“All right, I’ll also be quick,” Dr. Van Dyke said. A strikingly athletic young woman dressed in scrubs under a white doctor’s coat, she stepped behind the vacated podium and projected a confidence nearly equal to the chief resident’s, suggesting she was a dutiful understudy. In Mitt’s mind, it underlined something he’d already garnered as a medical student about the field of general surgery. It was based on a very hierarchical system that had changed little over its hundred-and-fifty-year history. Those on the lowest rungs of the ladder, like he and Andrea, had to be bullied or somehow cowed to earn entrance into the “club.”
“First and foremost,” Dr. Van Dyke said, “please make certain your cell phones are hooked up with the hospital communication system. For the nurses and me to be able to get ahold of you at all times is obviously of prime importance. And as recent medical school graduates, I’m going to assume you are more aware than I was that it is essential to enter everything you do and even think into our electronic health record or EHR. Do I have that right?”
Both Mitt and Andrea nodded. Establishing their connectivity had been one of the first things they had done, and they’d been fully indoctrinated into the demands of the EHR.
Dr. Van Dyke then pulled a couple keys from her pocket and held them up. “I have keys here for the two on-call rooms you will be using and which I will be showing you shortly. It’s vitally important that these rooms be locked at all times. I imagine you both have heard of the Dr. Kathryn Hinnant tragedy.”
Mitt and Andrea nodded. A bit more than thirty years previously a vagrant who’d actually been living in a Bellevue Hospital mechanical room raped and killed a pathologist who was working in her isolated office on a weekend. It had had a profound effect on the institution, as it should have.
“Literally thousands of people are in and out of Bellevue on a daily basis,” Dr. Van Dyke explained. “On-call rooms must always be locked.”
Both Mitt and Andrea nodded.
“Also included in my tour will be our eighteen ORs, where you will be spending a significant amount of your time, the OR locker rooms, as well as the surgical inpatient wards. I’ll also be quickly walking you through the ambulatory surgical areas as well as the intensive care units on the tenth floor.
“Now I’d like to follow up on Dr. Kumar’s comments about ACGME rules on resident hours. It will be your job to keep track of your hours and give them to me. We do want to make certain that the program is in compliance, as we don’t want to lose our accreditation.” She laughed hollowly. “If that were to happen, none of us would be able to become certified by the American Board of Surgery. I don’t have to explain to you what kind of disaster that would be.”
Mitt nodded once again as if he were agreeing that it was appropriate for him and Andrea to be responsible for reporting their hours. He could already see that the system was designed to thwart the attempt by the ACGME to limit resident hours for the safety of patients and for the residents’ health. If he, as a surgical resident, were to report — essentially complain — that he was being asked to work too many hours, he’d risk being blackballed and possibly fired. Such is life, he thought. But he wasn’t surprised. When he’d applied for a surgical residency, he had a pretty good idea of what was involved, including very long hours and a very hierarchical, almost feudal structure.
“Okay,” Dr. Van Dyke said. “Before we start our tour, are there any questions?” She left the podium and approached Mitt and Andrea, handing them both their on-call room keys.
“I have a question,” Andrea said, finding her voice. “Which one of us will be on call tonight?”
“Ah, yes. Thanks for asking. Dr. Fuller will be first at bat. I went with alphabetical order to make the decision. All right, let’s head out!”
Andrea turned and looked questioningly at Mitt as if to say: How the hell did you know?
Mitt merely shrugged.
Chapter 5
Monday, July 1, 11:30 a.m.
Mitt looked up at the institutional clock on the wall of OR #12 and could see that he’d been in the operating room for almost two hours. It was his first operation as a surgical resident, and it wasn’t going as well as he would have liked for multiple reasons. He was standing on the left side of the patient along with a fourth-year resident, Dr. Geraldo Rodriguez. On the opposite side was Dr. David Washington, a physically imposing vascular surgeon. The case was an excision of an abdominal aneurysm, which was a pathological outpocketing of the main artery of the body, the aorta, in the patient’s abdominal cavity below the diaphragm. The patient, Benito Suárez, was an otherwise healthy thirty-eight-year-old Hispanic male. The problem for Mitt was that he couldn’t see the operative field despite forcibly gripping the handle of a retractor with both hands. Mitt’s retractor was holding back the left side of Mr. Suárez’s incision, including some of the patient’s intestines, to expose his aorta.
Dr. Rodriguez had essentially crowded in front of Mitt, placing his right arm over Mitt’s arms in his attempt to assist the surgeon, who was currently struggling to work up under the diaphragm. This meant Mitt was being pushed against the anesthesia screen and forced to face the back of Dr. Rodriguez’s surgical gown — the operative site completely obstructed. All he could see was the wall clock by glancing upward, or by looking to the left past Geraldo’s backside, he could see the scrub nurse on her stool and facing the instrument tray. In the opposite direction and over the anesthesia screen, he could see the anesthesiologist sitting on his wheeled stool and monitoring the patient’s vital signs.
What this all meant for Mitt was that although he was physically in the operating room during what he imagined was an interesting case, there was no way he could appreciate any of the details. He had no real idea of what was going on inside the patient other than gathering that Dr. Washington was having significant technical difficulties sewing the upper portion of a graft to the patient’s aorta to replace the section that had been removed. The problem had been caused by the need to remove more of the proximal aorta than expected yet keep from going into the chest cavity.
Although Mitt couldn’t see her at the moment, there was another surgical resident standing to Dr. Washington’s right. She was a second-year resident named Dr. Nancy Wu. Mitt had been cursorily introduced to her at the same time he’d been introduced to the others by Dr. Van Dyke, who’d accompanied Mitt when he first entered OR #12. At that time the surgery had already been underway for an hour and a half. Mitt had seen that Dr. Wu was holding a retractor similar to the one Mitt was about to be handed. She was holding back the right side of the abdominal incision.
The situation was physically uncomfortable for Mitt as well as mind-numbingly boring, even though Dr. Washington would pause on occasion to explain what he was doing. But without being able to see either Dr. Washington or the operative site, it was nearly impossible for Mitt to picture what was happening. All he could do was hold on and watch the clock’s second hand as it slowly and repeatedly swept around the dial. At least the time gave him an opportunity to relive the morning.
The tour he and Andrea had been given by Dr. Van Dyke had been very helpful to quell some of their shared anxieties. Although Mitt, and Andrea to a lesser extent, had tried to break through Dr. Van Dyke’s formality and her air of superiority as a third-year resident in contrast to Mitt and Andrea’s lowly first-year status by offering personal information and asking personal questions, she’d resisted. For Mitt, it corroborated his impression of exactly how hierarchical surgery remained and how the system perpetuated itself.