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James Robert Nolgren MD: Nolgren MD, Intern-3
After anesthesia was induced, several fairly small incisions were made in the belly and instruments introduced into the abdominal cavity. A lot of blood was suctioned out and the belly rinsed with sterile salt water 0.9% solution ('normal' saline) and the lesion found with a blunt probe and lifted into the field of view on a TV monitor connected to a color camera on a laparoscope, the other end of which was in the belly.
The tell-tale bump had been obviously bleeding and a large clot peeled off the bump revealed some fresh bleeding from the rupture. They decided that it was now too late to save the tube, so the senior clamped across it to include the blood supply to the tube and cut its attachment, then sutured through the laparoscope (heeding the attending's advice to use O-Vicryl, not OOO-Vicryl, a flimsier suture for the task) to securely tie off the bleeding, cut the suture well away from the suture knot, then cut and removed the tube on the left with its 'bump' through a port in a small incision with a 'grasper'.
There was no sign of an embryo; those weren't usually ever seen or found in all the nooks and crannies of the intestines It was small and would simply resorb.
The instruments were removed, the wounds were sutured carefully, and dressings placed. Orders were written for pain, the IV fluids administered were analyzed as to type and amount given to date, new IV fluid orders written, a repeat hemoglobin scheduled, and 4 units of packed cells ordered to be type and cross matched and held.
James, still back up on the ward, sat in the conference room with Tommy. "We're not going to go through that debacle twice. Listen to me very carefully. Here is how we workup, analyze, follow and present a case. During that correctly-done process, a differential diagnosis list is made, and the correct diagnosis selected, and the appropriate treatment begun at the appropriate time."
"This process will become much easier after you seen your first two hundred patients and by the thousandth patient will seem even easy, but you are required here and through your career to be obsessive about it unless you love courtroom drama and lawsuits and million-dollar payouts for malpractice."
"While you are under my supervision, you will do exactly what I tell you, when I tell you to do it, or I will personally kick your ass out the door. Is that clear?"
Tommy grinned. "Why didn't anybody care enough to really teach me during the last couple of years. I want to do good work. Why wouldn't I? Are you going to be my daddy?"
James' face frowned. "I'm going to beat your ass like a daddy if you don't come up to snuff, that's for damn sure."
Tommy sobered, "I'll try."
"No, you'll do it. You don't have a choice." James went through the workup process in detail and told Tommy he would be waking at 5 am from now on. I will see you here on the ward at 5:30 am every morning, breakfast or no breakfast, and don't be late. Ever.
"Remember I'm not depending on you to be on time. I can do without your ass complicating my life. The patients are depending on you. They trust you with their health and sometimes their life."
James and Lawrence slept together that night in Lawrence's apartment after James recounted his day and Lawrence his. Naked, they kept each other warm in that cold climate with only a sheet and a thick blanket on top. James woke to the alarm at 5 am, showered quickly, kissed his lover, dressed, kissed Lawrence again, and arrived on the ward promptly at 5:30 am. Tommy was there making notes.
Renee and Rita Shafer were twin medical students assigned to the ob-gyn unit for the summer. The medical school only occasionally paired siblings to the same rotations, but it had happened that way. They showed at 6 am to review the patients assigned to them, followed at 6:30 am by Curtis Linder.
Each student was supposed to have an equal number of patients to workup. The current census, not counting the tubal pregnancy, was 18 divided by 5 students should have been 3 or 4 apiece. He planned to bring Tommy along deliberately.
Beryl could handle 4 or more but didn't deserve the extra work of an additional patient now so Curtis would get 4, Renee 4, Rita 4, Beryl 4 and Tommy 2 with the understanding that the next two were Tommy's to take. If he agreed to take on one of the other's patients so they could take one of the next two patients to come in, he might get just one.
They would play that one by ear. At least four of the students didn't mind how many they took and when.
Tommy was still coming up to speed and minded a lot. That would last one week, thought James. Not any longer; not on his watch. James took Tommy into the conference room and asked him to present the post-op case to him. Tommy got the age and G P and Ab status right and the number of hours postop right and the diagnosis and op findings correct. He flunked the part about transfusion, however.
"You need to look up the transfusion guidelines, but I'll tell you that we only transfuse if someone is symptomatic these days. If she stands by the bedside with assistance without dizziness and motates to the bathroom with minimal help, we hold off on the blood. There is some risk of transmitted infection of some kind with any transfusion. It's low, but real, so we don't transfuse unless the patient needs it. We don't treat hemoglobin numbers here. We treat patients. Remember that."
"So, if the patient is tolerating a 4-point drop and is now at 5 grams of hemoglobin, we leave her be and check again in the morning, sooner if she becomes symptomatic. We can always do an urgent hemoglobin and can always infuse blood. We can't undo a transfusion, however. If you want to be a great transfusion doc, remember that there is at least one other factor that decreases hemoglobin and that's an unattended IV."
"The clear (crystalloid) fluids we infuse dilute down the hemoglobin just as surely as losing it in the first place, although the kidneys eventually catch up by excreting the unneeded clear fluid. In an older person, that extra fluid could overwhelm their heart's ability to pump efficiently. That's why we use IV pumps to keep track of IV fluids. That said, we try to keep the hemoglobin up anyway on general principles, short of transfusing unnecessarily, because it makes a difference at any one moment how much oxygen the brain and kidneys and heart get." Tommy nodded.
"So, we shouldn't overload her with IV fluids."
"Bingo. Slow em down, Tommy, by about half and see what happens on tomorrow's numbers, watching her urinary output to make sure it is normal for the next 18 hours. We don't want her kidneys to shut down just because we were playing with her hemoglobin numbers, do we?"
"No, Dr. Nolgren."
"If you have a question any time of day, day or night, call me and we'll talk about it. By the way, order sips of liquids for now as her diet. Minimal ice. Too much cold might slow her bowels. The leftover blood in the belly and surgical manipulation will slow them down enough."
"Will do, thanks for taking the time with me."
Curtis presented his patient status-op from removal of an ovarian cyst and his patient admitted with the fetal demise with accuracy, rattling off data clearly, leaving future treatment open for discussion so the 2nd Year, and James too if wanted, to opine on that subject.
James recognized the punt for the maneuver it was. Frequently the smarter students would present the background of the case and then stand back to learn from their senior to save time. Other students, at times, wasted energy and took some risk wading into pools that were too deep for them just yet.
Curtis had two more patients at the end of the hall to present.
Rita and Renee presented their four each sequentially as they came to them. Mrs. A., 36 years old, G zero with unknown date of last period had been admitted for an infertility workup, an inability to conceive after 8 years of trying without contraception and endless years of frustration.
She didn't have regular periods, had never had since she began her periods at age 12 or so.
They just came when they wanted to, not every 28 or 29 or 30 days, not regular anyway. She didn't always have cramps or pain with her periods but sometimes did and the amounts were usually heavy without clotting. Her ultrasound showed nothing remarkable, no benign tumors of the uterus. Of some interest was the fact that she had never been pregnant.
She was overweight and snored. She was a hairy woman who didn't exercise much and showed signs of depression. She had been admitted for evaluation of surgery since she had multiple tiny cysts on ultrasound in each ovary.
One of the original treatments, which didn't work well all the time and caused scar tissue in and of itself was something called a wedge resection of the ovary, where a literal wedge-shaped piece of ovarian tissue was removed on both sides. The inflammation from the surgery or the removal of a few cysts might have had a temporary influence on ovulation but was not a cure and the procedure had fallen out of favor.
She had pre-diabetes, evidence of insulin resistance, common in PCOS.
Rita described her diagnosis, polycystic ovarian syndrome or PCOS as first having been described in Italy in 1721. High levels of male hormones were involved which interfered with ovulation and caused most of the symptoms including the infertility. Treatments varied and none of them cured the disease. Lifestyle changes and treatment with metformin, recently unpopular for a number of reasons, were possible.
After further discussion between the attending and 2nd Year, arrangements for lifestyle interventions, psychological support, treatments for excess hair (hirsutism), social work support, and information about adoption were made. She was referred to the Endocrine docs for management of her pre-diabetes and to a weight-management clinic.
Rita discussed three more patients and her twin discussed the progress of her four patients.
Tommy gave a good, much improved, synopsis of his postoperative patient, all of the students finished their updates on all of their patients finally and rounds were over. The attending, the senior both disappeared to the OR for a scheduled case and a new admit from the clinic appeared on the ward.
Tommy was assigned and began to work. James continued his chart review and made notes regarding information he needed and a task list for the day, keeping one eye on Tommy's patient to see if her problem was urgent or not.
Several students approached him with questions about diagnosis or treatment, about the type and order of tests in their patient's workup and he answered those. The 2nd Year was in a conference with other 2nd Years that morning so the ward was his to cure or kill. A unit secretary handed him a lab result marked 'critical value'. He saw the hemoglobin from during the night on the tubal pregnancy patient with the expectedly low value of 6 grams.
It was a 'critical value' but the computer in the lab had no way of 'knowing' that her hemorrhage had been cured already and was just reporting an abnormal result. He handed the result to Tommy without comment.
"Here's a lab for ya."
His eyes flickered down for a second. Tommy's 'daddy' remark the day earlier was just now processing. Tommy noted the look out of the corner of one eye, looked down for a second and only saw a white coat covering all.
He thought about yesterday and tried to remember James' reply to his flippant, nervous daddy remark. Something about he'd be his daddy and was it "spank?" his butt or "beat?" his butt...his own cock twitched just in time for James to notice since his white coat was open.
James looked up into Tommy's eyes and looked away with no change in facial expression and moved away.
Signal sent, thought Tommy. His cock twitched again but no one was watching him. He wondered if James knew just how hot he looked, just what a stud he was, not remembering how positive transference worked.
That phenomenon, a long-held theory in psychiatry, dealt feelings inside of a patient's head about another person that the patient transferred to their therapist and then expected the therapist to act in a certain way as a result. Tommy had mistaken his intern for a therapist.
Tommy expected James to be authoritative like a daddy, all powerful in some ways and certainly protective of him as a student.
Tommy's own abusive father hadn't been a great dad, he knew, and he'd been struggling with that all his life, stumbling to find someone to pick him up and tell him what to do, finding a child-like gratification in the process. It wasn't a mental failing, just the way it played out.
Transference would not normalize their relationship, whatever it turned out to be. Had he listened carefully in class he might have recognized the roots of his response to his intern.
James had taken the same classes in psychiatry that Tommy had taken and understood the underlying mechanisms at play. He didn't have a problem with the banter, didn't mind being the mentor, was alert about appearing protective and told himself to be careful about being overly authoritative beyond his previous remarks.
He wanted Tommy to figure out his own goals and to begin to trust himself as the arbiter of how to live his life.
James didn't think that intimacy with Tommy would advance that agenda, although it might be an interesting, salacious spin through the tulips physically.
Lawrence was enough for him at the moment.
The summer became a blur of days, most patients relegated to memory, new patients constantly crowding into the current agenda, workup, differential, labs, ultrasounds, discussion, treatment, surgery, deliveries, families, dads, moms, babies, the rare death, the compliments, the jerks, the sycophants, the lonely, the hypochondriacs, the bereaved, and the healed. Then there was wonder and relief of health again, the cessation of pain, incisions healing, incisions falling apart, Lawrence at night, Lawrence in the morning... ever more familiar, ever more loved.
The dental anesthesia fellowship was nearing an end now. The twelve-week experience waited for another batch of dental students. James and Lawrence avoided the topic until one day they could not.
"What happens to us now?" James brought it up on night after they had both screamed the Deity's name in pleasure.
"We sleep, I hope," replied Lawrence.
"No, you know...what are we going to do when your fellowship ends?"
"It ends. We don't."
"What if you have to go do a fellowship somewhere else? If you go to Denver or someplace to graduate after you finish?"
"What if you get accepted to do a fellowship in ob-gyn at Harvard?" Lawrence threw the ball back into James' court.
"What I'm trying to say is how are we going to work out being together if our careers take us in different directions?"
"I understand exactly what you are saying to me. You are anxious as am I that we might be separated someday sooner rather than later."
"That's it in a nutshell."
"Well, since even blind squirrels get a nut once in a while, we might get lucky and figure out a solution when the time comes. We can't figure it out before we know the details and I, for one, don't want to waste a single second unhappy...not when I can be ecstatic in your glowing presence..."
"Stop...I was just trying to think ahead."
"Some things just happen and get figured out then. Planning ahead works fine if one knows enough details, otherwise it's mental masturbation. It's just too early for either of us to know the future."
"I just freak a little when I even think of not living with you, being able to love your magnificent self, perving at will on ya..."
"Yeah, it must be disturbing all right," grinned Lawrence.
"Stop, twit of mine. There are replacements for ya out there somewhere, likely enough. I'm just worried I won't be able to find another you right away, I guess."
"Sorry, dear...you're not getting away that easy. I've gotten used to your ass now. I was the despoiler of a virgin and that was you, love. I'm not going to discard ya that quick. I've donated part of me to you...make that present tense...every night...and I tend to my investments very carefully."
"We dentists don't throw away treasure, not even the gold fillings we take out of people's mouths. You wondered what happened to those fillings, didn't you? You're my treasure, sweetheart. Move over here."
James moved, wondering if the average Joe knew that dentists can break down words into messages like anyone else. Lawrence had heard the real meaning behind the words and given the exact right response.
At the same time, James found comfort in planning and wrote down what he would like if everything went his way. "I would like to be with Lawrence, live in the same house or condo or ship, get married, have a kid(s), work in the same city, grow old together, travel, save up for retirement." It wasn't to be.
James found the note on Lawrence's door one night after work which turned his world spinning back the other direction for a week or two.
"Dear James, I'm sorry, but I cannot tell you in person. This is too hard as it is. I've been asked to do my next year at Cambridge, an opportunity one doesn't pass up. Will I miss you? Is the moon in the sky? I hope you don't forget me and at the same time, it's best if you and I move on. It isn't possible to remain close while apart; the telephone won't do it for either of us. Goodbye, dear heart. My heart is breaking. Lawrence."
Slumped against the door, James re-read the note, knocked, no answer, and a little lady from next door walked across the driveway.
"He said you'd be coming by. Could you use a drink?"