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  With a deep voice and a scar on his cheek, their boss was taller than all of them. His dark eyes roamed across their faces. “Let’s buckle down into a first visit and presentation of each patient. Dr. Mack, I understand this is your patient. Please tell us about this case.”

  “Mr. Kingman is a twenty-eight-year-old with a 55% body surface area burn,” Marlin said. “Besides meticulous care in the unit, he has a serious burn involving his face, head and respiratory system so he needed to be on ventilator support. He has had two skin grafts and is scheduled this afternoon for his third.”

  “For which you will assist,” Robby said. “And the students must realize that this patient is deeply sedated with pain medications. Burns of this magnitude are so painful that you don’t wish them on your worst enemy. As you get used to managing post-op pain control you will realize and see the difference with a burn patient. They easily need large doses of narcotics and then become tolerant which makes them require higher doses yet again.”

  “How did Mr. Kingman get burned?” Annabel asked.

  Marlin was standing next to her and mumbled while turning to the side. “Maybe he’s a firefighter and was trying to rescue Smoky the Bear.”

  Annabel couldn’t believe his remark but all Robby heard was “Maybe he’s a firefighter.”

  “Actually, I wish he had been a fireman,” Robby said. “Mr. Kingman was living with his grandmother in a single-story older home while he was finishing up his college degree online. It was a practical arrangement which allowed him a place to stay and he helped her out so she didn’t need admission to assisted living. Anyway, one night there was an electrical short in the wall socket behind her bed. He couldn’t get to his grandmother before the blaze engulfed her and he was badly burned trying to save her.”

  Annabel’s heart felt heavy hearing about the young man’s rescue attempt. Now his future was in jeopardy. Her chief resident’s eyes also softened and his upper lip pouted more than usual. She switched her attention to their attending.

  “Which student is assigned this patient?” Dr. Pittman asked.

  “I am,” Da’wan Roth answered.

  “Dr. Roth,” Dr. Pittman continued, “I am assuming you have the patient’s latest lab results from this morning. Of the different analyses, which one would be most important for us to know?”

  “The ABG?” Da’wan asked.

  “An arterial blood gas is important because you and Dr. Mack will be adjusting ventilator settings based on the results. However, I am looking for something else.”

  “I would think monitoring renal function with a blood urea nitrogen and creatinine would be important.”

  “Nice. However…”

  “What Dr. Pittman is looking for,” Robby said, “are the electrolyte findings.”

  “Yes,” Dr. Pittman said. “In particular, the patient’s potassium.”

  “Yes, sir,” Da’wan said. “I did see that somewhere. A burn patient can be worrisome for hyperkalemia because of cell damage.” He stood tall with bright eyes focused on his attending.

  “Perfect. On these rounds, we will bring book knowledge right to the bedside. It’s why I love teaching. These patients are living examples of the dry material you’ve been learning in medical school for the last two years and the textbooks you are still devouring in your time off the wards. Dr. Burk, fill them in.”

  “By now,” Robby said, “you should know that potassium is the most abundant cation in the human body; 90% of it is inside cells or intracellular and the other 10% is in the extracellular fluid. So with massive cellular damage from a burn, an abnormally high amount of potassium ends up in extracellular fluid. And if the proper ratio of this cation isn’t maintained between inside and outside the cell, there can be neuromuscular and cardiovascular excitability. A high lab value will spell trouble so we must manipulate and treat it before a patient goes into cardiac arrest.”

  “So, Dr. Roth, what is your patient’s potassium level?” Dr. Pittman asked, taking over again.

  Da’wan looked at the notes in this hand. “5.1,” he said.

  “And Dr. Tilson, what is the lab’s normal value for potassium?”

  Startled, Annabel took an educated guess. “3 to 5.5?”

  “Are you asking me or telling me?” the attending asked.

  “Telling you.”

  “You’re close but that’s not good enough. It’s 3.5 to 5. So I advise all of you to know when a lab value is outside of this laboratory’s normal range because your patient’s care is depending on it.” He gave her a slight stern look.

  Annabel gulped and looked down at her shoes. Besides all the knowledge she needed to absorb, and knowing the patients and their surgical and medical histories, the human dynamics of working closely with five people she didn’t know two days ago were going to be a challenge.

  -----

  Dr. Pittman waited until the team had finished seeing and discussing all of their patients, then asked Marlin Mack to sum up Mrs. Hardy’s case as they filed into the office adjacent to the nurse’s station. Pittman sat and crossed his legs.

  “Dr. Mack, we left Mrs. Hardy until last,” he said, waiting for Marlin to pick up his cue.

  “Mrs. Hardy was status-post cholecystectomy yesterday,” Marlin said. “She was found this morning by the tech doing vital signs; no pulse and not breathing, and probably for some time. Despite heroic attempts at resuscitation, we declared her dead. She was in her mid-sixties and had no medical history except for a little arthritis, reflux disease, and chronic bronchitis. She was a pack-per-day smoker and had had only one orthopedic surgery on her hand in the past. Yesterday Dr. Burk and I performed an uncomplicated laparoscopic removal of her gallbladder.”

  “So,” Dr. Pittman said, “this patient ended up with a result we never want. Dr. Burk will be teaching you all about surgical consent. Part of a surgeon’s job is to advise patient’s about their surgery ahead of time– the good and the bad. You will begin to formulate a differential diagnosis when things go wrong as in this case. But let’s start with what Dr. Burk would have told his patient before she signed her consent form.” He looked at Robby, his finger absent-mindedly stroking the scarred ridge on his cheek.

  “I tell these patients they will have much less discomfort post-op with the minimally-invasive technique,” Robby said. “Their hospital stay will be shorter, they’ll recover quicker, and they’ll have only small scars. It’s extremely safe and the complications run less than 2%. The potential risks are infection, bleeding, and bile accidentally leaking into the abdomen.”

  Robby glanced from one medical student to the next. When he paused, his ready smile settled on Annabel for a brief second, long enough to make her heart throb. Now she wondered about him. She didn’t see a wedding ring. Was he staying here in Ohio when he finished his training? Was he already committed to a practice? She listened to him continue but his words were making less of an impression than his gentle yet assured personality.

  “It’s also my duty,” he continued, “to tell the patient more specific risks, some of which are solely related to surgeons being human. What if we nick the common bile duct or intestine? Maybe the patient would need to be brought back to surgery to repair it. What if a gallstone is accidentally spilled into the abdomen?” He shook his head as if any of these were hazards of the job.

  “Other complications I consider to be more related to the patient’s history. They could be events such as a blood clot or a heart problem or pneumonia.”

  Dr. Pittman uncrossed his legs and leaned forward. “Dr. Mack, those are the precise things you would have discussed with your patient ahead of time had you been the one to procure her consent. What do you think happened?”

  “The exact surgical complications Dr. Burk mentioned aren’t in the equation because we were there and no perforations occurred.”

  “Excuse me,” Dr. Pittman said, “but an event like those mentioned can go unnoticed and still be in the differential diagnosis postoperatively when
the patient starts deteriorating.”

  Marlin shrugged but then noticed the attending’s annoyance. “Yes. That is so true. Surgical complications can be insidious. “

  The room became quiet. Someone’s stomach growled enough to be heard.

  “Dr. Tilson, this was your patient as well,” Dr. Pittman said. “What are your thoughts?”

  “Based on our discussion about laboratory parameters, I didn’t see anything abnormal with all the last minute information I received from the lab. But we did notice the ST segment ischemic changes on the EKG taken sometime during the night.”

  “I saw that,” he said, “but we must go back to what Dr. Burk mentioned. EKG changes like that can be nonspecific. But, yes, she most likely had a heart attack.” He looked at all the students. “But what else?”

  Da’wan cleared his throat. “Maybe she didn’t have on those ted-hose stockings which patients wear post-op to deter blood clots in their legs. Maybe she had a pulmonary embolus.”

  Robby smiled. “That’s a smart possibility, Dr. Roth. She was a tad overweight, probably didn’t get enough exercise, and was more prone to venous stasis.”

  Brandy Wallace had remained silent. As one of the two residents, Robby looked at her for input and she nodded.

  “I unfortunately agree and, since I fit the patient’s description, I think I’ll panic if I ever need my gallbladder out. However, I realize there is a tiny idea beyond the realms of these academic rounds.”

  “And what’s that?” Robby asked.

  Brandy twisted a ring on her finger. “Medical foul play.”

  “Great,” Dr. Mack said. “A nutcase hospital employee stole into her room during the night, white pillow in hand, and smothered her.”

  Dr. Pittman rose, making it appear as if rounds were over. He shook his head at Marlin.

  “Dr. Burk, it’s time to get these young doctors thinking like surgeons,” the attending said. “Not like Hollywood thriller movie makers.”

  -----

  Inside the office, Annabel hurried through a cold sandwich from the cafeteria, dabbed her lips with a napkin, and tossed the to-go container in the garbage can. She took another swig of water from her bottle, recapped it, and put it near her backpack on the windowsill.

  She considered what Robby had said before he left the room. “If any students beside Da’wan get caught up with their clinical duties, come to the OR to watch Mr. Kingman’s surgery.” He had looked at each of them, but her heart palpated when she imagined he locked his eyes on her a little longer.

  She got up and skimmed the bulky surgical textbooks on the shelf. Her paperback was a student’s condensed manual meant for studying and passing exams; it lacked the detail found in the texts in the office. She looked up burns and read an excellent dissertation on the subject. The information about the degrees of burns and complications was all there. Compared to the first two years sitting in lectures and labs, she already found the wards much more beneficial. Here she could see firsthand what the textbooks were talking about so it made the material easier to understand and retain.

  She lost track of the twenty minutes she spent reading and then realized she had better get to the OR. After donning a cap, booties, and a mask like she had been instructed the day before, she entered the appropriate room. The activity caught her by surprise and she was horrified at what she saw.

  Because Mr. Kingman had been mostly covered by sheets in the burn unit, she had no idea the real extent of his skin damage. From his lower face and down his neck to his upper chest, there was no skin to speak of. Now Annabel understood why many burn patients just wanted to die rather than live through any kind of recuperation. In place of skin all around his neck was yellow oozy fat charred like charcoal.

  “Excuse me.” A lanky anesthesia doctor grabbed some tubing extending from the patient’s wrist, taped it along the edge of the table, and handed it to a senior anesthesia resident. All their machines and equipment were at the head of the table and they hadn’t stopped being busy since she entered the room. They flowed from one thing to the next, working unified as a pair. The nurses in the room ran from the wall thermostat to fixing the drapes to changing the patient’s Foley catheter. The tech stacked lap sponges on the steel instrument table.

  Dr. Burk and Dr. Mack stood across the table from each other discussing the best location to harvest good skin. Da’wan tossed Annabel a look, as unsure of where he fit in as she was.

  As if reading her mind, Robby suddenly looked over at her. “Dr. Tilson, you may stand slightly behind Dr. Mack. We’ll be here a good two to three hours but you don’t have to stay the whole time since this isn’t your patient.”

  After they started surgery, Robby gave Marlin practical advice along the way. And with a reassuring tone, he described to all of them the critical importance and uses of skin grafting. “It accelerates healing,” he said. “In plastic surgery it enhances cosmetics and reduces scar contraction.” He looked at the students. “For burn patients like this, what would be another extremely important function?”

  Annabel noticed the anesthesia team hanging more IV bags of fluid, running them quickly through the warmer and she remembered what she’d read. Da’wan still considered the question so she said, “Skin grafting would help reduce the patient’s detrimental insensible fluid losses.”

  “Lucky guess,” Marlin said, turning his head to the side.

  Robby glanced at her with narrowed eyes. “That’s a well thought-out answer,” he said, “and precisely what I was looking for.”

  Under her mask, she sighed. She was not only pleased to make the clinical connection and come up with the right response, but she was even happier to have received recognition from her chief resident. However, Marlin was also correct about her being lucky which she attributed to the textbook she’d found in the office. And that book had had Robby Burk’s signature on the inside cover.

  Chapter 3

  Annabel entered the interstate heavy rush-hour traffic in Cincinnati and drove the fifteen minutes to her exit near the Ohio River. She veered to the east and entered an eclectic neighborhood, found a parking spot, and walked around the block to her apartment. It was the smallest rental of a converted three-story house; she opened the main front door and walked up the two flights of stairs.

  The heat and humidity of the August day had settled through the staircase and she wiped her forehead when she reached the top. Unlocking the door, she went inside the two-room unit. She smiled to be home but it didn’t last. Tomorrow was the team’s first day on call so she’d be gone from her little peaceful place for at least thirty-two hours. Besides eating, showering, and packing a small bag for tomorrow, she’d be lucky to open her surgery book this evening.

  She went to the refrigerator, pulled out strawberry jam and milk, then spread peanut butter on a piece of wheat bread and finished making a sandwich. When she sat on her kitchen stool, she contemplated calling her family about her first two days on rotation but her thoughts wandered to thinking about them rather than talking to them.

  Annabel was grateful to her parents because they paid her rent and tuition, and had supported her decision to go to medical school. Her physician father was a neurosurgeon, revered in his profession not only in Nashville, Tennessee - which was home - but nationally, too. His surgical skills were outstanding, his ability to solve stupefying medical problems was stellar, and his research work and inventiveness was almost as good as a medical engineer. But his one-time extramarital affair which produced a baby girl from a conniving villainess proved he wasn’t perfect.

  However, even though her father and mother had divorced over it, their devotion to each other was unbreakable; they had gotten back together again but hadn’t remarried. They had had cruel hardships along the way, including the death of their oldest daughter and a miscarriage not many years ago. Annabel loved the fact that they were reunited and realized that, for some time, she hadn’t appreciated them as well as she should. She’d been too critical of her
father and, after one semester of med school, she realized she’d been a know-it-all and too quick to judge him.

  Her mother was a high-school teacher and it was due to her dedication to her career that Annabel and her sisters learned that education and studying was as essential as breathing. Her oldest sister who had passed away had been hell-bent on becoming a doctor and her death had been too sad and ironic, particularly because EMS was on the other side of the door during her severe asthma attack, unable to get into the locked house to help her.

  Annabel slid right into her mold after her death, even felt it her duty to take up her sister’s goal of med school. So far, she had no regrets. The only remaining question in her mind was what specialty she wanted to go into. Because her father was a neurosurgeon, she wanted to resist the temptation that his field should be her calling as well. However, she was open to anything.

  She had only just begun but was resolute that every medical school rotation was going to be important to her. She wanted her passions to manifest with some particular specialty; some field of medicine should captivate her like watching a long-playing Broadway musical for the first time.

  With the last bite gone, Annabel finished the glass of milk and got comfortable in her recliner alongside her bed. She opened up the Independent Study Series on Surgery to gallbladder disease. One more good read on the subject and then she wanted to tackle another chapter. Her concentration waned, however, and she couldn’t focus on reading.

  During college, she’d had one serious boyfriend named David but they ended up being close friends after he suffered a head injury and subsequent problems. Since then, she hadn’t met anyone else she was fond of and she tried to keep it that way. Having years of studying, clinical work, and major exams ahead of her, she knew it would be difficult and complicated to have a relationship.

  So she had to get Robby Burk out of her head. First of all, he was her chief resident, hardly a colleague that she would be hanging out with and studying with. And he would never consider a medical student, even if he were available. But damn, she thought, why did she practically swoon when she stood right next to him or he focused those eyes on her or she listened to his soothing voice when he spoke? Even when he explained patients and surgeries to the group, she had to struggle against having a love-stricken meltdown.