Saturday, February 6, 2016

Med School Memories

The first year of Medical School was a jumble of lectures and labs punctuated with brief encounters with actual live patients.
 There was the half day at one of the local Emergency Rooms where I was joined by a fourth year student. I'd been in med school for about three weeks. I had become well versed in the anatomy of the back muscles and the histology of the liver and spleen, but I knew nothing of authentic diseases or their treatment.
We met one of the ER Attendings, an Internist, and I was treated to a few hour of medical heiroglyphics. We were quizzed on the therapy for urinary tract infections, a pretty simple question. As I began to answer, the fourth year spouted off a litany of different antibiotic choices, drowning out my suggestion of Penicillin. At that time in my medical career I thought penicillin was the antibiotic and was effective treatment for any and all infections. This may have been true in 1945. But, it was now 1980 and the list of antibiotics was growing longer everyday. I stayed quiet for the final few hours, listening and learning rather than demonstrating my ignorance.

My next encounter with real patients was a four week elective in Urology, myself along with two of my classmates. Our instructor was Dr. Leake. We also had two sessions with Dr. Cockett. Leake and Cockett. Can you think of two more appropriate names for Urologists? One of the highlights of these four weeks was visiting Mr. Godfrey.
Poor Mr. Godfrey had cancer of the prostate and was receiving combined Radiation and hormonal therapy. We saw him twice a week and each time Dr. Leake wanted us to do a rectal exam on the unfortunate  Mr. Godfrey. Without even a sigh Mr.Godfrey turned on his side and suffered through this biweekly ritual. The last session of this elective finally came which meant the last four rectal exams Mr. Godfrey would have to endure. We all arrived sporting those big "We're Number One" gloves frequently seen at sporting events.
“OK, Mr. Godfrey, time for your rectal exams.” We chimed in unison.
 Dr. Leake was not amused, but our patient had a nice chuckle.
There were no other memorable clinical encounters until the third year. The entire class eagerly began “General Clerkship.” Four weeks were allotted to teach us how to talk to, listen to and touch the, up until now, sacred creature called, “The Patient.”
We were told to let the patient talk, to listen actively and guide the patient down the history road so that they would impart as much information as possible. We were taught how to guide a rambling patient back to the clinical road which lead to the formulation of the all important “Differential Diagnosis.” Thus, it was emphasized over and over, the history would guide the next steps of a patient’s evaluation.
We discussed the philosophical and practical concerns along with the grave responsibility that accompanied the “Laying on of Hands.” The actual physical exam meant bursting through societal taboo’s against penetrating another individual’s personal space, sometimes invading their most personal and intimate parts, always towards the goal of healing.
“Just the act of physical touching may be beneficial to your patient’s wellbeing,” one psychiatrist lectured.
We were treated to Dr. L demonstrating a complete physical exam (except rectal and pelvic) on one of our classmates. He spent about forty five minutes observing, palpating and auscultating, in the end declaring:
As you can see, this complete physical need not be an all day affair.”
In our more modern times, when a primary care physician may see 50-60 patients a day, performiong a forty five minute exam on each patient would make for a very long day indeed.
We all waited with fear and trepidation for the “Pelvic Day.” This was the day when each student would receive indoctrination into the intricacies of the female pelvic exam. Professional models were hired, each set up in a private cubicle where the student was given about ten minutes of monitored probing.
“My uterus is retroflexed,” my model reported, “so you would need to do a rectal exam to properly feel it. You should be able to feel each ovary however.”
“Until you’ve done about two hundred pelvic exams you may as well be waving your fingers in the wind,” Dr. A, one of our instructors, commented.
Finally, the last pieces of the physical exam came up: the aforementioned rectal exam and the male genital exam. These we did on each other.
“Never go to a Proctologist who can palm a basketball,” one instructor joked.
“You should be concerned if you feel both your examiners hands on your shoulders during a rectal exam,” another quipped.
“All in good fun to lighten the tension,” they said.
Maybe they should have volunteered to be subjects… all in the name of education, of course.
Finally, we were finished with general clerkship and were ready to be set loose upon the unsuspecting patients of Rochester, New York.
“Go do an H&P on the new admission in 612, a Gertie Black, CHF,” my third year resident ordered.
Ready or not here I come, Ms. Black
I perused the chart of patient Black before venturing into see her. I glanced across the nurse’s station into her room and caught a glimpse of my new patient. She was about five feet tall and five feet wide. At the precise moment I looked over at her she bent over. Her hospital gown did little to cover her ample assets and I was treated to a “full moon over Rochester.” So went my introduction to clinical medicine at Strong Memorial Hospital in Rochester, New York.
It wasn’t long before I was churning out 10-15 page H&P’s on a daily basis. The history part, the H, was not a problem. Ask the right question and listen. My patients had no qualms about opening up to me, revealing the darkest secrets of their lives.
“I… like… to smoke… a few… joints… every day… well… several… times… a day,” Mr. M. confided. He had been doing this for most of his seventy years. His very measured, deliberate speech no longer was a surprise.
“I prefer women’s underwear,” another man confided. “It’s more comfortable.”
“I put my cat in the drying machine when I was seven,” an elderly woman reported. I really didn’t think it was relevant to her having hemorrhoids, but one never knows.
“I drink a little every day, maybe three beers a day, and a couple of glasses of wine, and I have two martinis after dinner and a brandy at bedtime,” a councilman confessed.
And so it went.
The intricacies of the physical exam, the P, were more of a challenge.
As a class we shared our interesting heart murmurs, palpable lumps and bumps, hernias, rales, rhonchi and wheezes. Gradually, I thought I was developing some physical exam proficiency.
Then came my day. I was chosen to present to Dr. M on rounds. My patient was Cora, sixty years old, with COPD and Congestive Heart Failure, admitted with shortness of breath.
I questioned her every way I could, going back to her childhood days, looking for any every possible contributing factor to her severe COPD. I tried to anticipate any and all questions.
I examined her from top to bottom and then bottom to top. She had a barrel chest, an S3, mild JVD, expiratory wheezing and, I decided, a right ventricular heave.
I wasn’t really sure about the right ventricular heave. A definition follows:

“When there is pulmonary hypertension, the Right ventricle has to overwork, it has to pump against the increased pressure in the lungs. So if the heel of the hand is placed immediately lateral to the LEFT sternal border, one can feel the right ventricle being pushed anteriorly. The heel of the hand is lifted off the chest wall with each systole, and this is the heave.”

 I’m still not sure if I felt anything. But, I read it was associated with severe COPD and poor Cora certainly qualified. I convinced myself it was present. And, this was my chance to impress the Attending staff.
My moment came.
“Cora is a sixty year old female who was admitted to the hospital complaining of shortness of breath…two packs of cigarettes a day for forty years…distant breath sounds bilaterally…right ventricular heave…being evaluated for lung transplant.”
Silence.
I’ve done it. There speechless. I’m sure they’ve never been so dazzled by a med student.
“Dr. Gelber,” Dr. M began, “could you demonstrate how one examines a patient and determines the presence of a right ventricular heave?”
Wait, I know this.
“Good morning, again, Cora,” I greeted her as  I moved to her bedside. “I need to check your chest.”
“Whatever you need to do, Dr. G,” she turned to Dr. M. “Dr. G’s a good doctor. He spent an hour with me yesterday, just listening and checking me. It’s OK, go ahead and do what needs to be done.”
I put my hand alongside her sternum. Unfortunately, I put it on the right side and felt nothing.
“I’m not sure it’s there,” I murmured softly.
“It would probably help if you put your hand in the proper spot,” Dr. M. observed.
“Oh, yeah,” I stammered, even more softly.
I moved my hand to the proper spot and still felt nothing.
Dr. M. moved in. he put his hand along the left sternal border, watched her breathing and then turned to our group.
“Definitely no right ventricular heave,” he announced. “Maybe, Dr. Gelber, you should be a surgeon.”
A seed was sown.



Wednesday, January 6, 2016

A Sweet Man

                            

He was a sweet man. That’s what the Chief said about Adrian. Adrian did have issues, that’s for sure. Number one was that he was yellow. I don’t mean yellow in the sense that he was cowardly; quite the opposite was true. Adrian was literally yellow.
That was why he was in our clinic. His skin and eyes were yellow and he had been having abdominal pain. He couldn’t eat and had lost almost twenty pounds. Obstructive jaundice was the diagnosis. I put him in the hospital to find out why.
Besides his yellowness, Adrian had other problems. He had been born with cerebral palsy and had spent most of his life in a variety of institutions. Maybe he was a bit slow to collect his thoughts, perhaps his words weren’t always clear and his eyes looked a little “off.” But, he had a smile that lit up the room. And when he smiled his eyes had a little twinkle that said “I know I look a little different, but looks are nothing. It’s the heart which counts.”
He and the Chief hit it off almost immediately. Even though they were worlds apart intellectually, socially and in every other way, the Chief saw something special in Adrian; call it purity or sincerity.
I, on the other hand, was given the task of finding out why poor Adrian was yellow and what could be done to fix him.
The history offered some clues. Adrian had suffered repeated episodes of upper abdominal pain, back pain with nausea. The pain lasted a few hours, occurred at all hours, but was worse at night.
So far, classic gallbladder disease with episodes of biliary colic.
Physical exam revealed scleral icterus and not much else. Specifically, there was no abdominal mass and neither the liver nor spleen was enlarged.
Lab tests were significant for a total bilirubin of 9.3, Alkaline phosphatase was 815. CBC, electrolytes, BUN, Creatinine and everything else was essentially normal. Ultrasound revealed gallstones and a dilated common bile duct.
Adrian was a classic case of chronic cholecystitis, cholelithiasis and choledocholithiasis, which means he had pain secondary to stones in the gallbladder and common bile duct. Surgery would be the proper treatment.
The time was 1989. Laparoscopic Surgery had not yet hit the United States in any big way. There was no MRCP and ERCP’s were not done if the patient was going to need surgery anyway. Besides, I was a resident, this was a teaching hospital and Cholecystectomy and Common Bile Duct Exploration was a good case; it was what we called a “Complex Interchangeable Case.” A minimum of sixty such cases were needed to sit for the boards. And, to top it off, this particular surgery, specifically common bile duct exploration, was the Chief’s favorite type of operation.
I scheduled Adrian during my regular operating time, which was on Thursday, three days hence. I notified the Chief and thought everything was set.
That’s when the problems started. Not with Adrian, he was fine waiting a couple of days. He greeted us every morning with his special smile. He told us how much he liked the food and how comfortable the bed was. And, and he waved goodbye as we left and told us how he looked forward to seeing us on afternoon rounds.
No, it wasn’t Adrian. It was me and a sudden flurry of very sick and complicated patients. Gregory had a mass in the right middle lobe of his lung and needed a resection. Thomas had a mass in the left upper lobe of his lung and he needed a resection. Jesse had stomach cancer, Johnny had colon cancer, Phil had a chest wall mass. All were in the hospital and all needed complex surgery. So much work, so little time. And the Chief was involved with not only Adrian, but Gregory and Thomas.
I must point out that at the county hospital each chief resident is allotted a certain amount of OR time. I had room twelve on Tuesday, Thursday and Friday. Scheduled cases had to be finished by three pm. I would need to do some wheeling and dealing to find the time to do this windfall of Complex Interchangeable Cases.
I called my co chief resident on the Trauma service and “borrowed his time on Wednesday and I rescheduled a few other smaller cases. Because of scheduling conflicts with other attending surgeons Adrian’s surgery was moved to Friday. Finally, I went up to the office to tell the Chief about the change in schedule.
He was not happy.
“I cancelled an important meeting to do that surgery. Do not ever take me for granted. Change it back,” he almost shouted, the first and last time he ever raised his voice at me.
A bit sheepishly, I got on the phone with scheduling, some of the other attending surgeons and the other chief residents and managed to put things back so that Adrian’s case, with the Chief, was back on Thursday. Of course, the other chief residents, feigning helpfulness, said that they would be willing to make the sacrifice and do one or more of these complicated surgeries for me. “Just to be helpful.”
Such help I did not need.
It took a bit of finagling, begging and dealing, but I managed to get all my cases scheduled in a timely manner, fulfill all my necessary duties and keep the Chief happy.
Adrian waited patiently. He remained yellow, but otherwise was well. On rounds the following day he was doing his best to help out some other patients as well as the hospital staff. We found him emptying the wastebasket in his room into the janitor’s larger trash can. He called the nurses when his roommate’s IV ran out, he bought food from the vending machines on the floor and shared his Frito’s and Cheetoh’s with the other patients.
The day before surgery I sat down at his bedside and explained his surgery to him. I presented the alternatives, risks, benefits and all the other details as simply and clearly as I could. He listened intently, nodding his head once in a while, but I was never sure if he truly understood. When I finished I asked him if he had any questions.
“You know,” he began, “it would be really nice if I could get a job here after my surgery. Maybe, I could sweep up or take out the trash.”
And he smiled his sweet smile.
“Let’s get you better first,” I answered. “I don’t have much influence over such things, but the Chief might be able to help. I’ll talk to him.”
“Thank you, thank you,” he responded and his smile grew even larger.
There are parts of being a doctor which have nothing to do with physical wellbeing. For example, I have a patient who had rectal cancer many years ago. I remember before his surgery that his biggest concern was getting back to work, which was janitorial. He was the sole support for his family. Neither he nor his wife spoke English, yet they managed. He told me that the worst thing was to be unproductive. He needed to be doing something which helped others, even if it was just mopping floors.
“Clean floors,” he told me through an interpreter, “are important to a hospital. My floors are the cleanest.”
And, I believed they were.
Adrian, I’m sure, had similar beliefs. He wanted to be productive. He wanted to look at a floor or an empty waste basket and feel pride in a job well done. Yes, he suffered from a chronic infirmity, but this so called disability was in no way an impediment to his productivity.
The question was: “When should I bring it up to the Chief?”
He was already annoyed with me. Should I do it now, figuring two annoyances at the same time will pass sooner than one after another? Or, maybe, wait until he calms down and forgets about my transgression. He likes Adrian; I’m sure he would be happy to help out one of his patients.
After considerable mental deliberation I decided to bring the issue up while we were operating. During the surgery Adrian would be center stage and doing all things possible to help him would be foremost in all our minds.
Finally, Adrian’s big day came.
The Chief waited in our tiny lounge while I began the surgery with one of the junior residents. The Chief always preferred midline incisions, even for gallbladder surgery. He poked his head into the room shortly after we started and scrubbed in as the gallbladder was passed to the scrub tech.
Adrian was very thin with a paucity of intraabdominal fat. The structures of the Porta Hepatis: bile duct, hepatic artery and portal vein each stood out. The bile duct looked dilated, almost two centimeters in diameter. This was about three times the normal size of about six millimeters.
“Looks pretty obvious, don’t you think Chief?” I asked, pointing to the bile duct.
“You still need to follow the rules,” he responded.
“I know, I was just testing you,” I shot back; he smiled at me.
The rule was that the bile duct always should be aspirated with a needle before it is opened. It was considered bad form to make an incision in a structure, assuming it was the common bile duct, only to discover it was the portal vein. Bad form for the surgeon and especially bad for the patient.
With 23 gauge needle and syringe in hand I aspirated the structure which I was sure was the CBD and was happy to see the syringe fill up with yellow fluid. I put stay sutures in the duct and made my incision. Bile and a big stone popped out.
Maybe this won’t be too difficult. Be careful. Don’t say anything or you’ll jinx yourself.
“Choledochoscope,” the Chief requested. As we were waiting for Jeanette, the scrub tech, to set up the scope the Chief looked up at me and then down at Adrian’s abdominal viscera.
“You know,” he began in his slightly gruff, grandfatherly way, “when you die and go to that big operating room in the sky, all your cases will be like this.”
This was the second time during my residency that the Chief made this observation; the other was on a similar case in a very thin, young healthy woman. And, I knew exactly what he meant. Surgery like Adrian’s were the Chief’s favorite type of case. But, this particular surgery was shaping up to be interesting, but without the struggles that we sometimes face when confronted with a patient who is very obese or has extensive inflammation or scar tissue. All of which can make for very tedious operations. Adrian, however, also proved to be a challenge.
The choledochoscope was finally ready. The Chief preferred the rigid scope. He thought the visualization was better and instrumentation was easier. This scope consisted of an optics portion which was inserted into the bile duct and an eyepiece which was at a right angle to the optical portion. Using this particular choledochoscope required a Kocher maneuver, which meant mobilizing the duodenum, so that downward traction could be exerted to straighten out the duct and allow for inspection of the entire duct.
 The Chief inserted this scope through the opening in the bile duct and then handed the scope to me. A stone was clearly visible.
We went to work and fished it out using a stone forceps. The scope went back in and another stone was seen and removed, then another and another. Before long we had ten stones.
“There are more in there,” I commented.
“Keep at it,” the Chief replied.
Five more stones were removed and there was at least one more.
“This last stone is stuck,” I noted. Looking with the scope we both saw the stone wedged in the duct and I could feel it behind the duodenum,
“I’ll try a Fogarty,” I decided and the Chief nodded his head in concurrence.
The Fogarty, a catheter with an inflatable balloon on its tip, would not pass beyond the stone. We tried stone forceps, irrigation, another go around with the Fogarty, but that stone did an excellent imitation of a mule and refused to budge.
“If this is what I have to look forward to in Heaven, I hate to think about the alternative,” I quipped.
The Chief gave me a look of frustration, then asked, “What’s your plan now?”
“The duct is big, I think a choledochoduodenostomy would be best. Adrian has a lot of stones. I wonder if some or all of them formed in the duct, rather than passing from the gallbladder,” I explained my reasoning.
“You wouldn’t consider a transduodenal sphincteroplasty?” He asked, playing Devil’s advocate I suspected.
“With the big duct and so many stones, I think the bypass operation is better,” I replied, “besides, we won’t have to worry about a cholangiogram.
These two procedures are similar. But have different potential for complications, short term and long term. A choledochoduodenostomy means anastomosing the duodenum and the common bile duct, thus bypassing the obstructed portion of the duct behind the duodenum. This allows for much improved drainage from the bile duct. A transduodenal sphincteroplasty means approaching the bile duct through the duodenum at the ampulla of Vater. The duodenum is opened and the ampulla, which is where the bile duct and pancreatic duct enter the bowel, is identified. This ampulla is then incised, which opens the sphincter, which is then sutured to the duodenal mucosa. This enlarges the opening between the common bile duct and duodenum. The latter procedure, in my opinion is best for impacted stones at the ampulla and short ampullary strictures. The sphincteroplasty also is useful when the bile duct is small as the biliary bypass procedure is more likely to fail if the duct is less than one centimeter. Long term, the sphincteroplasty is more physiologic and less likely to have the complication of ascending cholangitis, which means infection of the biliary system, which is more common after choledochoduodenostomy.
In Adrian’s case, his duct was large and there was concern that the stones may have developed within the common bile duct. Both these facts led me to recommend the choledochoduodenostomy.
The Chief agreed.
I already had a hole in the bile duct. I made an opening in the duodenum and hooked the two together with a minimum of fuss.
While suturing away I asked the Chief about Adrian.
“Chief,” I started, “Adrian asked if he could have a job with the County. Maybe, a janitor or something like that. He really will do whatever he can. I think he would be a good worker.”
“Such a nice, sweet man,” he answered. “You know, it would be the right thing to help him. I’ll talk to some of the administrative types.”
And that was that.
I finished Adrian’s operation in short order and he made a rapid, uneventful recovery, going from yellow to pink over a couple of weeks, when I saw him back in the clinic.
“I haven’t forgot about what you asked,” I reminded him as I felt his abdomen. “The Chief spoke with the Hospital CEO and you have an appointment with Human Resources on Friday. Can you make it?”
He gave me his big smile and his eyes shone.
“I’ll be there,” he answered and he smiled again.
“Wait, before you go the Chief wants to say hello,” I added.
The Chief came from the back and shook Adrian’s hand.
“Good luck, Adrian,” was all the Chief said and he walked away.
However, I did hear him murmur, “such a sweet man.”









Friday, December 25, 2015

Surgical Dilemma Part Three

                                  

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