LUQectomy

                      

Kerry was only twenty eight years old. He showed up in the ER one night complaining of upper abdominal pain which started suddenly that day. The Emergency physician did the usual workup and found two things which led to an urgent call: a large intrabdominal mass and free intraperitoneal air.

The large mass was not necessarily an emergency, but “free air”, that is, air outside its usual place inside the bowel, almost always represents a surgical emergency; a perforation somewhere along the long snaking tube sometimes referred to as the “alimentary canal.”

It was about midnight and I jumped, well more likely slowly crawled, out of bed and made my way to the hospital.

Kerry had wispy brown hair which was coupled with a receding hairline. He made his living playing the guitar. He told me gigs came and went, but he managed to scrape by. He reported vague discomfort for about three months and weight loss of almost thirty pounds. He said he was able to eat, but often didn’t feel hungry.

He was thin, almost cachectic, with pale skin and his face betrayed a fear that I could tell was permeating his body and soul. The most significant finding on exam was diffuse abdominal tenderness with signs of peritonitis, just what one would expect from a perforated hollow viscus.

His abdominal CT scan demonstrated a large mass in the left upper quadrant of the abdomen, in the area of the left transverse colon, stomach, pancreas, spleen, left adrenal gland and left kidney. There was obvious free air and fluid.

No choice, he needs to go to surgery.

I explained the findings and the proposed surgery to him, wrote orders, called the OR crew and then went to the physicians lounge to wait. The usual hour spent waiting for the team is something I’ve learned to avoid these days. But, back in the old days, twenty years ago, I always came to see the patient first before deciding if emergency surgery was necessary, be it a simple case of acute appendicitis or a perforated colon with septic shock. This always afforded me an hour or so to meditate on the upcoming procedure or, more often, watch remnants of whatever old B movie happened to be on late night television.

Before starting Kerry’s surgery I spent the time considering what I was going to find inside of him. Free air suggested that the primary pathology was in the either the colon or the stomach. The CT Scan suggested I be prepared to remove parts of the colon, stomach, pancreas and spleen, a Left Upper Quadrantectomy, as I’d called it in the past. I was sure he had a cancer of some sort, unusual and sad in someone so young. The tenants of cancer surgery dictate that it is best to remove the offending tumor en bloc, which means removing it all in one piece, preferably with a margin of normal tissue, something which is often not possible.

After my hour of contemplation, the nurse, tech and Anesthesiologist were ready, Kerry was wheeled into the room and moved himself over to the OR table. I couldn’t help but notice the look in his eyes as he scooted from stretcher to OR table. It reminded me of looks I’d seen in movies; seen on the faces of actors who are made to walk up steps to the gallows or to the front of a firing squad; a look of impending doom. I gave him what I hoped was a reassuring smile as he positioned himself in the middle of the narrow table. He did his best to remain still as EKG leads, pneumatic compression stockings and pulse oximeter were placed on the appropriate parts of his body.

The steady, almost monotone voice of the anesthesiologist began:

“…take a deep breath, you may feel some burning in your arm, you’ll be asleep before…”

And Kerry was out.

Prep and drape, throw off the Bovie and suction and we’re off.

I made a generous midline incision and soon entered his abdomen, neatly, exactly through the center, to be greeted by a big ugly tumor. There was some thin serous fluid and inflammation around the tumor which was in closest proximity to the left side of transverse colon. I could see the hole where the tumor had perforated into the omentum and observed only a small amount of fecal contamination.

Good.

I gingerly moved the tumor, back and forth, up and down. It was mobile. I’ve done cases in the past where moving the tumor back and forth caused the whole patient to move, suggesting fixation of the tumor to vital retroperitoneal structures, which means it is almost surely unresectable and probably incurable. Finally, it’s time to dive in and commit. First the colon.

I start on the left side, dividing the left colon’s attachments up to its sharply angled turn at the splenic flexure, as well as dissecting the omentum free. Then from the right. Here I start at the colon’s beginning, the cecum. The appendix was stuck down in the pelvis. I free it up and notice it looks a little inflamed.

Appendicitis on top of everything else.

All along the right side of the abdomen I work, freeing the right colon up to the hepatic flexure and the proximal transverse colon, grateful that it easily lifts off the duodenum, that the tumor does not involve this part of the bowel.

 No emergency Whipple tonight.

The right side of the omentum also is liberated, to be removed with the tumor. (Years ago I read an operative note where the surgeon described “liberating the splenic flexure of the colon.” I immediately had a mental image of colons running free shouting ‘I’m free, I’m free.’ But I digress.)

Now I’m starting to surround the tumor. The back wall and greater curvature of the stomach are adherent, but this is limited to only the most inferior portion. The vessels feeding this portion of the stomach are identified and divided, the stomach is divided with a large stapler and the uninvolved portion of the stomach retracted away and out of sight.

One organ out of my way. What’s next?

The colon needs to go now. His right colon is pretty short. If I resect only the transverse colon I’m not sure about the blood supply to the remaining segment on the right. I decide to remove the complete right and transverse colon all the way to the proximal descending colon. This will allow for an anastamosis between the small bowel and descending colon, which should heal without problem, rather than a colon to colon connection in unprepped bowel. It’s time for more staplers. GIA across the terminal ileum (last part of small bowel before the colon starts), again across the descending colon just beyond the splenic flexure.

I’m really zeroing in on this nasty beast now.

Next I see that the tumor may involve the distal pancreas.

Maybe I can separate the two structures? No luck. The pancreas and the spleen will need to go.

This actually doesn’t take very long. Kerry is very thin and the border of the pancreas is easy to see, as are the splenic artery and vein. Dissection is carried along the inferior border of the pancreas and an area is identified at the neck of the pancreas, uninvolved by tumor. The large splenic artery and vein are dissected free, clamped and divided and ligated. The neck of the pancreas is divided using the GIA stapler and the pancreatic duct is also separately sutured. Finally, the vessels remaining which enter the spleen are divided and the specimen is removed as one giant mass of tissue made up of the omentum, right and transverse colon, greater curvature of stomach, tail of the pancreas and spleen. I have performed the operation I have dubbed “Left Upper Quadrantectomy.” This is only a partial LUQectomy, as I was able to leave the left kidney and adrenal gland behind.

After removing this massive tumor I’m left with the task of putting everything back together. In this case this means only a single anastamosis, small bowel to colon. I do leave a drain, just in case and finish the entire procedure in just under two hours. Kerry is safely deposited in the Recovery room and I manage to get home by about 4:30 am to grab a couple of hours rest before the new day starts.

Kerry had an uneventful post operative course, out of the hospital in eight days. His tumor was adenocarcinoma of the colon, which is the most common type of colon cancer, but still unusual in someone so young. The size and presence of perforation put the cancer at a later stage. He was treated with chemotherapy and I wish I could report that he responded well and lived many years, but this was not the case. Even the best operation sometimes cannot overcome a cancer’s inherent biology. Kerry’s cancer recurred and he passed away eighteen months after his emergency operation. Still, he was remarkably pain free during this time and was able to play his guitar up to the end.

The LUQectomy is an operation I do about once a year, most times planned, but sometimes emergent.

Mary was a case similar to Kerry, only her tumor arose from the pancreas and presented with bleeding and perforation. She also had middle of the night, emergency surgery, the night cap to a day that included eight other scheduled and emergency cases.

I’ve attacked the left upper quadrant for tumors arising from stomach, colon, pancreas, adrenal gland and retroperitoneum. The pathology may vary, but the approach is almost always the same. Find a plane free of cancer and isolate the tumor; try to get a margin of normal tissue. Always be aware of what can be safely removed and what needs to stay behind. Know where the major blood vessels are and treat them with the proper respect.

It is truly amazing how much can be removed with little or no subsequent physiologic impairment. Large portions of the pancreas can be removed, yet the patient never develops diabetes or malabsorption. All of the stomach could be removed and rebuilt with small bowel. But the patient continues to eat, although some weight would probably be lost. Portions of the colon are removed frequently for a variety of reasons, but very well tolerated. The body has two kidneys and two adrenal glands and can easily compensate for loss of one. The spleen is removed routinely for trauma or disease, yet is often barely missed.

Thus the remarkable, incredible resiliency of the human body is demonstrated. Despite invasion by cancer and serving as a battlefield for the surgeon’s war against this malignant enemy, despite the removal of large parts of vital organs, we are able to persevere. Truly amazing.

Beam Me Up Night Clinic

                   

“Of course you’re working tonight,” Miss James stated. “Wherever there are bizarre events, that’s where Dr. Barnes will be.”

“I don’t know what you mean, Nurse. It’s been five weeks since my last shift here; are you telling me it’s been nothing but chest pain, abdominal pain and PIA?”

“Let’s just say that I haven’t seen a dragon in weeks.”

Can I help if all the crazies come out when I’m working. It’s not like I carry them with me.”

“Speaking of bizarre and crazy, you are aware that the Intergalactic Convention is in town again. Star Trek, Star Wars and every other outer space franchise all together. So I’m sure we’ll get our share of phaser burns, blaster bruises and transporter malfunctions. Oh, and to get us off on the right foot, Derek is back with his annual ‘Trouble with Tribbles.’ I’ve left all the usual instruments in the room for you.”

“Not again,” I moaned. “You would think that after four, no five years, he would learn.”

I picked up the chart and gave it a careless glance. Before I saw the words I knew the problem. I walked into the exam and saw Derek, a regular visitor, lying on his side on the exam table. Seated on a sterile tray were a rigid sigmoidoscope and a tenaculum.

“Derek, we’ve got to stop meeting like this,” I scolded. “And think of the poor Tribbles. They’re supposed to be comforting, I know, but you’re just supposed to hold them.”

“I do hold them, Dr. Barnes; for a little while. But, the way they coo and vibrate and shake. The possibilities are endless.”

“I hope it’s as simple as last year,” I remarked.

I put on a glove and lubed up my index finger and checked up in Derek’s rectum. Sure enough there was a furry object vibrating just inside. Past experience told me not to try to grab it with my hand; it would just slip away. I greased up the scope and passed it into his rectum. Immediately I visualized a furry yellow ball which was shaking and making low Tribble noises. I reached in with the tenaculum and grabbed the object in its mid portion like a pro and pulled scope and tenaculum out with a single, gentle pull. The Tribble, which was a toy available at the convention, popped out.

“Just one this year?” I asked, although I already knew there would be more.

“No, three,” he replied.

I repeated the routine, pulling out one purple and one red Tribble, both larger that the first and still vibrating.

“I’ll dispose of these for you, Derek. And, please, stay away from Tribbles. You know they’re nothing but trouble.

He gave a short grunt as I walked out of the exam room.

“What’s next, Nurse?”

“Intractable vomiting in Room one after imbibing ‘Romulan Ale,’ Darth Vader is in two with a couple of storm troopers.”

“Room one sounds easier,” I commented as I picked up the chart outside the door.

“Kang…unusual name,” I murmured to myself as I opened the door. “Good evening Mr. Kang. I’m Dr. Barnes, what seems to be the problem?”

I was greeted by a dark faced, sweaty man with a goatee, dressed in some sort of outer space uniform, seated on the chair, supporting a basin between his legs. As I approached him he violently vomited into the basin, a dark, violet fluid.

“Curse this Romulan ale,” he sneered. “you think I would have learned by now.”

“When did this vomiting start?” I asked while feeling his pulse. His wrist was wet with perspiration and he felt warm. His heart was beating at about one twenty.

“With the first swig of that vile liquid. I should stick with our own Blood wine. Klingons make by far the most potent drink in the Universe.”

“I’m sure you do Mr. Kang.”

“It’s just Kang.”

“Of course.” I examined his eyes, looked down his throat, listened to his heart and lungs, palpated his abdomen and then wrote him a prescription for Carafate and Phenergan and sent him on his way. He didn’t utter a word of gratitude.

On to Darth Vader.

I picked up the chart on the door. Shortness of breath, hoarseness…no age…no address. I knocked and opened the door to find myself staring at two Storm Troopers aiming what I assumed were fake blasters at me, while Lord Vader sat in the chair, head held high, his right fist clenched tightly. I raised my arms in mock surrender.

“Don’t shoot, I’m only the doctor,” I exclaimed. “Dr. Barnes, Lord Vader. What seems to be the problem?”

I heard the whoosh of jets from his black armored suit and then a raspy, shallow breath.

“I seem to have trouble breathing,” he answered, his voice deep but punctuated with a definite wheeze. “The Force is ebbing away from me.”

“When did you start noticing the problem?” I inquired in my usual doctor tone.

“I’ve been pursuing rebel warriors from one end of the galaxy to the other. The Force had been strong with me, but since I’ve come to this place I’ve suffered.”

“Hmm, it seems your Force has more sense than you; this is not the best part of town. However, I was referring to the breathing difficulty. Can you take that black outfit off so that I can examine you properly?”

“Dr. Barnes, I don’t believe you completely comprehend my situation. My life and very being depend upon this suit. It is designed to maintain the power that flows to me from the Dark side.”

“Dark side, light side, I don’t know how I’m supposed to treat you if I can’t properly examine you.”

“I find your condescending attitude disturbing, Dr. Barnes.”

“Listen, Mr. Vader. I know there’s an ‘Intergalactic Convention’ here in town, but you’re in my clinic now and you came to me for help, so give me a break will you? I’m trying to help you. OK…OK, let me listen to your lungs through your armor.”

I moved closer and pressed my stethoscope tightly against his back. He flinched a little. I was able to detect a definite expiratory wheeze  and even a slight inspiratory wheeze bilaterally. His expiratory phase was markedly prolonged.

“Seems to be an asthma attack, Mr. Vader. A bit of a breathing treatment should fix you right up. Let me find the nurse and she will administer the medication. Where should she put it? It’s designed to be inhaled.”

He fumbled with his black suit and exposed an injection port. I noticed his light saber at his side.

“The medicine can go in here,” he stated.

I left Lord Vader and his Storm Troopers, gave the orders to Miss James and went on to the next room.

Light Saber injury…Mr. Spock. Mixing space themes, this could be interesting.

I knocked on the door and went in holding my hand up in the Vulcan salute. “Live long and prosper, Mr. Spock; I’ve always wanted to say that and really mean it,” I quipped.

 Seated in the room was a dead ringer for Mr. Spock, a deep gash across his lower chest with exposed ribs and charred tissue dotted with greenish black stains, just what one would expect after being slashed with a  light saber. Standing next to the injured party was a companion, Captain Kirk I presumed.

“Mr. Spock had a run in with a tall raspy villain, dressed in black armor. He was slashed with his weapon, some sort of laser sword. Patch him up, doc. We have an appointment in two hours that we cannot miss.” Kirk explained.

“One hour fifty four minutes and eighteen seconds to be precise,” Mr. Spock interjected.

“Commander Spock, I need to get your shirt off so that I can inspect that wound more closely.”

My patient raised one eyebrow, but didn’t move.

“Surely you are aware, Dr. Barnes, that Mr. Spock never takes his shirt off or exposes his arms, except at the time of Ponn Far and that is not due for five more years. I, however, will be delighted to remove my shirt, particularly if your lovely nurse comes back. I’ll take her over Yeoman  Rand any day.”

“I don’t believe that my inspecting your body will do anything for your friend’s injury. Tell me again what happened, Mr. Spock?”

“We, that is, the Enterprise, was attacked by a band of interplanetary fighters. We were in pursuit of a Romulan vessel we suspected of attacking one of our outposts along the neutral zone. Unfortunately, we encountered an energy surge which then drew us into a wormhole, which then deposited us in a completely unknown area of space. We were accosted by a trio of interplanetary fighters when we emerged. We did our best to defend ourselves, but they managed to escape. We pursued him through some sort of portal which deposited the lot of us here, on Earth.”

After finishing his story, Mr. Spock pulled up his shirt just enough for me to get a proper look at his wound. It was about twenty centimeters long, but clean, with dark, dried, green blood along its edges.

These conventioneers go all out, I thought, green blood and everything.  I pulled out my stethoscope and listened to his lungs, which were clear, and his heart, but the heart sounds were barely audible.

“If you are trying to auscultate my heart you would do better to listen here,” he informed while pointing to an area in the right upper abdomen.

“Oh, yes,” I replied, nonchalantly, “I guess I forgot my Vulcan anatomy. I think I missed that lecture in medical school.”

I listened to the area he had pointed to and heard his heart, clear and loud, chugging along at a rate of one hundred thirty.

“Seems a little tachycardic,” I observed.

“It’s actually a bit slow for a Vulcan.”

“And just how did you get this injury, Commander Spock? A phaser blast?”

“I believe the weapon is called a light saber. We pursued the fighters to a venue not far from here. I confronted their leader, a tall being, more machine than creature according to my tricorder…”

His voice suddenly trailed off; I turned to see Captain Kirk gesturing, signaling for Mr. Spock to remain quiet.

“Light Saber certainly fits with the injury. I’ll clean it up as best I can, but you probably should see a surgeon soon.”

“That should be in one hour thirty nine minutes and four seconds, although, Dr. Barnes, your skills seem far superior to our ship’s surgeon.”

“Thank you, but, quoting Dr. McCoy, I’m just an old country doctor.”

Mr. Spock raised one eyebrow, but did not respond. After dressing his wound I turned and saw Captain Kirk with his shirt off. He had a coy look on his face.

“Dr. Barnes,” he inquired, “do you think you could convince that nurse to come give me a shot? Maybe, right in the cheek, if you get my drift?”

I gave him a long stare and handed him his shirt.

“She prefers the quiet intellectual type, Captain, sorry.”

“It’s in my contract, you know,” he informed me with a slight leer on his face, “paragraph twelve, section three states that I will remove my shirt at least every other episode and that sixty per cent of the time I get the girl.”

“This isn’t Star Fleet and Miss James is never anything but professional and never fraternizes with her patients, Captain. So, you may put your shirt on while I attend to Mr. Spock.”

I checked my tray of instruments, poured some antiseptic in one of the cups and filled the other with Lidocaine.

“I’m not sure if I’ll be able to close this up, Commander,” I stated as I began to cleanse the wound.

“I am sure that your efforts will be far superior to the norm, Dr. Barnes, Spock replied.

“I don’t know, I’m in Internal Medicine, not surgery.”

I started to inject some local but my hand was stopped by the strong grip of my patient.

“Not necessary, Dr. Barnes.”

I could see him gritting his teeth, however. But, I carried on, lightly trimming away dead tissue and then doing my best to close the gaping wound.

“Where is Captain Surgery when you need him,” I muttered to myself.

“Did you say something, Dr. Barnes?” Spock asked.

“Oh…no, there we go, all done.”

I pushed my stool away and stood up, admiring my handiwork. The stitches were even and symmetric, the wound closed in a neat straight line.

At that moment the door to the exam room burst open and my other patient, Lord Vader, entered, accompanied by his Storm Trooper sidekicks. I was sure I heard his Star Wars theme song as he raised his light saber. Spock and Kirk jumped back, simultaneously drawing their phasers. The storm troopers crouched at Vader’s side, blasters ready. I stood in the middle of this gunfight.

“Now can’t you…”, but before I could finish a beam shot out from Captain Kirk’s phaser, not more than two inches from my nose. Darth Vader smoothly fired up his light saber and deflected the beam into the wall where it left a gaping hole with smoking blackened edges. Prudency won out over foolish bravery as I dove under the exam table, just managing to dodge a shot from a Storm Trooper blaster.

At this moment Miss James opened the door and stuck her head in to check out the ruckus. Phaser beams and energy blasts shot back and forth while Vader’s skillfully deflected beams from side to side. Pock marks of smoke and flame dotted the walls as the battle progressed, but neither side suffered any casualties. It was just after Miss James entered, before she knew what was happening, that I heard a scream and glanced up to see Miss James pouring blood out from a gaping wound where her right arm used to be. The arm, meanwhile, lay on the floor, fingers still twitching.

Despite phasers and light sabers and blasters I jumped up and yelled as loud as I could, “LOOK AT WHAT YOU’VE DONE, YOU MONSTERS, AFTER ALL WE DID FOR YOU. STOP THIS INSTANT.”

They all looked startled as I jumped to Miss James and bent down and scooped up her arm.

“You should all be ashamed of yourselves. What are you fighting about, anyway? Good versus evil? To tell you the truth I don’t see a difference.”

Vader looked at me as his light saber retracted. “The Force is strong in you, Dr. Barnes. You don’t realize the power you could wield if you would give yourself over to It.”

“To be like you? A shell of a man existing inside a black suit of armor, pretending to be big and powerful? I don’t think so.” I looked at Kirk and Spock. “And you two, can you make this right? Undo the damage you’ve done? You zoom from here to there, playing god, yet never taking any of the responsibility that a God must assume. Star Fleet, my ass. Your wonderful Star Fleet is no better than Vader’s Empire. You speak about “the Prime Directive” yet break it on every episode. Why don’t you all just leave, go back to your own place and time.”

At that moment I heard a familiar whine, the sound of people materializing from a transporter. I recognized Dr. McCoy and Mr. Scott, along with some red shirted security officers (who I’m sure were destined to die sooner or later.)

“Better late than never, Mr. Scott,” Kirk remarked.

I turned away from the Enterprise crew, only to see that Darth Vader and his Storm Troopers were gone. I looked plaintively at Dr. McCoy.

“Doctor McCoy, Bones, do you think you can help Miss James?” I pleaded. I was cradling her head in my lap as she lapsed into unconsciousness, on the verge of shock.

McCoy looked at the severed arm and the wound at the end of her arm, which was no longer bleeding. “I’m just an old country doctor and I can’t perform miracles,” he said, “but, we need to get her to the ship if there is to be any chance.

“Right,” I answered. “just let me close the Clinic and we can be off.”

I saw Kirk looking at Spock and McCoy, shaking his head. Anger and frustration welled up inside me.

“I know what you’re thinking,” I stated, trying to remain calm. “Don’t get involved, don’t do anything to upset the status quo of what has happened or is supposed to happen. Well, your coming here may have already done that. Meanwhile, Miss James is in dire straits, she may be dying. Are you going to let that happen? Could you live with yourselves? Therefore, unless you can show me some compelling evidence which can convince me that nothing should be done and we should let Miss James suffer, you must do something to help.”

At that moment Kirk’s communicator chimed. “Let the fighters go, Mr. Sulu. We have another problem. Transporter room, we have six to beam up and have a medical team standing by.”

I felt a bit of trepidation at the thought of my molecules being disassembled and then reassembled. After all it was just a television show; one that was cancelled after three seasons. But, the familiar whine started and I was soon standing in the Enterprise transporter, still supporting Miss James. Her severed arm was in a plastic garbage bag, which was inside a second bag filled with ice. The medical crew loaded her and her arm onto a waiting stretcher and she was whisked off to sick bay, myself and Dr. McCoy at her side.

“It will be an honor and a true learning experience to watch you in action, Doctor,” I said to “Bones.”

He had a grave, almost worried look on his face and his hand was shaking.

“You have done this before, Doctor? I mean, I did see you restore Spock’s brain and patch up a badly injured Horta. Surely, reimplanting an arm is a common procedure in the twenty third century.”

He just looked at me blankly.

Miss James was placed on the table and her arm placed on a second table.

“Prepare the patient, Nurse Chapel,” Dr. McCoy ordered. The look of worry returned and his hand was shaking even more. I became more concerned. I’d seen the same expression on the faces of newly minted doctors on their first day of internship, but never on a veteran, seasoned surgeon. I took McCoy aside.

“Are you OK, Doctor McCoy?” I inquired, doing my best to keep the alarm out of my voice.

“It’s just that there are so many structures, arteries, nerves, muscle and it’s been so long. I’m just an old country doctor. That’s all I ever really was supposed to be, not a super ship’s surgeon. We’re not meant to flit about the galaxy. It’s not right; I’m just an old country…”

I cut him off, realizing he would never be able to perform such an operation, or any operation, for that matter. I was about to tell the Captain to return us to Earth when I heard a voice.

“Use the Force, Dr. Barnes. You are a doctor, you can do the surgery. The Force will be with you.”

“Obiwan Kenobi?”

“The Force is strong in you Dr. Barnes. Prepare for the surgery and let the Force guide your hand.”

More and more bizarre.

OK, here goes nothing. I stepped up to the OR table and looked at the stump of Miss James severed arm and the detached arm. I put on the operating visor which should have been on Dr. McCoy and, suddenly, the operative field became clear. The computer within the visor neatly illuminated each structure: brachial artery, humerus, basilic vein, biceps muscle, and every other structure became neatly color coded and labeled.

At least the anatomy won’t be difficult, but how am I to put each little vessel and fiber back together.

“Let your mind go, free yourself and rely on the Force,” Obiwan suggested.

Well I was no surgeon, that’s for sure. I’d only had a twelve week clerkship and I’d spent most of that time trying to pick up nurses in the ER.

I turned off the operating visor and put on a blinder. I thought about better times with Miss James and tried to think about nothing at all; trying to remember what Luke Skywalker had done when he blew up the first Death Star.

“Give yourself over to the Dark Side, young doctor. You don’t know the power you can wield.”

“GET OUT, GET OUT,” I shouted in my head, trying to remove Vader from my thoughts.

Miss James, Miss James filled my head, the image of her loveliness and all the time we’d worked together.

I sensed my hands dancing across the table, working rapidly, sewing sealing, cleaning, injecting. Vessel sealant here, neural stimulation there, osteoblastic compound, more sealant, dermal regenerator, all sorts of twenty third century medical instruments and therapies I had never thought could ever exist were employed as the Force and I worked wonders. I was oblivious to everything else until I announced:

“Finished.”

Miss James sat up and clenched her hand into a fist.

“Remarkable”, “Wonderful”, “Amazing”, were some of the accolades that were shouted from the many observers. I gave Miss James a hug and then sat down, finally realizing I was exhausted from the ordeal.

“I think it’s time to send the two of you back,” Captain Kirk announced. “But, before you go, there is one more thing to be done. Mr. Spock…”

How could I go back? Knowing what I knew. How could I ever go back to the knives and sutures of twenty first century medicine?

It was then that Mr. Spock approached me and Miss James.

“I shall be forever grateful to you Dr. Barnes, for repairing my injury in such a skillful manner and for teaching me, teaching all of us, about what is truly important.”

And he put his hands on myself and Miss James and I heard him mutter, “Forget, forget.”

We found ourselves back in the clinic. It was 6:45, just about quitting time. Miss James acted like nothing had happened. I however, did remember. I looked at her arm. It looked perfectly normal. I checked out the exam room, every charred, burned out hole in the wall had been repaired. It was as if nothing had happened. And maybe it hadn’t. No one would ever believe such a story.

I turned to Miss James.

“Breakfast?” I asked.

  .

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.

Painting

                  

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.

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.