Tuesday, July 2, 1:35 a.m.
Wearily, Mitt walked down the long hallway from the elevator bank and entered the resident on-call area. On this occasion, the lounge area was empty. When he’d passed through four hours earlier there had been a group of residents including Madison Baker relaxing in the room. He’d stopped to say hello and had been introduced to several of the internal medicine residents who were also on call. He hadn’t joined them as he was tempted to do, but rather had gone into his assigned room, taken a quick shower, and tried to get some sleep.
Unfortunately, as keyed up as he’d been, he hadn’t been able to fall asleep before being called to the sixteenth floor to check on a patient who had allegedly fallen out of bed.
On that mission, he’d learned that the first-year resident was required by hospital policy to examine everyone who had supposedly fallen out of bed even though most often no one had fallen out of bed at all. Instead, what normally happened was that the patient had sagged to the floor on the way to the bathroom, while in the bathroom, or on the way back to bed. This had been the case on his first such mission as well as on a second one he was just returning from at that moment. As he keyed open his on-call room door, he imagined that checking on people who were said to have fallen out of bed was going to be a common occurrence for him as the year progressed.
So far, despite his concerns, his first night on call had progressed without any major disasters or even a minor problem. He’d completed the three admission histories and physicals without an interruption. Following Madison Baker’s suggestion, he’d tried to limit the history taking, but it was difficult. In contrast to his medical school experience, where he’d been encouraged to be agonizingly thorough, he had to consciously limit his delving into the patients’ family histories of disease and injury. Of the three people, he’d been the most impressed by Ella Thompson, a grandmotherly eighty-two-year-old Black woman. During the course of the history, Mitt had learned she was actually a great-grandmother with fifteen great-grandchildren. Mitt had been impressed with how cavalierly she seemed to be facing open-heart surgery in the morning. She’d had heart issues since she’d had rheumatic fever as a teenager, and she told Mitt she was looking forward to having it taken care of once and for all by having her leaky mitral valve replaced.
The other two workups hadn’t been as interesting or easy. Both had required translators, which made the process much more difficult. It had been Portuguese for Roberto Silva and Spanish for Bianca Perez, and both patients through the translator claimed to know next to nothing about their family’s or even their own medical histories. They were also both minimally cooperative, as if resenting Mitt’s efforts. Following Madison’s advice, he concentrated on making sure there was no immediate contraindication for their scheduled surgery, which there didn’t seem to be. Helping the process to a degree, all three had extensive medical histories in their EHRs, which included documented cardiac issues for Thompson, details about pancreatic cancer for Silva, and a long history of diverticulosis for Perez.
Following the completion of the three admission workups, Mitt had gone back to the on-call room but had been quickly called out on his first falling-out-of-bed episode. This was followed by being kept busy hour after hour with one minor problem after another, often involving a combination of dosage questions, IV issues, sleep medication requests, or demands for laxatives. He found the nurses very helpful and often apologetic at having to call him to solve such problems, which they were certainly capable of handling but couldn’t because of hospital policy based on legal constraints. He was now hoping for a breather, having just dealt with his second falling-out-of-bed episode, and he hoped despite his predictive fears he could get some needed sleep.
Once inside his room, Mitt eyed the bed and then looked over at the bathroom door while feeling totally exhausted from having been on the go for some twenty hours. His momentary confusion was stemming from a debate on whether to take another quick shower. Despite his feeling rather grubby, the bed won out. Without even taking off his white coat or slipping out of his shoes, he lay down, stretching his tired legs out to the end of the bed and briefly massaging his thighs. He figured he would just relax for a few moments before getting up and at least washing his hands and face. But it didn’t happen. In the next instant he was in a dreamless sleep.
When his phone rang in his pocket, Mitt bolted up into a sitting position, feeling momentarily disoriented to time, place, and person. Quickly he oriented himself to the on-call room before struggling to get the phone out of his pocket. As he answered, he noticed the time. It was 2:10, meaning he’d been asleep for maybe a half hour.
“Hello,” he said. His voice was so scratchy that he had to repeat himself.
“Dr. Fuller, my name is Helena Santos. I’m a nurse assigned to your patient Benito Suárez, the abdominal aneurysm repair. He is complaining about pain.”
“Okay…” Mitt said, trying to organize his thoughts. Knowing firsthand the extensive surgery the man had that day, he knew that his having significant pain was hardly surprising. When Mitt had gone by earlier in the evening to introduce himself to the patient and check on him, Suárez had seemed to be doing reasonably well. Mitt had managed to learn this even though there was a significant language problem. The man was Brazilian, and Mitt didn’t speak Portuguese, and the man’s English wasn’t very good.
When checking the EHR at the time of his visit, Mitt had noticed that the patient had what Mitt assumed was adequate pain medication prescribed on a PRN basis, a Latin term for pro re nata, or as needed. There was even a setup where the patient could administer the pain medication himself via his intravenous line, with some limitations as to how often. “Do you know if he has been using his pain medication?”
“Yes, he has,” Helena said. “Plus, following written orders, I was able to give him some additional pain medication if needed, which I did an hour ago. But he is again complaining, and it is way too soon for him to be given yet another dose.”
“What would you have me do?” Mitt questioned, unable to think clearly in his tired state.
“You need to come and check on him,” Helena stated with a hint of irritation.
“Okay,” Mitt said, realizing from her tone he had little choice even though he didn’t think his being there was going to provide any answers. “I’m on my way.” He disconnected the call, put his legs over the side of the bed, and stood up. A wave of dizziness hit him, but it quickly passed. Going into the bathroom, he splashed cold water on his face. He stared at his image in the mirror as he dried himself off. Dark circles were prominent under his eyes, while the whites had spiderwebs of tiny red vessels. He certainly wasn’t looking his best. To try to help his appearance, he pushed his hair into a semblance of order. As he did so, he wondered what he was going to look like a month from now if he appeared this bad during his first night on call.
Trying to rally his energies, he headed out of the bathroom but was still in a daze. As he passed his bed, he eyed it nostalgically. Leaving the on-call room, he made sure the door was locked behind him. By the time he got to the elevators, he felt a little better and more awake, especially after taking a few deep breaths waiting for one of the cars to arrive.
Reaching the night-darkened fifteenth floor, he stopped at the appropriate nurses’ station on his way to Mr. Suárez’s room. In contrast with earlier that evening when he’d done his workups, the area was peaceful, with only three nurses silently busy in front of separate monitors behind the counter. No one even looked in his direction until he called out.
“Excuse me! I’m Dr. Fuller, and I’m looking for Helena Santos. Any idea where she might be?”
“I think she’s over in 1504,” one of the nurses said. She was the only one of the three who looked up in Mitt’s direction. “At least that’s where she was a few minutes ago.”
“Okay,” Mitt said. “If she appears, tell her I’m down there.” The nurse nodded but didn’t verbally respond.
As he headed down the darkened hallway with the muffled sounds of monitoring devices emanating from various rooms, he hoped that the nurse would still be there. He was counting on her offering suggestions of what to do. Otherwise, he might have to call Madison, which he’d rather not do for something as trivial as adequate pain medication. If and when he called her, he wanted it to be about something serious. He didn’t want to become known as someone who cried wolf over insignificant details.
As he reached 1504, he noticed the door was completely open and the rare single room was moderately illuminated. Entering, he could see that it wasn’t from the overhead lights but rather from a reading light behind the bed that cast long shadows across the rest of the room. There was also some light coming from the open bathroom doorway.
Benito Suárez was propped up, with his torso slightly raised by pillows behind his head and shoulders. Both side rails of the bed were up. An intravenous bag was hanging from a pole attached to the head of the bed, and the tube ran down into the man’s forearm. He was a stout, heavily built man in his late thirties who appeared much older. He had a ruddy complexion with short dark hair and rounded facial features that were currently pulled into a grimace of pain. Both hands were gripping the sheets on either side of his body. Save for the dressing over his abdominal incision, which was held in place with paper tape, he was naked from the waist up. A narrow tube that Mitt knew functioned as a drain snaked out from beneath the paper tape and was connected to a small clear container hanging beneath the bed. Beads of perspiration dotted the man’s forehead.
Feeling nervous and inadequate but pretending otherwise, Mitt walked up to the right side of the man’s bed, glancing at the drainage container as he did so. He noticed there was a small amount of bright red blood in its base, yet since the container and the connecting tube were mostly empty, he gave it little thought. He assumed the nurse on the opposite side of the bed was Helena. It had been apparent they were conversing when Mitt arrived but now both looked in his direction.
“Hello, Mr. Suárez,” Mitt began. “I understand you are experiencing some discomfort.” He purposefully tried to minimize the situation in hopes it would solve itself.
“Muita dor, Doutor. Muito! Muito!” he managed through a clenched jaw.
Mitt glanced over at Helena although he had a pretty good idea of the meaning.
“He says he has a lot of pain, Doctor,” the nurse said. “Too much.”
Mitt nodded in understanding. “And, just to be certain, he’s had all his prescribed narcotic, correct?”
“Absolutely. As I mentioned on the phone, besides his own pain meds, I gave him an additional dose just a little more than an hour ago, but it hasn’t touched him, as you can plainly see. He’s not due for another dose for another three hours.”
“Okay,” Mitt responded, as much for himself as for the others. His mind was in high gear, trying to decide exactly what to do. Short of calling Madison, the only thing that came to mind was possibly taking a peek at the incision and maybe gently palpating the man’s abdomen. At least it was something. He said as much to the patient, using gestures and very simple English, trying to ask if it would be okay.
“Por favor faça alguma coisa, Doutor. Por favor!” Benito managed.
“He said okay, go ahead,” the nurse translated.
As gingerly as he could, Mitt began to pull the upper edges of the paper tape off Benito’s abdomen, hoping not to make the man’s discomfort worse. Slowly he succeeded, and eventually he was able to fold the entire dressing down toward the foot of the bed, exposing most of the sutured incision that Mitt had done under Nancy Wu’s supervision. At the lower end, the drain tube issued forth, again with a tiny amount of bright red blood in its lumen but not a lot. From Mitt’s perspective everything looked normal, with the “ladder-rung” sutures crossing the incision every centimeter or so. At Dr. Wu’s direction they had all been snugged up but not too tight. The circulation of the tissues appeared fine.
“Do you need some gloves?” Helena questioned.
“That would be a good idea,” Mitt said, embarrassed he’d not thought of it.
The nurse immediately disappeared, leaving Mitt and the patient alone in the room. Benito looked up at him with what Mitt interpreted as a pleading expression. The problem was that Mitt still had no idea what to do.
“I’m sorry you are having so much difficulty,” Mitt said, feeling the need to say something while they waited for the nurse’s return.
“Eu não entendo,” Benito groaned.
“He says he doesn’t understand,” Helena explained as she came back into the room. She handed Mitt a package of sterile gloves. He was impressed by her speediness even though he knew this room was relatively close to the nurses’ station and hence to all the supplies.
“I assumed as much,” Mitt said as he tore open the package and struggled to don the gloves while maintaining their sterility. As he fumbled through the process in front of an audience, he thought that the proper technique for donning surgical gloves was yet another one of those little, practical things he should have been taught in his four years of medical school.
When he was ready, Mitt leaned over the patient and examined the sutured incision by gently palpating its edges. Everything felt normal, without any localized lumps that might suggest a hematoma or collection of blood. Then another idea occurred to him. Maybe he should press on the sides of the abdomen very carefully to get an idea of the man’s intra-abdominal pressure and explore the possibility that the drain was clogged. If that had happened, he asked himself, might fluid possibly build up and cause the acute pain the man was experiencing? It seemed like a plausible idea, yet as he continued to carefully palpate, the abdomen didn’t seem to be as tense as he would have expected if that were the case. On the contrary, it seemed to be as soft as normal even with the man tensing by reflex when Mitt gingerly pushed in.
Mitt straightened back up to his considerable full height. As potentially intellectually rewarding as the concept of a blocked drain had momentarily been, it now seemed out of the question. The problem was that he needed to come up with yet another theory as to what was going on to cause the man so much discomfort despite adequate narcotics.
While Mitt’s mind grappled with the issue at hand, he noticed something strange. The light in the room seemed to flicker. Mitt glanced at the source, the reading light at the head of the bed. When that was clearly as steady as normal, he wondered if the origin had been inside his own exhausted brain. Remembering his earlier, very weird phantosmia, Mitt shifted his gaze to the nurse for confirmation, and she, too, appeared momentarily addled, staring at the reading light. Seeing her reaction made him change his mind; maybe there’d been a blip in the power in the entire building.
But then Mitt was distracted by a strange popping sound, diverting his attention away from both the nurse and the flickering light back down to Benito’s incision. To Mitt’s surprise and shock, the uppermost suture of the midline incision had opened with a pop, as if the knot had just suddenly been untied by some mysterious internal force. Before Mitt could react to this strange phenomenon, the same thing happened to the second suture and then the third. It was as though the incision was unzipping. Even more alarming, at the very same time the sutures were spontaneously untying, Benito’s belly began obviously and rapidly swelling, akin to a balloon inflating.
With a reflexive urge to do something in the face of a growing catastrophe, Mitt shifted sideways to allow him to place the palms of his gloved hands along the sides of the progressively opening incision to try to push the edges together to keep further sutures from bursting open. But his effort was to no avail. The abdomen continued rapidly to swell, and the sutures continued to open, with some not untying but cutting through the skin. And now it wasn’t only the skin sutures. The deeper-layer catgut sutures were audibly popping open in the interior of the wound, same with the even deeper and stronger wire sutures as the man’s abdomen kept ballooning.
Before Mitt or Helena could react, the entire wound burst open with a sudden, pulsating geyser of bright red arterial blood. It came in gigantic spurts as each one of Benito’s heartbeats pumped out his life’s blood, drenching himself, the bed, Mitt, and even running down onto the floor.
Helena leaped backward, howled, and then disappeared from the room as Mitt continued to try ineffectually to hold the edges of the wound together, with the misguided idea that he could possibly stem the flow. In the next instant Helena and a bevy of other nurses came dashing back into the room carrying a host of sterile towels. Not sure what to do with them, Mitt grabbed them and jammed them blindly down into the gaping incision in hopes of stemming the blood loss. He was literally up to his elbows in gore, the sleeves and front of his white coat and his scrubs soaked in bright red blood.
At least Mitt’s pressure with the towels was working, or so he thought, since the blood flow significantly decreased and then appeared to stop. That was until one of the newly arrived nurses said that the patient had no blood pressure although there was a weak pulse. It was then obvious to everyone that Benito Suárez had bled out.
“What the hell are we going to do?” Helena yelled at Mitt.
Mitt stood up and pulled his blood-soaked arms out of the wound and looked blankly at Helena, as confused as ever. Before he could respond, Madison Baker came dashing into the room like a godsend. “Good God!” she voiced with a shake of her head as she confronted the scene.
All the nurses now turned to Madison as she rushed up to the bed, her eyes taking in the entire disaster. “Let me be sure: This was today’s abdominal aneurysm case, correct?” she demanded.
“Yes,” Helena fired back.
“Okay, cool it!” Madison ordered. Instead of barking orders as Mitt and the nurses expected, she pulled out her phone and then disappeared from the room.
For a few seconds, all the nurses and Mitt exchanged confused glances, then all but Helena and three others left. Mitt didn’t know what to say or what to do until he decided to at least remove his blood-smeared surgical gloves. As soon as he did, Madison returned.
“Okay, I spoke with Geraldo Rodriguez and told him what happened. He wasn’t at all surprised. He said the patient’s aorta was in super-sad shape, and he was surprised they had been able to attach the graft at all. Actually, I had already heard that from Nancy Wu, so when I ran in here, I wasn’t about to pull out all the stops for a full-scale resuscitation and order up an emergency surgery. Dr. Rodriguez fully agrees. Obviously, the abdominal aorta blew. Whether it was the anastomosis or another part of the aorta, we’ll have to wait for the autopsy to find out. Anyway, that’s all she wrote. It’s now a medical examiner case. Get housekeeping up here, ladies, please, and, Mitt, you do the paperwork. Okay?”
“Okay,” Mitt said, feeling shell-shocked. He didn’t know what doing the paperwork required, but he was reasonably sure the nurses would fill him in. He followed Madison out into the hallway. Helena and the three other nurses stayed back in the room, starting the cleanup. Mitt took off his blood-soaked coat and balled it up with the bloodiest parts on the inside.
“How long were you in the patient’s room before the shit hit the fan?” Madison questioned en route to the nurses’ station. To his surprise her tone was remarkably normal, similar to how she’d sounded down in the cafeteria.
“Not long,” Mitt said, finding his voice with some difficulty. He felt traumatized.
“Why didn’t you call me immediately?” Madison continued to question him matter-of-factly. “Why did you wait? Hell, that must have been a horrendous experience for you. More trial by fire, I’d have to say.”
“I was trying to handle it myself,” Mitt admitted sheepishly. “I suppose I should have called you. I don’t know why I didn’t. I’m afraid it is all a steep learning curve. I just wish I was better prepared, for the patient’s sake and my own.”
“Amen!” Madison responded as they arrived at the nurses’ station. “We’ve all had to go through what you are going through. It’s a bit of the luck of the draw. But chin up! Get the paperwork done and try to get yourself some sleep! You’ve got a full day of surgery ahead of you in a matter of hours. If there are any other problems tonight, I’m available if you need me.”
“Okay,” Mitt managed.
Madison gave Mitt an encouraging tap on his shoulder and a fleeting smile of encouragement before heading down the long, dark corridor toward the bank of elevators.
For a moment, Mitt watched her go. He felt decidedly envious of her experience and apparent sangfroid. Would he ever obtain a similar confidence in such a circumstance? He didn’t know, but he hoped so.