Morbidity and Mortality

Alex inhaled deeply and reminded himself what he had to do. Turning the knob, he entered the Department of Surgery conference room. Two people, seated on opposite sides of a large mahogany table, stopped talking and looked up at him. The table rested on a thick paisley carpet, surrounded by leather upholstered chairs.

Closest to him sat Dr. Murray Caldwell, head of vascular surgery and Vice Chairman of Surgery. He was mid-sixties, Black, with salt and pepper hair and a neatly trimmed mustache. Known as a pioneer in endovascular techniques, he was revered by all medical students, including Alex. A good recommendation from him would guarantee a spot in any surgical residency.

Across the table sat a woman with raven black hair and porcelain skin. She wore a perfectly tailored olive-green pants suit over a tight runner’s body. Her dark blue eyes darted over Alex, searching for weakness, or so it seemed to him. Spread in front of her were piles of papers including a patient chart, a yellow legal pad and multiple other documents. She pointed to the seat next to Dr. Caldwell.

Alex felt self-conscious in his faded green scrubs and short white lab coat. He wanted to pour a glass of water from the pitcher, which was sweating on a black coaster, but his arms felt foreign and awkward. Dr. Caldwell noticed his discomfort and poured two glasses. “Relax, young man,” he said, patting his forearm.

“Thank you for joining us. You are Mr. Alik Kovalenko, correct?” asked the woman, reading from her legal pad.

“Alex,” he said.

“Pardon me?” she said.

“My name is Alik, but everyone calls me Alex. If it’s okay with you I’d prefer to be called Alex, I mean, if you don’t mind. But, yes, that’s me.”

She listened closely, staring hard into his eyes, and said, “Okay, Alex. My name is Stacy Jennings. I am chief legal counsel for the hospital. I’ve been asked to investigate the death of Mr. Boris Petrov.”

Alex’s heart pounded. A kaleidoscope of images raced through his head. The blood, the refrigerated operating room, the crinkle of synthetic gowns, the beeping heart monitor, the tight latex gloves, the quiet murmuring of surgeons, but mostly the blood.

“Am I in trouble,” he asked, quietly.

“Mr. Petrov was here in Philadelphia for his daughter’s graduation from college,” she said, ignoring his question. She continued reading from a document. “At approximately 4:30 pm on the afternoon of May 17th he developed severe abdominal pain, at which point his bodyguard called 9-1-1. He was brought by ambulance to this hospital, where it was determined that he had a ruptured abdominal aortic aneurysm and that he needed emergency surgery. He was rushed to the operating room where he died.”

She looked up. “Is this correct?”

Dr. Caldwell responded. “Excuse me, Ms. Jennings, but Alex wouldn’t know all of the initial details. He only assisted in the operating room. But I am familiar with everything, and your description is accurate.”

“Thank you. Now, Alex, why don’t you walk me through what happened?”

“Okay, sure. My buddy, Samir Desai, had been working with Dr. Caldwell. Samir is a third-year medical student, like me. He was supposed to scrub on the surgery, but had a patient in the SICU, that’s the surgical intensive care unit, so he asked me to swap with him.”

“Let me interrupt you, please,” said Ms. Jennings, rifling through papers. “According to Mr. Desai, you asked him if you could assist in the surgery, and if he could cover you in the SICU.”

Alex frowned. “Um, maybe, but I thought it was the other way around. Whatever, it’s pretty common to swap assignments. I guess my point is that I wasn’t really supposed to be in the O.R., which is a bummer, considering what happened.” He glanced sideways at Dr. Caldwell, who watched intently.

“Continue,” said Ms. Jennings.

“Okay. There were a bunch of people in the operating room. It’s unusual to repair an abdominal aortic aneurysm with an open surgery; most people have them diagnosed before they rupture. I guess because he was from Russia he didn’t get great care.”

“How do you know he was from Russia?” asked Ms. Jennings, frowning. Her eyes, like searchlights, panned over him. He felt naked under her glare.

Suddenly, his mouth was filled with cotton balls. He took a sip of water, fidgeted, and tried to think. Multiple portraits of the former chairmen of surgery hung from heavy, gold leaf frames. They stared at him in stiff suits looking accusatory and angry. “Well, I mean, it’s kind of known he’s one of those billionaire oligarchs. When he arrived with a bunch of bodyguards, I guess someone Googled him. Anyway, I think most people knew who he was.”

“Okay. Kovalenko is a Ukrainian name, right?”

Alex paused and looked her full in the face. “Yeah, that’s right. So what? I’m an American.”

“Well, there’s a war between Russia and the Ukraine. And because Mr. Petrov is a high-profile Russian, the Department of State has asked the FBI to investigate. My job is to protect the interests of Thomas Jefferson University Hospital, and by extension, protect you. To do that I need to know everything.” She paused letting that sink in. “Please continue.”

“Right, okay. A lot of residents scrubbed into the operation, so the room was pretty full. I was only there because they needed a medical student to hold the clamp.” Ms. Jennings frowned. “Basically, the aorta is the largest artery in the body. In order to repair it you have to use a midline incision.”

He drew a line with his index finger from his breastbone to his navel to indicate the site of incision.

“The skin is held apart by a large clamp, and then the abdominal organs are moved aside. Once the aorta is visualized it needs to be cross clamped in order to stop blood flowing through it.”

He made a clamping motion with the second and third fingers of his left hand.

“You can’t suture, by that I mean sew, the new graft into the wall of the aorta if it’s pulsing with blood. My job was to hold the aortic clamp, to make sure it didn’t slip.”

“I think I’m following you, Alex,” said Ms. Jennings.

“Well, as I said, the room was crowded. I was standing sideways with only my left hand in his body. The surgical resident was pushed up on me and my head was on the drape separating me from the anesthesiologist.” His eyes unfocused as he remembered. He extended his left arm and leaned his head to the right. “But I could sort of see what was going on. Anyway, it turned out the aorta had to be clamped above the renal arteries. That means we had thirty minutes to do the proximal anastomosis before the kidneys would be damaged permanently.”

Dr. Caldwell interrupted. “The proximal anastomosis is where the graft is attached to the aorta.”

“Thank you,” said Ms. Jennings.

“So, we were on a thirty-minute clock. It gets very tense when you’re under the gun like that,” said Alex. “I was holding the clamp in my left hand, pushing down gently on the vertebral column which is right behind the aorta. I mean, I’m sure I had a good grip. The resident next to me turned his head to sneeze and bumped me. I was so shocked I flinched, and the clamp slipped free of the aorta.” He swallowed before continuing. “Blood exploded out of the aorta like a fire hose. In two heart beats the entire abdominal cavity was filled with blood, and the patient died. Just like that,” said Alex, snapping his fingers, “one minute we’re finishing up the anastomosis and the next his belly is basically a bathtub.” He could still feel the warm purple-red blood covering his fist and forearm.

Alex turned to look at Dr. Caldwell, who said nothing. He turned back to Ms. Jennings. She was nodding her head and reviewing a document.

“Thank you. That is similar to the other accounts I’ve received.” She put down a document and picked up another.

“It says here you’re from Philadelphia, and an only child, raised by a single mother. Your father died in the Ukraine in the 90’s, after which your mother emigrated to the U.S. You went to Abraham Lincoln High School in the northeast.”

“That’s where Sylvester Stallone went to high school,” said Alex.

Ms. Jennings looked up, irritated, “What?”

Alex regretted saying anything. “Sorry, it’s just that Sylvester Stallone went to my high school. I always tell people that, because he was Rocky and all.”

“Please don’t interrupt me. You graduated near the top of your class, went to Yale University, studied economics and graduated sum cum laude. You’ve done well in medical school where you are in the top ten percent of your class and are a member of the Alpha Omega Alpha honor society. Is this accurate?”

“Yeah,” said Alex.

She shuffled a few papers. “It says here that you failed a cannabis test in your first year of medical school.” She looked up, “Care to explain?”

Alex blushed from chin to hairline; his shoulders tensed. “Look, I don’t know how familiar you are with medical school, but it’s really stressful. We have exams every month. In the week leading up to an exam I literally study 10 hours a day. I wake up, eat breakfast, study, eat lunch, study, eat dinner, study, go to bed and start over the next day. That goes on for a whole week.”

“Okay,” said Ms. Jennings.

“Well, after the exams most of us unwind, get drunk, whatever. A few of us like to smoke weed. It’s nothing crazy or anything.”

“Where do you get the marijuana?”

Alex’s eyes darted from Ms. Jennings to Dr. Caldwell and back. He swallowed hard and bit his lip.

“Don’t worry, Alex,” said Dr. Caldwell. “I know medical students aren’t saints. You’re not the first person to fail a drug test. This inquiry is private, so please be honest.”

“Um, okay. I get weed from a friend, and I kind of sell it to my buddies.”

Ms. Jennings’s head snapped up. “Wait, are you saying you’re a drug dealer?”

“NO! I mean, not really,” said Alex. To his horror his voice squeaked. Clearing his throat he said, “I just, I don’t know, the stuff is expensive. I can’t afford to buy it and just give it away. A lot of my classmates have money, and honestly, they’re happy to pay. I’ve never sold it to strangers or kids or anything like that.”

“Okay, relax, Alex,” said Ms. Jennings. “I just need to understand everything.”

She picked up another sheet of paper, a bank statement. “I see that you’ve been to Atlantic City seven times in the last year, and every time you’ve stayed in the Presidential Suite.” Her eyebrows shot up. “Please explain.”

Alex smiled. “Oh, that’s easy. My Uncle Charlie is a whale, a high roller, at the Borgata. He gets comps all the time. If he’s not going he’ll offer it to me. He knows I like to play blackjack.” Alex looked at Dr. Caldwell and back at Ms. Jennings. “If you understand perfect basic strategy blackjack has the best odds at the casino. You can get them down to 51-49 against. If you compare that to the slots which are programmed to give the casino a five percent edge you can see why people love it.”

Ms. Jennings looked at him for a second. “I see.” Picking up another paper she said, “Uncle Charlie. You mean Charles Nazarovich, correct?”

“Yes,” said Alex.

“Charles Nazarovich the reputed mob boss, that’s your Uncle Charlie?”

Alex flushed. “Look, I don’t know anything about his business dealings. He was in the Ukrainian army with my dad; they were like best friends. When my dad died, Uncle Charlie promised to look after us. I see him at Christmas and a few other times per year, that’s it. He hooks me up with the comps in A.C., helped me get a car in high school and stuff like that.” He spoke quickly as his voice rose. “Honestly, I’m sick and tired of people judging me because of a family friend. My mom works as a cleaning lady for rich people on the Main Line so she can afford to eat, okay? So, sue me if we accept a little help from my dead dad’s best friend.”

“Ms. Jennings,” said Dr. Caldwell “is this necessary? You’re not seriously suggesting that this young man, this honor student, is somehow mixed up with the mob, are you?”

Ms. Jennings smirked. “No. I just need to know as much as possible, so I don’t get surprised by the FBI.”

Alex suddenly looked scared, and said, “So, where do we go from here? I mean, am I going to be arrested, or anything like that?”

Ms. Jennings clicked her pen, dropped it on the legal pad and leaned back. “Honestly, no. I don’t think anything is going to happen. Mr. Petrov died from an unfortunate accident during emergency surgery. What’s more, he was a criminal and an enemy of the United States. I doubt you’ll hear anything. Don’t worry; I’ll make this go away.” She stacked her papers together, carefully squaring off the edges. “Thank you for your time, Alex. I wish you luck in your medical career.”

Alex shook both their hands and left. It was twilight on a warm early summer day as he exited the hospital. The air felt clean on his cheeks. Between the roof tops he saw blue sky and a few white clouds.

He walked toward his apartment which was a couple blocks away. A black Lincoln Continental was parked near his corner. The driver, wearing a dark suit and sunglasses, stood next to the car. He nodded toward Alex and opened the back door.

Alex stooped to enter and sat on the plush black leather seat. Cool air filled the dark interior.

“Hey, Uncle Charlie,” he said.

Charles Nazarovich was overweight and balding. His light blue dress shirt was open at the neck revealing a thick gold chain. He wore brown orthopedic shoes because of gout. The laces were cheap and untied.

“How did it go?” he asked in his gruff, rumbling voice.

“I’m so glad that’s over. The hospital’s attorney knew everything about me, which was scary, but, she believed me.”

“Okay, good,” said Uncle Charlie, “so what’s next?”

“Nothing. She basically said the U.S. is happy Petrov is dead. She doesn’t think I’ll even hear from the FBI, much less be interrogated.”

Uncle Charlie laughed. “Well done! I knew you were the right man for the job.” He pulled a white envelope from the inner pocket of his suit. “I’ve taken care of your gambling debts.”

Alex just looked at him. His debts were with Uncle Charlie.

“You’ve got a clean slate. Here’s $2500 to help with expenses.” He placed his hand on Alex’s shoulder. “Now listen, I’ve spoken to my man. You can use my place at the Borgata if you want.” He dismissed him by popping the lock on the door.

Alex hurried home, calculating. It was 5:15 pm. He figured it would take 18 minutes to change and eat dinner, 7 minutes to get to his car, and 75 minutes to drive to A.C. He would be at the blackjack table by 8:00 pm.