A White Coat Is My Closet (15 page)

“Yes, Dr. Sheldon. You’re needed in the Emergency Room. Three-year-old. Auto versus peds. Trauma room three.”

“Auto versus peds” was the verbal shorthand to signify that a pedestrian had been hit by a car.

“Do you know the condition of the child?” I inquired.

Her answer was terse but not antagonistic. “I don’t have that information, Doctor, but they requested that you come STAT.”

“Thanks, on my way.”

As was always the case when I was called to an emergency, my mind went into overdrive generating the list of the possible complications I might be required to manage. A three-year-old hit by a car. I felt a brief surge of panic. The possibilities were limitless. The only certainty was that when a kid was hit by a car, the car always won.

I willed my legs to push myself a little faster without breaking into an overt run. Running through the hospital was bad form. It usually only succeeded in making visitors feel really anxious and seldom improved the outcome for a patient.

I knew because the child was the victim of a trauma, the trauma team would be in charge and, I had been called just to lend my expertise as it applied specifically to a three-year-old. I approved of the policy. All the trauma surgeons were extremely competent, but at the end of the day, they were most experienced in treating adults. Fortunately, the medical establishment had come to appreciate that children weren’t just miniature adults and had the potential of having unique complications. Having a pediatrician involved in the treatment of an injured child from the outset was more optimal for the patient.

As usual, the emergency room was a flurry of activity best described as controlled chaos. The trauma rooms were situated closest to the ambulance entrance, so I had to navigate my way to the far side of the building. The radiology technician was just maneuvering the portable X-ray machine out of the door of room three when I arrived. “Have fun,” he said with sullen sarcasm, “Dr. Klein is in rare form.”

Dr. Klein was infamous in the hospital. He was revered for being an exceptional surgeon but had the reputation of being arrogant and condescending. Were you ever to need emergency surgery, you’d hope he was available to operate, but you’d have an equally high sense of dread about the prospect of having to work with him. He was a perfectionist and would ridicule anyone whose job performance didn’t meet his standards. Unfortunately, on any given day, his expectations were arbitrary, and he seemed to derive a perverse sense of pleasure out of harassing his subordinates under any circumstances. He had recently kicked a surgical resident out of the operating room because the guy, frustrated that nothing he had done thus far had met with approval, had finally responded defiantly to Dr. Klein with a question: “So, do you want this suture to be cut too long or too short?”

Dr. Klein was barking orders at everyone as I approached the bedside.

Knowing Dr. Klein wouldn’t acknowledge my presence, I asked the surgical chief resident to give me a brief summary about the child’s condition.

The resident actually seemed relieved to see me, probably because he was optimistic that having another doctor in attendance would deflect some of Dr. Klein’s criticism off him. In the medical hierarchy, he was confident a pediatrician fell beneath a surgeon. With me in the mix, he was probably hoping I would become the new target.

The resident’s name was Victor Maldonado, and having followed a number of patients with him, I knew he was a pretty good guy. Clinically, he was smart. He worked to take good care of his patients, and for me, of equal importance was the fact that he respected me as a colleague. He hadn’t, at least as of yet, developed that surgical air of superiority.

Victor started his brief but concise summary. “I don’t know all the details, but this kid apparently got hit by a car when he was running through a parking lot. The car was reported to only have been going about ten miles per hour, which is why the kid’s still alive. Because he has a lot of contusions and abrasions over the left side of his head, we suspect a brain injury, so Klein is eager to get him into the CT scanner. Trouble is, his IV just infiltrated, so we don’t currently have access, and his blood pressure is a little unstable. Given the rest of the bruising over his body, he may have sustained other internal injuries too.” Victor glanced up at the clock on the wall above the bed and said, “He arrived about five minutes ago, and Klein insisted on being the one to intubate him. You’re now up to speed. Welcome to Disneyland. Enjoy the ride.”

Apparently, the paramedics had started an IV in the field, but it was no longer working. At that instant, a male nurse pulled a needle out of the kid’s arm after what was apparently his second unsuccessful attempt at starting a new one. His failure brought Dr. Klein into an immediate rage.

He yelled into the nurse’s face, “Get the hell away from my patient before you mutilate his limbs any further.” The nurse recoiled backward in demoralized embarrassment. Under Dr. Klein’s scrutiny, performing even a simple task raised the level of difficulty exponentially and significantly lowered the likelihood for success.

Dr. Klein’s stare bored unforgivingly into the nurse. He whispered under his breath, but loud enough to be heard, “Why do we have to hire incompetent faggots?”

I bristled from the comment. Not only did it make me feel infinitely sorry for the nurse, but it resulted in making me feel immediately self-conscious. Dr. Klein was inarguably a homophobic bigot, but I was apprehensive that his attitude was pretty pervasive in the hospital. Hearing such slurs accentuated my fear that I would be ostracized by my peers were they to ever know the truth about my sexual orientation. The internal struggle I had wrestled with for years came surging to the surface. On one hand, I was infuriated by his comment. On the other, knowing such sentiments existed in our society inevitably pushed me further into the closet.

Though the taste of my emotion was acidic in the back of my throat, challenging the inappropriateness of his remarks would have to be a battle for another day. For now, I had to swallow my feelings of both inadequacy and outrage and focus on the patient.

Dr. Klein steadied his glare onto Victor. “Can you get a line into this kid? Or am I gonna have to do a cut-down?”

Given the circumstances, with only one nurse having tried to start an IV twice, a cut-down would have been a little extreme. It was a procedure where an incision was made through the skin so the veins could be fully visualized, and then a catheter was threaded directly into one of them.

Victor paled ever so slightly, but he stepped forward confidently. “I’ll get it.” He reached for a tourniquet, wrapped it around the child’s left bicep, and looked anxiously up and down his arm, looking for a vein that would successfully welcome a needle. I could see a bead of sweat appear on Victor’s forehead when, after careful examination, he failed to identify anything he could predictably hit.

I could tell Dr. Klein had observed the same thing and that he was suppressing an urge to release another brutal barrage of criticisms.

As casually as I could, I reached past Victor and released the tourniquet. Victor snapped his head up furiously, but before he could level me with an indignant objection, I humbly suggested that I take a quick look.

Knowing Dr. Klein continued to critique the entire interaction, the offended expression on Victor’s face was unwavering. I knew, however, that rather than being irritated, Victor was actually relieved that he’d been made exempt from trying. If I was unsuccessful, it would be apparent to Dr. Klein that I was responsible for the failure. Victor, at least temporarily, was absolved from potential humiliation.

I drew a breath to calm myself, trying to quell the fear that I’d just kicked an angry hornet’s nest and at any second would have my ass handed to me. I took the catheter out of Victor’s hand and whispered to him without looking up, “You be my tourniquet. Put your hand around the kid’s calf and give it a gentle squeeze.”

I carefully ran my finger down a line just behind the child’s anklebone. I couldn’t see anything, but I knew where his saphenous vein ran and thought I could feel it as I softly palpated with the tip of my finger. Very slowly, I slipped the needle of the catheter into the skin where I predicted the vein would be. Miraculously, I was reward with a flash of blood. I threaded the catheter carefully into the vein and secured it with a piece of tape. I then confirmed the placement was good by flushing it with some saline. Finally, I connected the catheter to the IV tubing.

“We’ve got a line.” I tried to sound clinically objective rather than triumphant.
Friggin’ A
, I silently congratulated myself.
I nailed it right under Klein’s pissed-off eyes.

The kid’s condition, however, left no time to bask in the glory. While the nurses went about inserting a urinary catheter into the child and attaching the IV line to a pump, I resolved to quickly examine him myself.

The readout on the monitor indicated that his blood pressure was still dangerously low. While the respiratory therapist squeezed air into his lungs, I listened to his chest with my stethoscope. I was concerned that I couldn’t hear good breath sounds on the left.

“Okay,” Dr. Klein barked over the noise emanating from around the table. “Let’s get him to the CT scanner.”

I stiffened and my heart raced with anxiousness. I didn’t think the child was stable enough to be moved, but the prospect of contradicting Dr. Klein made my blood run cold. He was a god. He was infallible.

I reassessed the numbers on the blood pressure monitor and listened with more intensity through my stethoscope. I was concerned that his pressure had dropped a few more points from a couple of minutes before, but who was I to second-guess a directive given by the head trauma surgeon?

Dr. Klein became more impatient. “Get those portable monitors connected so we can roll. Pretend you know what you’re doing, people, and quit moving around like a bunch of damn amateurs. For Christ’s sake, I want this kid to still be alive tomorrow.”

Everyone started moving with an increased sense of urgency. No one wanted to fall victim to another one of the infamous Klein tongue-lashings.

Unexpectedly, I heard my tentative voice rising shakily above the uproar. “Dr. Klein, I’m afraid the child is too unstable to take to radiology yet. I don’t hear good breath sounds through his left chest, and his blood pressure appears to be dropping.”

Dr. Klein’s irritation was almost paralyzing. “Dr. Sheldon, thank you so much for your astute observation. You bet your ass the patient is unstable. He’s got a goddamned head injury that we have to identify before we can fix. How much of our time do you intend to waste before we can proceed with saving his life?”

His entire persona radiated intimidation. I immediately regretted interjecting, but now that I had gone out on a limb, my concerns would have seemed doubly irrelevant if I retreated from defending them. Incapable of injecting any confidence into my voice, I nonetheless proceeded. “I concur that the patient probably has a head injury, but that doesn’t explain the reduced breath sounds, and if his instability is the singular result of trauma to his brain, wouldn’t you expect his blood pressure to be elevated?”

Dr. Klein’s cheeks reddened with anger. “You concur? You concur?” The sarcasm cascaded from his mouth like hot lava from a volcano. “Dr. Sheldon, I can’t tell you how ecstatic I am that you concur with my assessment, but frankly, I could give a rat’s ass whether you concur or not. I’m in charge of this patient, and my job is to ensure that your negligence doesn’t kill him. Now, I’m impressed you succeeded in getting a line into him, and I guarantee you that I’ll recommend you for a good job on the phlebotomy team. The fact remains, however, that the responsibility of managing his care falls on the shoulders of a real doctor, so unless you have any other extenuating objections, get the hell out of the way.”

His reprimand was strident and demeaning, but even as it concluded, he was reaching for his stethoscope to listen to the patient’s chest. As belittling of me as he’d been, my concerns must have at least registered. Undoubtedly he was rechecking the child only to confirm that he’d been justified in dismissing me completely.

I held my breath expectantly, certain that his examination of the little boy would bring only a brief respite before an even more humiliating critique of my clinical abilities. Standing frozen in place, I was surprised when I observed his expression transforming from one of complete exasperation to one of confusion. He seemed incapable of interpreting the sounds he was hearing.

He had no sooner pulled his stethoscope out of his ears before the radiology technician returned with a copy of the chest X-ray. Without preamble, the technician slapped it up on the viewing box and, without directing his comment to anyone in particular, said, “Looks like the kid has a developing tension pneumothorax on the left. Must have broken some ribs on that side.”

In that split second, it was almost impossible to contain my jubilance. I had been right. As we had been futzing around with placing lines and securing the monitors, the child had been bleeding internally into his chest. As the blood accumulated, it had been both compressing his left lung and putting pressure on his heart. As a consequence, his heart was beating less efficiently, his blood pressure was dropping, and his left lung was being prevented from inflating completely. My concerns had been right on the money.

Dr. Klein cast only a confirmatory glance at the chest X-ray, then, without pause, he began to again bark orders. “Hand me a scalpel.” Without additional ceremony, he poked a hole through the skin in a space between two of the child’s ribs and inserted the chest tube. Bright red blood gushed through the tube and soaked the floor between his feet. By the time the force of the stream began to subside, more than a pint of blood had flowed out of the tube. The child’s blood pressure rebounded immediately, his color improved significantly, and the respiratory therapist indicated that he was meeting much less resistance bagging oxygen into his lungs.