Friday, August 22, 2014

Amazing New Technology

I Dog:

The latest and greatest thing in personal companions. The I Dog, along with the built in I Dog app, allows the user to select all the characteristics wanted in a canine pet. Size, personality, shedding, long hair or short hair, are only a few of the attributes available with the latest I Dog. Long for the complete Puppy experience? Turn off the built in house broken feature and your I Dog will Pee and Poop inside, just like a real puppy. And, don’t worry about astronomical food and vet bills; the I Dog is one hundred per cent digital fun. Just plug in and charge overnight and you are ready for hours of playful frolicking.  Finally, scare off those unwanted guests and would be attackers with the I Dog guard dog app.
The I Dog is coming in time for Christmas.

I Bed:

Tired of the same old mattress, sheets and blankets? This April, the I Bed arrives. Completely integrated mattress, box spring, sheets and blankets conform to every sleep habit. Bad Back? The I Bed senses tight, wound up muscles and arthritic joints, automatically adjusting to provide just the right amount of support and cushion to eliminate lower back muscle pain. Husband snores? The I Bed keeps him turned and even gives him a short jolt to startle him awake and stifle the annoying noise. And, for those intimate moments the Romance App (available separately) fills your boudoir with sensuous perfume, automatically sets just the right mood lighting and senses every thrust and roll to provide maximum stimulation.
The I Bed, available this spring wherever fine bedroom furniture is sold.


I Toilet:

The flush toilet has been around for years with very little innovation. Effective, but boring. Now, American Standard presents the I Toilet. Who says the bathroom can’t be fun? From the perfectly warmed seat to the amazing Elimination App, the I Toilet makes your bodily functions not only necessary but fun!! Even while it spares the environment, the I Toilet enhances the bathroom experience. The seat automatically conforms to even the largest buttocks for maximum comfort. Built in sensors monitor the acts of elimination and micturition and immediately calculate optimum sanitation and cleansing. The optional Bidet App cleanses your bottom with just the right amount of force at just the right temperature.  The included toilet paper app allows the pooper to choose strong or soft with infinite choices, including color. The flush sensors detect liquid or solid waste and adjust the amount of water per flush accordingly. No more annoying multiple flushes; studies have shown that this app actually saves water, thus preserving our limited resources. And, for those days when things just aren’t coming out right, there is a built in catalog of books, movies and music to keep you entertained. Look to the future, Look to the I toilet.


I Back Scratcher

Itches on your back can be sooo annoying. And, if you find yourself alone with an itch what can you do? Rub against a tree? Roll around on the ground? Not very effective or efficient. NO!! You need the I Back Scratcher, the latest in body comfort solutions. Adjust the I Back Scratcher to light scratch for that superficial, but annoying itch or program it for deep and long scratching to feel the comforting scratch deep into those tiring muscles. And, don’t worry if it’s a large area or a tiny spot. The I Back Scratcher automatically senses the itch and provides a timely and soothing scratch either with its five finger mode or, for smaller more localized irritation, the single finger nail probing scratcher. The I Back Scratcher, the latest in personal comfort devices.

I Garden

Don’t have a green thumb? Not even a yellow one? Don’t fret, the I Garden will turn the most incompetent farmer into Johnny Appleseed and fill your home with beautiful flowers and fresh fruit and vegetables all without any fuss or effort. Merely set the I Garden post into the middle of your garden and watch it flourish, all from the comfort of your personal I Garden lawn chair (sunblocking umbrella included only with I Garden Premium Edition).
“But I want to get down on my hands and knees and be part of my garden.” Don’t worry. The Green Thumb app allows you to do as much or as little gardening as you wish. Set it to the lowest level and the I Garden only provides fertilizer and pest control. Turn it up a notch and it will water your sprouting seeds to exact specification. Ramp it all the way up and watch the seeds get planted, watered, fertilized, cultivated, and harvested. Add the I Processor and your fresh fruits and veggies are scrubbed and stored to be enjoyed days, weeks, months or even years later. Worried about pesky crows absconding with the fruits of your labor? Have no fear as the I Scarecrow app zaps these pests and keeps your garden pristine. The I Garden, a must have for every outdoor hobbyist.

I Zoo

You go to the zoo, it’s July and it’s ninety five degrees. Your kids pester you to see the lions, which forces you to make the long trek from the cool confines of the snake house to the Lion’s Den. What do you find? A pride of lions sleeping in their caves, doing the smart thing and avoiding the midday heat. You think: I wish I was a lion, instead of a father having to explain to disappointed children why the lions are hiding.
Sound familiar? Well, you can avoid all these troubles with the incredible, intuitive and customizable I Zoo. Want to see lions. The I Zoo puts you right in the middle of the hunt with crystal clear, life size digital lions projected utilizing the latest in holographic imagery. The picture is so clear and lifelike that you’ll swear you can taste the blood of the wildebeest after the kill. And it’s not just images. The sounds, smells and feel of the African veldt are all available with the patented Sensarround app. Now, suppose penguins are your fancy. I Zoo allows you and your kids to slide down the ice flow, battle vicious seals and consume raw fish. You’ll swear you are right there in the Antarctic.
I Zoo let’s you choose the environment, animal and activity that interests you and it’s more alive and life like than the real thing.
The I Zoo, yours for only $599.95. Senssaround app sold separately.

I Shoes

Feet. We’re born with them, we take them for granted forcing them into any old shoe while all the time they take the abuse until…they rebel. Arches fall, bunions form, nails ingrow and then it’s too late. Chronic pain, crippling inflammation rule our lives because, no matter how hard we try, we can’t ignore our feet. What can one do? Like a noble white night the I Shoe comes into your life freeing you and your feet from endless days and nights of podiatric misery. One hundred per cent intuitive and sensitive to individual needs the I Shoe is practical, elegant, sturdy and comfortable. Built in apps include the arch app, nail maintenance app, odor sensing and elimination app and our very popular massage app. The I Shoe can be worn to a night at the opera or climbing Mount Everest. The sole is completely equipped with the latest 3D technology which allows it to go from a pump with 5 inch stilleto heels to a rugged work boot, all controlled from your smart phone or computer.
Live the life of comfort with the I Shoe, now available at Better Buy and Shoes Are Us and other fine clothing and electronics stores.

I Underwear

You’ve heard of Buck Naked underwear, boxers, briefs and boxer briefs, but we now present the revolutionary new I Underwear. I Underwear is guaranteed to be the most comfortable, versatile, durable and stylish underwear ever. Slip a pair on and the first thing you’ll feel is nothing. That’s right. I Underwear feels like your running free and easy. How can that be? Well, starting at the top, this amazing underwear has no elastic, no waist band, no tags, only the softest, smoothest cotton/nylon/linen blend which conforms to your personal body habitus. Built in sensors allow the I Underwear to anticipate every movement so that the fabric moves in perfect concert with all the body parts it is protecting. And what protection!! Not only are your movements anticipated, but every body fold, every nook and cranny is mapped and catalogued so that the I Underwear provides maximum support. Torn between boxers and briefs, but not sold on boxer briefs? No worries. I Underwear will scan for body shape, perspiration index, odor and nineteen other parameters and adjust to provide maximum support, comfort, hygiene and fertility.
I Underwear, slip into a pair today.


I Aquarium

Work, work, work. At least that’s what many fish owners say about maintaining a home aquarium. Clean the filter, clean the water, feed the fish, change the water, check the pH, stop, repeat. Over and over and over. Is there an easier way? Of course, let technology do the work. The amazing I Aquarium will maintain your fresh or salt water aquarium just like the professionals. Water composition, pH level, alkalinity and acidity, copper levels, aluminum levels, arsenic levels and every other level is continuously monitored and adjusted to provide the perfect, optimum environment for your fine, finned friends.
But, the I Aquarium can do even more!! Tired of the same old boring cichlids? The Piscean App can alter the optics of the tank and water so that even the most boring Black Molly can become a bright, colorful virtual Clown Trigger fish or lovely orange and white Clown Fish.
And, if you want to go a step farther activate the virtual fish tank app. This remarkable and free app will simulate an underwater paradise without the need for live fish or water or any cumbersome equipment. But, you’ll swear it’s all real or we will completely refund your money.
The I Aquarium, a must have for every fresh water and salt water aficionado.

I Car

Start with the first time you set your tush down on the seat and begin the amazing journey. The I Car scanners relay data on every nook and fold of your derriere and adjust the seat to maximum comfort. It’s at that point that you realize you’ve embarked on a special voyage in a special and extraordinary vehicle. But, the I Car is not just any vehicle. It’s a fully automated, customized driving experience which will take you to your destination with a mere push of a button and a few softly spoken words. Settle down into your seat, push START, murmur “supermarket” and lay back as the I Car expertly carries you to the market, all the time gently massaging those tired muscles, playing soft, soothing music while doing all the mundane tasks you dread.
Too tired to get up and push a shopping cart? No problem. Merely upload your shopping list and relax. The I Car delivers your list and arranges to have it brought to your car loaded and brought home. It even tips the grocery boy.
The amazing affordable I Car coming in 2015 from Apple Motors.



Sunday, August 3, 2014

I Wonder...

                     

I’ve been practicing surgery for more than twenty five years. Over these many years I’ve had innumerable interactions and encounters with patients, nurses, doctors and other health care professionals. Sometimes I’m left scratching my head in wonder and amazement. This is not always a good thing.
A few years ago Martha, a patient of one of my partners, called on a Sunday morning, which also happened to be July 4th. She had a colostomy created along with what’s called a mucus fistula following surgery for a colon perforation a few years before. A colostomy means that the colon (large intestine) was brought out to the skin level so that stool passes into a bag instead of taking its normal course to the rectum and out through the anus, a common practice when patients require emergency colon surgery. A mucus fistula means the other end of the intestinal tube is also brought out to the skin where a small amount of mucus will drain intermittently. Such mucus fistulas usually only require a light gauze dressing, not a complete stoma appliance.
Back to Martha. She was concerned because she was out of bags for her colostomy and she needed to change it and the medical equipment stores were closed. She gave me a brief rundown on her history and assured me that besides needing a new a new bag everything else was OK.
I gave some thought about what she should do. We don’t keep such appliances at our office, so I couldn’t help her directly and it was true that the medical supply shops were closed. All I could think to do was to send her to the hospital where one of the nurses could fix her up. I advised her to go to the ER and then I called and spoke with the head nurse in the ER, explaining the situation and asking if she could do the patient a favor and find her a colostomy bag to get her through the holiday weekend.
I didn’t give the matter a second thought, assuming the nurses would be able to accommodate the desperate patient without any fuss. But, I was wrong. Three hours later I get a call from the ER doctor informing me that Martha was there and he had just eyeballed her. Now he was asking me about my concerns. At first I didn’t remember her, but the lightbulb went off in my head and I told him:
“Oh, she just needs a new colostomy bag. She called me a few hours ago and I spoke to your head nurse about her.”
There was a long pause and then the ER doctor replied, “She has two colostomies and nothing is coming out of one.”
“Oh, that’s just a mucus fistula. I wouldn’t expect her to have much drainage from it. Just get her a bag and she’ll be fine,” I reassured him.
“Do you think I can talk to your partner who did her surgery? Because if she has a colostomy something should be coming out,” he deduced, again.
“Well, he’s usually not available on the weekends when he’s off, but Martha will be fine if you just fix her up with a colostomy bag.”
“Unless, I can speak with your partner I feel I’m obligated to do a CAT Scan,” he reiterated more forcefully. “Colostomies should have some drainage and I don’t see anything coming out.”
I was beginning to get a little annoyed.
“Did you actually talk to the patient?” I asked. “Did she tell you what the problem is?”
“I did talk to her,” he replied, his frustration also beginning to surface, “and she told me just what you said. But, she could be confused and a colostomy should have something coming out. I really think I should do a CAT Scan.”
I realized I was going nowhere fast.
“OK, OK, do what you have to do. I haven’t seen her and you have. I’ll see if I can get a hold of my partner.”
I realize that once the ER doctor saw poor Martha he was responsible for her care and he was only trying to practice good medicine, at least from his perspective, but he really broke a few rules. He didn’t listen to the patient, he assumed an elderly patient must be confused if she didn’t tell him what he expected to hear, he ignored his consultant and refused to consider anything but his own inaccurate diagnosis. This also is an example of relying too heavily on CAT Scans for diagnosis, while refusing to utilize any clinical judgment.
In the end, Martha got her bags and a completely unnecessary CAT Scan of her abdomen and pelvis. That particular ER physician was fired about a month later, my encounter being only one of many similar episodes. It made me wonder how some people make it through medical school and residency.
I had another incident today that made me stop and think. I was called to consult on a patient at one of the Long Term Acute Care (LTAC) facilities. LTAC’s are hospitals for patients who are not sick enough to be in a regular acute care hospital, but are too sick for a nursing home. I consult at these facilities when necessary to evaluate surgical problems.
Mitch was a complicated patient who had undergone major intra-abdominal surgery and had numerous drains which had been placed to treat abscesses which had developed after his surgery. I had not done any of the surgery and I had never seen him before, but I was called because the patient’s actual surgeons did not go to LTAC’s.
“Dr. P wants you to see Mitch because his drain broke,” the nurse reported.
I did my best to extract as much information as I could from the nurse. Mitch was stable, the drain hadn’t been collecting much fluid and it sounded like a closed suction drain’s tubing had broken off near where it attached to the suction bulb.
“Sounds like you can just cut the tube a little shorter and reconnect it to the bulb,” I deduced.
“It’s broke, I can’t do that.”
“OK, I’ll see him tomorrow.”
“But doctor. The tube isn’t draining into anything; it’s open to air.”
This was not much of a problem to me, the tube would behave like a different type of drain, called a Penrose, but I could tell the nurse was very worried.
“Just wrap it with some sterile gauze and tape it and he should be fine,” I suggested.
I went to see Mitch and found just what I expected. He had an intraperitoneal closed suction drain with plenty of tubing outside his abdomen.
“Where’s the bulb?” I asked the nurse, who was not the same nurse I had spoken with yesterday.
“I told them to save it, but they didn’t listen,” Mitch said. “They threw it away yesterday.”
The nurse was able to scrounge up another bulb, the tube was cut a little shorter and the crisis was averted, but only after I made a special trip to the LTAC to take care of a problem that should not have been a problem.
Then there are the techniques I have observed in other surgeons. I hear stories of surgeons taking two or three hours to do very simple procedures and I wonder what they are doing for so long a time. Sometimes I will ask that very question of the OR staff. The answers are scary:

“He wasn’t sure about the anatomy. He asked me my opinion, but I couldn’t help him,” reported by a surgical technician.
“He made a hole in the bladder and we had to wait for the Urologist.” I know things like this can happen, but not on a cholecystectomy.
“She just dissects very slowly, like she’s not sure what’s what.”

It’s always best to be as sure as you can be during surgery, and never cut anything unless you know what it is, but there is also some truth to the saying that “a good fast operation is always better than a bad slow operation.”
On occasion I assist younger surgeons in the OR. Most are careful and meticulous as they should be, but I have also helped some who can best be described as cavalier and sometimes dangerous.
I was assisting another surgeon on a colon resection for diverticulitis, an inflammatory condition of the colon. The segment of colon which was diseased was adherent to structures posterior to it. These structures are the ureter, iliac artery and iliac vein. Rather than carefully dissect the colon away, this surgeon took a pair of scissors and just cut away blindly, injuring the iliac vein in the process. I had to fix the vein as this surgeon did not do any vascular surgery. The patient lost about a liter of blood, because of this surgeon’s carelessness and inattention to the most basic rules of proper operative technique.

Incidents such as these make me wonder and worry a bit. If a nurse is not familiar with a particular drain, that’s OK. But, it would have been prudent to ask her head nurse what to do, rather than call in a consultant to address what was really a very simple nursing problem. I worry about the judgment, training and basic knowledge of personnel who are in positions where decision making and responsibility are of central importance. I see more and more incidents like these and I worry what will happen as I get older and face the infirmities that always come with age.

Saturday, July 26, 2014

Never Trust a Bone Doctor

      

I suppose the title above is a bit facetious and I really don’t mean it, but there have been times over the years when collaborating with my Orthopedic Surgery colleagues has caused sleepless nights; some I didn’t deserve.
Almost all these joint ventures have been on major trauma cases where severe bone injury has been paired with major vascular damage. Priority of repair, that is, who gets to go first is a common discussion. The answer to the question depends on the patient and the injury. In general life and limb threatening injury take precedence.
Such was the case of Mary, who suffered a closed fracture of her proximal tibia and fibula with associated occlusion of her popliteal artery and ischemia of her leg. The severe vascular injury could have led to Mary losing her leg and mending of the artery took precedence over the bony repair.
But, how could I have had the prescience to know that during the process of repairing the tibial fracture the orthopedic surgeon would cause a bony fragment to compress the artery which had just been patched and cleared of thrombus, (a blood clot which was occluding the vessel)? The vessel became occluded again. My protests went unheeded and I was forced to bite the bullet and redo the vascular repair utilizing a vein graft to bypass around the injured area.
At least I didn’t have to drive back to the hospital. As a resident I learned to never leave the vicinity until the bone doctor had driven his or her last screw, nailed the last nail and placed the final skin staple. Only after checking my work would it be safe to leave, secure with the knowledge that my orthopedic colleague could not wreak anymore havoc.
Mary, by the way, recovered uneventfully.
Then there was Glenn.
It was a Friday night and I was not on call. My family and I had just walked in the door after dining out when my phone went off and there was a message. Dr. Black was consulting me to see Glenn, who was admitted to the hospital with a fracture of the proximal right humerus. The nurse was concerned because she could not feel a pulse and Glenn complained of his hand being numb. It was about eight o’clock in the evening.
I called and talked to the nurse and then headed in to the hospital. Glenn was in his mid fifties, lived with his parents and had no significant medical problems other than being  “a little slow” to use his expression. He told me had tripped while on his parent’s front porch and fallen down the three stairs to the sidewalk, landing on his right arm and shoulder. This had occurred at 11:00 am, now almost ten hours earlier.
My exam confirmed that he had almost certainly injured his brachial artery. There was a large hematoma (collection of blood) in the upper arm and axilla, he could not move his hand, which was also numb, and there was no pulse in the arm, radial or brachial.
I called down to the OR where they weren’t very busy and told the crew that Glenn needed surgery immediately. Next I called Dr. Black and reported my findings and he responded that he was on his way to the hospital
I called the OR, again, and asked how quickly they would be ready, informing them, again, that this was a limb threatening emergency and that the patient should have had his surgery hours before.
“We’re opening now and anesthesia is on their way in,” was the reply.
I have to admit I was a more than a little frustrated. Mostly it was the lack of attention that threatened to cause serious harm to Glenn that bothered me. It’s not right for a patient to languish in the hospital with such an injury.
Dr. Black finally arrived.
“The ER physician told me it was an uncomplicated fracture. I had planned to fix it tomorrow,” he explained without my ever asking a question or making a comment.
Finally, at 10:00 the OR team was ready and Glenn was wheeled down to surgery. The operation began about thirty minutes later. Glenn’s arm had been ischemic for almost twelve hours.
I began to work, starting with an incision over the area where the subclavian artery emerges from beneath and behind the clavicle, following the rules and obtaining what’s called proximal control. What this means is that the artery is identified and dissected free in area closer to the heart than the injured area. Blood flows from the heart out to the organs under considerable pressure. Proximal control allows flow into the injured area to be interrupted should bleeding develop during the course of isolating the damaged artery.
I followed the artery out to the axilla, dissecting it free from the pectoralis major muscle and then into the upper arm where I encountered a large hematoma (collection of blood). This is where the artery had bled before the pressure caused by the blood spilling into Glenn’s tissues along with the body’s normal clotting mechanism caused the bleeding to stop. If this mechanism had failed Glenn would have bled to death, but the human body is remarkable in its ability to fend off such calamity.
I evacuated the large blood clot and found one end of the transected artery, pulsing away, but not actively bleeding as the end had efficiently clotted.
Next I had to find the other end of the artery. Rather than start digging through the bloody, damaged tissue at the site of injury, I decide it would be more prudent to start at a site beyond the injury. The distal artery was easily dissected free and then followed back to the other injured end.
The two ends were a bit macerated and had retracted such that a direct end to end anastamosis (like reconnecting two ends of a pipe) was not feasible. Luckily I had the foresight to prep out Glenn’s groin so that it was already sterile and I could harvest a segment of saphenous vein. This is the same vein commonly used for heart bypass surgery. Before starting on Glenn’s leg I placed a shunt between the two divided ends of the injured artery, allowing blood to flow to the distal arm, thus giving the starved tissue a “drink” of blood, delivering oxygen and nutrients.
An adequate segment of vein was removed from his leg and the reconstruction proceeded without incident. I added a fasciotomy to my procedure, which means I divided the fibrous tissue around the muscular compartments of the forearm to allow the muscle additional room to swell after it was reperfused, thus preventing what is termed “compartment syndrome.” This condition can lead to muscle and nerve damage as the tissue swelling which can occur after prolonged periods of ischemia becomes confined by the tight, closed space of a muscular compartment.
I felt the strong pulse in the artery beyond my repair and saw that the muscle, although pale, looked viable and I believed Glenn would be left with a functional arm.
At this point I must add I had considered allowing Dr. Black to do his repair first. I could have placed the shunt to allow the arm to be perfused and then done the definitive repair after Dr. Black had finished. But, he assured me it was a simple fracture which was minimally displaced. He anticipated an uncomplicated ORIF (Open Reduction Internal Fixation). Being the trusting soul that I am performed the more vital arterial repair first.
However, I am not 100% na├»ve. I did stay around until Dr. Black finished. I’m glad I did. It was about 1:00 am when I lay down on the couch in the doctor’s lounge and dozed off and on. Over the years I’ve never slept well at the hospital and I’ve always opted for driving home for a couple of hours sleep in my own bed rather than getting an extra thirty minutes in the less comfortable confines of a hospital call room. In this case, however, it was fortunate that I did not leave.
The phone in the lounge rang at about 3:00 am.
“Dr. Gelber, you need to come check this arm,” more of a command than request from the circulating nurse.
“Is Dr. Black finished?” I queried.
“Finished and gone, but you need to come.”
“OK, OK, I’ll be there in a minute.”
I made a quick pit stop, donned my hat and mask and went back to the OR room where the surgical tech recounted the sad and tragic “saga of Glenn’s repair.”
“Well, he was doing the repair with a Rush rod and it only took a few minutes. I thought we’d be home by two, but then I picked up the arm and asked him if the rod was supposed to come out the back of the arm? So he had to pull it out and that took a while. Then he had to do it again. I’m no Orthopedic Surgeon, but I don’t think it’s positioned very well. But, fFor what it’s worth, he’s done.”
The circulator then spoke up.
“The hand looks white.”
Sure enough there was no pulse or Doppler signal. So I was back at square one. I opened the wound and looked at my repair. There was an excellent pulse at the site of the repair and for at least three or four centimeters distal. I started dissecting farther and it wasn’t long before I found the problem.
Dr. Black had not only driven that Rod through the back of Glenn’s arm, but he had also managed to put it through the brachial artery at a point beyond the original injury. So, I repaired the artery a second time. At least I didn’t have to do another fasciotomy.
I finished at around 5:00 am. Glenn woke and had much improved function of his hand. He could move it and there was some sensation. He maintained good perfusion of his arm, but did have to have the orthopedic reconstruction revised at a later date. Eventually he regained 100% full, normal function of his arm and hand.
Dr. Black never talked about this particular case with me. A couple of years later he gave up the practice of Orthopedics. He was, overall a competent surgeon and his retirement from Orthopedics was for personal and health reasons, unrelated to Glenn’s case..
I hope that anyone who reads these words does not believe that I have no regard or respect for my Orthopedic colleagues. I could never do what they do and most are excellent physicians and surgeons. They do, however, have a singlemindedness in their approach to their patients. Their job is to fix, reconstruct and otherwise mend broken, worn out, degenerated bones and joints. Orthopedic surgical procedures are designed to stay away from vital structures such as nerves, major blood vessels and other organs which are soft and not amenable to nails, screws and plates.

What I’ve learned is that injuries and medical conditions which bring me into the Orthopedic Surgeon’s realm require that I maintain my utmost vigilance. And, never completely trust a bone doctor.

Sunday, June 29, 2014

24

                       

Back in the day, that is the distant past of 1985 the word “Internship” could fill a medical student with anxiety and stress. The internship was a rite of passage, a necessary stop on the road to becoming a full fledged, finished doctor, rather than a person with a couple of initials after his or her name.
And, the surgical internship was supposed to be the worst: thirty six hour shifts, every other night call, holding retractors for hours without a break, this was the plight of those of us who chose to pursue the surgical arts. It was a period of initiation which led to joining an exclusive fraternity called “Surgeon.”
I have to report that, at least for me, my internship was nothing like this. I was in a large private hospital where there was no “scut” work, the name given such mundane tasks like drawing blood, starting IV’s, doing EKG’s and such. These duties are important to patient care, but do little to advance the knowledge of the medical trainee. I do think there is some value in learning to draw blood and start IV’s, but doing my own CBC’s or urinalysis would have been a waste of my time.
All this being said there were days when the work was never ending and there was one day in particular which stands out as a shining example of what an internship can be.
It was during my final month, a month I spent away from the safe confines of my mother hospital and its friendly IV, EKG and phlebotomy teams; thus the aforementioned “scut” work still plagued the lowly intern.  I finished out my intern year rotating through the Pediatric Surgical Service at Children’s Medical Center (CMC) in Dallas. This included responsibility not only for CMC, but also Parkland Hospital, the county hospital for Dallas. I was paired with a fourth year resident as well as interns and residents from the program at UT Southwestern. We were responsible for all the pediatric surgery which included elective surgeries, trauma, the Parkland Emergency room, surgical consultation for pediatric patients in both hospitals and, finally, the nascent Pediatric Liver Transplant program.
The intern’s duties included: history and physical on all admissions, morning rounds which commenced around 6:00 am, drawing blood on all the liver transplant patients which needed to be done before morning rounds, assisting in surgery, afternoon rounds, making sure all tests that had been ordered were done and being the first to respond to any emergency that should arise throughout the day. In between all this we all hoped to find the time to actually do some surgery, the occasional appendectomy or a hernia, remove some lumps and bumps and so on.
There was a day, an unforgettable day which snuck up on me about two thirds of the way through the month. It was a Saturday which started like every other day. I arrived early enough to help the intern coming off call draw blood on the liver transplant patients and to check on my other patients before the fourth year resident arrived and formal rounds began. So far, so good.
Round and round we went, from Children’s Medical Center, to Parkland, which included a brief stop in the newly minted, but as yet untested, Pediatric Trauma Unit. There was a post op appendectomy, the previously mentioned post liver transplant patients, including little Terry. Terry had received her new liver four days ago, but was still looking green. We were all concerned that something wasn’t right. Diagnosing and treating her was priority number one for this Saturday.
“See if Radiology can do an ultrasound of Terry’s abdomen with Doppler to check her hepatic artery,” the Transplant surgeon attending commanded.
“Yes sir,” the fourth year resident agreed.
Rounds ending, this fourth year resident, who aspired to be a Pediatric Transplant surgeon, which meant an unusual amount of groveling and brown nosing of the Attending staff, turned to me and gave me the job of tending to all of Terry’s needs.
It was seven a.m. and the proverbial shit was poised to hit the fan. I started at the top of the scut list and ran down to Radiology to request the stat ultrasound on Terry. I checked the requisition up and down and front to back, made sure all the t’s were crossed and I’s dotted and ventured in to find the senior radiology resident. I finally found him hidden away in the dark, which is the usual place to find Radiologists, the vampires of the medical world who shun all light and live in shadow. I begged and pleaded and convinced him of the urgent need. I have to admit I almost brought tears to his eyes as I related the “Plight of Baby Terry.” The ultrasound was scheduled stat.
One task settled I moved on to the daily, mundane chores an intern battled. In those days, before computers, I gathered lab results and X-Ray reports and started writing my progress notes on each patient. It wasn't too long when I received the first of many "rude" interruptions.
"Dr. Gelber," the sweet voice called, "we've got a premie down here in NICU with a distended abdomen and the KUB shows pneumotosis."
A bothersome, but ocassionally disastrous NEC watch.  One more thing to complicate what was turning out to be a far from peaceful Saturday.
What, pray tell, is "NEC" watch?
NEC stands for Necrotizing Enterocolitis. This is a condition which most commonly arises in premature babies. Whether from ischemia, or infection, or some other unknown agent, the neonate becomes very sick. The child cannot be fed, they demonstrate signs of sepsis and their condition can deteriorate before your eyes.
I made my way to the NICU and took a look at baby girl Nicole born at 28 weeks and now sporting all the findings one would expect in early NEC, distended abdomen, mild tachycardia and an abdominal X-ray which revealed an area of “pneumotosis intestinale” which means air in the wall of the bowel. I communicated my findings and assessment to my fourth year resident, specifically that baby Nicole could be watched, tube feedings were put on hold and she was to start on IV fluids and antibiotics.
One crisis stopped before it started, I hoped.
I had just hung up the phone with the my senior resident when my beeper went off.
Parkland ER. Just great, what now?
“You are the surgery intern on call today?” asked the voice form the ER.
“This is Dr. Gelber, I am on call today.”
“This is Dr. Barry. We’ve got a seven year old who we think has appendicitis. Do you think you can come check him out?”
“OK, I’ll be there in a little bit.”
I took the time to write a couple of progress notes on the patients I’d seen earlier in the day and then made my way through the tunnel which connected Children’s Medical Center and Parkland. It was like moving from one world to another.
CMC always looked new and clean. It was a place I would want to bring my kids if they were ill. Parkland, although not dirty, looked older and worn, a spot which looked beaten down by years of caring for the sickest, most severely injured patients Dallas could offer.
I found Mikey in the pediatric ER accompanied by his worried mother. He had been sick for three days. From the door way it was obvious he was ill. He lay still on the exam table, his face was flushed. The bedside chart listed Vital signs: heartrate 130, Temp 103.1, blood pressure 86/40, Respirations: 20.
A typical history for appendicitis was obtained and a gentle tap on his abdomen elicited a grimace and wincing that screamed “PERITONITIS.”
I called my senior resident again and schedule Mikey for surgery. My beeper went off again: call the transplant floor.
“Terry needs to go for abdominal ultrasound now. The Radiologist is here and you need to bring her,” the unit secretary informed me.
Four years of college, four years of medical school and almost a year of internship and I’m still just a glorified orderly.
“OK, I’ll be right up.”
I left orders for Mikey and called the OR and told them I would call when we were ready for surgery. One good thing about Mikey and most patients with appendicitis was that an appendectomy was an intern case, so I would get to do the operation. I hustled my way back to CMC to wheel little Casey to ultrasound. On my way my beeper went off again and again and again.
“Michelle has a temp of 102.”
“Michelle who?” I inquire.
“Michelle S. in 204, She had a liver transplant ten days ago.”
“Oh, that Michelle. Get a UA, draw two sets of blood cultures and a CBC. I’ll be over to check her shortly.”
“Are you going to come draw the blood?”
“Yeah, OK, I’ll get to it as soon as I can.”
Next.
“IV is out on Darren in 331.”
“Darren?”
“He had an appendectomy two days ago.”
“Is he eating?”
“Clear liquid diet.”
“Is he on any meds?”
“Ampicillin, Gentamicin and Clindamycin.”
“Any fever?”
“No fever for twenty four hours.”
“Was the appendix ruptured?”
“How should I know?”
I looked at my sign out sheet. No mention of how bad the appendix was.
“OK,” I finally answered. “Could you please put everything at the bedside and I’ll be there when I can.”
And the third call:
“Dr. Gelber, Scott in 320 has a headache…”
Finally, something simple.
Now, onto the Transplant floor and little Terry. She was very small for her age and her skin was green because of her liver failure. Even after her transplant she stayed green and now she had fever. Everything said her new liver wasn’t right. But, the question remained: Was it a technical problem? Or rejection? Or infection? Thus the ultrasound and Doppler of her hepatic artery which would start to provide some answers, we hoped.
The nurses already had her loaded up on the stretcher. We began wheeling her down the hall to the elevator. She gave me a weak smile. Father and Mother trailed behind us talking in whispers. Terry was four days post transplant. I knew her fairly well and was very well acquainted with the veins of her right arm where I drew her blood every morning. Her mother was only worried, while her father seemed to mix his worry with distrust, as if the Transplant team was somehow conspiring to harm his little girl.
The Radiologist and the Transplant Attending were waiting for us. The ultrasound clearly demonstrated a patent hepatic artery and we brought Terry back to her room. On the way my beeper went off again. It was my Chief resident. It was a good time to do the appendectomy on Mikey. I called the OR and met the team in the ER and we wheeled our patient up to surgery.
With my Chief across the table from me I started the surgery. This was the final month of my internship and I was pretty adept at appendectomies. I delivered the offending organ, which was ruptured, and completed the surgery like a pro. No sooner had I tucked Mikey into the Recovery Room when my beeper went off again. Terry was crashing.
I raced through the tunnel and up the stairs to her bedside. My Chief was right behind. Her nurse wasted no time informing me that an ICU bed was ready. Terry was barely responsive, her BP was fifty over zero and she looked even greener. I scooped her up in my arms while her father stood behind me, screaming.
“If she doesn’t get better, you’ll never work in this city again,” he shouted. I think he would have punched me if he had the chance.
Meanwhile I laid her in the ICU bed. The Pediatric Anesthesiologist was standing by and deftly intubated her while the nurses opened up her IV and gave her a bolus of fluid.
“Rejection,” the Transplant Attending decided.
Terry was now functioning without a liver, more or less; her transplanted liver was causing more harm than help. She was placed at the top of the list so that the first ABO compatible liver that came available would be hers. Her father came in and stood at her bedside, glaring at me while I stood at the foot of the bed staring at the monitors. Her BP was better at 70/40 and her oxygen saturation was 100%. Still, she wouldn’t last long without a new liver.
It was early evening now and I finally had a few moments to catch up. I finished my charting for the day, drew some overdue blood tests and started a few IV’s which had been waiting for me. I was about to have “breakfast” when my Chief called me.
“A two year old girl is on her way by helicopter to the Trauma ICU. She was accidentally run over by her father.”
A minute later the call came. I was already on my way.
A crowd of nurses and paramedics surrounded the stretched as Christina was wheeled inside.
“BP 60/30, heart rate 125, O2 sat 100%,” a nurse screamed.
Two clear but terrified eyes stared up at me as my Chief arrived just behind me. Christina was awake and alert and breathing comfortably. A quick survey revealed bruising across her lower abdomen and pelvis and blood staining her diaper. There was obvious deformity of both legs.
Two distraught parents waited outside as the trauma team went to work. New IV lines were established and fluids administered. Blood was drawn for the blood bank and baseline lab tests. Antibiotics were given, oxygen administered. We did a quick peritoneal tap which was negative. Her vital signs were holding steady.
X-rays revealed a fractured pelvis and bilateral femur fractures. Her chest X-Ray was normal.
The OR was standing by and at 8:57 pm surgery commenced. My job, as intern, was holding retractors as the Attending and Chief Resident began the task of putting her lacerated perineum back together. Her vagina was torn down the middle and there was a small laceration of her rectum. Her fractures were to be treated without surgery, at least at this time.
The surgery dragged on, past nine o’clock, past ten o’clock, past eleven o’clock. All the while messages came, baby A needs a new IV, Mikey has a fever, Terry’s urine output is low and on and on. As midnight approached I began to feel a little dizzy. I sensed my heart was racing and I remembered I had not eaten anything all day. I concluded my blood sugar was probably around forty. I asked the OR circulating nurse to get me some orange juice.
The nurse found some apple juice and fixed it up with a straw and managed to get it into me. A few minutes later I was back among the living as the sugar filled my bloodstream. I was able to continue my relationship with the end of a Richardson retractor without passing out. Finally, shortly after one in the morning the vaginal and perineal repairs were finished. All that was left was to do a colostomy. I begged to be allowed to leave and finish all my undone work and to check on my other sick patients.
My superiors took pity on me and I was dismissed. I scrounged up a couple of Oreo cookies and went about the business of catching up. I checked on Terry first, gave her some more fluid and was informed that there was a potential liver in Houston. I started IV’s, answered calls for patients with fever or drainage from their wounds, drew the morning labs and thought I could see a glimmer of light at the end of the tunnel.
Christina was now back in the Trauma ICU and she looked stable, if not a little forlorn as she lay in bed with both legs up in traction, IV’s in each arm and tubes going every which way. However, she was OK and she still had those beautiful clear eyes, only now I didn’t see the terror.
Then my beeper went off. It was the ICU where Terry was clinging to life.
My Chief answered, “There’s a compatible liver in Houston. We’re leaving in ten minutes. Make rounds with the next crew and then you can go. We won’t be starting the surgery until about ten.
And there it was. My twenty four hour shift was now growing to twenty six. I did take a few minutes to get a real breakfast before starting morning rounds with the next team of residents.
Rounds were uneventful. We finished around eight thirty, but instead of leaving to get a little rest I stayed around to help with Terry. Dedication or stupidity? Both, I guess, but I assume it was mostly dedication and a sense of responsibility.
We started Terry’s surgery at around ten thirty and I took my position on the patient’s left where I would become reacquainted with my old friend, Richardson. The case went fairly quickly, at least for a liver transplant and after about two hours the new liver was in place. Every one left to take a break, that is everyone but me. Someone had to stay with the patient, who was still under anesthesia while the new liver “breathed.” I sat and watched the liver take on new life as Terry’s blood percolated through its sinusoids and it started to sweat bile. After about thirty minutes the rest of the team returned to do the final step, which was the biliary anastamosis.
I was happy to see the intern on call for that day return with them, which meant I was to be set free. It was almost two in the afternoon. My twenty four hour shift had lasted thirty two; a typical day for a surgery intern in 1985.
Christina, by the way made a complete recovery. Mikey spent about a week in the hospital but also recovered, while Nicole recovered from her NEC. Terry’s new liver worked for a few days, but she suffered through another rejection and this time it was too much and she passed away.
Modern medicine does indeed have its limitations.


Monday, May 26, 2014

Night Clinic ...Finale?

                

“Do you believe this? I mean this can’t be true,” I raved as I read the article in the “Post.”

           “City to Shutter Free Clinics
  Council cites Cost and Duplication of Services”

“You seem to taking this rather calmly,” I continued, addressing my dear wife, Nurse James.
She was preoccupied playing with our baby girl, Rose Elisabeth, who celebrated her three month birthday that day.
“Happy Birthday, sweet Rose. Who’s my big girl?” she cooed and held the girl up as high as she could reach.
Rose giggled and squealed.
“Forget the paper, at least for a while. Just look at this smile, this big beautiful smile.”
I did put the paper down and stood behind my two girls.
It will be OK. Just remember this is what is truly important. But, our patients? They’re important, too.
“I suppose you’re right, it will work out for the best. But, how many of our patients will be able to be cared for at the University Clinic? Walking two or three blocks is a lot different than taking a bus across town.”
“They’ll never close our clinic. We do too much good work,” she concluded.
“All the politicians care about is dollars, mostly how much they can put in their own pockets. You know what I always say…”
“Yes, yes, they are only two types of politicians, those that are in jail for corruption and those who haven’t been caught yet.”
“I’m glad you pay attention. Let me look at page eight where they go into more specifics about the clinics slated to be closed.”
Pages rustled and Rose laughed as I found the rest of the article.

“The free clinics which are to be closed has not yet been determined, but speculation is that clinics in neighborhoods where there is access to other care, such as private urgent care clinics and free standing Emergency rooms will be the first on the chopping block…”
“See, we should be OK. There certainly are none of those in that part of town.”
“There’s more. ‘In addition, those clinics in parts of the city where the crime rate is high or there is an unusual amount of gang activity also may be shuttered. Public hearings, where private citizens may voice their concerns, will be held in the next few weeks. Exact time and venue will be announced.’ I think that means we’re in trouble.”
Miss James stared at Rose and then held her close to her chest. Rose instinctively tried to help herself to a snack.
“Well,” Miss James began, “we’ve got a few weeks anyway. We should plan to go to those hearings. You know, speak up for the downtrodden.”
“You’re right, like always,” I answered as I looked at the clock. “Six thirty? I better be on my way. I hope there isn’t much traffic or I’ll be late. I don’t want to ruin my perfect record.”
Miss James smiled at me and my “perfect record,” but didn’t comment. I kissed Rose and my lovely wife.
“I wish it was next week and you were back at work,” I commented as I gathered up my white coat. “The other nurses are OK, but they are not Nurse James.”
I began the usual thirty minute drive to the clinic.
Not too much traffic for a change. I can’t believe they would even think about closing our clinic. On the other hand, if we moved maybe there could be a proper medical facility with a real modern lab and state of the art imaging. Dream on, doctor. This is not Beverly Hills or Beacon Hill. As far as politicians are concerned: no money, no voice. Then again, maybe I shouldn’t be so cynical. Here I am entering the “clinic neighborhood” and it’s not so bad. There are some trees over here and a little park. And, on the corner, members of one of our many independent youth group are hanging out. There’s even some new construction going up. It’s hard to believe, but someone, somewhere, actually has an interest in developing this part of town. Funny, I don’t know why I never noticed it before. Whatever that building’s going to be it looks very elaborate.
My head shifted away from my troubles as the radio blasted out some classic rock:

“Sitting on a park bench
Eyeing little girls with bad intent…hey Aqualung”

Jethro Tull seems very appropriate for this part of town.
I arrived at 6:55 and was greeted by Miss James sub, Mrs. Selma Cranston. She looked exactly like one would expect someone named Selma Cranston would look, mid fifties, matronly, dull brown hair tied back into a bun, adorned with a white, knee length dress, white stockings and white shoes,
I’m surprised she isn’t wearing a white nurse’s cap.
“Good evening, Dr. Barnes, I’m Mrs. Cranston. I’ll be helping you tonight. This is my first night here and I’ve never been in a clinic like this, so I hope you’ll be patient.”
“Glad to meet you. I’m sure you’ll do fine. It’s a bit of work, because it’s just the two of us. No techs, no aids, but we usually manage.”
What did she mean, “clinic like this?” We’re just like any other clinic; that is if those other clinics are visited by Ravens, bizarre superheroes, vampires, werewolves and mythological beasts.
“There’s a patient in room one, Milo Campo, 63, complaining of a non healing wound. He’s wearing a pith helmet and carrying a toy rifle. Oh, and I brought some fried chicken to eat, in case you get hungry later.”
“From Purdy’s Chicken Shack?”
“Where else?”
“Well, then let’s get to work.”
I picked up the chart for Mr. Campo. “Nonhealing wound on right buttock, no allergies, travelled to Tanzania recently, no other medical problems.”
I did my usual quick knock and went in.
“Good evening, Mr. Campo. What is the problem which brought you into our fine clinic this evening.”
“Get down, get down or he’ll get away,” he hissed through clenched teeth.
I looked back over my shoulder and then around the room.
“Who or what will get away,” I wondered out loud.
“The rhino, of course. Now get down before you get trampled.”
This can’t be happening.
Mr. Campo was dressed in beige safari gear, sported a gray pith helmet and was carrying a large, plastic hunter’s rifle. He grabbed me by the arm and pulled my arm, with considerable force, I must add. I joined him crouching behind the exam table.
“I don’t see the rhino,” I whispered.
He handed me his glasses.
“They asked me to check your wound, the one on your buttock,” I said. “How did you get it and when?” I added.
He looked around, pointed his toy rifle but then put it back at his side. He put his mouth against my ear.
“I was attacked by a rhino, a rare, vicious black beast who gored me in the buttock with his horn, almost a year ago,” He replied in a very low monotone. “But, I’m on the trail of that black demon. It’s not just any old rhino, you know. The monster I’m trailing is the rare Sumatran Three Headed Rhino. That’s right, three heads, three horns and a heart as black as its hide. When I get the rhino’s three horns, I’ll grind them up and sprinkle some of the dust on my wound. Its special properties will make it heal in a few days. The rest of the dust will be saved for the future. One can’t be too careful or unprepared these days.”
I nodded my head in agreement.
“Speaking of wounds,” I countered. “I believe you are here to have that wound checked, by a doctor, specifically, Dr. Barnes, who is me?”
“Oh, yeah, right. I’ve lost the trail anyway, Dr. Barnes.”
“Well, just drop your jeans and I’ll take a look.”
Mr. Campo slid his beige khaki pants and underwear down to his knees revealing a wound on his right cheek which was open to the air, about twelve by ten centimeters, extending into the subcutaneous tissue, but not involving any muscle or bone. There was some yellowish drainage, but no redness.
“How do you take care of this?” I queried.
“Take care of? I just leave it alone. It doesn’t hurt. I just have to change my underwear every few days.”
“Well, I think,” I began, “if you cared for it properly and kept a bandage on it, perhaps it might start to…”
“There it goes,” my patient screamed, “you won’t get away, you brute.”
And, Mr. Campo burst out of the exam run, trying to run while pulling up his underwear and pants at the same time. It was all I could do to hold the laughter inside as he finally got his pants pulled up and fastened and then bounded away, chasing his imaginary, three headed rhinoceros.
Oh, well, you lose some and then you lose some. Onward to new frontiers,
I moved on to room two, Myron Davis, 38, complaining of abdominal pain for five days. No previous medical problems, no allergies, no meds.
Should be simple.
“Good evening, Mr. Davis, what brings you into our night clinic?” I began.
Myron Davis was dressed in a black suit, white shirt with French cuffs, blue paisley tie, black socks and shiny, black leather shoes. He definitely did not have the look of our usual client. He was half sitting, half laying in the chair, his black hat perched on his chest, and did not get up to greet me. His face was flushed and beads of sweat dotted his forehead.
“Hiya doc, I hope you can help me,” he replied to my introduction. He looked around the room as if he there were other people present.
“It’s just you and me, Mr. Davis. Now what seems to be bothering you.
“It’s my gut, Dr….Barnes,” he answered staring at my name tag. “it feels like someone is driving a metal stake through it.”
“When did this pain begin?” I asked.
“Twenty years ago.”
“Did you say twenty years? Why did you come in tonight?”
“Excuse me Dr. Barnes, but are you recording this?”
“No,” I responded truthfully.
“Is any of what I say going into any sort of database or computer?”
“No, I’ll write it down and it will go into a chart.”
“A written chart, nothing electronic?”
“Sorry, to disappoint you Mr. Davis, but we are not a very well funded clinic. Computers and Ipads cost money; money the taxpayers are apparently loathe to spend. So, here we are, paper, pens, stone knives and bearskins.”
“That’s good, very good,” he concluded. “They won’t be able to find me.”
“Excuse me?” I had to ask, “But, who won’t be able to find you?”
“The spies, the government, our government, the Russians, the Germans, the Japanese, the Chinese, insurance companies, credit bureaus, credit card companies, banks, Disney; they’re all spying on us, spying on me, all the time, watching every move you and I make, watching every moment of our lives with massive computers.”
“Are you sure about this?”
“No question. Tell me, if someone makes an unauthorized purchase with your American Express card, do you get an e-mail or text message or phone call? Or, maybe all three. How do they know?”
“Hmmm…” was my reply, “but what about your abdom…?”
“Don’t trust anyone is my creed. No credit cards, no bank account, no social security number, just pay cash for everything, leave no digital footprint and no one will knock on your door in the middle of the night and cart you off to CIA headquarters.”
“Your abdominal pain,” I tried again to get a history, “When does it occur?”
He looked at me and then at his stomach and then took a deep breath.
“I began with this pain about twenty years ago when all this computer stuff started to grow. It was the World Wide Web which made me realize that no matter what I do, someone somewhere is going to find out or be affected. Then it was online banking and credit cards and My Space then Facebook and Twitter. But I learned the truth. Someone is always watching, always monitoring. I couldn’t find any peace. Sleep has become a luxury I just can’t afford. What if I say something about my pain? Someone will be listening. Well, my pain has just stayed with me. So, I took a chance and went to see doctors. I tried Tagamet, then Zantac, Prilosec, antacids. I had EGD’s and gallbladder surgery and finally resigned myself to my throwaway diagnosis: IBS.”
“So,” I interjected, “Why are you here tonight?”
“Oh, I need some meds refilled. If I call a pharmacy to get my prescription refilled they’ll put it in their computer and that’ll be the end. They will know where I am.”
“So all you want are some free samples? That’s easy. If we have any, you are welcome to them.”
“Just Carafate, it’s the only thing which helps.”
“Give me a minute and I’ll check in the back.”
“Uh, what are you writing?”
“Just your diagnosis and treatment. Probable gastritis, treat with Carafate. Samples given.”
“But, didn’t you hear anything I said. Everybody’s watching, they’ll find out. Sure, you only write it down now, but next month someone scans that chart and then, boom, I won’t be able to get health insurance, find a job, anything. I’ll be labeled, branded for life with…just the sound of it is ominous…gas-tri-tis. A mixture of gas and garbage. Just forget I was ever here. And, please, shred that chart.”
Mr. Davis got up, put on his fine black hat and walked out.
Two for two. A great start to the night.
“Room three,” I murmured, “Misty Rowe, ten, fever, cough, history of leukemia. No allergies.”
I knocked and went in starting my intro before I even saw my patient’s face.
“Good evening, Mis…” I started, but stopped when I was greeted by Evella, Goddess of the Night.
“Dr. Barnes, congratulations,” she said softly, her voice a bit raspy.
“Thank you Evella, Goddess of the Night,” I answered, but I was a bit shocked at her appearance. In the six weeks since I’d last seen her at my wedding, she had wasted away. Her skin was now a pasty yellow and her eyes almost glowed with jaundice. But, she still had her smile and her feisty demeanor.
“This is Misty, Dr. Barnes, a friend of mine. We met at the hospital while we were being treated. She’s in remission from ALL. Her mother works nights a lot and I watch her when I’m well enough. I do have a consent from her mother so that I can make medical decisions for Misty, if you’re worried about the legal niceties.”
“No, no, I’m sure everything is in order,” I said softly, a bit distracted by Evella’s cachectic appearance. I recovered my composure and added, “What’s the problem, Misty?”
“I’ve got a bad cough and my chest hurts. My fever today was 102.8.”
“Have you been treated for your leukemia recently?”
“My last chemo was four months ago. I thought I just had a cold, but Miss Worry wart here insisted we come to see you.”
I listened to her chest, which was clear, inspected and palpated, shot a Chest X-Ray which was normal diagnosed her with a cold and gave instructions for her to call her Pediatrician and Oncologist the next day.
I’m more worried about Evella.
“Misty, if you don’t mind,” I asked my young patient, “I’d like to talk with Evella, the Goddess of the Night, alone.”
“You don’t have to worry about me, Dr. Barnes,” she answered. “I know she’s got bad cancer and I know she’s probably not going to live much longer. Just like my friends, Justin and Liv. They died of their cancer. I cried for them, but, at least they didn’t have to suffer very long.”
“Kids with cancer live with death hanging over their head every day,” Evella explained. “You’re a doctor, you should know that. Anyway, anything you have to say, you may say in front of Misty. We have no secrets and she knows I’m dying. I assume that’s what you wanted to talk about.”
“Such remarkable intuition, Evella, Goddess of the Night, of course that’s what I want to talk about. Our first meeting taught me more about healing and the proper way to be a physician than all the lectures and rounds combined. And, you make great cookies. I’ll miss them and you.”
“You’re sweet, Dr. Barnes,” she said in that special voice she had as she patted me on the cheek and then on my derriere. “However, even though this vile cancer has had the gall to invade most of my vital organs, I am not planning to check out as soon as everyone thinks. I’ve got a lot of years of livin’ to pack into the time I have left. See this?”
She held up a colorful brochure.
“Two week cruise in the Mediterranean. Barcelona, Monte Carlo, Venice, Rome, Athens, all the food I can eat, first class all the way. If I’m going out, I’m going out in style.”
“Sounds great,” I observed. “You don’t need a companion, do you? Because, the news is that this place may be shut down which will leave me out of a job.”
“You’re still sweet, but not my type. Don’t worry about me, I’ll find some young buck to keep me company.”
“I wish you nothing but the best, Goddess,” I added.
I gave her a kiss on the cheek and, at that moment, we heard music coming from the lobby. The familiar strains of “Night Clinic Blues” no doubt being strummed by the talented hands of Wild Fingers.
Two in the morning? Very strange, very strange indeed.
We all went out to the lobby where Wild Fingers Dixon sat strumming his guitar, softly humming along. There were a few patients waiting to be seen and they seemed to appreciate the early morning concert.
“…Oh Night  Clinic Blues”
A familiar bluesy voice joined the guitar.
“Dear Nurse James, what are you doing here at,” I looked at my watch, “Two eighteen in the morning and who’s watching the baby?”
“She’s here, with me. Neither one of us could sleep and she kept pining away to see her father, so what could I do?”
She held little Rose up and I gave both my girls a big kiss.
“You do your work and all of us will keep Rose entertained,” she decided. “Good evening, Evella and…”
“This is Misty, a friend of mine who wasn’t feeling well, but, your wonderful husband has made us both feel better,” Evella answered.
“I’m not so sure of that,” I replied “and, if you’ll excuse me, I have a few more sick people to see.”
I left them in the lobby as Wild Fingers shifted to “God Bless the Child,” one of my favorites. I listened for the deep soulful voice of my wife while perusing the chart of my next patient.
“Elsa Walderstein, 78, deaf, complaining of severe headache.”
I hope she brought an interpreter.
I knocked and went in to room one. Fortunately, there was a younger woman seated with my patient.
“Good evening, I’m Dr. Barnes, what’s the problem you are having?”
The older woman sat in her chair and stared at me with a smile on her face, but it was obvious she did not comprehend. She was wearing a light jacket which covered her thin short dress, slightly worn white tights and square toed ballet slippers.
“Hello to you, Dr. Barnes,” the younger woman replied. “My name is Eva Schosser and this is my mother, Elsa Waldenstein. She has been having headaches for about three weeks and they seem to be getting worse. I’m sorry she can’t tell you herself. She’s almost totally deaf and only speaks German.”
Eva was middle aged, neatly dressed, with light brown hair and blue eyes which revealed only concern and worry.
“Why did you decide to bring her here tonight?” I queried.
“She told me that her headache was much worse and she felt like someone was pounding on the inside of her with an ax.”
“That’s how she described it? Pounding with an ax?”
“Yes. Does that mean something?”
“Probably not, but it is an interesting choice of words.”
 “How’s her health in general?”
“Considering her tortured past, excellent.”
“Tortured past?”
“Dr. Barnes, Elsa Waldenstein was famous in the old country. She was on her way to becoming Prima Ballerina for the top ballet company in East Germany. Unfortunately, one of the party officials took an unusual interest in her, a very intimate and unnatural interest. The rest of the story is not pretty. Let’s just say that she escaped East Germany and came to this country with nothing except the clothes on her back and a baby growing inside. Her flight to freedom was arduous with danger constantly lurking, but she survived and made it to this country. Unfortunately, there was a price. Hardship and injury caused her to lose her hearing, thus ending her dance career. She was granted political asylum here, but has lived a very hard and difficult life. A deaf woman with a newborn baby who doesn’t speak the language has few prospects. But, we survived. Only now she has these headaches and she cannot find rest. I’m afraid for her; afraid that this relentless malady will finally break her spirit.”
An amazing story.
“I will certainly do my best to help her,” I said hoping both Eva and Elsa sensed the genuine concern in my voice. “Let me examine her now.”
I started at the top and worked my way down. Everything was normal. As a matter of fact she appeared remarkably healthy for a 78 year old woman.
“Was she doing anything unusual when the headaches began? Or, has she suffered any injury, even something very minor?”
“Not that I’m aware of, but I’ll ask.”
Asking Elsa a question involved a complex series of hand gestures and written notes in German, which were followed by head shaking, nodding, more notes and finally, calm.
“She says no,” was the final result.
“I wish we had a CT Scanner, but we’re just a poorly equipped community clinic. Let me try something. I’ll be back in a minute.”
I asked Mrs. Cranston to start an IV on Elsa and then took care of the other two patients who were waiting, both with simple problems which were easily treatable with medications. They were sent on their way and I returned to Elsa and Eva.
“I’ve got something here that I think will help Elsa’s headache,” I explained to Eva. “It’s some medicine that will relieve any tension she may have in her muscles. It works almost immediately.”
“Thank you, Dr. Barnes,” Eva said and then she wrote a message to Elsa who looked up at me with hope in her eyes.
I took a syringe from my pocket and injected one milligram of Versed through her IV. She winced a little when it first went in.
Eva and I watched as the forlorn look on Elsa’s face began to fade. She closed her eyes and then the corners of her mouth began to turn up and a smile appeared. She opened her eyes and I saw a twinkle of life appear which had been absent a few seconds before. She jumped up from her chair and took off her coat, revealing her light dress and dancer’s body. She took my hand lightly and caressed it and then she did a pirouette.
“I think the medicine has helped,” I observed.
But there was more. She exited the exam room and when she saw Wild Fingers with his guitar she gestured for him to play. She stared at his fingers as he started to play, a classical piece which I didn’t recognize. Elsa, however, saw something that must have been from her past.
She began to dance, en pointe, moving gracefully across the waiting room on her toes, jumping and spinning in perfect rhythm to the music. The first rays of the sunrise pierced the clinic windows creating a dazzling display of colors and illuminating Elsa in an array of red, orange, yellow, green, blue and purple. She danced to me and curtsied, she elegantly leapt over chairs and spun around tables as those of us in audience stood in awe and applauded.
But, it could not last. The beautiful display was interrupted by three men, dressed in three black suits, wearing three pairs of black rimmed glasses and carrying three identical black briefcases.
This has to be bad news.
“Doctor,” man number one began, “I am Mr. Jacobs, from the Department of Health, this is Mr. Binder from the City Inspector’s Office and that is Mr. Berkowitz representing City council. May we talk to you.
Jacobs, Binder and Berkowitz. Perfect name for a law firm.
“Certainly,” I answered. “We can talk here.”
“Is there some place more private?” one of three inquired.
“Anything you have to say, you may say here, as I’m sure it may have some effect on my patients.
Wild Fingers, Evella and Misty, who was holding Rose, Eva and Elsa and Mrs. Cranston all stood silently, anticipating bad news. Miss James had vanished.
“As you wish,” Black suit number three answered. “We have an order here for this clinic to be vacated immediately. It is the conclusion of the City Inspector’s office that this building is unsafe and poses a hazard to anyone who occupies it. City Council has voted that this clinic be closed immediately. We are now requesting that the premises be vacated immediately.”
“But, Mr…uh…Berkowitz, what will become of the people who live in this neighborhood, who depend on this clinic for their well being, where will they go?”
“Doctor, I’m sure your intentions are most noble, but this building is unsafe. Would you want to be examining a sick child and have the building collapse? Of course not. All of your patients will be more than welcome at the County Hospital Clinic.”
“County? That’s five miles away. Do you expect our patients to walk?”
“Doctor…Barnes, I will not argue any further. The decision has been made. This building will be demolished and County Hospital will assume the care of your patients.”
“I won’t leave. I’m staying right here,” defiant words came from behind me, from Miss James. “You’ll have to cut my arm off to get me to move.”
At that moment there was a faint “click” and my dear wife handcuffed herself to a sink which was behind the reception desk.
“Misty, if you could please hand me baby Rose. Thank you.”
And, there we were, a stand off. On the one side were three carbon copy bureaucrats waving legal papers and, on the other, Miss James and Rose, battling for the little people. I was putting my money on my wife and baby.
The three men looked at each and then at Miss James and then at each other again.
I think she may actually win.
A voice interrupted the confrontation.
“THERE IT IS, THAT THREE HEADED MONSTER.” it shouted. Milo Campo returned.
“I’ve finally tracked it down after all this time. You won’t get away from me this time you vicious rhino. Black as night with a black heart to match. You’ll pay for what you did to me.”
“That’s a real rifle he’s pointing,” I whispered to Evella, who was standing close to me. Maybe we should get down.”
She nodded and we both stated to lower ourselves to the floor, as did the others in attendance.
My wife and Rose, they’re stuck.
“Prepare to pay,” Mr. Campo hissed through clenched teeth as he pulled the trigger.
Shots were fired and then there was a short scream. I jumped up and shielded Miss James and Rose, just in time to see Elsa jump, pirouette and push Jacobs, Binder and Berkowitz out of harm’s way. Evella tried to tackle Mr. Campo as he kept shooting, only now his rifle was pointing harmlessly at the ceiling, knocking out the lights and setting off the sprinkler system. Finally, the shooting stopped as Wild Fingers and Evella wrestled the gun away.
There was another scream as Eva knelt beside Elsa, who was lying in pool of blood.
I ran to her side as sirens whined in the distance.
Misty hung up the phone and shouted, “Ambulance and police are on the way.”
I felt a very thready pulse on Elsa as she smiled at me, struggling to breathe.
“Good doctor,” she whispered to me in English.
The pulse vanished.
I started CPR, but Eva stopped me.
“Please,” she said, “Please, don’t; you gave her a few minutes of peace and joy, but let her go. Just remember; remember the smile on her face and remember her dancing.”
Eva looked at her mother’s lifeless face and buried her face in her chest. Tears streamed down her cheeks when she looked up.
You know,” she began, trying to speak through her tears, “I had never seen her dance before. Oh, I’d seen newspaper clippings and photos in her scrapbook, but never the real thing. You gave me a gift that will be with me forever. And, I will be able to watch her happiness over and over.”
She had recorded her mother’s dance on her phone and now the graceful beauty of that dance would live forever.
The police came and took Mr. Campo away in hand cuffs. Jacobs, Binder and Berkowitz left their papers with the day shift crew who started to appear and begin the task of moving everything out. The police cordoned off where the shooting had occurred and went through the motions of performing an investigation. I resigned myself to looking for a new work venue.
My dear Miss James, however, remained defiant.
“Call the papers, call channel twelve,” she screamed, “I can see the headlines:

‘Bureaucrats try to oust Mother and Baby.’

“All the publicity will surely keep us open.”
“Are you sure about this?” I asked. “Is this what’s right for Rose?”
This cannot end well.
But, our luck was about to change.
I heard a car screech to a stop outside the clinic and looked up to see a big black limousine.
Even more trouble?
A burly chauffeur stepped out and opened the rear door. Out stepped a woman dressed in pink, bright pink which shimmered as the morning sun outlined her perfect figure. A broad white hat and dark glasses shielded her face. There was the sparkle of emerald and diamond earrings and emerald and diamonds rings adorning her perfect beauty. As this mystery woman walked closer, ignoring the police barricade, I realized I knew her.
Medusa.
I looked up at the sky and was not disappointed as Pegasus circled overhead. There was a faint whinny as that noble equine acknowledged me.
“Medusa…” I began, but she held up her hand.
She gave me a light kiss on my cheek as I took her hand and led her into the clinic lobby where she removed the hat and sunglasses, allowing her long silky hair to fall about her shoulders. She was even more beautiful than I remembered.
“I see you’ve moved up in the world,” I observed.
“My life is a rollercoaster. The fruit of immortality, I suppose. He’s good to me, fun and rich and generous. Which is why I’m here.”
“You’re going to make a donation to the Dr. Barnes Survival and Party Fund?” I asked facetiously.
She looked me in the eye and then answered, “Not quite, but close. Have you seen the new building going up a few blocks over? The fancy one?”
“Yeah, I was wondering what it was going to be.”
“That, dear Dr. Barnes, is going to be your new home, that is, the new Clinic. I read about the budget cuts and I was worried that this clinic might be in line to get the ax.”
I was speechless for a moment and then I said a soft, “Thank you.”
“No,” she replied, “Thank you.”
“Me?”
She looked down at the floor and then stared into my eyes again.
“I was cold and you made me warm,” she explained. “For that simple act of kindness I am grateful. And for all the acts of kindness you and the people at this clinic perform, we are all grateful and indebted to you.”
She reached into her Chanel purse and fumbled around for a moment before pulling out a big manila envelope.”
“Here are all the details. There is an endowment of $150 million to keep the clinic funded. The new clinic will have a larger waiting room, eight exam rooms, a procedure room, a complete lab which will be properly staffed, Radiology with a CT Scanner and ultrasound, also staffed, a kitchen, storage and doctor’s offices. You also have my pledge that you will not want for anything as long as I’m alive, which, as you know, will be a long time.”
“I don’t know how to thank you, for myself and all the people who live here. When will it be ready?”
“About two months from now.”
“And between now and then?”
“You’re stuck here, I’m afraid.”
“But, the building’s been deemed unsafe; we’re supposed to vacate.”
“Ah, yes, that. Politics and graft. My husband did some checking. Some of our less scrupulous political servants were trying to get this space at a cut rate price. They bribed a City Inspector to condemn the building so that they could put up some sort of shopping mall or low rent housing or something. Whatever, they’ll be on their way to jail soon.”
“Did you hear all that, Miss James?” I turned to my wife, still handcuffed to the sink. “I guess you can set yourself free.”
“Yes, it all sounds wonderful,” Miss James answered. “Now, if you’ll just get me the key, I’ll set myself free.”
“The key? What key?” I asked.
“The key in the desk in the back. It’s where you keep your stuff. I found these cuffs back there and came up with the idea to chain myself to the building.”
“I’ll go look, but I’ve never seen those handcuffs before. In the meantime, maybe Medusa would like to see beautiful baby Rose?”
I took Rose from my wife and handed her to Medusa and went into the back to find the key. I searched high and low, up and down, back and forth, but there was no key. I had no choice but to report my failure and suffer Miss James wrath.
“WHAT, NO KEY? DO YOU EXPECT ME TO STAY CHAINED TO THIS TOILET FOREVER?”
“It’s a sink,” I corrected.
She tried to kick me. Medusa once again came to my rescue.
“I think I can help,” she offered, “rather, Pegasus can help.”
“What can a horse do about handcuffs?” Miss James wondered, showing a distinct lack of faith and understanding of things mythological.
“I’m game to try anything,” I added.
Medusa let out a loud long whistle and Pegasus alighted outside the clinic door. Medusa whispered in his ear and he turned around so that his hindquarters faced my wife.
“Close your eyes,” Medusa commanded.
Both myself and Miss James closed our eyes. There was a sharp noise as Pegasus gave a precise kick and the handcuffs opened up.
Miss James rubbed her wrists as she got up and bowed before the winged horse.
“Thank you, both of you,” she addressed Medusa and Pegasus. “I wish you both a long and happy life.”
I also thanked them and walked Medusa to her limousine.
“Will we see each other again?” I wondered out loud.
“Perhaps, should the opportunity or need arise. I have a special place in my heart for you. The envelope I left has the name of the builder and architect for your new clinic. Good luck and be happy,” she advised as she climbed into her fancy limo and drove away.
“Rose,” I said, holding up my daughter, “I think you are due for a change. A diaper change.”
Miss James and I carried her to the back.
“And, just what were you doing with handcuffs?” she asked as she grabbed my arm.
“Me, I thought they were yours,” I answered. “What could I possibly do with a pair of handcuffs?”
“I can think of a few things,” Miss James remarked as she bent over to change Rose’s diaper, trying to hide the smirk on her face.