Christmas for Joshua - A Novel (2 page)

What else?

Nina entered the room and gave the wife an angry look. “I believe Dr. Brutsky has already rounded here.”

“
Rounded, yes,” I said, “but has he squared yet?”

My joke fell flat. She jingled her keys.

“
This is just a courtesy visit,” I said, faking deafness to her displeasure, “to make sure Mr. Gonzales will put the highest marks on our customer satisfaction survey.”

The patient laughed. “Do you know what VA stands for?”

We waited for him to tell us.

“
Vietcong Accomplices.”

“
Didn’t Kissinger make peace with them?” I smiled and took his hand, which was meaty, coarse, and a bit cool considering the room temperature. “May I examine you, sir?”

He had used a military decoration to fasten his hospital gown. The blue and golden-orange ribbon stood out against the greenish cloth. I detached it and looked at the bronze medal hanging from the ribbon. It portrayed an eagle, charging downward with two lightning rods in its talons. It was a United States Air Medal. I handed it to his wife and exposed his chest.

The cracked sternum was held together with steel staples, and the skin was reattached with tiny stitches that ran down the long incision like a black zipper. The wound seemed perfectly normal, and the transparent tubes showed nothing more than the usual murky drainage. There was no unpleasant smell or excess bruising. The yellow paste of iodine should have been cleaned up after yesterday’s surgery. I scrubbed it off with a wet wipe, which I held out for Nina. She took it with pursed lips.

Pressing his abdomen in different places, I poked through layers of fat that told of eating habits common to men who end up here. I detected none of the hardness associated with internal hemorrhage. Turning him on the side, I was taken aback by the abundance of old scars that covered his back, dozens of little craters, each about the size of a thumbnail. Otherwise, I saw no discoloration signs of ecchymoses on his back. The bleeding, if any, might be contained in the chest cavity until it was too late.

With the tip of my finger, I pressed down on one of the scars. When my finger lifted, the scar was white, but within five seconds it returned to its former redness. I tried another one. Same result. His circulation was slow, but not abnormal.

“
Disgusting,” Mr. Gonzales said, “isn’t it?”

“
Extensive scarring.” I helped him return to lying on his back. “You must have been close when it went off.”

He pointed at himself. “Cannon fodder.”

I placed the stethoscope cup against his ribs, moved it down, listened to his abdomen. Gas movement, but nothing suspicious.

“
Did you serve, Doc?”

His wife stepped forward. “Xavier, please.”

On the left side, higher up, my ears caught a swish of fluid that didn’t sound right. I stayed there, waiting for a repeat performance. But the sound failed to revisit my stethoscope, and I started moving it again.

“
You’re too young for the draft.” He thumbed the button that made the bed rise toward a sitting position. “But a real patriot could volunteer.”

“
Sorry.” I moved the stethoscope, continuing my search. “Never wore the uniform.” My exam hadn’t yet solved my dilemma, but it seemed to have emboldened the patient. Or was his mood change another ominous indication? I added, “Never been injured either.”

“
Feeling lucky?”

“
Don’t you?”

“
Ha!
” His loud exhalation sent an odd rumble through his airways, which were otherwise clear—no blood in his lungs. “Some luck,” he said. “Haven’t allowed anyone to see me without a shirt since nineteen sixty-eight!”

I adjusted the hospital gown back over his chest and fastened it with his Air Medal. “You came back alive, didn’t you?”

He knuckled the side of his head. “No one came back from ’Nam. Not really.”

His wife caressed his thinning hair. “We’ve had a good life,” she said. “The doctor is right.”

“
A civilian.” He looked away. “What does he know?”

“
I know my dad only from photos,” I said. “He
really
didn’t come back.”

The wife sucked in air and turned to the window with a hand over her mouth. But Mr. Gonzales was an old soldier who wouldn’t shy from meeting my gaze. “Sorry,” he said. “I was out of line. Should’ve kept my damn spigot shut.”

“
No sweat.” I took a deep breath, resolving to keep my own spigot shut, and drew blood from the arterial line at his wrist. “Let’s check the numbers.” I ran a stat blood count on the machine and compared it with the last few numbers in his chart. Minor decrease, but still within post-op anemic range. “No bad news here either,” I declared with a light tone of optimism that I didn’t feel.

“
As expected.” Nina turned to leave. She obviously hadn’t grasped that this was no longer a matter of pacifying a pesky wife, but a question of life and death that must be answered promptly despite inconclusive data. “Should I tell Dr. Brutsky to come by when he’s done in the O.R.?”

“
Sure,” I said. “And kindly get mine ready too. Engineering should set up a portable air cooler. It’s still morning, so we’ll be okay for a while, you agree?”

Her eyes widened, but she said nothing more and left the room to prepare my operating room for Mr. Gonzales.

My mind wasn’t made up yet, though. I pretended to study the heart monitor again while reviewing the facts in my head: The changes in blood pressure and heart rate were mild, and he wasn’t demonstrating discomfort. Blood count and physical exam weren’t helpful either. The only unambiguous fact was the wife’s impression of recent paleness. Such subjective complaints could be dismissed, as Nina obviously thought, for the common neurotic harassment of the medical staff by overly protective spouses. But this couple had been married for twice as long as Rebecca and I, and my gut told me to take her seriously. The easiest path was to prescribe a CT scan and leave it to Aaron Brutsky’s handling, based on the results. But a delay was risky. If there was a bleed, it could rupture and kill him. Still, how could I reopen this man’s chest based on little more than a gut feeling?

The electric motor buzzed as Mr. Gonzales made the head of his bed descend. The sound filled my ears. It could be a benign move, the patient merely making himself more comfortable, but to me it sounded like an alarm, triggered by his need to lie flat in order to counter the declining blood flow to his brain.

My decision made, I adjusted his IV to get morphine flowing. “Luke Air Force Base,” I said. “We used to take our daughter to see the air show. It was a lot of fun.”

“
I maintained them.” He cleared his throat. “The Thunderbirds. Great machines.”

“
We also took our son every year,” Mrs. Gonzales said, eager to reciprocate my friendly tone. “How old is your daughter?”

“
Debra is all grown up now.” I didn’t mention that she’d be expecting me and Rebecca on Skype at 2 p.m., an appointment I might not be able to make, depending on what transpired with this patient. I watched him get sleepy. Any sudden excitement could shoot up his blood pressure and turn a small bleed into a terminal gushing before we could reach it. “She’s a senior in college,” I added.

“
Very nice,” she said. “And your other children?”

I held his wrist, feeling the steady pulse. “My wife couldn’t bear more children, so now we’re early empty nesters.”

“
There’s good in every bad,” Mrs. Gonzales said sympathetically. “In my experience, grandkids are much more fun. They bring joy and light into your life without the hardship of childrearing. You’ll see.”

“
We’re in no hurry. Debra plans to attend medical school and finish training before starting a family.” I glanced at the heart monitor. All well. “How many grandkids do you have?”

“
Three precious ones from our son. He’s an electrician in Prescott.” She looked at her husband, whose eyelids fluttered and closed. “Xavier?”

He didn’t respond.

She shook his shoulder. “
Xavier!
”

I put a finger to my lips.

“
What’s wrong with him?”

Leading her out of the room, I said, “He’s asleep, that’s all.”

Despite my complete honesty about how little evidence I had for this drastic step, Mrs. Gonzales consented, and we rolled him to the operating room.

Scrubbed and ready, I murmured a quiet prayer behind my mask, reciting the Hebrew words that had become my private good luck charm: “
Blessed be Adonai, Master of the Universe, healer of the sick and infirm.
”

Minutes later, peering through his parted ribcage with a mix of satisfaction and concern, I watched the nurse suction out the blood that was pooling around his beating heart until the source was exposed—a fissure in the artery, less than a centimeter up from a bypass stitch.

It was the peculiar nature of my profession that making a correct diagnosis meant bad news for the patient. But more often than not, I was able to do something about it. I hoped this was one of those cases. I flexed my fingers and held out my hand. “A suture, please.”

When I left Mrs. Gonzales, she was clasping her sedated husband’s hand while thanking Jesus for saving him, which was fine with me—I didn’t mind sharing credit for success. The repair had been delicate, but I managed without reattaching him to the heart-lung machine, which saved a lot of time and risk.

Peeling off the sweaty scrubs, I took a cold shower, put my clothes back on, and headed downstairs to the first-floor conference room. A cardboard sign had been propped on an easel:

VA Medical Staff – Continuing Medical Education

Presentation by the

Efficiency Research Section of the U.S. Department of Veterans Affairs

The word
oxymoron
came to my mind, but as the session would count toward our CME requirements, most of my colleagues were in attendance, munching on their brownbag lunches.

Rebecca had made me tuna on wheat, accompanied by a New York pickle and a tall can of Arizona Green Tea. I ate while listening to the speaker. She was a bespectacled statistician with a Ph.D. and a nasal voice, who flipped through a drab Power Point presentation, reading aloud the text on the slides verbatim as if we were illiterate.

Their research aimed to show that VA hospitals could save money by discharging post-op patients as soon as they were off the ventilator. Over the past two years, they had managed to convince over six hundred patients nationwide to participate in this experiment in exchange for modest remuneration and a free instructional booklet titled:
The Virtues of Home-Based Recovery.
They calculated the average cost of keeping a patient in the hospital each day and multiplied that number by the total number of days their subjects would have stayed for in-hospital recovery, which resulted in a large dollar amount of theoretical savings.

Aaron Brutsky came in, still wearing his scrubs, the soft mask hanging under his double chin. He was a short man with short arms and short fingers that defied their stubby appearance with a delicate touch and a meticulous exactness that I could only aspire to match. He must have heard how I had plucked his patient from the Grim Reaper’s clutches, because he mouthed “Thank You” from the opposite side of the room and held both thumbs up. I grinned and patted my own shoulder. Technically Mr. Gonzales’s bleed wasn’t a surgical failure per se, but a patient’s death within twenty-four hours always reflected negatively on the surgeon, and I was happy to save one for Aaron.

The last slide was filled with numbers. The elaborate calculation was in fact a simple process of extrapolation of the research results to the whole VA hospital system, reaching a grand total of potential budget savings that could cover the costs of invading a small country.

Visibly proud, the speaker turned off the projector and invited questions. Everyone glanced at their watches and finished their cold drinks.

I raised my hand. “What was the consequent increase in patients’ mortalities, compared with the control group?”

“
There was no control group,” she said.

“
Budgetary constraints?”

She nodded, relieved that I understood.

“
How about using available statistics?”

Ph.D. and all, she clearly hadn’t considered the holes in her thesis. “Which statistics?”

“
The department tracks mortalities of VA hospital patients, classified by the type of illness, procedure, treatment stage, and so on. We use such statistics all the time to advise patients on risks. You could pull data by specific parameters; for example, the survival rates for post-op patients who stayed in the hospital for recovery, and compare them with the survival rates of your early-release research subjects.”

She removed her reading glasses. “We didn’t track our subjects’ survival rates.”

The room went dead silent.

“
Let me understand,” I said. “You convinced hundreds of veterans to go home right after a major surgery for so-called
home recovery
, but didn’t check if they actually recovered?”