Monday, September 16, 2013

Night Clinic and the Garden

                

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
















Sunday, September 8, 2013

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.

Thursday, September 5, 2013

The Making of a Page Turner

                             

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

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

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

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

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

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

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

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


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

Sunday, August 18, 2013

Night Clinic and the Seven Dwarfs

          

“I’m back,” I announced as I walked through the back door to the clinic. “Did you miss me?”
I hadn’t worked a shift at the Night Clinic for two months. A required  rotation through the ICU had me on call every other night. Miss James turned and walked away, silently.
What did I do to her? Went through my mind as I watched those shapely legs and derriere disappear into the supply room.
She emerged a few seconds later and gave me a big smile.
“Of course I’ve missed you,” she finally answered. “No monsters or superheros or dragons for months.”
“So, you heard about my last little adventure, a bit scary at least for a few moments. Maybe tonight will be different. I say we should have a nice boring shift. Nothing but sick babies, winos, hookers with STD’s, stabbings, gunshots, and drug overdoses for a change.”
“You’re cute,” she remarked, patting my cheek. “Speaking of winos, there’s one waiting for you in Exam three, Alvin, a regular; diabetic, congestive heart failure, obese, drinks about a quart a day. Says he’s short of breath.”
I gave her my best Groucho Marx leer and picked up the chart on the door. Alvin was fifty-five years old, had a list of medications a mile long and usually was seen at the University Clinic. His vital signs were HR 80, BP 210/90, RR 28, O2 sat 88%. I took a deep breath and went in to see him.
“Hello, Mr. Gates, I’m Dr. Barnes,” I introduced myself, smiling and I held out my hand to shake his. He was sitting on the edge of the exam table, staring at the floor. His lips were a slightly blue and he was taking short rapid breaths.
“I’m sorry, Dr. Barnes. I mean for not getting up. I can’t seem to catch my breath.”
“When did you notice you were having difficulty?” Alvin was very large, his weight on the chart was listed as 350 pounds, but I would have guessed he was at least 450. He was dressed in a sleeveless t-shirt and dirty khaki pants, the tops of which were hidden by his massive belly. The t-shirt was drenched in sweat. He had worn out sandals on his feet, one of the straps replaced by some rough twine. The smell of dried sweat and spoiled wine filled the room.
“I never breathe real good, but it was last night. I guess I forgot to take my meds.”
“Forgot for how long?” I asked as I fastened an oxygen mask around his head, which was in addition to the nasal cannula he already sported. The pulse oximeter fell to 84 while he was talking, but rose to 89 with the additional oxygen.
“I guess I missed going to the clinic last week and then I ran out of some of my medicines, but I just took double the dose of some of the others; I figured it would be OK. I guess I was wrong.”
“Can you tell me what you did take?”
“Let’s see. I took four of the big blue ones, no five, and one of the little white pills, three green capsules. I used the big inhaler and the small one two times yesterday and two times today. Took my water pill…”
Alvin’s voice trailed off as he turned a darker shade of blue.
“Alvin…ALVIN,” I shouted as I stood up and shook him.
“Wha…oh sorry Dr. Barnes. Sometimes that narcolepsy catches up with me. Where was I? Oh, yeah, pills.”
“Never mind, Alvin. I think you need to be at the hospital. We’ll call an ambulance.”
I left the room and asked Miss James to call the University ambulance crew. I started an IV on poor Alvin, drew some basic labs and Miss James did an EKG. Alvin’s lungs crackled everywhere and his feet and ankles were giant tree trunks of brownish edema, but, surprisingly, no ulcers.
I gave him 80 of Lasix and waited for the ambulance.
While Miss James sat with him I treated a two year old with an earache, a drug addict with an infected arm, splinted a sprained ankle and broken finger. When the ambulance finally arrived I helped load Alvin onto the stretcher and wished him well as he rolled out the door.
I was looking forward to a few moments of quiet when I heard a loud thud outside the clinic door and a car’s squealing tires as it raced away. Miss James and I investigated the noise and found a young woman, a young and very attractive woman, passed out on our doorstep. Her beauty would have rivaled Helen of Troy with long black hair, soft white skin and bright red lips. She was dressed in a royal blue dress which clung to her every curve and had dark blue boots which came up to her knees. There was a ring on her left hand with a large blue stone which sparkled in the waiting room light.
We managed to get her into Exam room one. All the while she didn’t move, didn’t open her eyes, didn’t even moan. She just lay like a rag doll on my exam table. She had no ID, no purse, no place to hide any money.
“If she’s a working girl, she’s done a good job of hiding her earnings,” I commented.
“Probably robbed, hit over the head and dumped here,” Miss James concluded.
I listened to her heart which was clear and regular, her pulse was strong, lips, fingers, toes all pink, her respirations were regular. Pulse oximeter read 99%.
“She looks quite serene lying there on the table, almost like she’s been enchanted,” Miss James observed.
Her words were prescient as a loud noise, followed by shouting, came from the waiting room. I ran out to see about all the commotion and found seven “little” people at the reception desk, one was banging on the bell and another was pounding his walking stick on the desk.
“May I help you, Mr…” I asked. The dwarf was about three feet tall, with a large red nose and a long gray beard. He was dressed in a black suit and had a gold ring in his left ear.
“Where is she?” he demanded banging his stick on the reception desk. “Where is Crystal Blue?”
“And you are…?”
“Sleazy, if you must know. And behind me are Slutty, Skanky, Busty, Hunky, Tiny and Norman.”
“Seven dwarfs, huh?” I observed. “I would have thought you would have been named Happy, Sneezy, Bashful, Dopey, Grumpy, Sleepy and Doc.”
“We prefer ‘little people’ and those would be silly names for us. But, back to the matter at hand. Where is Crystal Blue? She works for me and I expect her out on that stage in ten minutes.”
Miss James appeared and exclaimed, “You’re from that place over on 14th, the “Enchanted Room.”
“If you please, nurse, it’s the ‘The Enchanted Emporium Club’ a place where men and women can leave all their worries and cares behind,” Sleazy explained. “Now getting back to Crystal…”
“One moment please,” Miss James said and then motioned for me to follow her.
“Legally, we can’t let these little people do anything or even see Crystal Blue, assuming that is her name. Maybe, we should call the police.”
“Perhaps,” I answered, “but no one has broken any laws and our first responsibility is to our comatose patient. The dwarfs will have to wait.”
I went back to the reception desk and spoke to Sleazy.
“Crystal Blue, if that is her name, is sick. She seems to be asleep and won’t wake up. I certainly cannot release her to just anyone and she is in no condition to perform. You and your companions are welcome to wait for her here in the waiting room.”
I left them and went back to attend to my patient. By this time some of the tests were available.
“Let’s see,” I mumbled. “CBC is normal, chemistry normal, pregnancy test negative, UA negative, tox screen negative. Chest X-Ray…whoa, what’s that?”
I stared at the film. The lungs were clear, but the cardiac silhouette was more than unusual. It looked like an apple; not just a vague apple-like appearance. It looked like someone had taken the outline of a perfect apple and pasted it where her heart was supposed to be.
Some new tropical disease? Apple fever? Apple poisoning? Maybe I should begin looking for the evil queen. As these thoughts popped into my head Miss James appeared.
“A new patient has just arrived, Dr. Barnes,” she announced.
“Nothing too serious I hope, Miss James. I’m sort of in a quandary with Miss Blue.”
“I think you are going to want to see her right away. She’s been beaten up pretty badly.”
“OK, OK, I’ll be right there.”
I took a quick look at Crystal Blue before I left. She lay on the table quietly breathing, her chest silently heaving up and down.
I guess she’s OK.
My new patient was in the exam room next door. Miss James was hard at work removing her tight fitting, sequined body suit. There were bruises on her face and arms and as the suit slowly came off there was a bruising and abrasions across her chest, abdomen and pelvis.
“Do we have a name, Miss James.”
“You won’t believe this, but this is the Wicked Queen. At least that’s her stage name. Her real name is Margaret Henson.”
“Don’t tell me. She works at the Enchanted Emporium Club as a dancer.”
I gave her a quick exam. Her vital signs were normal, she was breathing normally and, although groggy, she was able to answer questions.
“Ms. Henson, I’m Dr. Barnes. Can you tell me what happened?”
“Wha..what happened?” she asked as she gradually became more alert. She started to sit up, but winced and then lay back down.
“It looks like you’ve been roughed up pretty badly. What hurts the most?”
“My chest, every time I try to breathe.”
I’d already put oxygen on her and Miss James had an IV running in her left arm.
“Any abdominal pain?” I began taking a more thorough history.
“No, just my chest, on the right side.”
I pulled up her spandex top and saw bruising all across her chest and upper abdomen.
“Do You have any medical problems, take any medicine regularly, any allergies?” I asked.
“No, no and no. I don’t smoke, drink alcohol, or use any type of illicit drugs. My only vice is that I take off my clothes to entertain degenerate men and once in a while leave with one, if he is cute enough and rich enough.”
She finished her speech and then winced as she took a deep breath.
“Well, Ms. Henson. If I were a betting man, I would wager that you have some fractured ribs on the right side. We’ll get a Chest X-ray just to be sure. Can you tell me what happened?”
“I was ambushed. Somebody snuck up behind me and ‘WHAM’ on the back of my head, then ‘Whack’ across my chest. Next thing I know this cute doctor is standing over me poking and prodding and feeling all my unmentionable parts.”
“It’s my job Ms. Henson, figuring out what’s wrong and then trying to fix it. Now if you will sit in this chair, Miss James will wheel you down the hall for an X-ray. In the mean time I will have a little chat with the seven dwarfs.”
Miss James wheeled her away, asking her what it was like to take off her clothes in front of a bunch of strangers. I couldn’t hear the answer as they disappeared in the X-ray suite. I went up to the reception area.
“Sleazy, could you come back here, now,” I commanded.
All seven little people followed him into exam room three.
I turned and addressed Sleazy.
“Miss Henson accuses you of assaulting her. Is she correct in her assessment? Before you say too much, I must inform you that I am obligated to report the incident to the police.”
“Miss Henson, the Wicked Queen, you mean, or the Wicked Witch, as we like to call her, works for me and is never happy. I’m sure she cannot name the name of her assailant as it is obvious from her injuries that she was attacked from behind. I would also like to add that it is almost certain that this Wicked Queen poisoned Crystal Blue and she will most definitely try to bump her off again if she is allowed the opportunity. That witch hates our poor Crystal.”
The other six dwarfs echoed Sleazy’s sentiments.
“Why,” I inquired, “this severe animosity between Ms. Henson and Ms. Blue?”
Sleazy sat down in the lone chair, stroked his gray beard and began his story. His six companions sat on the floor as the story commenced.
“I opened the Enchanted Emporium about two years ago. My original intent was to create a place where the outcasts of society could congregate without feeling self conscious. The seven of us manage the club. We started just with a bar and a bunch of large TV screens and video games, like every other bar and club. It was Norman who hit on the idea of adding the live entertainment. So, we hired a few girls of various size and shape. It wasn’t long before I learned that there are a lot of people willing to take off their clothes for money and a lot of people who will pay to see it. And, this is where we stand out from the crowd, it isn’t just the mainstream ‘beautiful” girl who can find an audience. Fat, thin, tall, short, young, old, every size and shape, male or female has an audience somewhere. Surely, you’ve heard of our geriatric night? No? Well, it always draws them in. but, I’m getting off the track.
“The Wicked Queen started working about eighteen months ago and she was a big hit. She’s beautiful in the traditional sense, all the attributes that make for a successful dancer, big shapely chest, cute butt and she did magic. While she performed she made snakes appear and change into birds, turned cats into dogs and other such tricks. There was the time she made a particularly unruly patron disappear; I don’t think he was ever found.
“Anyway, she ruled the runway for more than a year. Until, Crystal showed up. Crystal Blue, that’s even her real name, came from somewhere in the Midwest. She just got on the bus and ended up here, running away or going somewhere, I don’t know and she has never told us. I think she was lost on the streets for a while and wandered into the Enchanted Emporium one night.
“Even through her ragged clothes I could tell she was a real beauty with an air about her that made her special. I’m not sure if it was her innocence or quiet charm, or what. I do know that I and my fellow managers were captivated from the start. She worked as a barmaid at first, but then asked if she could try her hand at performing. She certainly had the look and she could sing, too.
“She doesn’t have the typical exotic dancer body; only medium boobs, but very shapely tush, t she radiates charm, however, and she has such a sweet voice. She was a big hit from the start. Every time she was out on that stage it was magical. Well, you can imagine the trouble, the jealousy, the envy. I’m not surprised it came to this.”
At this moment Miss James interrupted.
“Here’s the Chest X-ray on the Wicked Queen, Dr. Barnes,” she reported.
“Excuse me fellas, but I need to check this.”
As I suspected, the Queen had fractured ribs four through ten on the right side with maybe a contusion to the lung. There was no pneumothorax or effusion. I went and checked on my two patients before hearing the rest of the story. Crystal Blue continued in her serene and unrelenting sleep, while the Queen was sitting up in the chair and appeared to be fairly comfortable. I informed her of the X-ray results, listened to her chest again, checked her vital signs and abdomen. I asked her to wait a bit longer so that I could evaluate her one more time before she left, but I also hoped I could get some information on what had happened to the comatose Ms. Blue.
I left and returned to hear more of Sleazy’s story.
“Tell him about the mirror,” one of the other dwarfs, Slutty, I think, interjected.
“Don’t tell me she has a magic mirror on the wall, as in ‘Mirror, Mirror on the wall who’s the sleaziest of them all?” I asked.
“No, no, nothing like that, at least I don’t think so. She, does, however, stand in front of the mirror for long periods of time, hours, it seems, primping her hair, talking to herself. It’s a bit bizarre if you ask me. Old Mamba says it’s all just vanity.”
“Who’s Old Mamba?” I just had to ask.
“She’s our cleaning lady, a withered old prune from Haiti. I think she’s about a million years old,” Tiny explained, in a high squeaky voice. “But, she and the Wicked Queen have some sort of thing going on, because they’re always together.”
“Tell me, Sleazy,” I asked, “what happened to your star dancer tonight? Did Crystal Blue suffer some sort of psychotic breakdown leaving her in a catatonic state? Or, did the Wicked Queen trick her into eating a poisoned apple which plunged her into an everlasting sleep only to be awakened by true love’s kiss? Or is it something else?”
Miss James stuck her head in the room at that moment.
“Chest pain in four; an old black lady, looks like it might be bad.”
“On my way, Nurse,” I replied. “We’ll pick this up in a few minutes, lads.” I left the little people and went to attend to my patient. For some reason, Norman followed me.
“That’s Old Mamba,” he cried out and all the other dwarfs suddenly appeared.
“You all need to wait outside,” I said sternly and Miss James ushered them out.
I glanced at the monitor and saws very elevated ST segments  on her EKG with an irregular rhythm with frequent PVC’s and a BP that was 80/50.
“This does not look good, Nurse. Mamba, can you hear me?”
My question was answered by a long groan. Miss James was on the phone calling for an ambulance as I started an IV, put oxygen on Old Mamba and started a Lidocaine infusion along with low dose Dopamine. Her oxygen saturation was around ninety even with O2. Her lungs had crackles from top to bottom.
“Get the crash cart,” I mumbled, but Miss James was ahead of me.
“V fib,” I shouted. I intubated the old woman as Miss James started CPR and warmed up the paddles to shock the dying woman.
Epi, bicarb, bag, shock, compress, repeat, nothing worked. I even brought the dwarfs in to help with chest compressions, but we lost her.
After thirty minutes the ambulance arrived and was sent away. Miss James went through the layers of poor old Mamba’s clothing, which lay in a heap on the floor.
“What’s this?” she muttered as she folded the dress.
Madame Marie’s Incantations and Spells: The Complete Guide to Withcraft and Voodoo by Marie, Voodoo High Priestess
And, what’s this? Miss James pulled out a likeness of Crystal Blue.
“Perhaps it was old Mamba who put a spell on poor Crystal,” Busty remarked.
Miss James was thumbing through the book.
“Dr. Barnes,” she shouted out suddenly. “This particular spell is circled. It’s called the ‘Living Death’.”
“Let me look at that, please,” I requested.
“Voodoo doll…lock of hair…two dead chickens…incantation  and douse with…Miss James did you notice the funny smell in room one?”
“Come to think of it, I did, sort of like cinnamon mixed with fruit.”
“That’s right, cinnamon and apples. It looks like old Mamba cast this spell on poor Miss Blue. I suspect our other patient, the
Queen, may be able to tell us more.
At this moment we all heard a scream from Exam room two. All of us raced into the room and found Norman standing on the exam table with a scalpel held to the throat of the Wicked Queen.
“Admit it,” he screamed with an almost comical high pitched voice, “tell everyone how you cursed poor Crystal Blue. Say it or you’ll be joining Old Mamba.”
Skanky tried to calm his companion. “Now, Norman, I know you have no great love for the Wicked Queen, but are sure about her? I ask because the doctor and nurse found this in Old Mamba’s clothes.”
He held up the voodoo doll and book. Norman only squinted and then held the knife tighter to the Wicked Queen’s throat so that drops of blood started to well up.
Busty stepped in and started to approach Norman.
“Norman, Norman, I know you’re upset about our dear Crystal Blue. She’s always been so sweet and loving. Even if the Queen did cast a spell, do we want to stoop down to her level?”
Busty voice was even higher than Norman’s. She (or was it he) had smooth skin, except for a bit of stubble on the chin and a big chest, but her manner was very masculine.
“Busty used to be Brutus, before all the treatment and surgery,” Slutty whispered to me. Busty kept right on walking towards Norman. Norman started to hold the knife even tighter against the Queen’s throat as blood started to run down her neck. Busty stopped and Norman relaxed for a moment.
“Ow,” Norman squeaked.
Miss James grabbed his arm as she pulled the needle from his buttock and the Wicked Queen broke free from Norman’s hold. Norman slowly slumped to the ground as I ran to examine the Queen’s wounds, then held a wad of sterile gauze against the laceration to stop the bleeding. She broke away from me and delivered a sharp kick to Norman’s side.
I finally reached the point where I just couldn’t take it any more.
I yelled at the top of my lungs, “EVERYONE STOP, JUST STOP, RIGHT NOW.” I let my voice drop a few decibels as Miss James joined me at my side.
“Now, listen, all of you. There will be no more knives or spells or anything. Everyone out to the waiting room and sit. Not you, Ms. Henson, not until I can check your neck more closely to see if you need any stitches. Miss James, would you please call the police and the Coroner for Old Mamba. Thank you.”
The seven dwarfs slowly made their way out to the waiting room. Sleazy started to speak, but I held up my finger gesturing for him to be silent. I examined the Queen’s neck more closely. The cut was superficial and had stopped bleeding. I cleaned it with Betadine, then dried it, steri stripped it closed and applied a new, sterile dressing. I then motioned for her and Miss James to follow me out to the waiting room.
The Queen sat alongside the seven dwarfs, while Miss James stood by me. I stared out at a bizarre scene, the wicked Queen dressed in black Spandex, seven “little” people sporting beards, dressed in outfits ranging from seventies leisure suits to Sleazy’s black suit and red bow tie. I paused for a moment before I spoke. Sleazy tried to speak, but I signaled that he should be silent.
“You have made this one of the more unusual night’s we’ve experienced here art the Clinic,” I began, “and that is quite a trick considering some of the bizarre things that manage to pass through those doors. But, we have had assaults, magical spells and death join us here and it is now time to get to the bottom of this. I will start with you, Ms. Henson. Do you have knowledge regarding the illness which has come upon Crystal Blue?”
At first the Queen just sat there.
“I promise you, Ms. Henson, that if you are truthful your diminutive employers will do you no more harm. Isn’t that so Mr. Sleazy?”
I waited for a reply and then repeated, a bit more forcefully, “I said, isn’t that so Mr. Sleazy?”
“Yeah…” he answered, barely audible.
“What?” I responded.
“Yes, we won’t hurt her anymore,” Sleazy answered, clearly. His six companions nodded in agreement.
“Now, Ms. Henson, what do you know about voodoo and witchcraft, as practiced by the now deceased Old Mamba?”
The Queen looked around and seemed a bit embarrassed, but finally spoke.
“I did mention, one time, to Old Mamba, that I wished Crystal Blue was gone. That I had been the top girl until she showed up. But, that’s all. I never asked her to do anything. Well, maybe she saw me moping about and she would ask me what was wrong and I’d point to something blue or make some sort of gesture. I never thought she would or even could cast such a spell.”
“But, you are always doing magic as part of your act,” Sleazy observed.
“Sure, cheap parlor tricks I learned from an old boyfriend, pull some flowers from a hat or make a bird disappear. You never saw me do anything else, did you?” the Queen asked, her question directed to everyone listening.
There was a general murmuring that actually did agree with her.
“It seems, however, that Old Mamba has managed to cast a true spell, or drug or hypnotize or something to Ms. Blue; there is no question,” I observed. “Living Death. That’s the spell she circled in her voodoo book. Do any of you know anything about it; how to break the spell?”
“In the old story, it was true love’s kiss what worked,” one of the dwarfs, Hunky, I think, remarked.
“Well, that may be as good a place to start as any,” I decided. I, for one, was stumped. Narcan didn’t do anything; allowing time for a drug to metabolize wasn’t accomplishing anything. There was no mark on Crystal that would suggest she was injected with anything. Her liver, renal, and respiratory function were all normal. She just wouldn’t wake up. She did not respond to any neurologic stimulus, no posturing, no localizing of pain, no eye opening, nothing. And she looked peaceful, so peaceful sleeping, just sleeping. We didn’t have a CT Scanner at the clinic, but I had no doubt it would have been normal. I turned back to the dwarfs.
“True love’s kiss is as good a place as any to start,” I announced. Do any of you know if she has a boyfriend of any family?”
“She lives alone,” Norman reported. “And, she’s never mentioned any family. She used to say that our little emporium was her family. I guess it’s kind of sad.”
“Norman, don’t you have a key to her apartment? Didn’t she give you one in case there was some sort of emergency? This certainly qualifies as one,” Sleazy said.
“Yup, got it right here,” and he held up a key ring with about a hundred keys on it.
“What’s with all the keys?” I had to ask.
“Well, let’s see. This one is to my apartment, this one is to the Emporium, this one is to my mom’s house, the front door and this other is to her back door. This one goes to my locker and …”
“Never mind, I get the picture. Now go see what you can find and take someone with you.”
Skanky shot up his hand. “I’ll go.”
“OK, OK, check it out and bring back anything that will give us a clue as to the lovers in her life. Oh and before you leave, why don’t you each give her a kiss; just in case one of you is her true love.”
They looked at each other with a smirk on their faces and then rushed into room one.
“Just on the cheek, you two, and just a light kiss.”
They looked disappointed as they each planted a light kiss on her cheek. Nothing happened.  They left to check out her apartment.
Each dwarf in turn planted a kiss on her cheek and even the Wicked Queen kissed her, all without success.
“What we really need is a handsome prince,” I remarked. For completeness sake Miss James and I also kissed her, with, thankfully, no results. Once all this kissing was finished a police car pulled up.
Officers Kreplock and Jenson came in.
“Hey, Doc. Good evening Miss James. What’s going on?”
I proceeded to recount the events of the night with embellishments thrown in by Sleazy and Busty.
“So let me see if I’ve got this straight,” Officer Kreplock summed up when we’d finished our story. “There has been some sort of assault on a stripper named Crystal Blue and two assaults on stripper Margaret Henson aka the Wicked Queen, the old cleaning lady from the strip joint may have been one perpetrator, but she’s dead, while one or all of these seven dwarfs may also be perpetrators. Meanwhile two of these dwarfs are off on some sort of home investigation trying to find some clues as to the identity of the now drugged or comatose Crystal Blue because you all have a wild idea that ‘true love’s kiss’ will break the spell she’s under and wake her up from her coma?”
“That’s it in a nutshell, Officer,” I replied.
“Doc, you’ve been watching too many late night movies. Let me call the hospital and get an ambulance over here to take your comatose patient to the hospital.”
I looked him in the eye and then looked through the open door into exam room one and the peacefully sleeping Crystal Blue. I knew he was right to take her to the hospital. Still I’d seen so many peculiar, bizarre occurrences, met innumerable weird and wonderful and eccentric patients here at the clinic that a magic spell cast over one of my patients just didn’t strike me as being much out of the ordinary, at least for this nighttime clinic.
“I’ll tell you what, Officers,” I negotiated, “just wait to see what the two dwarfs, Norman and Skanky discover. If we can’t wake Miss Blue up, then we’ll send her to the hospital.”
“OK, Doc, as long as it’s not too long a wait.”
“Oh, it shouldn’t be long. Here they are now. What did you find?”
Norman walked in empty handed.
“Well, her apartment is pretty empty. Nothing on the walls, no photos, no computer, no diary, no letters, nothing. But, while we were looking around we heard growling from the bathroom and found him.”
Norman pointed outside where Skanky was wrestling with a big headstrong German Shepherd.
“At first he growled at us and bared his teeth as we searched around. But, I think he figured out we were there to help, because he calmed down after a few minutes. As we were leaving, feeling pretty much like failures he ran to the door with his leash in his mouth. I didn’t think we had time to take him for a walk, but he wouldn’t let us out the door unless we brought him along. I think he decided we would take him to see our poor Crystal.”
“Keep him in the waiting room for now, please,” I suggested, but then I thought for a moment. “No, wait, let him free.”
Skanky and Norman looked confused, but then released the dog. The beast started barking and then bounded into exam room one and stood up on his hind legs and started licking Crystal Blue’s face. As he did this there started to be flashing lights of red and blue, a wind blew from nowhere and a white light engulfed the dog and Miss Blue. We all stood by, dumbfounded, as the light and wind grew brighter and stronger and then suddenly stopped.
I half expected to find the room empty, while also half expecting Crystal Blue to walk out with a handsome prince on her arm. And, she did walk out, only with her dog at her side. The dog was not an enchanted prince. He was just a German Shepherd. He did have a tag, however, with his name engraved upon it. In big white letters it said “PRINCE.”
After this every one filed out of the Clinic. News of the miraculous occurrences made the Enchanted Emporium a top tourist attraction and the popularity caused Sleazy to tone down some of the more unusual performances. Miss Henson and Miss Blue became fast friends and started an act together, playing to packed houses up and down the coast. Prince was prominently featured in the show.
After everyone had left it was just about quitting time. Miss James and I had breakfast together.
“I guess there’s no love like a dog’s love for its master. Prince sure proved that,” Miss James sighed.
“Well, that is one kind of love and I certainly believe it is true love. Maybe you and I can discover some other type of love…”
Her eyes widened and then she stared down at her bacon.
“Why Dr. Barnes…” and she laughed as we finished our breakfast.