Night Clinic Artist

               

“I’m here again, ready for another adventure into Never Never Land,” I announced as I blasted through the door which led to the clinic work station.

“You have some nerve showing up here,” Miss James remarked. “I waited for two hours outside the concert hall. It’s too bad, you missed a great show.” There was a touch of venom in her voice.

“Didn’t you get my message? I’m sure I sent one. Dr. Mercal sent over a sick lady from his office. It was too much for the intern to handle. So I was stuck.”

“No, I didn’t get any message. And then I expected you to at least show up at my apartment afterwards.”

“I didn’t finish with that patient until two am. She turned out to have Legionella and a perforated ulcer. Couldn’t find the surgery attending for two hours. It was Bastrock, of course, probably off with one of his floozies. I wouldn’t mind so much if he was a better surgeon, but his patients always have problems. I wish they would take him off the call roster. I’m sorry. Love. I’ll make it up to you, I promise.”

“And, one more thing. Have you made a decision yet? My lease is up in six weeks, you know. They’re pestering me to renew.”

“You know I wouldn’t stay in that apartment any longer, no matter what. It’s too small and drafty and all the appliances are pretty much on their last legs.”

“True, true, but the price sure is right. Anyway, it’s time to get to work. Caleb, the artist is in two, severe headache.”

“Caleb the artist? Should I know him?”

“Probably not personally, although you probably know his work. He’s a street artist around here; he’s done murals and such on the sides of most of the buildings. I think he’s quite talented. He did this sketch for me while he was waiting.”

Miss James held up a drawing in pencil of  our clinic, the light over the door, the neon word “Clinic” in the window along with the red cross symbol for hospital. Our storefront clinic stood out from the buildings around the neighborhood. Even in that sketch there was something that shouted “Come here and be made whole.” I looked forward to meeting this Caleb.

I knocked on the door and went into exam room two and announced my presence in the usual way.

“Good evening, Mr….” I glanced at his chart. The only name was Caleb, no address, no phone number, just a single name.

I stumbled a bit, “Uh, Caleb, I’m Dr. Barnes. What brought you in here today?”

He didn’t reply immediately. The room was darker than usual. The only light was from the X-ray box, which provided a soft illumination. Caleb was facing the far wall, his arm dancing back and forth. I noticed a long pony tail, leather jacket and blue jeans. He ignored me and kept on working, creating a mural on our blank exam room wall. After about a minute he turned around.

“Hello, Dr. Barnes. I’m Caleb. I hope you can help me.”

“I will certainly do my best,” I responded, doing my best to put some concern in my voice, while trying to get a glimpse at the newly created art work which now adorned are previously sparse exam room. Caleb wore dark glasses and a white bandana around his head. He put out his hand which I took, receiving a strong handshake. I glanced down at his fingers which were long and smooth.

“What is the problem you are having?” I asked.

“I’ve had this headache for about two weeks. I assumed it was nothing, but it hasn’t gone away.”

“Where do you feel it most?”

“Right in front, like someone is boring into my brain. The light makes it worse.”

“Have you tried taking anything? Tylenol, Motrin?”

“I’ve taken some expired Ibuprofen which helps a little bit, maybe for about an hour, but then it comes back. It seems better in the mornings when I first get up, but by afternoon I can barely move, it’s so bad sometimes.”

“Any other medical problems? Heart, kidney, abdominal pain, nausea, vomiting, fever, weight loss?”

“No.”

“Take any medications, any allergies, rash, blurred vision, or any visual changes?”

“No, except the light bothers me.”

“OK, OK. Let me check you. I need to turn on the light.”

“Go ahead, I’ll be OK.”

“Let me check a few things with the lights off first.”

I took out my flashlight and shined it in his eyes. His pupils reacted briskly.

“I’m no Opthamologist and I haven’t done this since fourth year, but I’ll give it a try. I picked up the opthalmoscope and aimed it towards his eyes. I was greeted by the red reflex and was able to get a clear look at his retina.

Still have the old touch. But, what am I looking for?

I could see blood vessels and the optic nerve, but had no idea if any of it was pathologic.

Where’s the CT Scanner when you need it?

“I’m going to turn the lights on now.”

“OK,” he answered, but there was a sense of apprehension, almost doom as I flicked the switch.

Caleb winced and squinted when the light came on, then put his hands to his temples and rubbed them vigorously as if he was trying to vanquish the demons that were pounding on his head.

“I’ll try to be quick,” I assured him as I auscultated, palpated and inspected form head to toe. Everything was normal. I turned the light off as Miss James stuck her head in the room.

“I need you in three. An elderly man just came in, wheezing, blue lips, doesn’t look too good. I put him on a hundred per cent oxygen.”

“Did you call for an ambulance?”

“Started to, but the man said he wouldn’t go to the hospital.”

“I’ll be back in few minutes, Caleb. Just lay here with the lights off, that’ll probably help.”

I glanced at the chart outside exam room three.

“Heinrich Dietrich, ninety three,” I murmured as I quickly knocked and opened the door.

“Good evening, Mr. Dietrich, I’m Dr. Barnes,” I started with my usual bedside banter.

I was greeted by the raspy sound of labored breathing. Mr. Dietrich was sitting upright, his chest heaving as each breath came with herculean effort. His lips were blue, his eyes sunken deep into their sockets. His skin was a grayish yellow with superficial scratches and healing sores. I understood immediately why he didn’t want to go to the hospital.

“Terminal?” I asked.

He nodded in the affirmative.

“What can I do for you?”

He handed me a piece of paper and gestured for me to read it.

“Chaim Fiesel, 3233 Elm, #11”

“Send for him…Please,” he requested, his voice, with a bit of an accent, a barely audible rasp.

“But, I can’t…”

“PLEASE,” this time almost a command.

I looked at the paper and then at my dying patient.

“OK,” I answered.

I left the room and found Miss James at the nurse’s station.

“Anything else waiting?” I asked, sort of nonchalantly.

“Quiet as a mouse. What’s going on in three?”

“Mr. Deitrich has terminal cancer. He’s dying and he knows it. He asked me to find this man, a Chaim Fiesel. He’s supposed to be in an apartment over on Elm, only about five minutes away. I thought, maybe, one of us could run over and fetch him. You know, grant the dying man his last request.”

“I’ll go,” she replied. “that way if anything bad comes in you can take care of it.”

“I hate to let you go by yourself. It may not be safe.”

“I’ll be OK. I know that apartment building. It has a big, mean, watchdog and is pretty secure. It should only take a few minutes, assuming Mr. Fiesel is there and will come with me.”

She was out the door in thirty seconds and I manned the front desk. A woman came in with her child suffering from an earache. They were quickly examined, diagnosed, treated and out the door. I went back to check on Caleb. He was up on a chair, creating a new masterpiece on the wall. All I could make out in the dim light were shades of black, gray and white.

I heard the door open and saw Miss James and a short, bent, elderly man come in. He was dressed in a dark gray suit, wore thick glasses and had a dark gray moustache. His eyes however, were alive, a vibrant blue. I hurried to meet them.

“Dr. Barnes, this is Mr. Fiesel,” she reported as the man put out his hand. I noticed the fingers were bent and twisted.

“Nice to meet you,” I said, taking his hand in mine, giving him a strong greeting. “Did the lovely Miss James explain the situation?”

“She did, she did,” he answered, his voice marked by an Eastern European accent, not much different from Mr. Dietrich’s. “I do not know this Heinrich Dietrich and I do not know why he would ask for me. Perhaps, you can find out more?”

“I’ll go ask,” I replied. “Maybe he’s a long lost relative and wants to leave you some money. He is dying, you know.”

“Yes, yes, Miss James did tell me that.”

I returned to room three. Mr. Dietrich seemed a bit more comfortable.

“Mr. Fiesel is here, but he is wondering why you asked for him. He says he does not know you.”

“It’s true, he does not, but in a way he does. Tell him I must see him. I must tell him I’m sorry.”

“Sorry? Sorry for what,” I had to ask. “I ask you because I know that he will ask me.”

“Sorry for what I did, to him, to his people, during the war at Dachau.”

Now it was clear to me. Mr. Dietrich, with his clearly German accent. Mr. Fiesel, a Jew, also German, perhaps a survivor of one of the camps, all adding up to a search for peace on one’s deathbed.

“I’ll carry your message to him,” I whispered in Mr. Dietrich’s ear.

I hope Fiesel understands.

I went back to the lobby where Mr. Fiesel was waiting and explained the situation. Fiesel’s face turned red as he heard my report.

“I was in Dachau; my whole family, mother father, two sisters, died at Dachau. He may have been their executioner, for all I know,” his voice was growing louder. “I should hear the confession of a murderer, a man who served in a place that took my whole life from me? No, I will not. I cannot.”

“But surely you can find it within yourself to forgive, to give this man some peace before he goes?” Miss James asked.

But Fiesel said nothing. He sat down and stared at his gnarled hands.

“I was a violinist,” he said softly. “I started playing at the age of two. I was the youngest performer ever with the Munich Symphony. But, they took that from me.” His voice started to rise and tremble. “Look at these hands, look at what they did to my hands. First they smashed my violin into a million splinters, then they smashed my hands.”

And I saw his broken hands, reflections of a broken soul. I left him and returned to the dying Dietrich, but first I saw a light coming from exam one. I had almost forgotten about Caleb. I opened the door and saw him sitting up in the chair. And, I saw his finished mural. It was a scene of horror. A death camp surrounded by barbed wire, emaciated bodies withering away and dying while soldiers brandishing rifles watched, laughed and did nothing. The sky was filled with black clouds which matched the blackness of death in that camp. Except, at the end of the mural there was a bit of yellow, a sliver of sunlight which illuminated a corner of the camp where one soldier was stooping down, giving a red apple to a boy. The boy was like the rest of the prison, wasted, dying, dressed in a ragged striped uniform.

I felt a body brush up against me. I turned, expecting to see Miss James, and was a bit surprised to see Mr. Fiesel. Tears were streaming down his face. He looked up at me and then left me and went into exam room three.

I continued to stare at that mural adorning the room’s previously empty wall. It was a masterpiece of death and hope. The blacks and grays, the ominous clouds, the pall of death which hung over that camp were all overshadowed by the small expression of kindness set off to one side. In the midst of all that despair, one glimmer of hope shined through. I turned to offer my critique to Caleb, but he was gone.

Mr. Fiesel emerged from room three shaking his head, but also smiling.

“You see,” I began to comment, “a bit of forgiveness…”

He held up his hand to stop me. Miss James stood at my side to hear his story.

“You don’t understand, Dr. Barnes, neither of you do. This picture, this vision of death with its small ray of light illuminating a solitary act of human decency is not just an abstract artist’s interpretation. All that death, all those guards and barbed wire is exactly as it was. And, that soldier giving the apple to that little boy is real. That little boy is me. Look at the date on the picture. September 13, 1943. I remember that day, it was my birthday. I turned ten on that day. I was so hungry, I thought I wouldn’t live for another minute if I didn’t get something to eat. One of the guards took pity on me. He was about to eat an apple and must have seen me staring at him. He smiled at me and then got up and came to me. He bent over and gave me that apple and, along with it, gave me the hope and will to survive. You see, I was all alone, my family was gone, murdered by the Nazis; all I could hope for was death, disease and despair. But, he gave me hope and I did survive. I never became the musician I should have been, the Nazi’s made sure of that, but I did come to this country and became an art dealer. This picture reminded me that in the midst of hatred and chaos and evil, human kindness still may exist.”

“Is that why you changed your mind? To pass on this human kindness?” I asked.

“Maybe,” he answered, “but there is even more. Look at the image closely, look at the helmet.”

We bent over and stared at the soldier and saw, clearly on the brim of the helmet the letters HD.

“Heinrich Dietrich, the dead man in your exam room is the soldier in this mural. He gave me his apple and a second chance at life and I had to thank him. You know, Dr. Barnes, he lived only two blocks from me for over thirty years but I never realized it and he could never gather the courage to come to me. He told me now he would walk past my art gallery; he did this hundreds of times. He even found the courage to come inside once. He asked for me, but when I came out he had left. When I saw him today I knew him immediately. He asked my forgiveness. He offered no explanations or rationalizations. He knew what was done, what he had done, how he had helped it all happen and how he had done nothing to stop it. Yet through all that evil, there still existed this one tiny shred of humanity.”

We three stared at the painting for a bit longer.

“Where is the artist?” Fiesel asked. “I would like to meet him and thank him personally.”

“Caleb; he must have left. He lives somewhere in this neighborhood, I’m not sure exactly where. I’m sure you’ve seen his work all around. He has created murals, like this one, all over the city.”

“I have seen them, it is truly remarkable work, a wonderful talent, but, perhaps in need of a little guidance,” Fiesel murmured. “I will have to search for him. After all, I am an art dealer.”

He shook my hand and gave Miss James a light peck on her cheek and went away.

It was coming up on seven when he left, almost the end of our shift.

“What should we do with this mural?” I wondered. “I don’t think it is quite right for a medical clinic.”

“Death, despair and hope?” Miss James said out loud. “Isn’t that what we deal in here?”

“Perhaps…but not in that order,” I observed.

“I’ll tell you what,” she replied. “I’ll call up Fiesel later today and ask him if he wants it for his gallery. I’m sure he can figure out a way to get it from here to there.”

I snapped photo of the mural, just in case it was somehow lost, and then we went back to the nursing station and found a final gift from Caleb.

On the desk was another picture, bright and colorful. It was my apartment. Seated on the couch were two people, myself and Miss James. There was an open door which showed the bedroom and the bathroom, with two towels on the rack and two toothbrushes hanging by the sink. Next to the drawing was a note.

“My headache is gone. Thank you so much, Dr. Barnes.”

Caleb

Miss James and I stared at each other and then, almost simultaneously asked.

“How does he know?”

We didn’t have an answer.

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.

  .