“Thanks for the suggestion,” Mitt said. “I certainly will. But I’d first like to ask a question, if I may.”
“Of course,” Dr. Singleton said. “What’s on your mind?” He sat back down.
“I’m a little confused, Dr. Singleton,” Mitt began hesitantly. “I’m wondering if Andrea Intiso and myself are being purposefully teamed up with either you or Dr. Rodriguez for some specific reason. Particularly today, it didn’t seem necessary for an experienced fourth-year resident like yourself to be assisting on a vein stripping or a breast biopsy.”
Dr. Singleton smiled. “First of all, you can call me Kevin. Second of all, yes, it was Dr. Kumar’s idea that at least for your first week, Geraldo and I would make sure you were introduced to your surgical residency appropriately, with a wide variety of cases and attendings, some of whom are better than others when it comes to teaching. We were also tasked with evaluating your technical skills, since residents arrive here with a wide variety of experience.”
“I see,” Mitt said. It did make pedagogical sense. He then glanced across the room at Elena Aguilar. He could see there hadn’t been any change. To his chagrin, she was still intubated and on a ventilator. He’d hoped she’d be off by now and the longer she stayed on, the more worried he became, as much for his own peace of mind as for the patient. At that point, she’d been in the PACU for more than two hours. “What are your thoughts about our first patient? Are you concerned?”
Kevin glanced across the room. “I guess,” he said somewhat vaguely. “Why don’t we go over and have a chat with the nurse? The PACU nurses know their stuff. Let’s get her take.”
Relieved that Kevin was taking an interest, Mitt eagerly followed him over to Elena’s bed. As they arrived, the assigned nurse was making a slight adjustment to the ventilator.
“What’s the good word?” Kevin asked.
“Not so good, unfortunately,” the nurse responded. “She’s not fighting the ventilator like she was earlier.”
“Uh-oh! That’s not what we’d like to hear,” Kevin said. “Has the anesthesiologist been by?”
“Certainly, a number of times. She also called for a Pulmonary consult because the patient’s oxygen saturation started to inch downward. And there was also a Cardiology consult.”
“Cardiology? Why Cardiology?”
“She started having episodes of premature ventricular contractions. Cardiology started a beta-blocker and ordered a stat electrolyte test. Surprisingly, her electrolytes were totally out of whack, which required immediate adjustments. At the moment they are all fine, but I tell you, it’s been an ongoing challenge.”
Mitt felt a general chill as well as some pins and needles on the insides of his arms while he listened to what the nurse was saying. As he looked down at the patient, he sensed that a worst-case scenario was relentlessly underway. The patient was mysteriously going downhill and it would continue, all of which made his concern that he was in some way responsible rocket skyward. He felt all this despite his rational sense trying to convince him of the opposite, namely that everything was happening by chance and chance alone.
Chapter 17
Wednesday, July 3, 1:22 p.m.
Mitt stood at the stainless-steel scrub sink outside of OR #4. He was in the process of using a disposable, blue plastic nail file to clean the subungual area of each finger. Dr. Kevin Singleton was to his right. To his left was Dr. Taylor Smith, Bellevue’s chief of Head and Neck Surgery. All three men were scrubbing for the upcoming thyroidectomy on Diego Ortiz. Mitt was attempting to concentrate on what he was doing to proactively avoid thoughts about Elena Aguilar in the PACU and his possible role in her seemingly downhill clinical course. He specifically didn’t want to wonder how her electrolytes could have gotten so screwed up.
Kevin had introduced Mitt to Dr. Smith out in the surgical lounge but the introduction had been cursory, as Dr. Smith had simultaneously become preoccupied by an incoming call on his mobile.
To Mitt’s eye, Dr. Taylor Smith was a man of indeterminate genealogy, probably in his early fifties. He was darkly complected, rather hirsute, and slender with a scraggly, graying goatee and mustache, which Mitt thought might be to compensate for scant hair on his head. Mitt mused that he’d rarely come across Taylor as a male given name although he knew several women, including the popular singer. As these arbitrary mental gymnastics about Dr. Smith passed through his mind, Mitt recognized it was merely an attempt to keep from thinking about Elena Aguilar.
“Dr. Smith,” Kevin called, interrupting Mitt’s thoughts. “When I introduced Dr. Fuller out in the surgical lounge, I didn’t get a chance to tell you that he is one of our brand-new NYU surgical residents.”
“You don’t say?” Dr. Smith questioned with a slight English accent that confused Mitt even more. “Welcome, young man. How are you finding it so far?”
“Challenging,” Mitt responded, which certainly was the case.
“Well, then, we’ll have to make this interesting for you,” Dr. Smith added. “I was wondering why I was getting two assistants, and a fourth-year resident at that. How much do you know about thyroid surgery?”
“I know approximately where the thyroid gland is located,” Mitt said.
“Ha, ha, I like your sense of humor!” Dr. Smith responded. “To start off, do you know why this is being handled as an inpatient rather than an outpatient procedure, which is the way I’ve been doing most of my thyroidectomies these days?”
“I’m not sure,” Mitt said.
“The patient has a history of severe hypothyroidism requiring thyroxine replacement. Post-surgery, he’ll need to be covered intravenously for a short time until he can take it orally. It is safer as an inpatient.”
“That makes sense,” Mitt said. He remembered the patient’s history from doing the admission workup.
When the three had finished scrubbing, they entered the OR in descending order of status. Once inside, Dr. Smith introduced Mitt to the two nurses, Marianna, the scrub nurse, and Juana, the circulating nurse. During the gowning-and-gloving routine, the same order was followed with Dr. Smith first, Dr. Singleton second, and Mitt last. During the process Dr. Smith maintained an explanation of what had already been done to facilitate the surgery, namely that the patient had been intubated with a special endotracheal tube that incorporated a monitoring device to protect the function of the recurrent laryngeal nerve. He went on to explain that damage to that particular nerve was one of the complications of the surgery and needed to be scrupulously avoided by continuously monitoring the nerve’s function. Additionally, at his request the patient had been positioned with his head nestled in a donut to maintain its position and a roll had been placed under the patient’s shoulders to hyperextend the neck, all to facilitate the surgery. Dr. Smith gave credit to the anesthesiologist and Juana for carrying out all these preparations.
Mitt was impressed by Dr. Smith’s pedagogical inclinations and was now genuinely interested in the upcoming procedure. He believed it might turn out to be the best teaching experience he’d had so far in the operating room. At the moment he wasn’t even feeling tired, and more important, he wasn’t obsessing about Elena.
“Which side do you want to be on?” Dr. Smith asked Mitt after the patient had been draped, and Marianna, the scrub nurse, moved the instrument tray over the patient’s legs to be close enough to hand the surgeon what he needed. When Mitt glanced at the instrument tray, he couldn’t help but notice there was a fairly large instrument he didn’t recognize that looked like it belonged in a plumber’s toolbox. It seemed that there were lots of new aspects to the case. Earlier Dr. Smith had used a marking pencil to indicate where he would be making the incision while explaining to Mitt that careful planning of the exact location of the incision would improve the cosmetic result, hiding the scar within a neck fold.