Wednesday, July 3, 6:10 a.m.
Mitt got off the elevator on the tenth floor and with great trepidation walked into the ICU. Just across the threshold, he felt overwhelmed. He’d visited it briefly on the rapid Monday-morning tour with Andrea and Dr. Van Dyke, but that was different. Now he was alone and dressed like the doctor he was supposed to be, but he was inwardly terrified that someone would ask him a critical question or, worse yet, to actually do something. Not only would he invariably not be able to respond but how little he knew would be exposed to the world at large. In truth he felt like a total charlatan in his white resident’s outfit and wished he were invisible.
His plan was to check on Bianca Perez as quickly as possible and then get the hell away. But first he had to find out where she was. The layout of the ICU was similar to the inpatient floors, eighty or so patient rooms located around the periphery, with windows and natural light, while all the support services were sited in the core of the floor. Here, though, the nurses’ stations weren’t centralized but rather dispersed, small discrete stations that served only the two adjacent patient rooms or patient slots. He didn’t even know if they called them nurses’ stations.
Mitt found the ICU intimidating because not only were all the patients in a critical clinical state, but it was also an UpToDate medical-technological wonderland that had already gone through a total renovation since the Bellevue high-rise had opened. Mitt had only a vague idea of the function and details of some of the important equipment, like the ventilators that were breathing for those patients who couldn’t adequately breathe on their own. If a nurse were to ask him even a simple question about one of them, he’d be lost.
The ICU was also an inordinately busy place with numerous technicians, other support staff, and nurses for each patient such that the whole floor was in a kind of anxious frenzy, with people coming and going in constant activity. Also unique, most everyone was dressed in surgical scrubs, making the place visually very egalitarian. On the positive side, Mitt knew there were a number of intensivist residents and attendings mixed in with everyone else since Critical Care was a medical specialty in its own right.
Building up his courage, Mitt stopped a woman carrying some blood tubes, apparently on her way to the laboratory. “Excuse me,” he said. “How do I find a specific patient?”
She pointed off to Mitt’s left toward a central station of sorts where there were a number of monitors. “The easiest way is just type in the name and hospital number. It should pop up.”
Mitt thanked the woman and wondered why he hadn’t thought of the idea himself. Although most of the monitors were in use, he found one that was free. He didn’t bother sitting down. He typed in Bianca Perez, and even without the need to add the hospital number, her ICU room number, 10 South, appeared. Immediately he turned off the monitor and headed toward the designated room, even though he knew he could probably find out what had happened to her from the EHR. As upsetting as it might be, he needed to see Bianca Perez so he could say he’d done so at morning rounds. He couldn’t quite believe that his sole patient had had a major postoperative complication.
Just getting to 10 South was a little like broken-field running in football with all the people he confronted. It seemed that every bed was surrounded with caregivers, and as Mitt passed down the row of patient rooms, he was beset with a continued low cacophony of monitors beeping and ventilators functioning, like the soundtrack of a science fiction movie.
Mitt stopped at the entrance to 10 South, and at first glance, it did not look good. Bianca was intubated and a ventilator was cycling through positive and negative pressure like an auditory seesaw. Multiple IV bags were hung on poles at the head of the bed. Even from the doorway, he could see that her eyes were taped shut. A woman, presumably a nurse, dressed in scrubs including a surgical cap was on the left side of the bed using a blood pressure cuff. A bank of monitors hung from the ceiling with one tracing an ECG across its screen and beeping with each heartbeat. At least that appeared normal. Mitt took in a deep breath to try to prepare himself and walked in along the empty right side of the bed. The nurse glanced up at him and nodded a greeting but didn’t say anything, as she had the earpieces of a stethoscope in her ears and was obviously listening.
While he waited for the nurse to finish taking the blood pressure, Mitt lifted the sheet covering the patient enough to gaze at her abdomen. A new, large midline incision was covered by a narrow dressing. From the bottom of the dressing a drain emerged that was connected to a container that hung under the bed on Mitt’s side. There was a small amount of blood visible in the clear tubing and the container. The five small incisions that had been made during the colectomy that Mitt had helped on all looked fine under their simple transparent paper-tape coverings.
“Can I help you?” the nurse asked in a no-nonsense but friendly tone as she took the stethoscope’s earpieces from her ears.
“I hope so,” Mitt said before introducing himself as a first-year surgical resident. He then confessed it was only his third day. He now could see her name tag, Gabriela Martinez. “I’m sorry to bother you, but what happened to Ms. Perez? I helped with her surgery yesterday afternoon, which went entirely smoothly. When I went to visit her in her room, I was shocked to hear she was down here in the ICU.”
“Not a happy story. My understanding is that she bled out from one of her mesenteric arteries. She was rushed to surgery and transfused, but I’m afraid she suffered significant brain hypoxia in the interim. At least that’s what I was told by the anesthesiologist. Presently she’s in a coma, and as you can see, she’s not breathing on her own, ergo the ventilator. Otherwise, her vitals are good. We’ll have to see if she comes around. The anesthesiologist and the Neurology consult didn’t sound optimistic, but there’s always a miracle. It’s up to the good Lord now.”
“Thank you,” Mitt managed in a scratchy voice, not knowing what else to say. He swallowed in an attempt to ease his suddenly dry throat. At the same time, his predictive powers, accompanied by a slight tingling on the insides of his arms, informed him the patient was not going to “come around,” which was more than disturbing. It meant that the lives of every one of his assigned patients had ended, even if one was technically still living. Bianca Perez wasn’t even breathing on her own.
Of course, all four patients were also Dr. Geraldo Rodriguez’s recent patients, too, and Mitt wondered if that realization had crossed Dr. Rodriguez’s mind. Actually, Mitt doubted it because Dr. Rodriguez had the benefit of hundreds if not thousands of patients during his years as a resident and could easily explain these recent losses as happening just by chance, which Mitt was struggling to do.
In a daze, Mitt left Ms. Perez to hurriedly rethread his way back through the ICU to return to the bank of elevators. Despite the disturbing news, at least he had gotten out of the unit without having been embarrassed. He pressed the Up button, wondering if during morning rounds anyone would bring up the issue of his bad luck—a wild understatement. If someone did bring it up, what would he say? What could he say? And more important, what might Dr. Kumar say?
When the elevator arrived, it was packed, and Mitt had to literally squeeze in. Although no one said anything, he could tell from their expressions that some of the people aboard were mildly put out they had to make room for yet another passenger when the car was already packed. As the elevator rose to the next floor, Mitt found himself wondering if the architects and designers of the present Bellevue Hospital high-rise had thought in the 1970s that ten passenger elevators and six service elevators would be adequate. It sounded like a lot of elevators, but to him it was already apparent that there weren’t nearly enough, and he had only been a resident for two days.
On the fifteenth floor, as he approached the door to the surgical conference room, Mitt couldn’t help but be reminded of the mysterious blond girl disappearing through the same door, especially after seeing her again that very morning. What particularly mystified him was why and even how his imagination was conjuring up this same illusion, if that’s what it was. As far as he knew, he’d never met or even seen anyone who resembled the child, so why would the vison always be so consistent? And why the curious period dress? And were those bloodstains on her bodice or did they just look like bloodstains? And what was the instrument she’d pulled from her eye socket? He had no answers to any of these questions, and he wondered if he ever would. More than anything, Mitt hoped he’d seen the last of her, yet when he asked himself the question, his predictive powers and a minor accompanying sensation of pins and needles told him that he had not.
“Will wonders never cease,” Andrea quipped when Mitt came into the surgical conference room. She was alone in the room, sitting in one of the student desk chairs. “I don’t believe it. You’re almost ten minutes early.” She made an exaggerated expression of disbelief after checking the time on her phone.
“Okay, okay, let’s not create a scene,” Mitt said. He took the chair next to hers, and as he did so, he noticed, contrary to him, how “put together” she appeared, just like always, with her bobbed hair perfectly in place. Her only concession to her new status was that she was wearing scrubs under her white coat and not one of her colorful dresses. “To be honest, I made an effort to get here in time to find out how your night was. I know it can’t have been good with what happened with my only patient, Bianca Perez. You had to have been involved.”
“Obviously,” Andrea said. “When I was called to her room just after two a.m. and heard what was happening, I was horrified to learn her name. I knew her having major complications was going to be a serious downer for you.”
“ ‘Downer’ isn’t nearly a strong enough word,” Mitt said. “ ‘Devastating’ is closer to the truth. She was my only patient. I’m starting to feel directly responsible.”
“Oh, come on! Let’s not be melodramatic. You and I are totally green as first-year residents. Hell, it’s only our third day. You are not responsible. No way. I’m sorry, but that’s being way too paranoid.”
“I know that rationally. At the same time how can I not feel some responsibility? Except for Dr. Geraldo Rodriguez, I’m the only connection between all four patients.”
Andrea looked askance at Mitt. “Are you being serious? Come on!”
“I don’t know if I’m being serious or not,” Mitt admitted. He nervously ran both hands through his hair, shook his head, and then looked directly at Andrea. For a split second, he was tempted to bring up the hallucinations he’d been having to get her take and have a sympathetic ear. As they had been talking, he’d progressively realized it was the combination of the hallucinations and the deaths that was really getting to him. If it had only been one or the other, he probably would have been able to take it in stride. But the two simultaneously was something else entirely. Yet now that he’d broached the idea of responsibility, he felt he had to justify it. “Let me put it this way: It’s a combination of the deaths and my insecurities about being a resident, with one magnifying the other,” he added, as it was true. “I don’t know about you, but I’m constantly on edge, terrified I’m going to be asked a question or to do something I’m incapable of doing. A few minutes ago, I was in the ICU to check on Perez, and I was a nervous wreck. I couldn’t wait to get the hell out.”
For a moment, he stared at his co-resident to gauge if she bought his explanation. He wasn’t willing to admit to the hallucinations. If it had been the other way around and she told him she was experiencing recurring hallucinations of a blond preadolescent girl and suffering fleeting phantosmias, he’d be seriously concerned about her, maybe even questioning if she should be a surgical resident.
“I’m with you in relation to the anxieties of feeling unprepared,” Andrea said. “But I’m certainly not with you in feeling responsible for what’s happened to your patients. To be honest, listening to you makes me think you’re suffering from a touch of ‘illusory superiority.’ ” Andrea added the last part with a half laugh, obviously trying to inject a bit of humor into the conversation.
“Okay, I get it. You’re teasing me now,” Mitt said. He took a deep breath, then forced a smile. There was some truth to what she was saying. There really was no way he could be responsible. He was, as she’d suggested, giving himself too much credit.
“Of course I’m teasing,” Andrea said. “You deserve to be teased, saying something so ridiculous. I can assure you that Dr. Rodriguez doesn’t feel in the least bit responsible despite his being on the same cases as you.”
“Okay, okay,” Mitt said. “Enough about me. What about you? How was your night, besides having to deal with the mental trauma and sleep deprivation caused by my patient?”
“Truthfully, your patient didn’t cause me any grief other than the first moments of panic when I arrived in her room. I had the presence of mind to realize I was in way over my head when faced with a patient with no blood pressure, a weak pulse, pale as a ghost, and a tense, swollen abdomen. I had Dr. Wu immediately paged. Seeing all the blood in the drain container, I ordered a transfusion, but that was all I did, meaning I was just standing there wringing my hands. Luckily for me, Dr. Wu arrived within minutes, took over, and arranged for the patient to be rushed into surgery. She also contacted Dr. Rodriguez and the attending, Dr. Sanchez. Most important, she got Dr. Rodriguez on his way into the hospital.”
“What was found at surgery?”
“I don’t really know.”
“Why not? Weren’t you there? Didn’t you have to scrub in, too?”
“No, I didn’t. Dr. Wu did. She and Dr. Rodriguez operated and wanted me to be available to handle any problems that might pop up with the other inpatients while they were tied up doing the case. Luckily for me, nothing did, although I was worried something might. Anyway, I just went back to the on-call room and fell asleep. I ended up getting a total of about six hours, which was more than I expected, especially after hearing about your night.”
“Whoa, I’m jealous,” Mitt admitted. “But I suppose I’m also encouraged. Maybe my first night was an outlier and tonight won’t be so bad.”
“Let’s hope so,” Andrea said.
At that moment, the door opened and in came a large group of residents and Dr. Van Dyke, all noisily chatting. Some were carrying paper coffee cups. The moment Dr. Van Dyke saw Andrea and Mitt, she came directly over to talk to them.
“How was your first night?” Dr. Van Dyke asked Andrea.
“It was fine,” Andrea said.
“Wonderful,” Dr. Van Dyke said. “And I heard there was some excitement with a postop patient hemorrhaging, but I understand you handled it well. Kudos, Dr. Intiso.”
“Thank you, but I didn’t do much. Dr. Wu handled it.”
“You did what you needed to do. But that was then and this is now. Today you both have three surgeries. I should also mention that there is a Journal Club in this room at three p.m., and you are encouraged to come if your surgery schedule permits. Well, you’re more than encouraged. If you are free, it is a command performance. Okay?”
Both Mitt and Andrea nodded in unison.
“Now I wanted to talk briefly about tomorrow. I trust that you both are aware it is the Fourth of July, meaning the hospital will be in holiday mode. There will be no scheduled surgery, only emergencies. As for you two, the on-call schedule determines your coverage. Dr. Fuller, you are on call tonight, so that means you will be officially off tomorrow. Dr. Intiso, holiday coverage will fall to you. Understood?”
Both Mitt and Andrea again nodded. Mitt was mildly surprised. He’d completely forgotten about the Fourth of July although he shouldn’t have. During his childhood it had always been a high point, marking the beginning of summer. With everything that had been going on, the idea of being off for a day and a night seemed tantalizingly welcome, like a sudden, unexpected cease-fire in the middle of a pitched battle.
“As for the surgery schedule on Friday,” Dr. Van Dyke continued, “I will be assigning you three cases each as per usual. Although most of the USA thinks of Friday as part of the Fourth of July weekend, we here at Bellevue do not. That means that admission histories and physicals will need to be done tomorrow. For you, Dr. Intiso, that will be easy since you will be here. For you, Dr. Fuller, you’ll have to decide what you want to do, meaning whether you want to come in and do the H&Ps or have Dr. Intiso do them. Various first-year residents handle holidays differently. It’s up to you guys.”
Once again, Mitt and Andrea nodded.
“Okay, that’s it,” Dr. Van Dyke said. “Enjoy your surgeries today, and I’ll hope to see you at Journal Club this afternoon.” She then moved off, immediately engaging in conversation with some of her resident colleagues.
“I’m happy to do the H&Ps,” Andrea graciously said.
“Thank you, but I live around the corner. I’ll come in. I don’t want to add to your burden of having to cover for the holiday.”
At that moment, exactly 6:30 a.m., the door to the hallway burst open and in swept Dr. Vivek Kumar in his inimitable, commanding style. He was, as usual, impeccably dressed in his whites, with his thick, black hair combed to a tee. He was trailed by Dr. Geraldo Rodriguez and the other fourth-year surgical resident, Dr. Kevin Singleton. Dr. Kumar went directly to the podium and commanded: “Okay, everybody, let’s get down to business!”
Once started, morning surgical rounds were carried out in an efficient style. First Dr. Vivek called out the name of an inpatient, then the more junior resident involved in the case gave a rapid synopsis and the current up-to-the-minute status. This was immediately followed by comments from a more senior resident also connected to the case. If there was a complication, the team thoroughly but quickly discussed the issue and decided whether the patient should be rapidly seen by the team. When Bianca Perez was brought up, Mitt swallowed his nervousness and gave a rapid review including her present status of being comatose in the ICU.
“This is a strange but interesting case,” Dr. Rodriguez said, taking over after Mitt’s brief summary. “During the re-op early this morning, something rather odd was discovered. The polypropylene ligature on the inferior mesenteric artery had seemingly become untied. There it was, loose in the abdomen. I’ve never seen anything like it. I’d tied it and secured it myself.”
“That is curious,” Dr. Kumar agreed. “Has the attending been notified?”
“Yes, for sure,” Dr. Rodriguez said. “She’s equally mystified, as she, too, had checked the ligature.”
“What about the issue that the patient’s deteriorating status wasn’t recognized until the blood pressure had fallen to near zero?” Dr. Kumar asked.
“That is an important consideration,” Dr. Rodriguez agreed. “I’m scheduled to meet with Helen Straus, head of nursing, this afternoon to figure out what happened. The patient was under the usual postop protocols. Seemingly, the event was remarkably precipitous, as the patient had been documented doing well minutes before the blood pressure alarm sounded.”
“You’ll let us know what you learn?” Dr. Kumar asked.
“Absolutely,” Dr. Rodriguez said.
“All right, let’s move on,” Dr. Kumar said. He called out the next patient’s name.
So progressed morning surgical rounds. Mitt got a chance to present the three cases he was assigned to for surgery that morning, as did Andrea with her cases. Other residents did the same for an extremely rapid review of the day’s upcoming surgeries. A brief mention was made of the previous days’ surprising deaths of Mitt’s two patients, causing him to stiffen, fearing he’d be called upon to say a few words, but he wasn’t, to his great relief.
At that point morning rounds were terminated and the whole group marched off to visit the few patients where there was any type of controversy involving future treatment options. When those rapid visits were over, the residents scheduled for the first cases, which included Mitt and Andrea, headed off en masse to the surgical suite on the eleventh floor.
As Mitt watched the elevator’s digital floor indicator during the descent, he found himself hoping that the cases he’d been assigned today would go smoothly in contrast to what had happened the day before. But then he made the mistake of actually asking himself the question directly, and the moment he did, he sensed that there was going to be trouble of some sort. But at least the paresthesia sensations were mild, so he hoped that whatever was going to happen wouldn’t be anything like yesterday.