KEVIN BARTHOLOMEW WAS WRITING medication orders in the residents’ room, a den of tattered couches and rickety folding chairs cluttered with the detritus of take-out food delivered from local ethnic restaurants. One of Kevin’s fellow senior residents walked in and grabbed a day-pack. He looked at Kevin’s scrubs and waist-length white coat, already rumpled and stained with spattered coffee and blood.
“How many hits so far?”
Good question, thought Kevin. He had lost track. He thumbed through his clipboard, searching for a list of patients admitted to his ward team today.
“Six, plus one in the ER waiting for an ICU bed.”
“Oh, man! It’s only four in the afternoon. You’ve got sixteen more hours to go.”
Kevin gave a fatalistic shrug and continued writing.
“Be a wall.”
Kevin kept scribbling.
“No dirtballs you can sweet-talk the ER into dumping back on the street?”
“Nope.”
“No one you can transfer to surgery or psychiatry?”
“They’re all keepers,” Kevin replied with no hint of complaint.
“You’re impressive, man.”
Kevin stopped writing and squinted at Jay Seward, weighing how much sarcasm there might be in his use of “impressive.” Kevin still had trouble deciphering that in compliments from native Californians.
“No, seriously, I mean it,” Jay insisted. “Seven admissions by four in the afternoon and I’d be screaming at any ER doc who called me with another hit and throwing charts at any student who asked for help. I’d be in mortal terror my head would never get above water.”
“Thanks, Jay, but not thinking about that possibility is how I cope.”
“Oops, sorry. Well, try to protect your interns. Give all the dirtball admissions to what’s his name, that gross slob of a fourth year student you’re stuck with.”
Kevin frowned. While the macho house staff patter at times soothed his frayed nerves, he wasn’t completely comfortable with it, and cruelty was definitely going too far.
What an asshole, he thought, watching Jay leave the room and cross paths in the hallway with a tall, middle-aged, Asian-American attending physician. “Herb Wu” was embroidered on the lapel of the man’s pressed, immaculate, knee-length white coat. City Hospital’s chief of pulmonary medicine gave Jay a brisk nod. Jay smiled back eagerly, but Herb Wu didn’t slow down.
“A kiss-ass, too,” Kevin muttered.
He knew Jay wanted to be accepted into a training program for pulmonary specialists, preferably the university one here in San Francisco which included rotations under Herb’s supervision at City Hospital. Kevin had also applied for a university fellowship, one in infectious diseases. Though he didn’t really care whether he was accepted or not. He was sure one of the local public health clinics would hire him. A clinic job or a fellowship would pay more than his current salary, and both options entailed vastly more sleep than he was getting now.
But it would be cool, he mused, very cool knowing how to use all the microbiology tests at an infectious diseases specialist’s disposal, being able to make rare diagnoses like typhoid fever or brucellosis. Even more alluring were the cures when you got the diagnosis right and prescribed the correct antibiotic in time. This reminded him of his latest admission. He jumped up and ran after Herb Wu.
He found Herb in the intensive care unit huddling with house staff discussing a case Kevin had heard about in morning report—an alcoholic in withdrawal who unexpectedly developed heart failure.
“I don’t get it,” said the junior resident. “His heart rate’s rising and his blood pressure’s dropping, but he doesn’t have a fever or a white count, so I don’t think it’s sepsis. And he’s not agitated. In fact, he’s clearing mentally. His crashing can’t be due to DT’s, can it?”
“His last EKG’s OK,” added the intern, her hands full of heart monitor tracings and laboratory printouts. “There’s less pulmonary edema on this morning’s chest film, his cardiac enzymes are normal, and his blood gas is improving. So it can’t be a myocardial infarct, or worsening heart failure, or a pulmonary embolism, right?”
“Good thinking, guys,” said Herb.
Kevin knew Herb Wu was the child of Chinese immigrants, that English was his second language. Yet Herb had a patrician aura, like the lawyers and corporate executives who lived in Back Bay townhouses and dropped off their Mercedes and BMWs to be serviced at Bartholomew Motors during the summers Kevin had worked in his father’s South Boston shop. He supposed Herb’s charcoal, razor-cut hair and thick black eyebrows were part of the effect, as well as the way he dressed—Brooks Brothers wool slacks, Oxford shirt, herringbone sports coat. There was also the thin, diagonal scar across his lower lip that suggested mysterious sophistication.
No, Kevin thought, it’s his gracious self-assurance. That’s what’s classy about him.
Herb crossed his arms and shook his head.
“We’re missing something. Let’s see the x-rays again.”
Kevin followed the group to a glass box where the intern attached two rectangular sheets of black film and pushed a light switch. The patient’s lungs appeared as negative images—black spaces between white rib shadows. The faint patches of white haze in yesterday’s x-ray were absent in today’s film. Herb peered closely. With the tip of his forefinger, Herb outlined the white heart shadow in each x-ray.
“What do you think?” he asked.
Neither house staff answered.
“The heart’s enlarged in both films, yes?”
They nodded in agreement.
“When he was transferred to the ICU, we thought he was in congestive heart failure. You guys gave him a diuretic. He put out a lot of urine. And today we see less fluid in his lungs—just what we wanted to happen. But look carefully at his heart. If anything, it ought to be smaller now. It’s not. That’s clue number one. If you look at the shape, you’ll see clue number two. Yesterday, normal like a pear. Today, rounder like an apple.”
Kevin understood immediately. Something must be irritating the stiff, fibrous sac surrounding the man’s heart. Maybe a virus, or perhaps a toxic effect of one of the medications that had been administered. Whatever the cause, his body’s inflammatory response had resulted in fluid accumulating inside the sac, enough fluid to keep his heart from filling completely with blood after each contraction. The condition was called cardiac tamponade and would be fatal if not relieved soon.
“Holy shit!” cried the resident. “He’s in tamponade. That explains everything. Wow, thanks Herb.”
The two house staff rushed off to gather equipment, thrilled at the prospect of the procedure they were about to do. Kevin felt a pang of envy. He wished this was his patient, that his hands would be the ones to guide in a long needle, suck out the fluid without injuring the beating heart inside, and save this man’s life.
Impressive pick-up, he thought, studying the two x-rays. The difference in the two shadows was subtle. Kevin wasn’t sure he would have noticed the change in shape if Herb hadn’t pointed it out. How could Herb see so much in a chest film?
Kevin suddenly realized Herb had already honed in on the cause before he even compared the films. In the time it took to mount two x-rays on a light box, he had picked up all the clues and walked their strings back, narrowing the possibilities down to the most likely suspect, cardiac tamponade. He was expecting to find a rounder heart.
Now in his third and final year of internal medicine training, Kevin could fully appreciate Herb’s skill at diagnosis, particularly his relaxed precision and speed. As an intern, whenever Kevin had been the first to discover the cause of his patient’s illness, he would continue contemplating each plausible alternative over and over to convince himself of certainty. He had seen mistaken diagnoses lead to giving the wrong medication with catastrophic results. Even a correct diagnosis could be terrible knowledge if it revealed a grim fate. Eventually, he learned to suppress his fear of lurking dark truths. Now he craved the confidence and accuracy that Herb had.
“Next?” said Herb.
Kevin gave a staccato summary of the case he was admitting to the ICU. Herb stopped smiling as soon as he heard the patient’s blood oxygen level.
“Here’s his chest film,” said Kevin, clipping an x-ray to the light box with a practiced upward twist of the wrist.
Herb sat down and studied the film, tapping his fingers on the desk top. His eyes darted across radiographic landmarks, hunting for signs in the shadows.
“Benign history, right?”
“Other than shooting speed in the remote past. And I believe the remote part. I’ll call his clinic doctor to confirm it. Oh, he’s had a few STD’s. I think he works the bathhouses for income.”
“You said normal blood count?”
“Except for low lymphocytes. That mean anything?”
“Maybe.”
Pointing to the x-ray, so homogenously white that ribs could hardly be distinguished from underlying lung, Herb said, “You can never say never when it comes to TB, but I don’t think that’s what this is. Sorry, Kevin, no clues here. You can get more sputum for TB testing in the morning, but your patient is in bad shape. We need to go where the money is. He has to be bronched tomorrow.”
“God, I was hoping you’d say that. Thanks, Herb.”
“We’re here to serve.”
As Kevin trudged to the ER, he thought about Herb’s reaction after hearing the patient was homosexual. There had been no sardonic amusement, no undertone of distaste. That was unusual among the senior medical staff at City Hospital. Not that Kevin would have been offended. Such snide disdain seemed almost respectful when he remembered the overt disgust he had witnessed in South Boston, especially at high school and his father’s garage. Of course, none of it had ever been directed at him. Kevin had been too cautious to be discovered until he was sure he could escape.