Chapter One The partisan, when he is engaged in a dispute, cares nothing about the rights of the question, but is anxious only to convince his hearers of his own assertions. --Plato, Phaedo Go ahead and sew him up, Ms. Reyes." Natalie stared at the slice down Darren Jones's forehead, across his eyebrow, and down his cheek. Until this moment, the largest knife wound she had ever seen was one she had accidentally inflicted on her own finger. Treatment then had been a couple of Band-Aids. She forced herself not to make eye contact with Cliff Renfro, the surgical senior resident in charge of the ER, and followed him out to the hallway. In her three years and one month as a medical student, she had sutured countless pillows, several varieties of fruit, some ragged stuffed animals, and recently, at what she considered great peril, the seat of a pair of her favorite jeans. Renfro's order didn't make much sense. She was only two hours into her second day on the ER rotation at Metropolitan Hospital of Boston, and although Renfro had checked her diagnostic skills out on several patients, he had yet to see her sew. "Dr. Renfro, I . . . um . . . think maybe I should go over things with you before--" "Not necessary. When you're finished, write a scrip for him for some antibiotic--any one. I'll sign it." The resident turned and was gone before she could respond. Her classmate and good friend, Veronica Kelly, who had already finished her surgical rotation at Metropolitan, had told her that Renfro was in his final year before taking over as chief surgical resident at White Memorial, the flagship of the medical school's many famous teaching hospitals. After years of training, he had the air of one who had seen it all and was burnt out on what he considered the lowlife patient population of Metro. "Renfro's smart and damn competent," Veronica had said, "and he'll take the really messy trauma cases. But he couldn't care less about the routine stuff." Apparently he considered a black teenage loser in a gang fight to be routine. Natalie hesitated outside the boy's room, wondering what the fallout would be if she chased Renfro down and asked for a demonstration of his skill. "You okay, Nat?" The nurse, a gravel-voiced veteran of years in the ER, had given a portion of yesterday's student orientation, including the tradition that in a hardscrabble place like Metro, almost all the staff used first names. Hers was Bev--Bev Richardson. "I asked for this rotation because I heard the students got to do a lot of procedures, but sewing up a kid's face on my second day is a bit more than I had expected." "Have you sutured before?" "Nothing that was ever alive, except a few unfortunate oranges." Bev sighed. "Cliff's a darn good doc, but he's a little immature at times and can be hard on people. And the truth is, I don't think he cares all that much for our clientele." "Well, I do," Natalie said, stopping short of a litany of the many times earlier in her life when she had been wheeled or carried or dragged into this very ER. "We like having people working around here who care. The patients have it hard enough everyplace else. Their hospital ought to be something of a sanctuary." "I second that. Well, Dean Goldenberg has told me that he's heard I'm going to be accepted into the White Memorial surgical residency. Maybe Dr. Renfro has heard the same thing and he's just testing me." "Or maybe he senses that you're not like him and he wants to see if you'll back down from the challenge." "He wouldn't be the first," Natalie replied, already setting her jaw and mentally ticking through the pages of the plastic surgery text she had reviewed during the week before this rotation. "You're the runner, aren't you?" The question didn't startle Natalie in the least. Her tragic accident during the Olympic trials was chronicled on the local and national news and the cover of Sports Illustrated. From the day she started med school as a thirty-two-year-old first-year student, people knew who she was. "Past tense," she said, her terse response requesting a change in subject. "Think you can do this boy's face?" "At least he'll have someone working on him who gives a hoot, if that means anything." "It means plenty," Bev said. "Go ahead in there. I'll get you set up with some six-oh nylon suture. Even though most of them aren't, we assume everyone down here who is bleeding is HIV-positive, so best wear a gown and plastic face shield. If I think you're going wrong in any way, I'll clear my throat and you can come away and we can talk. Keep your fingers away from the needle. Straight instrument ties, double overhand knots about an eighth of an inch apart. Don't pull them so tight that the skin edges bunch, and don't shave his eyebrow because they never grow back right." "Thank you." "Welcome to the ER," Bev said. "You doin' a good job, Doc?" Natalie looked up at Bev Richardson, who nodded proudly that she was. From the moment Nat had numbed up the skin edges, Darren Jones had been talking nonstop. Nerves, she guessed. If he only knew that he was hardly the only one. The procedure had taken probably three times what it one day would, and Natalie was still just through the forehead and eyebrow, with the cheek yet to go, but the repair looked quite decent. "Yes, I'm doing a good job," she replied matter-of-factly. " 'M I gonna have a scar?" "Every time skin is cut there's a scar." "Women like scars. They're mysterious. Besides, I'm tough, so why not announce it. Right, Doc?" "You seem pretty smart. Smart is more important than tough." "Tough men like me scare you?" "The guy who cut you would probably scare me," Natalie said, smiling beneath her mask. "You still in school?" "I have a year to go, but I quit." "You should think about starting up again." "Fat chance." Darren laughed. "You wouldn't know about such things, Doc, but where I come from, the only thing that matters is being tough." Again, Natalie grinned. Matched up against this boy in almost any measure of toughness, she would win hands down. She reminded herself that it wasn't the first person who had suggested she get back into school that had led her to the Edith Newhouse Academy for Girls, or even the second. But somewhere along the line, thanks to those who had tried before, someone had finally been able to breach the ramparts of her own toughness. "Tough is swimming against the stream and having the courage to be different," she said, tying off the last of the sutures. "Tough is realizing that this is the only life you're going to have, so you might as well do what you can to make the most of it." "I'll keep that in mind, Doc," the teen said with little sincerity. Natalie glanced over her shoulder at Bev, who gave her technique a thumbs-up and mouthed the words, "Steri strips," motioning at the packets of paper stitches she had placed on the instrument tray. After ineptly fumbling several of the strips into useless balls, Natalie figured out how to cut and place them across the incision to reduce scarring by taking the tension off of her suture line. "Five days," Bev mouthed, holding up one open hand. "These stitches will probably be ready to come out in five days," Natalie said, grateful for the hedge inherent in the word "probably," at least for the time being. "You got soul, Doc," Darren said. "I can tell." Natalie stripped off her face protector and gloves. Another milestone, she was thinking. It was a huge advantage to be thirty-five and a med student--especially one who had seen more than her share of life. Decisions came easier to her than to most of her classmates, many of whom were a decade younger or, in a few cases, even more. Her perspective was often more finely honed; confidence in her convictions was stronger. "Don't sell yourself short, my man," she replied. "Stick around, Darren," Bev said. "I have a tetanus shot, some instructions, and some medication for you." "Pain meds?" Darren asked hopefully. "Sorry, antibiotics." "Hey, you claim you're tough," Natalie said, heading out the door. "Tough guys don't need no steenking pain medicine." She wrote her note at the nurses' station, feeling very pleased with the way she had performed under pressure. Renfro had issued the challenge and then had walked away, but she had more than measured up. She had set high school, college, and national records on the track, and had made it to within one unfortunate step of being on the Olympic team. Along the way, she had dealt with any number of Cliff Renfros, bent on feeding their egos off the insecurity of others. Well, she was still the same woman who had run 1,500 meters in 4:08.3. Let this particular Cliff Renfro keep trying. She hadn't knuckled under to any of the others, and she wasn't going to be intimidated by him either. Bev materialized at her elbow. "Saralee just came over from room four. You know what that is?" "Yes, for the alcoholics." "And other street people," Bev added. "Patients are put there when they're particularly . . . um . . . grimy." "I know. I worked in there for a while yesterday. It wasn't so bad." "Well, apparently the ER got a little backed up while you were off suturing and a code was going on in the other wing. So, much to his chagrin, Cliff is holding down the fort in room four. He wants you to take over in there as soon as you're done." "I'm done now." "Good. You handled that kid well, Nat. I think White Memorial made a good choice. You're going to make a fine doctor." "That hospital may be the best of the best, but they're still a decade or two behind when it comes to accepting women into their surgical programs." "So I've heard. Well, like I said, you'll do great. Take it from one who's seen them all come and go." At that moment, they turned toward the sound of a commotion coming from down the hallway. "I'm telling you, Doc, you're wrong! There's something the matter with me. Something bad. Right here behind my eye! I can't stand the pain!" A man was being escorted out of room 4 by an orderly. Even at some distance, there was no doubt that he qualified to have been there. Grizzled and worn, he was in his forties, Natalie guessed, or maybe even his fifties. He had on a tattered windbreaker, stained chinos, and sneakers without laces. An oily Red Sox cap with its brim pulled low still failed to hide the sad hollows of his eyes. Hands on hips, Cliff Renfro appeared in the doorway and glanced to where Natalie and Bev stood before addressing the man. "What's wrong with you, Charlie, is that you need to stop drinking. I would suggest you get yourself over to the Pine Street Inn and get them to show you to the shower. They'll probably have some clothes for you, too." "Doc, please. This is serious. I've got lights flickering in this eye and the pain is killing me. Everything keeps going black." Clearly irritated almost beyond words, Renfro ignored the man and stalked down the hallway past where the two women were standing. "You've got to move faster down here, Dr. Reyes," he paused long enough to say. "Now, please take over in four. I'm going to get washed up and," he muttered, "maybe fumigated." Natalie caught the briefest spark of anger and frustration in the patient's eyes before he turned and allowed the orderly to lead him toward the waiting room, and beyond that, the street. "I'll bet Renfro didn't even examine him," Natalie whispered. "Possibly, but he usually--" "There's something seriously wrong with that man, I just know it. Horrible pain, flickering lights, lost vision. I just finished six weeks on neurology. That guy has a tumor, or maybe a leaking aneurysm, or even a brain abscess. These people deal with pain and discomfort every day. If his symptoms are bad enough to have him drag himself in here, something's the matter. Did Renfro order any tests?" "I don't know, but I don't think--" "Listen, Bev, I want to check that guy over and then get a CT scan. Can you arrange that?" "I can, but I don't think it's such a good--" "And some bloods. A CBC and Chem-Twelve. I've got to catch him before he gets away. Believe me, if he were a well-dressed businessman at White Memorial, he'd be over having a CT scan right now." "Maybe, but--" Before Bev could finish the sentence, Natalie was off. She checked the waiting room, then hurried out the doors to Washington Avenue. The man was a dozen yards away, shuffling slowly toward downtown. "Charlie, wait!" The derelict turned. His eyes were bloodshot, but he held his head erect and met her gaze evenly, perhaps even with some defiance. "What is it?" he growled. "I'm . . . Dr. Reyes. I want to check you over a little more and maybe order a test or two." "Then you believe me?" Natalie took his arm and gently led him back toward the ER. "I believe you," she said. Bev Richardson was waiting just inside the door with a wheelchair. "Room six is empty," she said in a conspiratorial whisper. "Hurry. I have no idea where Renfro is. Lab is on the way. Hopefully we can get his blood drawn and get him over to CT without anyone seeing." Natalie helped the man out of his clothes and into a blue johnny. Renfro was right about one thing, she was thinking, Charlie really did smell. She did a modest neurologic exam, which disclosed several definite abnormalities in strength, eye movements, hand-eye coordination, and gait, any and all of which could be due to a brain tumor, abscess, or leaking blood vessel. A technician had just finished drawing blood when Bev backed into the room hauling a stretcher. "I pulled some strings," she said. "They're ready for him in CT." "He has some clear-cut neurologic abnormalities. I'll get him over there, and then get to work in room four." "I'll clean up in here." Natalie wheeled the stretcher into the hallway. "Thanks, Bev, I'll be right b--" "What in the hell is this?" Cliff Renfro, livid, stormed toward her from the nurses' station. "I believe there is something seriously wrong with this man," Natalie said. "Maybe a tumor or a leaking aneurysm." "So you chased him down after I had discharged him?" Renfro's voice was raised to the point where staff and patients alike stopped and stared. Several people emerged from the examining rooms, several more from the nurses' station. Natalie held her ground. "I wanted to do the right thing. He has some neurologic findings." "Well, this isn't the right thing. The findings, like everything else about him, are the result of alcohol. You know, I had heard from a number of people that you were too arrogant and hard-edged to be a good doctor. Just because you had fifteen minutes of fame doesn't mean you can step in here and act as if you're in charge of the place." "And just because you like to keep your clinic coat from getting soiled doesn't mean you can brush off patients like this man," Natalie shot back. Bev Richardson quickly inserted herself between the two combatants. "It was my fault, Cliff," she said. "I was worried about this man, and thought it would be a good learning experience for--" "That's nonsense, and you know it. Don't protect her." He stepped to his left to get a clear line of sight at Natalie. "There is no place in medicine for anyone as self-absorbed and conceited as you are, Reyes." Natalie's jaws clenched. She was furious at being rebuked so publicly, and anxious to have all the witnesses know why Renfro's prejudices had led him to do an inadequate job in evaluating this down-and-outer. "At least I care enough about people like Charlie here to do a complete evaluation on him." "Five years as a doctor have made me perfectly capable of deciding what is and is not a complete evaluation. I intend to make sure that anyone at the medical school who will listen learns about you and what's happened here." "Well, I think before you do that, you should see what this man's CT scan shows." Renfro's glare could have melted block ice. He looked as if he were going to say something else, then turned and stalked off toward X Ray. Two exquisitely tense minutes later, a CT tech came and wheeled Charlie away. Natalie sighed her relief. "Whew. I was certain he was going to cancel the test out of spite," she said, as she and Bev walked back to the nurses' station. The seasoned nurse looked at her and shook her head. "I'm sorry I couldn't get him to calm down," she said. "There was probably a better way to have done this." "Renfro could have admitted he was wrong," Natalie said. "The fact that he went ahead with the scan says as much. When they find a tumor behind poor Charlie's eye, he's going to be grateful I saved his bacon." Tumor, abscess, leaking aneurysm. In her mind, Natalie was already projecting the reactions of Renfro and the staff when her approach to the man was vindicated. Hopefully, whatever the poor guy had would be operable. She thought about how her mentor, surgeon Doug Berenger, would react to her coup. Midway through her undergraduate years at Harvard, well before the incident that tore her Achilles, he had sought her out and offered her a position working in his lab--a job she still held. Later, he had brought together the best sports medicine people around to aid in her recovery, and still later, he had talked her into attending med school. Berenger, perhaps the foremost cardiac transplant surgeon in Boston, if not in the country, was already talking about a fellowship in his department when her surgical training was complete. He had a framed sampler hung on the wall behind his desk chair: believe in yourself. He would be damn proud of the way she had believed in herself and held her ground against Renfro's unnecessary onslaught, especially when Charlie's diagnosis became known. Natalie went into room 4 and worked up the three patients waiting there. Her pulse continued to race--in part fallout from the acrid exchange with Renfro, and in part from the excitement of soon getting the results of the lab work and scan on her patient. Finally, through the doorway of room 4, she saw Renfro pass by, wheeling Charlie on his stretcher. A manila X-ray envelope was tucked under the thin mattress. Moments later, the resident called out her name. "Dr. Reyes, staff," he said quite loudly. "Could I have you all out here, please?" A group of perhaps a dozen stepped quietly into the hallway. Renfro waited until it seemed there would be no more, and then continued, holding up the envelope with the CT scan for emphasis. "You were all here a little while ago for the . . . um . . . discussion about patient care that occurred between Ms. Reyes and myself. Well, I have all the lab work and the CT back on our patient. I would like to inform you that there is nothing abnormal on any of them. Nothing. Charlie here has just what I said he had--just what he always has, Ms. Reyes--an alcohol-induced headache. He had a blood alcohol of one hundred and ninety when he came in, and I don't suspect it's much lower now, since he just managed to get at the pint of Thunderbird in the jacket in his clothing bag. Bev, please discharge this man for the second time. Be sure to fill out an incident report. "Ms. Reyes, go home. I don't ever want to see you on my service again." Copyright © 2007 by Michael Palmer. All rights reserved.