” it on, starting as a small square (and always a square) around the umbilicus and then move out farther from the center with a  larger square and then larger and larger until the entire field and a large distance beyond was coated in this yellow-brown covering. Then the painting process was repeated. For an abdominal surgery the area painted usually ran from nipples to knees.

Times change, preps change and painting techniques change. Modern self expression now allows the circulating nurse free reign to demonstrate his or her creativity in the surgical prep area. Of course, the prep material is now more varied. The drab yellow brown of betadine still is a staple of the surgical prep armamentarium, but is often supplanted by the orange or blue green of Chloraprep, the yellow of Duraprep, or pink or white of Hibiclens. The prep consistency ranges from the watery betadine solution to the thick gel found in Prevail.

However, beyond color and consistency, the actual painting technique has evolved. Square painting still is common, but circles are more common. Bold straight lines, vertical or horizontal are also commonplace. The most creative nurses will squeeze the prep fluid out as a squiggle of continuous lines, then meld them together as a “Z” or “W”, before completing the prep by filling in any unpainted areas.

Another variable is the vigor the nurse will demonstrate during the application process. Male nurses, perhaps trying to display their machismo, paint with such strength and verve that I sometimes wonder if layer of skin has not been removed along with all the nasty bmicroorganisms. They must believe that their added muscle will kill the resident bacteria by shear force. Maybe it does. Some of the newer, less experienced nurses will daintily apply the prep, working only from the edge of the applicator, slowly painting the operative field at the same rate Michelangelo painted the ceiling of the Sistine Chapel (see The Agony and the Ecstasy, Irving Stone). Others insist on two coats, logically concluding that two layers of paint will cover more and kill twice as many potential microinvaders (never proven, however).

Sometimes as the prep is being applied I will offer my critique of the painter’s skill. The most skilled artists have been offered a job painting my house, an invitation which has universally, but politely, been declined.

Finally, the size of the prepped area has changed. Nipples to Knees is reserved for only the most major cases: Aortofemoral bypasses, Whipples, esophagectomies and such. Most of the time, now it appears that the nurse has decided that a wide and extensively prepped area is either too much work or will cause some sort of terminal illness as they limit the area to a size which sometimes seems barely larger than an Elvis Presley stamp. If I am late getting into the OR room the nurse will be forced to break out a new prep kit and expand the cleansed territory.

Nurses are not the only members of the OR team who are allowed to paint. The truly creative painting is reserved for pathologists. Technically, these doctors are not in the operating room. They may be in a room next door or down the hall, but they are, nonetheless, vital cogs in the surgical process. Their job is to examine specimens after removal, sometimes immediately, and determine if the surgery has removed adequate tissue, most important in cancer operations. It is during the examination of these resected tissue specimens that the pathologist’s true character is revealed.

They get to paint the removed organ or tissue; they call it “inking” the margins, but it looks like preschool playtime to me.

The purpose of this inking is to tag the edge of a specimen so that its margin can be clearly identified under the microscope. Different colors are employed based on the pathologist’s preference. Mostly working with primary colors, the intrepid pathologist may mark the superior margin with blue, medial margin with red, and inferior with green and so on. So what? Nothing creative about that.

However, it is the technique that the pathologist employs which is truly fascinating and, perhaps, revealing. For instance, some pathologists prefer finger painting, dipping their gloved hand into the ink and smearing it with glee on the tissue margin. By necessity, either the glove is changed or different fingers are utilized for each color, but the mirth and joy in the lab are almost palpable. I’ve watched my  Pathology colleagues almost squeal with delight as they get to do their finger painting. Other pathologists, perhaps a bit more prim, employ wooden sticks to paint their specimens, carefully inking each side and tossing the finished stick away, never using one drop too much or too little to accomplish their task. Still others use a brush, dipping and painting, all the time keeping a watchful eye on the process; doing their best to maintain artistic purity. There is an air of solemnity in the lab as each new tissue inking is created and, once finished, almost suitable for framing.

Sometimes I regret not going into pathology. The inking of the specimens always looks like so much fun.

Thursday, September 5, 2013

The Making of a Page Turner


It was suggested to me that an interesting topic for a blog article would be what ingredients are necessary for “making a page turner.” First I had to ponder the meaning of this request. The phrase “page turner” has different connotations. It could mean “a mechanical device which turns pages.” Such a useful device would free a reader’s hands for more important tasks, such as reaching for a cold drink. It would also eliminate the need for said reader to lick his fingers to facilitate the page turning process, thus saving saliva and preventing soiling of the printed page.

But, the “page turner” need not be mechanical. A servant could render the same task. Picture the page turning servant. He stands above the reader, fanning him with a large palm frond, when, suddenly the master/reader makes a subtle gesture. The skilled page turner deftly reaches around his employer’s shoulder and turns the page, all without missing a beat with his fan.

However, I do believe that the request referred to the written word, specifically stories which grab a reader’s attention and hold it tight, while forcing the enthralled booklover to stay glued to the book, turning page after page to find out what happens.

What, then, is the recipe for baking the perfect page turner? Start with a story, something that people care about. Lost puppies, families torn apart by war, lovers who are doomed by a terminal illness, the end of the world; you get the idea. Perhaps a family of puppies suffering from a terminal illness which threatens to cause the end of the world. Maybe, but that sounds a bit too complex.

Now, add in the proper characters. Ordinary people forced by circumstances to act in an extraordinary manner is one tool, a favorite of mine. Or, a mysterious character with a secret past who may just be a spy or the lost king, anything that keeps the reader guessing. Add a touch, or a heavy helping of romance and stir well. Create a roller coaster of highs and lows and juxtapose them so that the now thoroughly immersed bookworm just has to find out how our protagonist is going to get out of this mess or triumph over the evil villain.

To spice up the story, add a villain, one who hates our hero or heroine, perhaps with good reason. Maybe our hero has his flaws; is trying to live down a shady past. All the better. Purely good or evil characters can become a bore; multidimensional characters are far more interesting.

Finally, add a dash of comic relief. A dog or parrot or supposedly simple child who has the wisdom of the ages. Mix everything together, bake at 350 degrees for one hour and, voila, a page turner is created, we hope. Or else it may be a soufflé.

An example from my body of work: Minotaur Revisited follows the Minotaur of Greek mythology on a journey over thousands of years. He is trapped in the Labyrinth, which immediately makes him a sympathetic creature, even though he is of monstrous appearance. He is thrust into situation after situation which threaten to destroy our hero. He meets people who only want to use this sensitive monster for their own evil purpose, he suffers over and over, but in the end finally finds true happiness. Along the way he has numerous and varied sidekicks and companions to keep the reader interested and turning the page. These secondary characters are either sympathetic or villainous, thus making the reader care.

Making a page turner has one essential ingredient. It’s all about making people care.