Solomon awoke as the car came to a stop at MLK and Washington Boulevard, sitting up hesitantly and looking around at the sidewalk illuminated by yellow streetlamps.
“Hey, sleepyhead,” said Rita, reaching across the stick shift to pat his leg. “We’re almost home.”
Solomon yawned. “I can see that. Last thing I remember was getting on 495.”
“Yeah, you were out. Not particularly arousable. Must have been the best sleep you’ve had in a while.”
“With Paula out on maternity leave, the rest of us are taking more call. And those two papers in revision are kicking my ass.”
“Yeah, that reminds me that I need to get in touch with one of my students. He was supposed to have a draft for a book chapter done by now.”
“Perhaps I should see if Hannah wants to help with one of these papers.”
“She just started her surgery rotation. I doubt she has time.” Rita turned onto Pratt.
“Then we might have more time to collaborate together. How do you know what rotation she’s on?”
“I try to keep tabs on any students who might be matching into Family Medicine. Make sure they’re doing okay, not floundering on their clerkships.”
“You people.” Solomon chuckled.
“Us primary care doctors? We can’t tempt students to match into Family with giant piles of money like you, so we have to find other ways to attract them to our specialty.”
“I guess Surgery might do better in the match if we were nice to our students every now and then. But then we might match someone who felt like they need that shit all the time to survive.”
“Imagine that, the concept that residents need affirmation and support all the time to become good doctors.” Rita shook her head. “It’s a good thing I like you, Solomon, because sometimes you say things that drive me crazy.”
“Why do you like me?” Solomon, having stated his question, was immediately surprised by its bluntness. He felt a pang of regret for being coarse and wondered if it would have been better to rephrase it, which was something that he had noticed happening more frequently the longer that he and Rita were together.
“Oh, are you going to psychoanalyze me now, huh?” inquired Rita with a grin. “Finally turning the tables.”
Solomon laughed, allowing his anxiety to dissipate. “What can I say? I’ve finally learned something. I might praise a student for showing up and doing what he was told next if I get too carried away.”
“Whoa, whoa, whoa. A little too much there.” Rita slowed the car and pulled into the condo’s garage, first letting a family dressed in Orioles gear pass by in front.
“Do you want to come upstairs with me?” asked Solomon.
“You’re not going straight to bed?”
“I’m making myself a cup of coffee so I can survive another round of editing.”
“You don’t think sleep would be better? Y’know, like actually taking care of yourself?”
“Is that what you tell your residents? No wonder they don’t know what they’re talking about when I try to have conversations with them at 2 in the morning on our consults.” Solomon unbuckled his seatbelt.
“C’mon now, you told me yourself that you were very impressed with Kevin last week.”
“You must have been dreaming. It can happen with all the sleeping you do.”
Rita laughed. “You’re too much. I’ll gladly come up, but you can make mine decaf.”
“Did you get enough to eat at the wedding? Want me to make you something?”
“I’m good, thanks.”
They both climbed out of the car, clasping hands and settling into a walking pace through the garage to the elevator. Solomon rubbed his eyes as they received the harsh light fluorescent lights above. He untied his tie and began to fold it carefully as Rita pushed the elevator button.
“My aunts and uncles had an awful lot of questions for me today,” she said as the elevator door opened.
“What did they ask about?” They entered the elevator, not resuming eye contact until after the doors closed..
Solomon rolled his eyes. “I figured. What did you tell them?”
“That we weren’t ready to get married.”
“Oh. That’s what they asked about.”
“Well, I’d expect nothing less from people whose minds are mired in tradition.”
Rita let out a small grunt that sounded like clearing her throat. Solomon watched her face tighten as her eyes quickly turned red and filled with tears that she was clearly trying to suppress. He bit his lip and reached his hand out for hers, but she pulled away, turning her body to face the doors. She appeared to be looking beyond them, as if she could see through the brushed metal to the floors rising past them.
The elevator opened and they walked down the hall to Solomon’s suite. He turned his key inside the lock, then turned back to face Rita before he opened the door.
“You don’t have to agree with them to respect them, Solomon.”
“I suppose respecting your relatives that would be one of the prerequisites for marriage.”
“Along with wanting to get married.” Rita dabbed her eyes with a handkerchief that she pulled from her purse.
“That too, I suppose.”
He walked into the room, holding the door open behind him. Rita did not delay in following him in. He switched on the lights and went over to the kitchen, where he loaded his coffee maker. As he placed the mug under the spigot, he murmured “Sorry.”
“Hmm?” Rita, who had been staring out the window in the living area, turned her head.
“I’m sorry.” He lifted his eyes from the coffee maker to the dark wooden cabinet above, but did not turn to face Rita.
“Really?” asked Rita.
“Yes, really. I am sorry for… being rude towards your aunts and uncles. It’s a… different way of doing things.” Solomon felt like his words were heavier. It seemed to take more effort for his lips and throat to coordinate and speak them.
“Yeah, it is.”
“It’s a way of doing things that… here, let me save you some trouble and analyze myself for a change– it’s a way of life that I left behind when I went to college. All my aunts and uncles– the ones who are still alive– would probably say the same kind of thing to me.”
“I don’t think you’ve ever mentioned your aunts and uncles,” said Rita hesitantly.
Solomon finally turned to face her. “Well, probably because they’re a bunch of alcoholics who either beat me or ignored me until I started making money and then I was their best goddamned friend in the whole world.”
He immediately wished that he had kept facing the cabinet, as Rita’s eyes began to water again. The intensity of her emotions overwhelmed him; he had carefully moved in his mind from righteous indignation at her family’s traditionalistic obsessions to the realization that he at least needed to temper his critique, if not actually respect their opinion. Now he felt outmatched as he tried to comprehend why mentioning his family brought up more feelings on her part than his. He quickly realized that this stream of tears on his behalf somehow reflected the depth of their connection; somehow she was able to feel things for him that he did not– or had not– felt for himself.
She moved forward, her arms opening to embrace him. He began to instinctively step back, as if she were brandishing a knife, for that was the best metaphor that came to his mind when he thought of how he would describe the sensation in his chest. As he felt his back foot bump against the open dishwasher, he dug in and then moved towards her.
She buried her face in his chest, sopping his shirt with warm tears and mascara. “You said sorry.”
“Is that was this is about?” he exclaimed, returning her embrace.
“Well, part of it, maybe. I’m not quite sure why I’m crying so much. I am pretty tired.”
“Well, that makes two of us,” he croaked.
Rita chuckled and looked up. “I don’t think I’ve ever heard you apologize.”
“I try to avoid having to.”
Rita shrugged her shoulders playfully. “I guess that’s a good life philosophy to have. But seriously.”
“I can’t say I ever heard it said much as anything but an excuse. In between some platitude about Lawd help us do better next time, God been so good to so-and-so.” He exaggerated his accent to comedic proportions, although doing so failed to make Rita laugh. Her hands moved from around his neck to gently grasp each shoulder.
“So the faith you absorbed was… impotent and shallow.”
“That’s a generous description.”
“Solomon, I think…” She blinked away tears again, releasing his shoulders to wipe them away before taking his hands. “You’re traumatized.”
Solomon clenched his teeth and again tried to move backwards without conscious effort, but was halted by the open dishwasher and Rita’s hands. “Is this why you sent me those articles about childhood trauma and health outcomes? All those kids who got molested growing up who are now dying of heart attacks in their 40s because they drank soda to stay fat so no one would try to touch them?”
“I sent those to you because I thought they were interesting, not because I thought they applied to you. You asked me what sorts of nonsense I teach my residents when we have journal club, so I told you.”
“But you’ve thought it for a while. You’ve wanted to say it.”
Rita was silent.
“So to you, I’m just like a fat parasite sitting in your office trying to score some Percocets because that’s all I’ve learned. All that I have. All that I own. All that I’ve accomplished.” He turned and closed the dishwasher, his eyes locked on the counter. He reached for the buttons to turn the dishwasher on, but stopped. He held them up, turning them back and forth gently as he stared at the dark brown flesh on one side and his melanin-free palms.
Rita kept her hands on him.
“You don’t think it’s possible to have a lot but still be missing something?”
“Like what?” His head moved while he kept his shoulders square, his eyes catching her in his peripheral vision. Her lips opened as if to speak, but she failed to produce any words. Her face gathered, and she shook her head.
“Like what?’ he asked again, this time turning to face her.
Solomon tried to contain his disappointment, but he could tell from Rita’s reaction that she had sensed his countenance fall.
“That is… well, what I wanted to say is that’s… never mind.”
“Take your time, Solomon.”
He handed Rita her coffee. “If you insist.”
“I do,” she said, taking a sip. “Let’s sit.”
He started the process for his own cup and followed her back to the living area, where he sat next to her on the black leather couch. The lights across the city outside twinkled in the darkness, blurring gently and then clearing again as his eyes moved from one side of the window to the other. He slowly became aware that Rita’s eyes were fixed on him as he wished she would give him credit for not saying the first thing that came to mind. He then chided himself for how petty that thought was.
“You were going to say ‘That’s bullshit,” weren’t you?”
Solomon frowned and turned to face Rita. A smile was starting to emerge on her lips.
“You know me,” he said. “Better than anyone else. Better than myself, sometimes, I think.”
Rita nodded slowly.
“And you tolerate my bullshit because… I don’t know. You like the challenge or you admire me or you always wanted to date a bad boy but never had the chance during the agonizing process of medical education.”
“I like you,” insisted Rita. “For who you are.”
“I don’t know if anyone has ever… liked me for me.”
More tears appeared in Rita’s eyes, before Solomon even finished his sentence. He watched her mouth “I knew it,” which unleashed that same stabbing sensation in his chest. This time, however, he was trapped by her body on the couch with nowhere to go.
“All my life I’ve had to prove myself by what I did. There was no faith in me. There was no provision from above. Every prayer I ever uttered– every song I ever mumbled along to in church– they were just words that meant nothing when I was finished saying them. There’s no God looking out for me or you. There’s only self-discipline, self- improvement, self-determination. God’s not going to punish us for wrongdoing, either– we only have one another to answer to.”
“Not all of us are as disciplined or determined as you are. Some of us need something else.”
“So you’re saying faith is a crutch?” he countered, raising his eyebrows.
“If we’re all crippled, yes it is. Sometimes it’s a crutch. Sometimes it’s more than that– it’s a cardioverter shocking us back to life.”
Solomon blinked. “I’ve… never really thought of it that way.”
He looked back out the window. “Still doesn’t quite apply to me, still.”
“Well, maybe you don’t think so,” jabbed Rita.
“I don’t. And like the people who tell me that milk thistle cures their hepatitis: when I see the evidence, I’ll change my mind. When I change my mind, I’ll change my practice. Doesn’t it seem anti-scientific to you, the existence of some… dimension we can’t see that interacts with us capriciously?”
“I go back and forth,” Rita said. “Growing up, I kind of went along with what my parents said and I drifted away in college. Didn’t help that every service was in Greek. But when they died, I just saw how my other relatives were so animated by the hope that this tragedy, this thing that felt so… you said it, capricious– this thing that felt so capricious part of something bigger, that it meant something and that was going to be a resolution to it. And I’ve been wrestling with what that meant for years now.”
“Well, when you find some convincing proofs, just let me know.”
“I’m not sure there are any convincing proofs beyond the longing.” She kissed his cheek and rose from the couch. “I’ve got to get some sleep. Thanks for the coffee.”
He stood up and embraced her. “You’re welcome.”
“I think God is changing you. You actually said ‘sorry’ and meant it. And you didn’t say something was bullshit when you wanted to.”
“Well, I guess that’s all the proof you need,” he chuckled. “Good night, Rita.”
Gainers laid down on his bedroll and kicked off his shoes. He figured, based on the smell emanating from them, that they were probably not worth stealing. A handful of other men under the bridge were rolling dice close to the sidewalk along Martin Luther King Jr. Boulevard, while others set up their tents or sleeping bags for the night. Gainers put his hand inside of his jacket and felt it bump up against his pill bottle.
“Oh, shit,” he announced. “Gotta take my medicine.”
He reached behind his head into his backpack and pulled out a water bottle. He stared at the pill– it had been a few weeks since he had last taken it
He carefully dropped one pill from his bottle into one palm and put it in his mouth, then filled his other cupped hand with water from the bottle and washed it down. Cars were still coming by on Franklin Street every few minutes, but for the most part it was quiet in this dark corner of the underpass now that it was nearly midnight.
“Got anything good there, man?” came a voice from behind him.
Gainers looked up and back towards the concrete wall. He saw a boot coming straight towards his face and rolled to dodge it, still feeling the firm plastic sole scrape his cheek as it came across. A higher-pitched voice laughed as he felt a kick in his ribs.
“I only got Haldol, fuck off!” yelled Gainers as soon as his breath returned. Another kick came.
“Get inside his jacket.”
A thin, desperate pair of hands began to work their way across Gainers’ chest. He flailed on the ground, shouting and cursing as one of his assailants searched him and the other kept kicking.
“Shut up!” The searcher stopped his task for a moment to punch Gainers in the face. Stunned, he stopped yelling for a moment, in the hopes that it might stop the beating.
It didn’t. He felt blow after blow connect with his ribcage. They had already let his Haldol go without much thought– the pills were scattered all over his chest and face. Clearly they were looking for something else.
“Hurry up!” called the kicker.
“Fuck, I’m tryin’,” said the searcher.
Gainers closed his eyes, mouthing Oh God Oh God Oh God over and over until he heard another pill bottle hidden inside his jacket pull loose with a shaking sound.
“It’s Tramadol!” cried the searcher.
“Shit!” yelled his accomplice.
Another boot rushed past Gainers’ face as both of his attackers screamed. He heard more feet and fists connecting with softer body parts, followed by yelps of pain. He breathed a word of thanks that none of them came from him and looked up.
The two thieves– one white, one black– had tumbled over one another and were lying on the ground. Gainers’ pill bottle lay clenched in the hand of the one on top, while the other struggled to get free of his friend. Standing over them was a much larger man who was dressed only in a black sweatshirt and jeans, alternating between kicking and punching both men.
“Let it go, you bastards!” he demanded.
The orange bottle slipped free. Gainers leapt forward to snatch it away.
“Okay, okay, stop!” cried the searcher, a skinny black teenager with a shaved head dangling out of his open parka.
Gainer’s savior stopped, then emitted a guttural growl. Both of the men on the ground tripped over one another again as they got to their knees and began to skulk away. The kicker, an older white man whose matted hair clung to his stained black sweater, let out a grunt of pain as he rose to his feet.
“Fuck you, Larry,” he moaned.
“Fuck you back,” replied Larry, who turned to face Gainers. His sun-worn red face and chest were exposed by the U-neck shirt that clung to him with cold sweat. His fleece was unzipped as well, showing off a number of tattoos that seemed to dance on his neck as he looked from side to side.
“Th-th-thank you,” sputtered Gainers.
“We gotta look out for each other, man. Those aren’t Oxys they just spilled all over you, are they?”
Gainers looked down at the Haldol pills scattered across his body and blanket.
“Naw, man, just my an-ti-psychotic. Got it down at Healthcare for the Homeless today.”
“I ain’t been there before. What’s it like?” His accent sounded vaguely Southern.
“Aw, it’s real nice. You can just show up and if they ain’t busy, they’ll see you if you wait. I even got an appointment with a case manager to see about gettin’ my S-S-I back.” Gainers began to gather up his pills and scoop them back into the bottle.
“No shit. They pretty free with the Percs?”
“Naw, you know they’s crackin’ down everywhere on that shit. I asked. All they gave me was Haldol and some Tramadols. But I can get Oxys at just about any ER in town on accounta my back.”
The other man spit a large wad of tobacco and reached out for Gainers’ water bottle. “Really? I ain’t had no luck with gettin’ any kind of narcotics from the ER here. I came from West Virginia, y’know, and they were not nearly as hardassed as the ER docs here in Baltimore.”
Gainers handed him the bottle. “Well, my sister done broke a bone in my back or somethin’, and when they see that broken bone they take pity on me and gimme a few pain pills.”
A guffaw emerged that echoed through the underpass. “The gift that keeps on giving! Them doctors don’t want to believe anything unless it shows up on a blood test or an x-ray.”
“Ain’t that the truth,” murmured Gainers. “But they was real nice today. Didn’t treat like me I was some kinda junkie or nothin’ like everybody else always does. And they gave me that Haldol. Keeps my voices away.”
“Hmm. I’ll haveta check ‘em out. I ain’t had a full physical in a long time. You gonna hold on to those Tramadol?” Larry nodded towards the other bottle in Gainers’ hand.
“Naw, man, I’m tryin’ to stay as clean as I can. My sister kicked me out on accounta drinkin’ again, so I’m only using it when I need. You got cash?”
“Uh-uh.” Gainers saw more tattoos dancing as Larry shook his head. The Haldol had yet to kick in, so some of the tattoos seemed to continue moving even when his head stopped. “Trade you, though.”
The man’s eyes darted towards his pants. Gainers looked down to see that he was unbuttoning them with one hand and reaching inside his underwear with the other.
“Aw, no, man, I ain’t into that kinda transaction…” Gainers because to look around, praying for another deliverer to save him from his first.
More laughter echoed through the concrete. There were a handful of people gathering now to watch.
“Trust me, my personal equipment only sees the highest quality. What I have to offer is far less discriminating where it gets stuck.”
Gainers heard a soft click and looked back down at the jeans. A brief flash of light glinted at him from Larry’s palm.
Gainers gazed at the switchblade. The handle appears to be made of cheap black plastic, not nearly the same quality as his old one.
“I’ll give you thirty.”
“C’mon, I know they musta given you at least sixty pills.”
Gainers trembled. He looked up from the knife to his trading partner’s face, then up to the steel girders above. The loud rumble of cars and trucks overhead gave way to murmurings in the back of his head. He shivered with the thought of his vulnerability, how he did not have the strength he had five years ago when he had last slept on the street and didn’t bother carrying any medications, anyway.
“Forty. I know I’m gonna need a couple after the beating they just gave me.”
“Fifty. My knee’s killin’ me, man. You want me to take you to the ER?”
“Naw, I’ll go tomorrow mornin’. Need to get some sleep tonight.”
Gainers carefully opened his Tramadol bottle and slowly began to count the pills out. He looked up every few seconds to make sure that no one else was coming and that Larry was not going to use the knife against him. When he reached forty-five, he dumped from his sweaty palm in Larry’s grimy one. He closed his fist just in time to protect the tablets from a sharp, biting gust of wind.
“You sure you don’t wanna get seen tonight, man?”
Gainers shook his head. “No, I just wanna be alone for now. I don’t think they broke anything.”
“Be careful out here. You new?”
Gainers shook his head. “Well, I was walkin’ the straight-and-narrow for a while, but I done fell off that path. Tryin’ to get back on my feet before I really slip and slide back down to the bottom, y’know what I’m sayin’?”
“Oh, I know,” said Larry. “I hear there’s more open slots for methadone out here. Tryin’ to get me into a clinic if I can. Plus, I’m a poet and the poetry scene in Baltimore is way better. You know any?”
“Sorry, I don’t. It’s been a long time since I been on that methadon. It’s always been booze for me.”
“I hear you. Well, stay safe. You don’t stay in the shelter?” He dropped the knife at Gainer’s feet.
“Too crowded. My– my, uh, illness can’t take it.”
“Yeah. I’ve been banned myself.”
“Well, I appreciate your kindness tonight. Don’t know what I would’ve done without you.”
“There’s some bad people in this world, man. They’d fuck you over for a nickel. Some of ‘em live under bridges, some of ‘em live on Capitol Hill.” He paused to pop a few of his pills into Gainers’ mouth.
“Thanks, man. That’s beautiful.”
“I’ll be at Red Emma’s on Thursday night.”
“I’ll, uh, do my best to make it if I can,” said Gainers, not sure if that was a promise he could keep or not.
“See you there!”
Larry spun around, walking south towards University of Maryland Medical Center in a determined manner that Gainers recognized; he knew that on a night as cold as tonight Larry would have to slow down eventually and find some shelter from the wind, but it was not quite midnight and there were probably still more deals to be struck.
The clack and roar of the vehicles on the highway overhead continued on. As Gainers closed his eyes and listened, he thought he heard Jessi’s low voice cutting through the sound. She seemed to be scolding him about the knife, although the Haldol was starting to kick in and her voice was faint.
“I, uh, I’m sorry. I gotta protect myself,” he said aloud.
“Shit!” came a voice.
Gainers sat up. The two thieves had returned, sticking their heads out from the other side of the wall.
“He took it all,” barked Gainers. “Scram.”
“He’s gone now,” said the white one, his thick hair bouncing in the shadows.
“Get outta here.”
“No way. We gonna fuck you up now.”
They inched forward, then pounced. Gainers tried to leap to his feet, but was tackled by the black one. His left side ached– he wondered if they’d managed to hit his fragile liver before. He squeezed the black plastic handle and let out a roar as he pushed upwards, putting all of his strength into resisting the assault. His effort was imprecise, but still effective on account of his attacker’s weight and the effect of the knife. He felt warm liquid spilling onto his hands; a scream rattled his eardrums.
Gainers got to his feet as the black one rolled onto the ground. The knife was still in his hands, though his hands trembled as if he was about to let it go. The white thief still stood in front of him with a defiant stare on his face.
Gainers swung the knife wildly as he lunged. He felt resistance as the blade met his attacker’s face, spilling more blood across Gainers’ hands. His fingers felt the man’s lips move with a shriek of pain that gave way to a scream of rage. Gainers felt his legs give way as he was tackled again; he felt for sure that he had finally broken a bone with this fall back to the ground.
“You little fuck,” growled the assailant, pushing down on Gainers’ shoulders with both hands as blood rained down on Gainers’ face from his, sopping from his beard to Gainers’ stubble
Gainers jammed the knife upward again with his right hand, but was stopped by the man’s hand against his forearm. Gainers saw him wince in pain as the tip of the knife caught his skin, but he stayed above the length of the blade and raised his own right hand to punch.
“No!” cried Gainers as the fist connected with his nose. He felt his teeth rattle as the back of his head hit the pavement, sending pain across the back of his skull. He felt the pressure on his face relent and winced as he prepared for the next blow, which was telegraphed to him by the man shifting his weight onto Gainers’ right arm.
“You’re– gonna– aaaagggh!”
Gainers felt the weight shift off of him; he pushed to his left and felt his knife dig further into the man’s chest. As he opened his eyes, he realized that it had entered during the wind-up to the punch; his rage and adrenaline had dulled him to the switchblade penetrating his left lung. As Gainers rose to his feet, he watched the man gasp for breath. Somewhere in there, Gainers, supposed, there was a blood vessel leaking into the space where air belonged.
A handful of others had gathered at a distance to observe the melee. They had been cloaked in the darkness of the bridge, but the noise had drawn a crowd and now even a car had stopped. Gainers looked up at them and then down at his tattered sweater, so soaked with blood that it was now dripping onto his shoes. He looked down at the pair of thieves, trembling as he watched them breathe in agony. The instincts he’d suppressed for years had been called out without any intention on his part, guiding the knife towards vital organs.
“S-s-s-sorry,” he mumbled as the knife dropped onto the ground. He turned to the onlookers. “S-somebody call uh-uh-uh ambulance.”
They remained still, eyes darting back and forth between him and the bleeding men.
“For the love of God, I don’t have a phone.”
He heard a siren in the distance. He ran back and put on his backpack, then gathered his bloody bedroll into his arms. He looked west, wondering if he could get inside a vacant house somewhere for the night before the police came and began to investigate. Some of the people watching might know these guys. Some of them might even be friends.
He hesitated after taking a few steps. He heard the rumble above and looked up.
“I’m sorry. You see what I gotta do.”
He turned around and picked up the bloody knife from the cold dirt, then wiped it on his sleeve.
“Somebody gonna call?” He wondered if this was a voice in his head or if it was one of the bystanders, but it seemed clear and distinct. It was probably not his own imagination.
He darted west across the street, not paying attention to any of the cars coming. One honked as it approached him, but veered away as he made it to the opposite sidewalk where a stunned crowd of fellow homeless simply stared at him.
“Jessi, I’m sorry.”
He did not hear a response.
Hannah’s arms ached. She had been holding her retractor in exactly the same position for at least half an hour, gently tugging downward on a particularly bothersome length of small bowel that had been continually invading the field where Dr. Patel and his fourth-year resident were carefully dissecting. The field looked– and smelled– nearly the same as when the surgery had begun hours ago, a tangled mess of mesentery and skin. The OR lights shone directly on their work, but every time she moved to a position where she could rest her arms while keeping enough tension on the retractor to fulfill her duty, the field moved out of her view and all she could see were wrists in yellow gloves stained with blood, surrounded by the dark green drapes.
“What a mess,” remarked Tom, the resident.
“You know what a great project would be for one of the Gen Surg residents– or even a particularly enterprising subintern– would be to make up a list of these frequent flyers with some maps,” said Dr. Patel.
“You know, like some anatomic illustrations and stuff. Here’s Mr. Jenkins with his ileostomy here and his ureteral pouch there. Mrs. Black has that giant mass of scar tissue in her right lower quadrant and a drain that can’t be removed or her abscess will accumulate. Just writing down the knowledge we lose every time it’s a weekend like this and a new team comes on. I know you have your signout, but that only contains the information about this particular admission, not the sum total of someone’s surgical misadventures.” Dr. Patel began to tie off an artery that had been bleeding into their field for the past five minutes.
“It’s aggravating when we have to explain everything that happened in the past month for these patients who are here for weeks at a time,” said Tom.
Dr. Patel quickly cocked his head to face Hannah. “Let’s tag this. I can finally see what I’m doing here for the first time since we got started. Hannah, you’ve been awfully quiet since the surgery started. What do you think?”
Hannah, startled by being addressed directly, held her mouth agape. She was glad that Dr. Patel couldn’t see this with her mask in the way, but she was sure that her face betrayed her surprise nonetheless. She had nothing particularly relevant to say, so she decided to repeat some of the banter she had overheard the surgical residents giving last night in the lounge.
“Well, sometimes for these complex patients who are here for a month and get admitted four times a year it would be nice if they were just on the medical service and they just called us when it was time to reoperate.”
Dr. Patel chuckled dismissively. Hannah wondered if perhaps he was chiding her for using the word “us”– having only been on the team for a week, she felt hesitant describing herself as part of it even though she pre-rounded with them starting at 5:30 in the morning and hadn’t left before 7 in the evening yet.
“Dr. Bode told me you had a funny bone, Hannah, but I didn’t realize you had the sense of humor necessary to be a surgeon,” he said, his eyebrows becoming more animated. The scrub tech, a tall man whose forehead seemed especially pronounced with his Ravens-themed cloth scrub cap tied tightly above it, handed Dr. Patel his clamp.
“I can’t think of any faster way to kill all our patients than turning them all over to Internal Medicine for five minutes,” chimed in Tom, eliciting more laughter from Dr. Patel as well as the scrub tech and the circulating nurse.
Hannah, realizing that the sentiment expressed last night in the lounge was more a statement of desperation than a legitimate suggestion for improving workflow, decided to play along. “Yeah, we like to kill our patients nice and slow on this service!”
Her comment brought in another round of guffaws, even including the anesthesiologist– who Hannah could not see.
“There we go! I just had to give you permission to speak and there we go. I can’t handle how timid the students are these days. It’s like at this time of the year they’re all too traumatized to jump in and speak their minds.”
“Hannah’s not your usual third-year, though. She doesn’t disappear when there’s work to be done or complain when we yell. Can you believe someone said that in an evaluation?” scoffed Tom.
Dr. Patel shook his his head. “I can.”
“I mean, I’m not the activities director on a cruise ship!”
The entire OR erupted again in laughter.
“So, Hannah, Solomon tells me that you’re considering applying for a surgery residency.”
Hannah nodded. “He’s right, I am.”
“Well, if my experience with you on the team over the last few days is anything to judge by, I think you’d make an excellent surgeon.”
“That’s very kind of you to say, Dr. Patel.”
“And you know Dr. Patel doesn’t just say that about anyone,” observed Tom.
“Dr. Powell is correct, I’m not just saying that because you’ve been retracting excellently for the past half an hour. Thank you.”
“In general, though, you’re nicer to the students than a lot of other surgeons,” piped up the circulating nurse, a woman almost as tall as Hannah whose name she had already forgotten since being introduced this morning.
“He doesn’t have much competition,” offered Tom. “Dr. Bode, Dr. Zigfelter…”
“Now, now, Dr. Powell. You know one of my rules for the OR is no talking about other surgeons unless it’s tell us something they taught you.”
Hannah breathed a sigh of relief beneath her mask, not wanting to get drawn into another discussion about Solomon. She had already sensed that the surgical residents treated her differently because they had seen her tagging along behind Solomon for the past several years, though no one had said anything explicit about this and she couldn’t recall a particular example when she tried to think of one. It could have been a lot of different things– none of the other students seemed interested in matching into Surgery, for example– but it was merely the recognizance in their eyes whenever they began discussing patients together, or the cautious tone with which they ordered her around.
Dr. Patel’s voice interrupted her train of thought. “So, Hannah, what do you think of your Surgery rotation so far? Everything you hoped it would be?”
She almost said that it wasn’t, but she thought better of that answer. “Just about. I mean, I guess I had never really encountered these patients– these, uh, frequent flyers. They’re pretty sick.”
Dr. Patel sighed audibly. “Yes, that’s one of the challenges of practicing in a great big urban teaching hospital. Your bread-and-butter surgery cases get spread out between a couple of highly specialized services and you see the sickest of the sick. People who have been operated on so many times, they should get their own wing named after them… if you like academic medicine, it’s fun. But it’s harder if you want to have more of a community practice. You know what you want yet? Going to follow in Dr. Bode’s footsteps?”
“You mean Transplant?” Hannah’s voice was hesitant. “It’s… a pretty demanding lifestyle. Especially with all the research, which is what drew me in.”
“Not everyone can handle the stress, for sure.”
“And I’ve thought a lot about practicing overseas…”
“Oh yeah, that’s right! You were telling me about your hospital in… Kenya, right?” chimed in Tom.
“Ghana!” said Hannah. “Yeah, they don’t have an OR yet, but it’s possible they could build one. Right now anyone who needs an operation has to drive 2 hours on dirt roads…”
“Hannah, you have your own hospital?” Dr. Patel’s voice was excited but skeptical. He took a large white stapling gun from one of the sterile trays. “Alright, there’s not too much bowel that has to go, but I hate to take out another 6 inches every time we go in. His mesenteric vascular supply is just shot to shit, so it’s just not healing well. Tell me more about this hospital!”
Hannah chuckled. “It’s not mine, it belongs to the Ghanaians who built it. And, I guess, Verilife who funds it. It’s complicated.”
“But you… helped to build it?”
“I helped with the community decision-making and fundraising process, yes.”
“Fascinating! So, you’d want to practice there?”
“I’ve thought about it…” She could now see Dr. Patel take a section of intestine between the flat blades of the stapler, carefully sealing it shut and pulling at a mechanism she couldn’t see to divide the bowel.
“I hear you, it’s tough. I went on a trip to Honduras last year, and it’s just hard to practice down there where you don’t have the same supplies, don’t have the same resources. Even the staff isn’t nearly as good.”
“It didn’t slow down any of your complaints about the staff here!” chirped the circulating nurse. Hannah wished she could remember her name.
“Thanks, Michelle. Appreciate the observation. Anyway… that probably doesn’t pay too well, does it?”
“There’s actually a single payer health care system in Ghana. There’s just not enough funding to get enough providers and hospitals out to the people who need it.”
“Hannah’s also thinking about Family Medicine,” interjected Tom.
“Family Medicine!” exclaimed Dr. Patel, turning to Hannah. She felt her cheeks getting red and hot beneath her mask, embarrassed that Tom had outed her.
Tom sighed. “It’s true.”
“Family Medicine,” repeated Dr. Patel, as if he were trying to ward away an evil spirit. “But you’re so smart! Too smart to spend your time seeing patients with runny noses and back pain all day.”
Hannah took a deep breath. “I… think you have to be really, really smart to manage multiple chronic conditions. Patients go to specialists who only know one organ system or one part of the body; they need a doctor to help them understand everything that’s happening. Plus, I really like how a lot of primary care doctors do stuff at the population level and aren’t afraid to deal with the crazy social issues that bring patients into the hospital over and over again.”
Dr. Patel shrugged. “Aren’t social issues what… y’know, social work is for? Or even psychiatry? I mean, if I wanted to listen to my patients complain about how they don’t have money for anything but cigarettes and a new cell phone, I’d have gone to counseling school.”
“That’s what I do when I run into a social issue! Consult social work!” chimed in Tom.
Hannah shook her head, trying to maintain her grip on the retractor. “Some doctors like talking to patients about something other than what’s wrong with them.”
She grit her teeth, then relaxed as Dr. Patel guffawed. “I guess you’ve got a point there. I do have nice conversations with my patients sometimes. Mostly when they come see me and say, ‘Thanks for fixing me, can I get back to playing golf?’ The people you get to know over a long time in Surgery, they’re mostly not exactly the most upstanding citizens.”
“People who are not exactly the most upstanding citizens are still people, too. They may not be the people that we associate with– we might not even be able to have a relationship with them outside of the hospital– but they’re people.” said Hannah.
She realized after she had spoken that this riposte might have come out too aggressively, which was evident by the length of time before Dr. Patel spoke again.
“You are Solomon’s protege.”
Hannah’s felt the heat in her cheeks again.
“Following your rule, sir, I can say that Dr. Bode has definitely taught me not to take any bullshit from anyone else, regardless of who they are or what letters come behind their name.” Tom’s voice was surprisingly earnest. “Of course, he usually meant it in terms of not letting some internist tell you who you are or aren’t gonna operate on…”
“You can let go of that retractor, Hannah.” Dr. Patel sighed audibly. “Well, he sure didn’t get into the New England Journal of Medicine by kowtowing to anyone.”
Hannah released her grip, squeezing and relaxing her fingers to overcome the stiff ache that had been developing for the past half-hour. She leaned towards the open abdomen, disappointed that she could tell no difference between what it had looked like when they started the operation and what she could see now.
“Alright, let’s get an 0-Vicryl suture to Dr. Powell and do our final count before closing,” announced Dr. Patel. “Any other big cases this afternoon?”
“Just need to discharge a few of Ziggy’s Piggies.” Tom shook his head as he took the needle in the needle driver from the scrub tech, trailing a black thread across the operative field. He dug the needle into the edge of the abdominal incision closest to the patient’s feet. Hannah instinctively reached for another retractor to help him see.
“Is that what you call Dr. Zigfelter’s gastric-bypass patients?” Dr. Patel’s eyes narrowed.
Tom, not looking up, murmured in the affirmative.
“Well, Hannah, I’ll say this: Surgery could probably use a few more people like you. Believe it or not, surgeons in academic medical centers are people, too.” Dr. Patel refrained from eye contact with her. “Dr. Powell, it looks like you can handle this closure by yourself. I still have to finish rounding on the Gudelsky patients. You’re on call tonight, correct?”
“Yes, sir. I’ll call you if anything goes bump in the night.”
“Let Hannah do the skin closure, please.” Dr. Patel stepped away from the table and began to pull off his gloves.
“I was planning on it.”
Chapter 13 will be released on September 1, 2015
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Trousseau Syndrome by Matthew Loftus is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License.