Friday, December 25, 2015

Surgical Dilemma Part Three


For the moment, I was unemployed. However, my little book, “The Amazing Journey,” continued to be a hot seller, thanks to Annabelle and a thousand positive reviews. Sales passed 250,000 which made me number one among all books about surgery, number five on the nonfiction list and promised to put more than half a million bucks in my pocket.
Even though it looked like I would be financially secure, I was more than troubled by my recent disaster. I did call the hospital to speak with Art Shaw, the current Chief of Surgery.
“Take some time off while we investigate. You’re not officially suspended or anything, but it would be best for you to keep a low profile until we talk to all the parties involved. Just take a vacation for a few weeks. You deserve it anyway,” he advised.
I did my best to follow his recommendation.
I took the dogs for a couple of walks every day, began a sequel to “The Amazing Journey,” sorted through myriad offers to market it, make it into a movie or TV show, to interview me and everything else which one could possibly associate with a bestselling book.
And, like any older middle aged man going through a crisis I did the only logical thing possible. I bought myself a Corvette. Not a red one; no mine was black, a top of the line Z06. I considered a Lamborghini or Ferrari, but my practical side won out and I settled for “Black Beauty.”
And I thought about Lori, all the time. I knew she had survived the ordeal of the accident and the greater ordeal of surgery. My contacts in the ICU kept me in the loop, sending me daily updates on her condition. She was still on the vent, was being dialyzed regularly, was awake at times, but she was not completely out of the woods. The next ten to fourteen days would be most important.
I tried to visit her once. I made it through the hospital entrance, even past the fish tank in the lobby. But, when I pushed the button for the elevator, I felt my heart pound and sweat began to bead up on my forehead. The same contemptuous laughter that had chased me from the OR filled my head and I turned and quickly walked out.
Now I spent time driving around town in “Black Beauty.” That’s when I saw her. She was standing outside Saks, staring into her phone, probably waiting for Uber. It was my one time circulating nurse.
Ms. Vargus.
Alone on that corner she did not resemble any OR nurse I’d ever known. Wind blew through her long dark hair creating a tousled, sexy mess, her top was sleeveless with the top three buttons open which caused it to billow out with each gust. At the same time her dress clung to her, accenting every perfect curve.
Chivalry and lust forced me to pull over and render aid to this poor, suffering angel.
“You look like a lady in distress, Miss Vargus. May I offer you a lift?” I asked, my voice wavering a bit.
She gazed intently at my face and then into my eyes, looking like she was trying to remember if we had met previously and then she started to answer.
“I don’t think…” she began before I interrupted.
“Surely you can trust your favorite surgeon. I did manage to bring your Boss back from the abyss and save your skin in the process.”
She stared into my eyes and then smiled.
“Oh, Doctor…thank you. I need a lift home. My ride seems to be stuck in traffic.”
“Have no fear, dear lady. I am at your service; a gallant knight to do your bidding.”
She climbed into the front seat, bending forward just enough to give me an eyeful of her ample bosom.
“Home, driver. 1311 Elwood.”
I wasn’t sure where Elwood was, but between her directions and my navigation system I delivered her outside her apartment in just a few minutes.
“Thank you so much for the lift. I don’t know how much longer I would have waited,” she remarked as she hoisted herself out of the Corvette.
Then she added, “The Boss is away on business for a few days, which means my life is nothing but an empty bore. Would you like to come up for a cup of tea?”
Come up for a drink? A pickup line? Why not. I am certainly not doing anything important.
“Sure, as long as it’s a good black tea.”
“English breakfast?”
“I’m on the sixteenth floor, number 1604. The Boss is across the hall in 1601,” she informed me.
I parked the ‘Vette” and met her in the lobby.
“You must do pretty well for yourself,” I commented as I we entered through double doors into a huge foyer and living room. The floors were all marble and exotic hardwood and there were floor to ceiling windows opposite the entry which looked out over the park below.
“The boss treats me well. His apartment is even bigger and fancier. “Now what am I supposed to do? Oh, yes, tea.”
She disappeared into the kitchen while I settled into a plush leather couch. She reappeared ten minutes later carrying a tray loaded with pastries, cheese and crackers, a large teapot and two cups. She had taken the opportunity to change into a sheer bathrobe which did a poor job of hiding her ample assets.
“Try one of the scones, they are simply to die for and the cheese is imported from Paris,” she said as she poured out the hot water.
I put my hand on her hip and spun her around, her robe coming undone as I pulled her down towards me.
“I’ll skip the scones for now, if that’s OK with you.”
“Why, of course, Doctor,” and she pressed her open mouth against mine.
It was two hours later when I finally had my cup of tea. I found a man’s bathrobe in her closet and was staring out her window when she tapped on my shoulder and handed me a cup of tea.
“Now, I think I’m ready for one of those special scones,” I decided.
We ate rich pastries and drank some fine tea and then I reached over and grabbed her around the waist.
“I’m ready for the main course now.”
It was six am when I finally left her apartment. We made plans for dinner.
The dogs will be mad at me. It will be past their dinner time.
I quickly fixed five bowls for my canine buddies and then went to the computer. First I made dinner reservations for the two of us at Angelo’s and then I tried to search out some information on my new love.
“Lillie Vargus,” I entered into Google. There were a lot of women with that name, but none were my Lillie Vargus.
I could not find anything on her.
Maybe I should be more trusting. Sure, great sex is something, but she works for Satan. No harm in checking her out. But, the sex was fantastic. Keep your thoughts above the belt.
“What’s the name of their company? I know I saw it on the dresser by her bed…Vixen Enterprises, that’s it.”
I went back to the computer and searched for Vixen Enterprises. The company’s web page popped up.
“International finance, shipping, industrial investment…”
Nothing unusual. What about their people?
“Stewart Young, CEO, graduated Wharton School of Business. Been with company twelve years…”
“Michel Bostick….”
Just a boring company. No Lillie, no Satan, just a bunch of men in suits. I guess I shouldn’t be suspicious. Maybe this isn’t even the right company. I’ll try to bring it up at dinner tonight.
Dinner at Angelo’s was a great prelude to an even better night. Lillie was dressed in a little black dress. Her only adornments were sparkling diamond stud earrings and a large sapphire and diamond ring.
“Gifts from past admirers,” she explained.
“The Boss?” I wondered out loud.
“Oh, no, that’s not his style. I work for him and that’s it.”
“You know, I haven’t really met the Boss, at least not in a conscious state. So tell me, what’s Satan like?” I asked.
Her eyes sort of glazed over as she contemplated my question.
“Satan,” she began, but she stopped.
“Satan is misunderstood,” she began again. “Popular lore has it that Satan hates humanity, all of mankind. This is more than unfair. The Satan I know liberated Adam and Eve from servitude, slavery really. They were in paradise? I don’t believe it. They toiled for a God who kept them naked and ignorant. Satan had great foresight and freed then from oppression. Satan set them on the path which has led to the world of today. Men and women have unleashed all the power of their own intellect and ingenuity and have taken advantage of all the resources this Earth can offer.”
“Some would say exploited with no thought towards consequences,” I countered. 
“This world was created for humanity. Why shouldn’t all mankind be allowed to exult in its abundance?”
“But what about death and disease, war and hunger and the evil which has been a part of human history almost since the beginning?” I added.
“Every great advance comes at a price; that is true. But do you think god really cares? He’s been angry ever since that first act of rebellion. A true god would have been proud to see his children growing up, leaving the nest.”
“What about you? Has Satan treated you well?”
“I’m here aren’t I? I have never seen Satan hurt another person without a proper reason or justification? Could god say the same?”
“I don’t know.”
The conversation had become more heated than I intended and I decided to change the subject.
“Is your fettucine to your liking?” I asked.
I suspected she was just as anxious to change the subject.
“Best I’ve had, ever. Can I have another glass of wine?”
We finished dinner with small talk about nothing and headed back to my place for an after dinner drink and more.
Later that night, as we lay in bed, I wondered out loud.
“What would it be like to have the power of Satan, to be the Boss?”
She sat up and faced me.
“Are you serious?”
“Probably not,” I answered. “Just speculating. I mean, as a surgeon, I’ve brought so many people back from the brink of death, including your Boss. I suppose this has given me a tiny taste of power. But the power Satan must have is enormous. I know he’s not God, but he was given the power to rein over the earth.”
She looked at me sort of funny.
“You know,” she finally replied. “It could be done. You could take the Boss’s place.”
“Really, though, I don’t think I want to be the purveyor of evil throughout the world.”
“It doesn’t have to be evil, you know. You’re a surgeon. You help people every day, cure them of dread diseases, cut out their cancers, mend broken bodies. You could take Satan’s power and harness it for good.”
“How could such a thing be done? What would compel Satan to give up his power?”
“You would have to kill him.”
“You mean he has to die.”
“No. For his power to flow to you, you would have to be the arbiter of his death. You would have to be responsible for his demise.”
“I’ve been down this road once before, my dear Lillie. I had his life in my hands and I gave it back to him.  Killing is not my style.”
“Well, I think it could be done in such a way that it isn’t really murder. I think if he is ill and you have the power to intervene and cure him, but you withhold the intervention or there is some sort of, what do you call it, complication, the result would be the same.”
Maybe it would be a good thing. Not intervening or having an unavoidable complication is definitely different from a deliberate act of murder. Or, is it?
“Well, such speculation makes for good philosophical discussion. However, the last time I saw your Boss he looked to be in peak health. I really did a great job on him, even if I do say so myself.”
Lillie didn’t answer right away. She appeared lost in thought.
“You know,” she finally replied, “he did have cancer, cancer of the pancreas. From what I know of this disease, even with a supposedly curative resection, it is notorious for recurring. You never know. The Boss could return from his trip with cancer racing through his body.”
Too much talk and not enough sex.
“My dear, I think that we should let the Boss and his cancer alone. If it is destined to race through his body, then so be it. But, while wait for cancer to race through his body, I wouldn’t mind racing through your body instead,” I remarked as I grabbed her around the waist and pulled her towards me.
The next morning, after Lillie had left I mulled over her proposal
You could have such power; you could do so much good and Lillie would be with you. You could live forever, be a sort of Surgery God. All the petty politics of the hospital would be meaningless. No more SCIP, no more battling soulless EMR’s. All your valuable time could be spent doing what you love best.
“I need to clear my head,” I said out loud.
I jumped in “Black Beauty” and headed out or town.
I’ll cruise some of the country roads.
About forty miles outside of the city, the suburbs give way to a jumble of forests and farmland. Fields filled with corn alternate with cow pastures. The roads twist and turn and the farther one goes the sparser are the homes.
I opened the sun roof and the throttle and raced up and down hills and around hairpin turns. I turned my music up as loud as I could stand, allowing Roger Daltry to serenade the countryside.
…teenage wasteland, it’s only teenage waste land…they’re all wasted…”
I sang along, letting all thoughts of Satan, surgery, Lori and even Lillie fade away as I exalted in the warm rays of the sun, the wind and the Who.
“Ever since I was a young boy I played the silver ball…”
“Tommy” filled my ears as I raced along deserted roads. I was driving over a narrow bridge when I noticed the smell.
It was smoke, like burning oil and then I saw a black gray cloud wafting up from the bottom of a ravine. I slammed on the brakes and spun the car around and drove back to the ravine, stopping at the edge. Down at the bottom I saw smoke billowing out of a car which was wedged between two trees.
I grabbed the first aid kit from the trunk of my car as well as the Swiss Army knife I kept in the glove compartment. I felt like a Boy Scout, prepared for anything. I raced down the grass covered hill to the car, hitting 911 on my cell phone.
“No signal.”
I don’t think I have time to find a spot with a signal. I hope that car doesn’t explode.
I reached the car and saw there were, or had been two passengers, an older woman and a young girl. The older woman was obviously gone as she had been nearly decapitated, but the girl, who looked to be about five was moving in the back seat, still strapped into a child’s car seat.
Hurry, hurry. My god, look at her face.
Indeed, her face was bloody and swollen and I heard gurgling noises as she tried to breath. I tried to open the door, but it was jammed. All the doors were jammed. The windshield was smashed and it looked like crawling through from the front seat was the only way to get to her.
Carefully, carefully, but with determination I jumped on the hood and began to slide myself through the open space where the windshield had been, going head first on my back. My clothes snagged on the shards of glass, which scraped and tore my skin. As I reached the girl the car suddenly settled  and smoke began to pour out from the floor.
Don’t blow now. I’m almost there.
I managed to reach her and began to release her from the car seat. The seat belt latch was folded under the twisted wreckage. My pocket knife came in handy as I cut her free.
I made a quick survey of her, trying to discern any potential injuries as I cradled her in my left arm, doing my best to support her head and neck. She was still making gurgling noises and I could tell she was moving some air.
Try not to make her injuries worse, be gentle, but be quick.
After an eternity, I had her out and I laid her on the flattest surface I could find, well away from the smoldering car. I felt for her pulse and was pleased to feel a strong radial and carotid. Her face was a mass of edematous eyes and cheeks, her jaw was deformed and there was blood in her mouth and nose. She seemed to be moving adequate air, but as I was assessing the situation, more blood started to pour from her mouth and the gurgling stopped. I tried to clear her airway without success.
Cricothyrotomy. Let’s go Swiss Army Knife.
I pulled open the pocketknife, did my best to feel the landmarks on her neck and started to cut.
My hand started to shake.
Come on, you can do this. You have to do this.
My hand shook even more. I kept cutting, finally poking the tip of the knife blade into her windpipe.
Blood poured out.
I tore open the first aid kit. There was some gauze which I used to wipe away some of the blood and I stuck the can opener blade on my knife into the airway and rotated it as I tried to prop open the airway. Blood was still oozing from the hole.
There must be something I can use to keep the hole from closing.
I found some gauze and tape, a bee sting kit, rubber gloves, a flexible splint and a few other odds and ends.
That might work.
I took the splint and cut it in two. Then I took some of the adhesive tape and began to wrap it around the splint to create a tube.
I hope it’s not too big.
As I began to put my makeshift endotracheal tube through the surgical airway, my hand began shaking again, this time so violently that the tube went flying and my knife which was keeping her airway open became dislodged, falling into the grass.
Blood poured into her neck and she stopped breathing.
“NO, NO, NOOO,” I screamed.
I found the pocket knife and made a futile effort to reestablish her airway, but blood kept pouring out.  I was too slow.
She was gone.
I felt for a carotid pulse, but there was nothing. The poor girl lay lifeless.
I put my face into my hands and then looked up at the blue sky.
“WHY, WHY?” I screamed to an invisible god. “Why am I made to suffer?”
“Hello, Hello down there. Do you need some help?” an unseen voice called out.
“I did,” I replied weakly. “I did need help, but it’s pointless now.”
Two men came running down the hill.
“I tried to save her. I did my best, but I failed… again,” I mumbled as I walked away like a Zombie. “I’m sorry. So sorry. I did what I could, I really did.”
They stared at me as if I was crazy as I slowly walked up the hill.
“Wait…” one of them said, but I just kept on walking. I climbed into my car and sped away.
I might as well just quit for good. How can I do any sort of surgery ever again? Maybe Lillie is right. Take the power, use it for good. That may be my only hope.
But, it’s Satan? Could any human handle such power; wouldn’t the evil control me? What if I became a monster?
You don’t need to work. You’ve got plenty of money now.
But, I do need to work. It’s like breathing.
I was racing at breakneck speed through the back roads, up and over hills and through twists and turns. As I raced around one turn I suddenly was staring at a dump truck moving slowly along the road, heading straight towards me as I veered into his lane.
For a moment I raced straight at him. I heard his horn blaring, but I stepped on the gas. At the last moment he veered to the right and I turned away. I watched him through my rearview mirror as he stopped and jumped out of his truck and stared back at me as I sped away. As soon as he was out of sight I slowed down.
The decision was made.
I called Lillie.
“I’m ready,” I said as matter of factly as I could.
“Wise choice. You will be the most famous, respected and beloved surgeon on this planet,” she answered, although there was something in her tone that I found disconcerting.
“Are you happy with my decision, my dear?” I asked.
“Of course, it is what we both want.”
I thought for a moment and then I added, “What about you? Before you told that your life was bound to Satan’s. If I take his place, will you be OK?”
“I will then be bound to you, body and soul.”
Not such a bad prospect. But what about the Boss?
As if she had read my mind, Lillie began espousing her plan.
“The Boss called today. He is on his way home and he told me he is not feeling well. He said his stomach was hurting and he had a lot of nausea. He asked to have his doctor waiting for him. Can you be here by four? He’ll get to the office around that time.”
“Sure, I’m about an hour away and I’ll need to pick up my little black bag.”
“We’ve got plenty of medical supplies here. Just be here by four,” she sounded a little annoyed.
“Certainly,” I answered and then I hung up.
I’d almost forgotten about the car accident and the little girl and my failure. The sorrow and self pity I’d felt only a few minutes earlier gave way to a jumble of new feelings: excitement, elation, anticipation and hope.
I will be a surgeon again. I will have the respect I’ve deserved all these years. No more review boards, no more mindless documentation, no more…
My thoughts vanished as I approached town. I’ll make a quick stop at home first. It was only half past two. I had plenty of time to clean myself up. I drove past the elementary school on my way home. The children were in the yard, playing, running, laughing, doing all the things little children should do. My thoughts wandered back to another little girl, a girl lying dead, a girl I had killed.
I’ve killed a helpless little girl and I almost killed Lori. I’m getting good at this sort of thing. Disposing of the Boss will be easy.
I turned on the TV as I took a shower. There was an old movie playing, “Mr. Skeffington,” with Claude Rains and Bette Davis. It was a story about a good, patient man and his vain, cruel wife. I changed into my black scrubs, had a bite to eat and watched the end of the movie. Job, the Claude Rains character, is found sitting on a park bench, a broken man at the hands of Nazi Germany. He is brought to his former home, where his ex-wife, Fanni, played by Bette Davis, lives. She has become worn and has lost her once legendary beauty to disease. In a heartwarming scene the two are reconciled while their former roles are reversed, Fanni will now care for the broken Job.
Stupid old movie. Time to go.
As I started Black Beauty I felt the same sense of exhilaration, along with a touch of apprehension I usually felt before a big complex surgery. I began to consider all the possibilities and pitfalls.
Don’t worry about all that. I’m sure Lillie has taken care of everything. You just have to be there and the deed will be done. And you’re not really killing him. Just not treating him. It’s not the same thing.
As I drove away I thought about all the times I had put my faith in others. How many times, as a resident, did I ask an intern or junior resident to draw blood or follow up on an X-Ray, only to learn later that the task was never done, leaving me to explain why to my superiors. Or, even, now the multitude of missed or neglected orders on my patients which may have led to complications if I hadn’t been so compulsive and checked on every little detail. I guess the point was that other people are often unreliable and tend to disappoint.
Should I have such confidence in Lillie? Or is she like all those interns and residents. She seems very efficient, maybe that’s why I love her so, why I am willing to go along with this deed. No, it’s more than that. It’s a second chance, a new start for me and for humanity. A chance to free the world from evil, perhaps forever.
Lillie, my dear Lillie, you have been wonderful. Now we will take a big step together and take Satan’s power and together the two of us will bring so much good into this forlorn world.
I pulled up in front of their office building and headed up to the fortieth floor. The big glass double doors at the entrance opened automatically and Lillie me ushered me into the inner office. Huge floor to ceiling windows looked out over the city, filling the room with sunlight.
“Let me get the curtains,” Lillie remarked. She hit a button and the blinds closed and the lights automatically came on.
At one end of the room was the Boss. He was on an exam table, an IV running into his arm, breathing was labored, he looked yellow again and there was dried blood around his mouth.
This all looks very familiar. Didn’t I just go through this a few weeks ago? I just saw him and he looked completely recovered, more healthy than me. How could Satan go from vigorous good health to the brink of death so quickly? What is going on?
As I was thinking The Boss turned his head and vomited, filling a basin with dark blood. His labored breathing mixed with the monotony of the monitors and an occasional groan.
“He certainly is at death’s door. Ironic, isn’t it? Satan, the villain who brought Death into the world will get a taste of his own horror,” I observed. “But, my dear Lillie, how is it that his power will be transferred to me. If I just watch him die, how will I take his place?”
“Well,” she explained, “it’s not as easy as all that. If you want to assume The Boss’s place, you’ve got to be a little proactive.”
“What do you mean, proactive?”
“It means you must have a hand, even if it’s a miniscule hand, in his demise. He’s dying anyway, just give him a little push.”
But what about merely withholding potential lifesaving treatment? That is what she had told me. I don’t like the rules changing in the middle of the game.
As she said these words, the Boss vomited another bucket of blood and his breathing became even more irregular and raspy.
“If you want his power you had better hurry. He doesn’t look long for this world. Just look around you. There is a tray full of anesthetic agents, a table full of surgical instruments, a variety of endoscopes and lots of other meds. Surely, you can do something. Perhaps, you are planning to do an endoscopy, which would require some sedation. Just give him some of the Propofol which is already drawn up and sitting on that tray. Maybe, you give a bit too much for his weakened condition and he arrests. You were trying to help him, but he just had a “complication,” just a miscalculation on your part.”
Can power be worth such a price? But, he’s dying anyway. His death should not be in vain. His evil power could be transformed into so much that is good.
I walked around him. Lillie shadowed my steps, staying against the curtain, but exhorting me onward with each step.
“Yes, yes, take the syringe, inject it into his IV. We will have our life together and the world will be free from “The Boss.”
As I picked up the syringe a jumble of thoughts filled my head.
I will have my life as a surgeon back.
Lillie will be with me forever.
Evil will be vanquished.
“Go ahead, free us, free me.” I heard Lillie’s voice in the background.
It’s always her voice.
The Boss has never spoken evil to me. I’ve never seen him commit a malevolent act.
Then my thoughts jumped to a totally different subject.
Mr. Skeffington? Job and Fanni? An odd thing to think about at this time… Job?
Carlos Anais.
That was the most bizarre thing to pop into my head at such a moment. Carlos Anais had been a patient of mine when I was Chief Resident. He was only thirty, had been losing weight, had severe abdominal pain with signs of peritonitis and he was HIV positive. All the consultants on the case agreed he needed surgery although no one had a clue about the underlying cause. Most thought he had some sort of malignancy, others considered dead bowel.
My preop diagnosis was much different.  I diagnosed intraperitoneal atypical mycobacterium. I even went so far as to document this unusual conclusion in the chart. Sure enough, that was what I found. I couldn’t do anything to cure him, but I became a legend.
Why should I recall a patient from almost thirty years ago, at this moment? One thing is clear, when Carlos Anais’ name popped into my head, all my muddled thoughts crystallized. Lillie, the Boss, evil, it all became very clear.
I stared at the white milky fluid in the syringe and stuck the needle into the Boss’s IV and began to inject it. I heard Lillie take a deep breath. But, before any of it reached his arm I ripped the IV out, wheeled around and pushed my darling Lillie as hard as I could.
She reeled backwards, between the curtains, smashed through the window and plummeted towards the street below. I ran to the window and looked out just in time to see two black winged creatures swoop down out of nowhere and catch her. Then I watched as three black winged monsters flew away. A loud screeching noise filled my head until they were out of site.
“Doctor,” I heard a raspy voice call. It was the Boss.
I went to his side and held his hand. I started to call 911, but he put his hand up and pushed my cell phone away.
“How did you know?” he asked, his voice barely audible.
How did I know? Good question. Was it logic which managed to poke its head through my own lust for power? Good overcoming evil? Divine intervention? A dangerous wager against evil?
“Lucky guess,” I finally answered.
“Please, doctor, what is your name?” he asked, reaching up and grabbing my scrub top.
“Zachary. Zachary Morse.”
“You are a smart doctor, Zachary Morse. You have freed me and saved yourself from a millennium of torment. Now, please, let me go,” he whispered.
“But we can save you.’
“You already have, you already have. Now, it’s my time for rest.”
He mouthed some inaudible words and gave a faint smile and then he passed away.
I left that place quickly.
I went home and waited, walked the dogs, drove my car and wrote this story. I expected to hear a knock on my door one day. Perhaps the police, the FBI, a priest or a black demon, but so far I have been left in peace.
The hospital finally finished its investigation. I was given a slap on the wrist. The panel agreed that I had called for help appropriately when I realized I would be unable to complete Lori’s operation. There was some questioning of my decision to be her surgeon because of our relationship, but technically no rules were broken. I was to undergo a complete physical exam including neurological testing and I was to be proctored for my next five surgeries. I wasn’t concerned. My hands would be steadier than ever.
After another week I finally dug up the courage to go to the hospital and visit Lori. I saw her sitting up in bed, extubated, eating, starting on the first few steps with Physical Therapy which would lead to complete recovery.
“I’m sorry,” I whispered. “I should have saved you.
“From what I’ve been told, you did,” she answered.
I held her and we didn’t say anything for a while. Finally, after a few minutes she spoke again.
“You know, while I was so out of it I had the most bizarre dream. I dreamt that Satan was an evil woman and she was trying to entice you to join her and that you were tempted and almost did her evil bidding. It was just at the last moment that you came to your senses and escaped. Isn’t that strange?
“Yes, very strange; impossible,” I answered.

Sunday, December 6, 2015

Surgical Dilemma, Part Two


“I’ll be about an hour late for my first case,” I informed the OR desk.
“OK, Doctor,” Eve replied. “There’s nothing behind you, so that shouldn’t be a problem. I’ll let anesthesia know.”
After another shower I pulled on some clean scrubs. The dogs sniffed me more than usual as I put out their bowls and filled each with a mixture of dry and canned dog food. While the pack went to work on the daily meal I sipped a cup of tea and read the paper.
Nothing new under the sun.
The sweet sound of Bach filled my car during the twenty minute drive to work.
“Good Morning, Dr.” the preop nurse greeted me with a big smile. “Your first patient is in room twelve.”
“Thank you, nurse. You’re always so efficient,” I replied smiling back, weakly.
Mr. Jackson, right inguinal hernia. At least all the cases are pretty straight forward today. Two hernias, a gallbladder and a breast biopsy. I don’t feel like working too hard today.
“Hey, Jeb,” I called out to Dr. Samson, my anesthesiologist for the day. “Sorry I’m late.”
“It’ll be the death of you, burning the candle at both ends. Up all night? You need to give that nurse a rest once in a while.”
“Lori is upstate at her mother’s for a few weeks. I was working, if you must know.”
“Really? It wasn’t here.”
“Long, complicated story. Maybe, I’ll tell you when I have more time. Anyway, let’s get to work.”
Mr. Jackson’s hernia took only about twenty five minutes. With minimal fuss he was followed by Mr. Kendall’s umbilical hernia, Miss Cates’ gallbladder and Mrs. Lane’s right breast lump. It was noon and all I had left was rounds on five hospital patients and a dozen patients in the office.
I stopped for lunch in the doctor’s lounge. The TV was blaring a popular talk show which featured an abrasive and pompous host, Annabelle, no last name.
“Today, looking through Annabelle’s book shelf I discovered an extraordinary book about surgery. The title is ‘The Amazing Journey….’
At the mention of the title I almost choked, spilling my water. “The Amazing Journey” was the book I had written about surgery, self published five years before. Why would Annabelle, of all people, suddenly ‘discover’ such an obscure book?
Well, I suppose I may sell a few more copies. A little extra cash never hurts. Maybe I’ll get enough to take Lori out to Peter’s Steakhouse for a nice dinner.
I finished my lunch and made quick work of my rounds. I called the office and arranged for my patients to come in earlier.
My office manager, Suzy, was waiting for me as I arrived through the back door.
The regional director for Affiliated Health Care sent this e-mail.
“We have finished our audit on the recent claims which we had disputed. We have determined that all of your claims are appropriate. We will be sending you a check for $86,355.61 as payment for those claims which had been under investigation. This amount includes the outstanding fees plus interest. We consider the matter closed. If you have any questions do not hesitate to contact me.”
“This should ease your burden, Dr.” Suzy stated.
“Not enough to retire, though.
“Maybe you won’t have to work quite so hard.”
“Perhaps, but I like to work. All I have at home are the dogs.”
“You could see them more.”
“Their fine. Jeannie from next door takes care of them and gives them plenty of attention when I’m not there. I like to think my patients need me.”
“Speaking of patients, all the rooms are full. You should be out of here by three today.”
“Good, because I’m really tired.”
“I thought Lori was away visiting her mother.”
“I was working last night, Miss Know-it-all. You know, saving lives, stamping out disease, making the world a safer place for society.”
Maybe the last part isn’t true.
I zipped through ten post op patients, a new patient with gallstones and another with colon cancer and was on my way home by three thirty.
My cell phone buzzed. I didn’t recognize the number.
“Yes, this is the doctor.”
“Yes, that’s me.”
“This is Saul Lewin, from the Sun Times. I was wondering if you might be free for an interview? Your name came up as a local personality that we could feature in our ‘Hero of the Day’ column.”
What’s going on? Anabelle and now the local paper? I suppose the President will be next.
“I’m sort of tired today and I think I’m pretty booked up this week. Maybe, next Tuesday? Call my office, Suzy can tell you when I’m free,” I answered.
“We were hoping that we could feature you in this Sunday’s paper. I can make it early. Why don’t you meet me at ‘Leo’s’ at five thirty. Drinks and dinner are on me.”
Free dinner at Leo’s? I guess I do have to eat.
“OK, five thirty, but it will need to be fairly short. Like I said, I was up most of the night and I need some sleep.”
“I know. It must be rough being a surgeon. See you at Leo’s.”
Coincidence? Or is Satan paying me back. Scotch and steak from Leo’s isn’t a bad start. I just have time to shower and change.
Saul Lewin wrote a weekly column in the Sun Times. Once a month he featured the ‘Hero of the Day.’ Most of the time this was a police man who had thwarted a robbery or fire fighter who had rescued a kitten from a storm drain. Occasionally, a returning war hero was interviewed. Medical professionals had never been included in the ‘Hero’s Club.’ I was anxious to learn why I was being honored.
I arrived at five forty and met Saul at the bar where he was finishing a double Scotch on the rocks.
“Mr. Lewin?” I inquired.
He stuck out his hand and gave me a limp handshake.
“Saul,” he replied. “You are the famous surgeon I’ve heard so much about?”
“Surgeon? Yes. Famous? Only in the eyes of my mother.”
“Annabelle disagrees.”
I didn’t answer. The MaĆ®tres d’ ushered us to our table where a bottle of champagne was waiting.
“Dom Perignon? You must want more than an interview.”
“The paper gave me free reign and an expense account.”
“So, tell me Saul, why this sudden interest in me. How did Annabelle stumble upon my obscure book and why should you have any interest in a run of the mill general surgeon?”
“I find surgery fascinating. I’ve been planning to do a feature on a general surgeon for months and when I asked around your name kept popping up as the best. Now, if you don’t mind, I’ll ask the questions.”
“Can we order dinner first? I’ve barely eaten all day.”
We each ordered a steak.
“Now, tell me, surgeon, what is about surgery that made you choose it as your specialty?”
“Well, back in the stone age, when I was finishing medical school and it was time to apply for residency I seriously considered Pediatrics. There was something about taking care of sick kids, making them better which I found very appealing. But, as I talked with other Pediatricians and residents it became clear that most of Pediatrics is mundane and routine. Surgery, however, also cured people, sometimes dramatically. I saw patients who were dying from disease or injury go into surgery and then walk out of the hospital a week later.”
“Has your opinion of surgery changed over the years?”
“No. ‘To cut is to cure’ the poet once said. This hasn’t changed.”
“What’s your favorite operation?”
“Big cancer surgeries, such as those on the stomach or pancreas or colon. Such operations are very anatomic, require a bit of thoughtful planning and often are curative.”
He went on asking similar trivial questions for a while until dinner was served and devoured. With the arrival of dessert and coffee the tone and substance of the questions changed.
“Have you ever operated on someone; someone seriously ill let’s say, who didn’t deserve to live?”
Does he know something? How could he?
I think he saw the perplexed, distressed look on my face.
“I mean,” he added, “for instance, suppose you had a gang member who had been shot by the police after he had performed some heinous act, say after raping a little girl. He’s now bleeding to death on your OR table. Would you be tempted to not do your best?”
Coincidence? Tempted? Tempted is not the same as doing.
“Never, I’ve never considered not doing my best for my patient,” I lied. “When I graduated I took an oath. It is not my place to act as judge. When I do surgery I do nothing but my best. Now, I’m going to finish my coffee and be on my way. I really need to get some sleep tonight.”
“You were up all night last night, doing surgery?” He wondered out loud.
“Yup, saving a life.”
“What were you doing?”
Why would he ask? Does he know? I think he’s fishing.
“Sorry, can’t say. HIPAA and all that,” I replied.
I finished my coffee and said my goodbyes, thanking him for dinner and for the free publicity.
“Be sure to mention my book,” I added as I got into my car.
I took a long hot shower before going to bed. I stared at the ceiling for hours, tossed, turned and stared some more. I think I finally drifted into fitful sleep around four am.
That night sleep was anything but peaceful as images of children being tortured and murdered punctuated my dreams. I awoke drenched in sweat, lay on my back staring at the ceiling for another hour before I gave and climbed into the shower again.
The dogs greeted me with their usual energy in anticipation of their morning meal. As they munched away I read the morning paper. My eye caught one of the front page headlines:
“Israel and Palestine Reach Historic Accord”
Farther down on the page was another headline extolling good news:
“Terrorist Cell Arrested”
And on page three:
“Serial Rapist and Killer Apprehended”
“Mother Dog rescues Puppies”
All this good news. Maybe Satan’s being sick has kept him from meddling in human affairs. Or, maybe my act of decency has rubbed off on the Prince of Evil.
The dogs finished their food and I was off to work. First would be rounds and then surgery, a few small cases followed by a big gastric cancer.
Miles Belson was the patient with the stomach tumor. He was sixty six, rotund with a bit of heart disease, diabetes and a tumor which started just below the esophagus and covered the lesser curvature. Workup suggested the tumor extended close to the aorta and maybe the vena cava, but should be resectable.
I made my incision at eleven. I found nothing unexpected upon entering his abdomen. The tumor was palpable along the lesser curvature of the stomach and there was some extension into the surrounding fat. As I mobilized the stomach a bit more, there was about one centimeter where the left lobe of the liver was stuck, so I sliced out a wedge of liver with the specimen.
It was after this, as I freed the tumor from the right side of the abdomen that I noticed it.
It’s nothing, just lack of sleep.
There was a tremor. In my hands. I don’t think the scrub tech or my assistant noticed, but I did. As I worked around the vena cava behind the liver my hand shook. I stopped for a minute and then I rested my hand on a lap pad as I worked. This seemed to help. The tumor lifted off the vena cava and I thought I was home free. I finished the resection which required removal of the entire stomach and sent the tumor off to pathology for frozen section.
Never had a problem like that before, even with lack of sleep. Maybe I’m getting old.
The phone rang bringing the free and clear message from pathology.
“Let’s put Mr. Belson back together,” I announced to no one in particular.
I was left with the end of the esophagus and the closed off duodenum, which meant reconstruction of his GI tract would require an esophagojejunostomy. I went to work mobilizing the small bowel. As I started sewing esophagus to jejunum the tremor returned, a bit more pronounced.
“Is everything OK, doctor?” the tech asked.
She sees the shaking. I’ll bet everyone can see it.
“Fine, just a bit of a reach putting him back together,” I answered, doing my best to hide my concerns.
I managed to finish the anastomoses and close up Mr. Belson. As I sat in the dictation room I stared at my hands.
Are you trying to tell me something? Is it time to put the old scalpel away?
My hands failed to answer. I finished the post op chores and went off to the office where twenty four patients were scheduled. I gazed into my phone as I crossed the street to see that “The Amazing Journey” was number one among surgery books on Amazon. I checked the sales, 44,303 copies of the e-book had been sold in the last two days, which translated into over $80,000 dollars in my pocket.
Well, at least if my hands are betraying me, I can live off royalties from my little book. Probably a lot of print books have gone out the door, too. I’ll check later.
But, I was not ready to give up surgery. The office brought me six new patients. One with breast cancer, one with a large polyp in the colon, three with gallbladder disease and one hernia. The post op patients were all recovering without problem and I was done by five.
The next few weeks brought little change. Work stayed busy, the tremor in my hand remained, although it didn’t get any worse, book sales continued unabated and the world looked like it was on its way to becoming a better place. Economic news was all positive, accords were reached between NATO and Russia which promised to make the world a safer place. A new antibiotic was approved which was effective against a large number of resistant bacteria and advances were announced in genetics which promised new weapons in the battle against many cancers. The world was a better place.
I was a wreck.
Sleep, for the most part, eluded me. I started taking sleeping pills on my weekends off. They did put me to sleep, but at the price of a hangover which usually lingered for hours. And, the nightmarish images still haunted me, day and night. Surgery became more of a chore rather than the pleasure and refuge it used to be.
There was one bright spot, although too brief. Lori returned from her mother’s. She was sitting in my living room waiting for me about four weeks after my momentous Whipple.
“You,” I exclaimed as I wrapped my arms around her, “are a site for sore eyes.”
I gave her a very long kiss.
“Your mother is better?” I asked.
“Amazingly. She is out of bed, walking, eating and in Rehab. I didn’t think she was going to survive. She is, after all, eighty five, bad heart, arthritis, but there is something inside of her which keeps her going.”
Another gift of gratitude?
I shook my head.
“Everything OK?” she wondered out loud.
I kissed her again.
 “It is now.”
I gave her another long, deep kiss, then another and another.
“I’m starving,” she said, as she pulled away, “for dinner. Bed can wait a bit.”
“Alright, fair maiden. What will it be? Pizza? Sushi? Something quick would be better.”
We sent out for pizza and then fell into each other’s arms. That night, for the first time in weeks I slept peacefully; seven uninterrupted hours. The only dream I had was filled with puppies, butterflies and sunlight. I even looked forward to going to surgery the next day. I thought it was a good omen as I faced the day, the schedule filled with six cases and I was on call for the ER.
The first three surgeries went by without a hitch: two inguinal hernias and a big lipoma on the back. As I finished dictating on the lipoma my phone went off.
“This is Dr. Jonas in the ER. We’ve got a Level I trauma, pedestrian struck by auto.”
“I’ll be right over. I’m just down the hall.”
The trauma room was at the far end of the ER and it was filled with yellow gowned nurses, technician, and the ER physician, Dr. Pete Jonas.
“What happened?” I asked.
“Pedestrian struck by a pickup truck. The truck drove away.”  Looks like a fractured pelvis, broken ribs on the right; C-spine and head are OK. I’m waiting on the Abdomen CT.”
“She stable?”
“Last BP was 90/65, heart rate is 110. She’s awake. I bet she’ll have something in her belly.”
We went into the trauma room together.
What? Lori?
Even through the blood stains and C-collar I recognized my Lori. I ran to her side.
“Lori, can you hear me?”
She gave me a weak smile.
“Doctor…you’ll take good care of me and we’ll be back together,” she whispered.
At first I couldn’t say anything, I held her hand and she gave me a squeeze back. Then I spoke softly into her ear.
“I promise…promise to do everything.”
“BP is 70/40,” a nurse shouted.
“Do we have blood ready or at least O negative?”
“Here it is.”
“Pump it in, call the OR and make sure they have a room,” I commanded, going into full trauma mode.
“CT says she’s got a lot of blood in her belly,” Dr. Jonas reported.
“OR is ready.”
“Let’s go. Make sure we’ve got more blood available.”
Two nurses and two techs accompanied me as we rolled down the hall and into OR five where the crew was waiting. While Lori was moved to the OR table I washed my hands, ready to start as soon as she was asleep.
Get in, pack everything, stop the bleeding, make sure there aren’t any holes in the bowel and get out. Quick and easy.
I stood gowned and gloved as Lori was prepped. I looked up at the ceiling and closed my eyes trying to picture what I would find inside her abdomen.
With the last swipe of the prep I moved to her right side.
“Let’s go,” I commanded.
A stem to stern incision and some rapid work with the Bovie brought me into her abdomen where I was greeted by blood.
“Laps,” I barked and proceeding to pack every corner of her belly while suctioning and pulling out blood and clots.
Do it right. Start in one corner and work around. She’s stable at the moment.
And she was relatively stable. BP was 110/50, heart rate was 100. So I gingerly pulled the lap pads from the left upper quadrant. The spleen was intact, no hematoma, the stomach was OK. Next the left lower abdomen, also pristine as was the right lower quadrant. The small bowel had only a small mesenteric hematoma.
Looks like the money is on the liver.
I pulled the packs from around the liver and saw a small laceration which was not bleeding. The final lap pads were below the liver. As I lifted these dark blood began to well up.
I couldn’t tell where the blood was coming from.
Maybe behind the duodenum? Vena Cava? Time for some fancy footwork.
I repacked the area and then cut along the lateral right colon and in ten seconds had reflected the right colon to the left, followed by the duodenum. Blood was welling up from the area of the right kidney and Inferior Vena Cava.
I need to work fast.
I exposed the vena cava below the kidney and compressed it with a sponge stick.
“Hold this and try not to move,” I instructed my assistant with my “serious” voice.
The bleeding slowed a little. Next I tried to expose the vena cava below the liver. I divided the attachments to the duodenum and began to “Kocherize” it, lifting the duodenum off the cava. Blood poured out even more. I took another sponge stick and pressed it above the area of bleeding.
“Pressure is 40,” the anesthesiologist called out.
I noticed my hand starting to shake.
Not now.
I reached up to below the diaphragm and felt for the aorta. Once I felt its now weak pulse I squeezed it closed beneath my thumb and first finger.
Good thing you’ve got healthy arteries, Lori.
“Pressures better, 70…90,” the voice at the head of the table reported.
“I’m running out of hands. Can you get me another body?” I requested loudly.
“I’ll try,” the circulator answered.
There I was. One hand clamping down on Lori’s aorta, sponge sticks compressing the vena cava above and below the right kidney which was still bleeding, although less than before.
And my hand was starting to cramp.
“I’m here,” Anson, one of the surgical techs declared.
“Good, I need some more hands,” I answered.
As soon as he scrubbed in I put his hand where mine had been and told him to squeeze, keeping the aorta compressed while I went to work to stop the bleeding. I shook my hand a few times to get rid of the cramping and then I started exposing the vena cava and right renal vein. I noticed the slight shaking of my hand as I dissected.
I rested my hand on the patient trying to steady it, which helped a little. As I approached the site of bleeding the tremor increased.
“Are you OK?” Anson asked.
“It’s just because my hand was cramping while I was compressing the aorta. I should be OK in a minute.”
I kept working and finally found the hole which was right at the junction of the renal vein and IVC. The renal vein had torn and blood was still leaking.
“I need a vascular clamp, actually I need three vascular clamps, two Satinsky’s and a straight one.”
Finally, the injury was isolated and ready to be repaired.
“5-0 Prolene,” I requested.
The hole was about 8 mm. As I started to sew my hand began to shake again. I stopped and steadied my hand, then started again. Once again my hand began to shake so badly that each suture tore out of the vein before it could be pulled through. I backed away from the table, took a deep breath, looked up a that ceiling as if I was appealing for some divine intervention, took another deep breath and went back to work.
The needle driver felt solid in my hand which was steady as a rock. The needle sat properly perched between its jaws and the area of injury was perfectly exposed.
It doesn’t get much easier than this. Just do it. It’s Lori. She’s depending on you.
As the needle moved closer to the vein the violent tremor began anew.
“Nurse, could you call Dr. Ponce, please. Ask him if he can come and help me out,” I requested quietly.
Lori is depending on me.
The silence in the OR was almost deafening. I could almost hear my OR crew’s thoughts.
“He froze.”
“He shouldn’t be operating.”
“This patient may die because of Him.
“…because of his incompetence.”
Dr. William Ponce arrived.
“Bill, sorry to have to call you but I’ve got some sort of problem with my hand. Could you scrub in and help me?”
“Sure, no problem.”
“There’s a hole at the junction of the right renal vein and IVC. Just needs a few stitches.”
He turned and went out to scrub his hands and was gowned in gloved in two minutes. I backed away, allowing him room to do the repair.
They’re all laughing at me, I know it. He’s over the hill, that’s what they’re thinking, can’t cut it anymore. That’s what they’re all thinking.
The sound of laughter; I’m sure it was real laughter, loud and derisive filled my ears. I couldn’t take it. I ripped off my gown and gloves, covered my ears and walked out as fast as I could, leaving a shocked Dr. Ponce and OR crew behind.
I didn’t stop walking until I’d reached Jeena’s Pub across from the hospital. I took a seat at the bar, bloody scrubs and all, and ordered a single blend Scotch on the rocks. I drained it in one gulp and ordered another. I turned around and looked around the bar and I saw him.
He was seated at a booth, Ms. Vargus at his side. He looked robust and healthy, dressed in a dark gray business suit. They were meeting with Allen Fender, a well known business man who was also on City Council.
I guess I used to be a pretty good surgeon. Mr. Satan looks like he’s made a complete recovery.
As I glanced in their direction my eyes met Satan’s. He gave a short smile and then went back to his meeting, I left a twenty on the bar and walked out.
As soon as I hit the street my phone chimed. A message from the hospital CEO followed by the Medical Staff President. I kept on walking to my car and drove home.
Repercussions would have to wait.
My career was over.