Good Medicine - Residency II
Copyright© 2025 by Michael Loucks
Chapter 3: Appendectomy
February 26, 1990, McKinley, Ohio
The formal funeral for Deputy Sommers was conducted on Monday morning, but I wasn't able to attend due to my shift at the hospital. She received full honors from the Sheriff's Department, the McKinley Police Department, the Harding County Fire Department, and the Ohio State Patrol. The flags at every fire and police station in the county had been flown at half-mast for her, and every member of law enforcement and fire protection had worn a black band around their badges.
At the time I knew the funeral mass was to begin, I was in the lounge. I quietly recited the prayers for the departed, using the standard form rather than the abbreviated form used for non-Orthodox. She had, as I saw it, given her life defending and protecting our patient and the medical staff, and as such, deserved the full prayers. After finishing the prayers, I went to visit Loretta in the CCU.
"How are you doing this morning?" I asked.
"I have feeling in both legs, but it's still limited, and I can't move them."
"That's an improvement," I replied. "You and I both know that the kind of improvement you're seeing is a very good sign."
"But not determinative."
"True, but it's a strong indication you'll be able to walk again, though possibly with the need of assistive devices."
"There goes my medical career."
"You don't know that, and neither do I! What have Vanderberg and Cohen said?"
"Wait and see, but they're encouraged by the fact that I have increased sensory function."
"There you go! How long are you in the CCU?"
"Until Friday, most likely, then I'll go to a rehab facility in Columbus."
"I'm going to ask for permission to escort you," I said.
"I appreciate it. Come see me tomorrow?"
"Of course. I'm going to see Shelly now. Is there anything I can get you?"
"A working set of legs."
"In time, Doctor," I said. "You know how this works."
Loretta rolled her eyes, "Easy for you to say from that side of the bedrail!"
"We doctors make the worst patients," I commiserated. "And I was bad before I became a doctor."
"Like most men!"
"Whatever!" I chuckled. "See you tomorrow."
I kissed her cheek, then left the CCU to head to Medicine, where Shelly was in a semi-private room with a young woman suffering from kidney failure.
"Morning, Shelly," I said. "How are you doing?"
"Better now that they moved me here, but I still haven't managed the pizza!"
"I'd kill for a pizza!" Cathy, the young woman in the other bed, exclaimed.
"And I'd be dead if I tried to sneak one in here! Tim Baker would have my butt in a sling!"
"Doctors are just no fun!" Cathy groused.
"Shelly and I are fun!" I countered. "It's the Chief of Internal Medicine who's the problem here!"
"Damn straight!" Shelly agreed.
"Just how much fun?" Cathy asked with an arched eyebrow.
I held up my right hand. "About as far as this ring allows!"
"Wrong hand!" Cathy exclaimed.
"Correct hand for an Orthodox Christian," I replied.
"Well, there goes my idea of trading for a pizza!" she teased, causing both Shelly and me to laugh.
"No offense intended," Shelly said mirthfully, "but fired AND divorced? Nobody is THAT good!"
"You left out 'dead'," I chuckled, "because, despite her protestations of being French, my wife is VERY Russian in certain aspects of her personality!"
"Are you sure about that?" Cathy asked with a smirk.
I laughed again, "Positive, and no, that's not an opening for you to ask for a chance to prove it! Mind if I ask about your condition?"
"Polycystic kidney disease; I'm having a transplant later this week from my cousin. It was delayed by what happened last week. Were you there, too?"
I nodded, "I was in the trauma room Shelly — Doctor Lindsay — had just left, and where the Deputy was shot."
"Holy smokes!" Cathy exclaimed.
"If things go a certain way, Mike might assist with your surgery," Shelly said.
"Well, that would be one way to get him inside me!" Cathy smirked, once again causing both Shelly and me to laugh.
"You, young lady, are dangerous!" I chuckled.
"I'm a college student!" she exclaimed. "We're supposed to be dangerous! Being a sober, responsible adult can wait until after I graduate!"
"What's your major?" I asked. "I mean, besides guys ... or girls, for that matter."
Cathy laughed, "It would increase my chances of a date on Friday nights! Finance with a minor in computers. I plan to get my MBA and become a CPA, same as my dad."
"What year?"
"Junior at OSU, but my family lives here, so that's why I'm here instead of there. I took the semester off, but I'll take classes during the Summer to make up and should graduate on time."
"My wife is at OSU," I said. "She's a poli-sci major and is planning a Master's in public administration."
"What's her name?"
"Kris Korolyov. She's on what amounts to a five-year plan because we'll have our first child together in June and plan the second one about two years from now."
"First together? You have other kids? Or she does?"
"I have a daughter with my first wife, who died the day our daughter was born."
"Holy smokes!" Cathy gasped. "I don't even know what to say."
"Most people don't," Shelly said. "I can say this because I know Mike really well, but it was just one of those rare, random things that there was no way to detect or prevent. It was genetic, similar to your kidney condition."
"Is it OK to ask what happened?"
"In layman's terms, a blood vessel in her brain burst in an area where it caused her heart to stop."
"Whoa!" Cathy gasped. "Unreal."
"Surreal is more like it," I said. "I was a medical student, and all I could do was stand and watch helplessly as the medical team tried to resuscitate her. I'm sorry to cut this short, but I have to get back to work."
"Sorry if I upset you," Cathy said.
"You didn't. I need to get back to my students. Shelly, I'm glad to see your liver enzymes are completely normal. When are they kicking you loose?"
"Friday."
"When can you come back to work?"
"I have to complete my psych evals, and Doctor Roth has to clear me medically. I'd be happy for you to do the exam."
"I BET!" Cathy teased. "He's hot!"
Shelly laughed, "And taken! I'm no homewrecker! But I trust him to give me the benefit of the doubt, unlike the headshrinkers."
"Any chance you can see someone outside the hospital?"
"No. Owen got quite a bit of guff for allowing you to do that, but he made it stick."
"I had no idea, but I guess I should have known, given my relationship with them."
"Washouts who couldn't even Scramble for dermatology!" Shelly exclaimed.
"On that note, I'm headed back to the lounge! I'll come see you tomorrow."
"And me?" Cathy asked.
"If you're here, then I will."
"Sadly, for two more days before the surgery, then a weeklong recovery."
"See you both tomorrow," I said.
I left the room and walked towards the surgical ward when my pager went off, signifying a consult in the ED. Rather than stopping to use the phone, I simply picked up my pace and reported to the nurses' station.
"Doctor Casper needs you in Trauma 2 for a rule-out appy," Karli said.
"On my way."
I went to the lounge and let both Erin and Todd know they could accompany me to the ED.
"Morning, Ghost," I said when we walked in. "What do we have?"
"John Smythe, twenty-six, presents with typical signs of acute appendicitis. Ultrasound scan confirms."
"Let me take a quick look," I said. "You know the drill."
"A snot-nosed Resident has to confirm the diagnosis of an Attending!" Ghost teased.
"Pretty much!" I agreed, stepping over to the trauma table. "Good morning, Mr. Smythe. I'm Doctor Mike from surgery, and as Doctor Casper irreverently put it, I need to confirm that you're a candidate for surgery. As we're a teaching hospital, I'd like my Sub-Intern, Erin, to perform the exam."
"She's gorgeous, Doc!" he said quietly, then louder, added. "Sure!"
"Erin, physical exam and ultrasound, please."
"Right away, Doctor Mike!" she exclaimed, sounding almost giddy.
She performed the basic exam, then, with guidance from me, the ultrasound.
"What do you see?" I asked.
"Enlargement, along with free fluid in the right iliac fossa. That, along with the other symptoms, is determinative. A surgical case."
"Indeed it is. Call upstairs and let them know we'll be bringing him up. Then call for an orderly."
She moved to the phone to place the call.
"Are you going to do the surgery?" John asked me.
"As Doctor Casper put it, I'm still a 'snot-nosed Resident,' so I'll assist, but a fully-trained surgeon will perform the surgery."
"How long have you been a doctor?"
"About nine months," I replied. "Surgeons train for about seven years, some longer, if they specialize. Let me explain the procedure to you, then we'll go over the consent forms."
I went over the steps of the procedure, along with the risks, then asked Todd to walk Mr. Smythe through the consent form, which he did. The orderly arrived just as that was completed. I signed the surgical admission form, clipped it onto the chart, then we headed upstairs. After handing Mr. Smythe over to the nurses, my students and I went to scrub.
"How much of this do you feel comfortable doing?" Doctor Aniston asked.
"I know the steps and assisted Doctor Blake as second surgeon on one last July. I've seen several since."
"Not the question I asked," Doctor Aniston said.
"I would be comfortable performing each step, so long as I was under close supervision and could ask for assistance."
"Then you take the lead."
"As a PGY1?" I asked.
"You can say 'no'..."
"Contrary to the opinions of numerous young women over the years, I'm not a complete idiot!"
Erin and the two nurses in the room all laughed, and Todd nodded his commiseration.
"A problem every guy has, no matter what!" Doctor Aniston agreed.
"My gay friends didn't," I said. "But otherwise, yeah."
"Being gay limits your opportunities for being an idiot," Nurse Linda declared.
"Doctor Aniston," I said. "When I assisted Doctor Blake, my medical student was allowed to close the dermis and epidermis. I'd like Miss Jackson to do that; she's signed off for unsupervised suturing."
"Seriously?!" Erin gasped.
"Seriously. Doctor Aniston?"
"Let's see how things go; if there are no complications, I'll allow it. Miss Jackson, you'll suction for us. Now, everyone scrub in!"
We did and went into the operating room together, with Doctor Aniston directing me to the primary surgeon's spot.
Doctor Bernard, the anesthesiologist, raised an eyebrow but didn't say anything.
"Hi, Mr. Smythe," I said. "Contrary to what I said before, I'll be the lead surgeon with Doctor Aniston here watching me like a hawk."
"You're in excellent hands, Mr. Smythe," Doctor Aniston said. "We're a teaching hospital, and Doctor Mike is ready for this. He's assisted before and knows the procedure."
"Go for it, Doc!" Mr. Smythe said.
"Put him under, please," I said to Doctor Bernard.
He did, and two minutes later, announced that the patient was sedated and had stable vitals.
"Are you sure about this, Bob?" Doctor Bernard asked. "Mike's a PGY1."
"I'd let him perform the procedure on my son," Doctor Aniston said. "Good enough for you?"
"You're the boss."
"Mike, let's begin," Doctor Aniston said. "Tell me each step before you perform it. If anything out of the ordinary happens, I'll decide whether to take over. This should be perfectly routine, as he appears in excellent health and is in good shape."
I nodded, took a deep breath, and looked to Nurse Linda, "10-blade, please."
She handed me the scalpel.
"I'm going to begin with a transverse incision parallel to McBurney's point," I continued, "incising the epidermis and dermis."
"Proceed," Doctor Aniston directed.
I made the incision as I'd seen Doctor Blake and others do many times, then handed the scalpel back to Linda.
"Retract, please, and I'll use the Bovie to dissect down to the external oblique aponeurosis, then I'll open the aponeurosis, exposing the internal oblique muscle."
"Continue."
"Bovie, Nurse," I requested.
I successfully dissected down to the muscle, then returned the Bovie and asked for a scalpel to open the aponeurosis.
"Retraction, please," I said to Doctor Aniston, who placed a second retractor in the surgical site.
"Now I'll divide the muscles, then locate the appendix," I said.
"Continue," Doctor Aniston directed.
I divided the muscles, and Doctor Aniston shifted the retractors.
"Forceps, please, Nurse."
I grasped the peritoneum with the forceps, made an incision, and located the appendix.
"Suction, please, Erin," I instructed.
She cleared away the fluid.
"Babcocks, please, Nurse," I requested.
Linda handed me the forceps, and I grasped the taeniae coli and advanced until the appendix was externalized.
"Appendix is inflamed and enlarged," Doctor Aniston declared. "Proceed with excision, Mike."
"Next is dissecting the mesoappendix," I said.
"Continue."
I did that, then asked Linda for clamps, which I attached to the appendiceal vessels.
"Next, I'll divide the appendiceal vessels and ligate them with sutures."
"Correct," Doctor Aniston said. "You're doing great, Mike."
I divided the vessels, then asked Linda for the needle driver and silk sutures, and used them to ligate the blood vessels, then removed the clamps.
"Suction, please," I said to Erin.
She did that, and I examined the surgical field.
"No leaks," I said.
"I concur," Doctor Aniston agreed.
"Excision and then invert the stump into the cecum," I said.
"Proceed."
I excised the inflamed appendix and dropped it into a metal basin. Next, using forceps, I inverted the stump into the cecum.
"Very good, Mike," Doctor Aniston said. "No rupture, no involvement of any surrounding tissue. Nicely done and a clear field. You may close; your call on closing the dermis and epidermis."
"Erin," I inquired, "tell me how you would close this incision."
"I would begin with an antiseptic lavage, then close each of the three muscle layers separately with running absorbable sutures. There was no rupture, so no drain is necessary. I'd close the dermis with 3–0 subcuticular absorbable sutures, then close the epidermis with basic mattress sutures."
"Very good," I said. "Doctor Aniston, if you would move aside, and Todd, if you would take the suction, Miss Jackson will assist me, then close the dermis and epidermis. Linda, surgical closure tray to me, please."
"A Fourth Year? Suturing?" Doctor Bernard asked.
"Owen instructed us to be more aggressive in our training," Doctor Aniston said. "Miss Jackson is one of our top draft choices for the Match. And we're short surgeons, too. Mike and I are both comfortable."
"It's your rodeo; I'm just along for the ride," Doctor Bernard said.
I closed the muscle layers, then turned the patient over to Erin.
"Erin, step by step," I said. "There are no prizes for speed. If you have questions, ask; if you are not confident, say so, and I'll close the final layers."
"I can do this with your supervision," she said confidently.
"Then proceed," I said.
She took her time, similar to the way I had done the exact same thing back in July, though I'd been an actual Resident at the time. I watched extremely closely, as did Doctor Aniston, to ensure she completed the procedure correctly, and he and I both offered advice as she worked to close the incision.
"Nicely done, Miss Jackson," Doctor Aniston said. "Neat, evenly spaced sutures with good tension."
"We're finished," I said. "Doctor Bernard, please terminate anesthesia. Erin and Todd, once Doctor Bernard disconnects Mr. Smythe, please escort Mr. Smythe to Recovery. I'll be along shortly."
Doctor Aniston and I moved to the scrub room while the others prepared Mr. Smythe for transport.
"There is going to be blowback," I said quietly.
"Well, Frank can complain to his Chief, but Owen cleared this with Cutter, so we're good. How do you feel?"
"Pumped!" I replied. "But not nearly as pumped as Erin! I just hope the Match gods are kind to us."
"Why?"
"She broke up with her boyfriend, who is here in McKinley, just before she had to submit her Match list. She's from Cincinnati, and Shelly is concerned she listed those hospitals ahead of us."
"She could technically resubmit her list," Doctor Aniston said. "Wednesday is the deadline for late submissions. She'd need to pay the fee for late registration, but she could submit a revised list."
"Where did we list her?" I asked.
"Third after Ryan Harrison and Mary Anderson."
"That's rough," I said. "Hospital preferences take precedence, and even if she lists us first, a hospital in Cincinnati might snatch her. We know Mary will Match for trauma surgery because we put her first, and she put us first. Can we revise to put Erin second?"
"Let me speak to Owen. Do you know where else Ryan tried to Match?"
"He had five other interviews, all in Columbus or Dayton."
"OK. Erin can't hurt herself if she simply swaps us for another program, but you know the rules, right?"
"Yes. I can't expressly tell her we listed her, but I can encourage her to change her list, which will convey the message."
"Exactly. It's a dumb system, and we really ought to be allowed to tell the students."
"My proposal is that a hospital receive two or three draft choices for students at its affiliated medical school. That would save everyone time and effort because we know Mary Anderson knows she's going to Match for the only available slot for trauma surgery. It's really silly to pretend that position is actually competitive."
"That's actually a good idea, which is why it will never fly!" Doctor Aniston said with a grin.
"Trotsky was right!" I said with a grin of my own.
"Trotsky?"
"He said the bureaucracy would betray the revolution, and he wasn't wrong."
"Amen, Brother. Go change and check on your patient. Leave me your procedure book, and I'll fill it out."
"Thanks," I replied.
That was a nice thing to have, but I needed more practice, better training, and my Board certification before I could perform even that simple procedure on my own. That said, I was WAY ahead of any other Resident, including some PGY2s who were on the 'old' program.
I went to the locker room, changed into fresh scrubs, put on my baptismal cross and wedding ring, then headed to Recovery. I verified Mr. Smythe's vitals, then asked Todd to sit with him while Erin and I stepped into the corridor.
"Thank you, thank you, thank you!" she gushed. "I'd hug you, but the rules..."
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