On Call

Lucas cradled the phone between his ear and shoulder so he could get to his beeper. It was clipped to his scrub bottoms and vibrated insistently.

“Hello,” said a pensive voice in the phone receiver.

Lucas grabbed the phone off his shoulder. “Hey, Sarah, it’s Lucas Walker. Are you on back-up call tonight?”

She paused, and then said tersely, “Yeah.”

“I’m really sorry, but we’ve got a stroke head in the E.R. I’m going to have to assist Dr. Friedman, so you’ll need to come in.”

“Are you serious? Why can’t you just do the case and catch up when it’s over?” she asked, agitated.

“Because it’ll take three or four hours. You know we can’t leave the E.R. uncovered for that long. Besides, what if there’s a trauma?”

There was silence. For a second he thought she’d hung up. “Look, I’m sorry Lucas, but I don’t think I can come in. You’ll just have to figure it out.”

Lucas’s brow furrowed and his voice deepened. “Sarah, you listen to me, there’s no “not coming in”, got it? You’re coming in. You can pick up the beeper in the control room in interventional radiology. If you’re not here in thirty minutes my next call will be to Dr. Mulhern, and after that you can kiss your career goodbye.”

“Fine,” she said, followed by click, then a dial tone.

“Who was that?”

Lucas turned and saw Wayne D’Souza standing behind him. He was a thirty-two-year old radiology tech with curly hair, light brown skin and an overfriendly demeanor.

“Sarah Goldin,” said Lucas.

Wayne smiled. “She’s such a phony.”

“Yeah,” said Lucas, looking at his watch. “You got here quick. I just sent the alert fifteen minutes ago.”

“I was working out at the med school gym across the street. So, what’ve we got?”

Lucas removed his white lab coat and placed it on a hook. He dropped the beeper next to the keyboard in the control room. “The patient is Derek Brown, 52-year-old Black male. He works at a local supermarket and had a witnessed collapse about two hours ago while stocking shelves. They called 9-1-1 immediately.”

“Seems young to have a stroke,” said Wayne, “does he have diabetes or high blood pressure?”

“No, but he had cocaine on board,” said Lucas.

Wayne simply nodded. He flipped the switch in the main part of the interventional suite. Fluorescent lights flickered briefly before turning on. The center of the room was dominated by a cushioned fluoroscopy table. It sat on top of a stout metal pedestal with an internal hydraulic pump. Next to it was a double C-arm fluoroscopy camera perched above and below the table looking like the pincers of a giant insect. The camera had wheels for easy maneuvering.

“Where is everyone?” asked Wayne.

“Dr. Friedman is on his way, so is nursing, I think Lori’s covering tonight. The E.R. said neurology would help transport the patient up here,” said Lucas. “Hey, what’s the trivia question of the week?”

Wayne popped back into the control room, smiling. “Okay, check this out. Princess Diana died in a car crash last year, right? What did she actually die of?”

Lucas plopped into the swivel chair and leaned back. “Oh, man, that’s tough. I don’t know. Was it a head injury?”

“No way, dude, nice try. Lacerated pulmonary vein. I got it from my cousin’s friend whose uncle is a trauma surgeon in London. That’s top-secret info, so mum’s the word, comprende?”

“Really, she had a lacerated pulmonary vein? That’s super rare,” said Lucas.

“I know, right?” said Wayne.

Lucas said, “Alright, hot shot, I’ve got one for you.” He was thinking of a game of Trivial Pursuit he played with his buddies in high school. Ben Borneo was the smartest guy in his crew, which is why they nicknamed him “Moses”. He eventually went to Stanford, but drank too much his first semester, lost his scholarship and ended up going to LaSalle College in Philly. They stopped playing the game after Ben got this question right. He retired undefeated like Rocky Marciano.

“Hit me, boss man,” said Wayne. He continued prepping the room for the procedure.

“Who was Secretary General of the U.N. during the Cuban Missile Crisis?”

Wayne looked up from the wheeled cart, now covered in wires and catheters. “Dude, that’s ridiculous. I have no idea. I mean, whatever, Dag Hammarskjold?”

“Nope, try again,” laughed Lucas.

“Try what?”

Lucas turned to see Dr. Friedman enter the control room. He was in his early fifties, had a nose that was a little too big and slightly bucked front teeth, but both were deemphasized by a glorious mustache. His dark gray V-neck sweater had a Mercedes logo on the breast. It was well-known that he was having an affair with the lead ultrasound tech. She was twenty years younger than him and looked kind of tired all the time and had sun damaged skin, but she a body that could stop a clock.

“Oh, hey, Dr. Friedman. Wayne just busted me with the weekly trivia question, so I hit him with my best shot. By the way, did you know Princess Diana died of a lacerated pulmonary vein?”

“I did know that,” he said, nonchalantly. “What was your trivia question?”

“Who was Secretary General of the U.N. during the Cuban Missile Crisis?”

Dr. Friedman frowned, then tented both hands over his nose and mouth. Shaking his head he said, “I don’t know,” paused, and said, “U Thant?”

“No way,” said Lucas, “literally no one has ever gotten that one before.” Except Ben Borneo, but he didn’t count because that was a million years ago, and anyway he failed out of Stanford.

“What can I say, I know everything,” laughed Dr. Friedman. “I’m going to jump into scrubs.”

As he turned to leave Wayne yelled from the main room, “Hey, Doc, can you believe we’re back already? It feels like we live here.”

Dr. Friedman smiled and said, “Come on, Wayne, you know that saving lives doesn’t just occur between the hours of nine and five.”

Wayne laughed.

Dr. Friedman crossed the hallway and entered the staff lounge to change into scrubs.

Soon after he left, the double doors to the main room swung open. A transporter wheeled Mr. Brown into the room on a gurney. He was unconscious and covered with a thick, white blanket up to his chin. Wayne hurried over to help move the patient onto the fluoroscopy table.

“Dr. Lucas, can you give us a hand, please?” asked Wayne as he pulled the blanket off Mr. Brown. Underneath the patient wore a threadbare blue hospital gown which buttoned in the back. He had faded tattoos up and down both arms. The transporter helped Wayne and Lucas scoot him over.

The neurologist and his resident entered through the double doors while Dr. Friedman came back in through the control room.

“Hey, Pavel, what’s up?” said Dr. Friedman to the neurologist. Then he said, “Lucas this is Dr. Wojcik; Pavel this is my resident Dr. Lucas Walker.” They shook hands.

Lucas said, “Um, hi Dr. Waj-kick.”

Dr. Wojcik had a big belly, thinning sandy blond hair and a serious face. “It’s pronounced Voy chick, like boy with a “V” and “chick” like a chicken.”

Lucas’s cheeks burned. He said, “Wojcik, got it. Sorry about that.”

“Is it true you’re being forced back to Poland in a couple months?” asked Dr. Friedman.

As they talked Wayne cleaned and prepped the patient’s left groin using an iodine-based cleanser called Betadine. The patient had dark skin, so the brown solution blended invisibly with his skin. After sterilizing a wide area of the upper thigh Wayne removed his sterile gown and gloves and replaced them with new ones. Next he pulled a sterile drape over the patient. It was light blue and had a hole in the center which Wayne adjusted until it was directly over the left hip.

“Yeah, my attorneys have run out of deferments,” said Dr. Wojcik. He saw Lucas frowning and continued, “I came here on a J-1 visa eleven years ago. Normally you have to go back to your home country for two years after training, ostensibly to share your new knowledge with the doctors back home. But you can usually defer things. Unfortunately, I’ve run out of luck, so I have to go back.”

“I guess the hospital is trying to get every bit of work out of you before you head home,” said Dr. Friedman.

Dr. Wojcik chuckled, “Same as you. What is this, our third case this month?”

“Death and disease don’t take a break,” laughed Dr. Friedman, “neither do I!”. Then he continued, more seriously, “Looks like a right middle cerebral artery infarct?”

“That’s correct,” said Dr. Wojcik, “your resident made an excellent call on the CT scan.”

Lucas glanced over at him without expression. Forty minutes ago, he’d read the CT scan of the brain on Mr. Brown. He called a stroke based on a subtle increase in density in the right middle cerebral artery, the so called hyperdense MCA sign.

When Dr. Wojcik looked at the scan with Lucas he’d angrily remarked, “This artery is hyperdense and this artery is hyperdense and so is this one (pointing all over the brain). I’m so sick of having to come in because of weak radiology residents.”

Lucas had been proud of the call but now felt like an idiot. Dr. Wojcik then performed a physical exam on the patient and bustled out saying, “You were right, he’s got a stroke. Please alert the team.” Lucas had managed not to smile or say, “I told you so”, but with difficulty.

“He’s one of our best residents,” said Dr. Friedman.

Just then Sarah Goldin popped her head into the room. “Hey, Dr. Friedman, hey Lucas,” she said while waving the beeper, “I’ve got you covered.” She smiled and winked at them before leaving. Lucas didn’t say anything.

“Have you ever thought of doing interventional radiology?” asked Dr. Friedman.

Lucas raised his eyebrows and said, “Maybe, yeah. I’m keeping my options open, but it’s definitely on the list.”

“Well, if you want to do a fellowship with me, I’d love to bring you on board my team once you finish residency.”

At that moment the nurse, Lisa Hernandez, dashed into the control room. She was plump, light-skinned and had hair pulled back into a ponytail. Frantically she said, “You started without me?” as she dropped her keys on the counter and pulled off her coat.

“We don’t typically wait for nursing in an emergency situation,” said Dr. Wojcik.

She didn’t reply to that other than to clench her teeth, snap her stethoscope over her neck and rush into the room.

Dr. Friedman and Lucas put on lead shields which included vests that velcroed in the front and skirts that were snuggly wrapped around their lower bodies. Over this they wore light blue sterile gowns, tight-fitting surgical gloves and masks with transparent face shields.

“Excuse me, Aaron,” said Dr. Wojcik to Dr. Friedman, “can you walk us through the procedure? My resident hasn’t seen a thrombolysis before.”

“Sure. First, I’m going to enter the femoral artery,” he accompanied this by puncturing the groin with a long needle. He was simultaneously feeling the femoral artery pulse, which acted as a guide. “I’ll know I’m in when the blood jets out of the needle.” As if on cue, bright red blood squirted out of the back of the needle, pulsing with the heartbeat (squirt, pause, squirt, pause). “Next, I’ll insert this wire through the needle into the femoral artery.”

At this point Dr. Friedman stopped looking at the entry point and shifted his gaze to the fluoroscopy screen. It was like a television and hung from the ceiling by an articulated arm. “You’ll notice how easy it is to see the wire with all of the soft tissues and bones nearly invisible on the screen.” He rapidly advanced the wire into the pelvis. On camera it flew upward, through the pelvis and abdomen and into the chest. “If you look closely, you’ll see I’m fiddling with the tip of the wire. I need to find the right brachiocephalic artery, which is one of the three branches off the arch of the aorta. It’s mostly done by feel...” He squinted at the screen. The wire danced around the top of the chest, but then suddenly jumped into the artery.

“Okay, were going to insert a catheter over the wire, then inject some contrast into the artery. This’ll give us a road map of the blood vessels in the right side of his brain.” The arteries filled with contrast, looking like black strands of spaghetti on the mostly white screen.

“Ah ha,” said Dr. Friedman, “there it is. See where the artery is cut off? That’s where the blood clot is.” As he spoke, he worked the catheter into the right middle cerebral artery. “I’ve just lodged the tip into the clot, which you can’t really see on the screen, so you’ll have to take my word for it. Now I’m going to inject tPA while Dr. Walker tells us what that is.”

Lucas’s head snapped up. “Oh, ah, yeah, tPA. Let’s see, that’s tissue plasminogen activator. It converts plasminogen into plasmin which is an enzyme that dissolves blood clots.”

“Very good, Dr. Walker,” said Dr. Friedman. He blasted the clot with three tight boluses of tPA before taking another look. “Now let’s see how we’ve done.” He pulled the catheter back and injected contrast. Like magic the blockage was gone. Contrast, and of course blood, flashed downstream through the now open right middle cerebral artery. The brain was faintly visible as it perfused with oxygenated blood.

“Nice job,” said Dr. Wojcik, smiling.

“Thanks,” said Dr. Friedman. He turned his attention to the groin and, lowering his voice, said, “Lucas, when I remove the catheter there’ll be a hole in the femoral artery. I need you to hold pressure over the artery until it stops bleeding, which will take a while. Can you do that?”

“Sure thing, Dr. Friedman,” said Lucas. He placed his hands on the groin next to the catheter. Dr. Friedman pulled it out in one quick motion, and Lucas rolled his fingers, stiff as a board, over the site. He could feel the artery pulsing under his fingertips.

“Okay, good, now don’t check the site for fifteen minutes. One last thing, did you hear about the doctor who gave his patient three months to live?” Lucas looked up at him questioningly. “The patient said he couldn’t pay his bill, so the doctor gave him another six months.”

Lucas smiled, “Good one.” The rest of the procedure flew by as he assisted with stabilizing the patient.

Three weeks later Mr. Brown’s case was presented at Grand Rounds in the department of Neurology. Lucas made a point of attending the lecture. They reviewed the history and physical examination, the procedure (which included images from the angiogram Dr. Friedman had taken that night), and the fact that he went home a week later. The speaker, Dr. Wojcik, explained that without treatment Mr. Brown had about an 80% chance of dying, and a 100% chance of profound disability, within the first three months after the stroke. Instead, he walked out of the hospital.

Lucas raised his hand, “Excuse me, Dr. Wojcik, did Mr. Brown have any mental or physical deficits?”

Dr Wojcik said, “Excellent question, Dr. Walker.” He reviewed the chart in front of him before answering. “Yes, it looks like he had minor weakness in the muscles of his left hand, near the base of the thumb. That’s it. Speech, mental acuity and ambulation all returned to normal.”

That was the moment when Dr. Lucas Walker, pioneer in the field of interventional neuroradiology, inventor of the laser guided clot buster, and future president of the American Academy of Neuroradiology, decided to accept the fellowship with Dr. Friedman. After all, he figured, if death and disease don’t take a break, why should he?