Death's Pale Flag

CHAPTER 2 A DAY IN THE LIFE-2

Despite the magnitude of the surgery, the patient came round nicely, and the two surgeons and the anesthesiologist wheeled her into the post-anesthesia care unit. After taking their leave, Ryan and Darla were off again in a crisscrossing blitz throughout the hospital. An hour and a half later, Ryan and Lisa were operating through a tiny incision on the lower back of a middle-aged man.

“This patient has a herniated disk, or ruptured disk, or slipped disk—they all mean the same thing,” commented Ryan to Darla. “A chunk of crabmeat-like material rips out of the cushion between two vertebrae and smushes a nerve that’s trying to leave the lower back. The nerve gets all upset, and the patient gets severe shooting pain everywhere the nerve goes. That is, all the way down the leg. What do you think the best treatment for this is, Darla?”

“I would have to guess surgery.”

“Ha! Trick question! The best treatment is time. Ninety percent of the patients will get completely better on their own. The crabmeat doesn’t move, but the nerve learns to put up with it. We only operate when the nerve refuses to feel better after several weeks. If that happens, we sneak in, find the nerve—that’s it on the screen right now—protect it, then get the crabmeat out. The results are often instantaneous for the patient.”

Indeed, when they visited the patient shortly after surgery, he thanked Ryan for a “miracle cure.” Then Ryan and Darla were at it again, frenetically racing about the hospital. Somewhere between ICUs, Darla asked, “Hey, Dr. Brenan, when do you eat . . . drink . . . go to the bathroom?”

“Oh jeez. Thanks for reminding me. Some days you kind of forget. It’s stupid, really. I even got a kidney stone when I was in the Army from not staying hydrated enough on OR days. You’d think I’d have learned my lesson. Come on . . .”

They shot down a set of stairs and ended up in the cafeteria. Ryan paid for Darla’s meal, and the two sat down at an empty table, Ryan’s phone still buzzing. Within two minutes Ryan’s plate was clean and he was fidgeting. Darla choked down the remainder of her salad and they were off again. Soon, they were back in the OR.

“So, Darla, we’ll knock out this last case, check on our post-op and ICU patients, and get out of Dodge at a reasonable hour,” commented Ryan, as he and Lisa went about driving screws into the neck of an eighteen-year-old girl. She had sustained a fracture in a diving accident. The team had attempted to treat the fracture with a brace—allowing the bones to heal themselves—but it became obvious that the spine would need some surgical help.

“Is this your typical day, Dr. Brenan?” asked Darla, with a note of incredulity.

“Pretty typical. It can be calmer . . . or crazier. Call days tend to be quite a bit crazier.”

“Crazier than this?”

“Oh sure. Imagine today with anywhere from five to fifteen additional patients to see, one or two maybe needing immediate surgery. It’s the joy of working at a level-one trauma center. And then you have the night to look forward to. That’s when things really heat up. It seems that the worst disasters—strokes, fractures, bleeds, etc.—always occur after midnight. We can get twenty or more emergency consults in the middle of the night.”

“Sounds awful.”

“It kind of is . . . at least for the residents. Isn’t it, Lisa?”

“Oh, no,” replied Lisa with exaggerated enthusiasm. “Love every friggin’ minute of it.”

“And it’s not just the surge in consults,” continued Ryan. “They’re getting bombarded with calls. Worse, believe it or not, than what you’re seeing today, because the whole service gets focused down onto one person—the on-call resident. Needless to say, they get zero sleep. But at least they get the next day off. We faculty neurosurgeons stupidly roll right on through into another full day of work.”

“So, what’s your night call like, then?” asked Darla.

“Certainly better than the residents. I go in for any surgery, of course; and if a resident is having difficulties. I’d say, on average, I get two to three hours of sleep on call nights. But you tend to sleep ‘with one eye open,’ if you know what I mean. And then there’s what I call “call psychosis.”

“Call psychosis?”

“Yeah, when you’re on call you feel utterly vulnerable, unable to relax, constantly on edge. And there’s good reason. Any attempt to play, or hang out with friends, or do something fun, is invariably interrupted by an emergency. Thus, when on call, you kind of go into a cocoon—afraid to do anything—your phone just sitting there, pulsating evil, waiting for you to enjoy yourself in any way. Am I exaggerating, Lisa?”

“Nope,” replied Lisa. “I’d say you’ve got it pegged, Dr. B.”

“How often are you on call?” asked Darla.

“Every fourth or fifth night.”

“But aren’t there, like, a dozen neurosurgeons here?”

“Yeah, but two will only cover kids, three only cover strokes, and two have aged out of night call. So, those willing and able to cover general call aren’t all that plentiful. But no call for Lisa or me tonight, so it won’t be long before we’re both chillin’ with a nice glass of cabernet, eh, Lisa?”

“Got that right, sir.”

As if on cue, sixth-year resident Cara Klein, valedictorian graduate of Rutgers University, popped into the room.

“Hey, Dr. Brenan, remember that shunt kid?”

“The one we just operated on?”

“No, the seven-year-old over on peds who was vomiting.”

“Got you. Looked okay when we stopped by . . .”

“Yeah, well, he’s worse. We got another MRI. Vents are bigger. I know you’re not on call anymore, but I thought you’d probably want to do it.”

“Well, Darla, so much for an early evening,” said Ryan. He looked up at Cara. “Yeah, get her down as soon as you can, will ya? We’ll go speak with her parents as soon as we’re done here.”

When they got out of the spine repair, Ryan told Darla she was certainly free to leave at any time. He noted that she had gone well above and beyond the call of duty. Darla, however, insisted on staying, despite having developed an obvious limp from blisters on her feet. Noticing this, Ryan had her sit down alongside him at a computer bank as he attacked the fifty or so emails that had stacked up over the past few hours. Soon they were back in the OR.

“See, Darla,” remarked Ryan, “this is a VP shunt that was working fine for several years in this sweet little girl. But protein, and cells, and whatever, has blocked it up. We’ve disconnected a couple pieces of it, and it’s clear that the blockage is in the piece going into her brain. We’ll have it replaced, and this case done, in minutes.”

And so they had. But they had surprised the anesthesia team with how fast the procedure went, and thus it took an unnerving hour for the girl to wake up.

“Yeah,” remarked Ryan to Darla, “one of the joys of operating on the nervous system is never being 100 percent sure that all is well until the patient can show you that it is. All sorts of complications can be hidden from you until you can examine your patient awake. So, we kind of sit on pins and needles until they wake up, even though we’re pretty sure things are okay. This is why I never tell my wife when I’ll be home.” Ryan looked up at the clock, his eyes darkening. “Any time I’ve ever said that I’d be home by a specific time, I’ve ended up being off by a mile. And God help me if there’s a kid’s event that I’m planning to get to. Invariably, a post-op patient will go sour, or a sick kid will come in, and the next several hours are filled with CT scans, ICU interventions, and family discussions.”

The girl eventually woke up and looked good. Ryan and Darla headed out to speak with the parents, then made some more rounds.

“Come on, Darla, time for you to get out of here,” commanded Ryan between ICUs.

“Are you leaving now?” asked Darla.

“Me? No. I’ve got to hit the computer for a while.”

“But didn’t you work all weekend?”

“Yeah. But that’s the thing. There’s always so much left to do after a weekend of call.”

“What do your wife and children think about your schedule?”

Ryan shuddered for a moment. Direct hit, he thought. “Yeah, well, I’m not sure they’re too happy with it. But you get swept up into these days. And all these sick and broken people. I guess you make compromises for their sake.”

“It seems like a pretty one-sided compromise.”

“Yeah, I guess you kind of shortchange your loved ones a fair amount. But maybe that’s narcissistic. You’re presuming you’re something worth having around . . .” replied Ryan with a sad smile.

“There isn’t a way to get out of here at a more reasonable hour?” persisted Darla.

“Not that I’ve figured out,” said Ryan with a sigh. “Anyway, get out of here before you turn into someone like me. Or your feet fall off!”

Darla took him up on the offer and, after expressing her gratitude for an “amazing day,” limped away down a darkened hallway. Ryan shuffled to a nearby ICU and slumped into a chair. He sat for a good ten minutes looking at nothing, thinking nothing, then resumed his battle with the ever-ravenous electronic medical record. Finally calling it quits, he made his way to the changing room and threw on his original outfit for the day. He checked on the last surgery patient and then shuffled his way toward the doctor’s parking lot through 4 West.

He was shocked to find the usually hopping ward silent and lifeless. No personnel at the nursing station. None of the constant din of beeps, alarms, and chatter. No nurses, no ambling patients, no ubiquitous blue-green TV light emanating from any of the rooms. He looked into several—all empty. He continued down the ward’s long, jaundiced hallway, drawn to the very last room. He pushed the door open.

“At last, Dr. Brenan, we’ve been expecting you.”

The room was filled with begowned personnel, several restraining a female patient on an exam table. Ryan could see her legs kicking furiously but, despite his considerable height, couldn’t see past the mass of heads and shoulders obscuring her body and face. Someone in the crowd, presumably a nurse, handed him a scalpel, and the crowd parted to allow him access to the patient’s head. He looked down, as he prepared to incise the scalp, and saw that it was Kelly.

“Hey, Dr. Brenan. Are you okay?”

Ryan came around to someone shaking him by the shoulders.

“Huh? What?” asked Ryan. His eyes coming to focus on the nursing station of the Four North ICU.

“You were asleep . . . and crying. And saying, ‘no, no, no,’” said a young ICU nurse in maroon scrubs. “Sorry to startle you, but you looked like you were having a nightmare. I was worried you might fall off the chair.”

“Sheesh, sorry about that. Thanks for waking me. I guess I better get home.”

He stood up on shaky legs and made his way to the doctor’s parking lot, but dropped down to the ground floor, giving wide berth to 4 West.