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    . . .a thin triangular flap of a heart valve. . . a small book usually having a paper cover . . . a medical lit-art e-journal from The Permanente Press
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606 University

Prose, Volume 2; Issue 1

Lee W. Hickok, the surgeon, was in the operating room again. As chief resident of surgery at the University of Texas Medical Branch in Galveston, the OR was where he preferred to be. The case was a gunshot wound to the abdomen, common enough in the life of a general surgeon, but this case was different; Lee W. knew the patient.

He stood waiting anxiously with arms crossed; dressed in a blue sterile gown, gloved, wearing a paper mask, stretchy surgical hat, and paper shoe covers over his worn ostrich-skin cowboy boots. The surgeon tapped his foot impatiently, aware of a bead of sweat forming on his brow. He stared at the ticking operating room clock; a clock whose second hand swept with an exceedingly slow pace. He bit his lip and turned annoyingly to the nurse as she finished her prep. The scrub nurse was busy to his left, laying out the hundreds of instruments they were about to use. Anesthesia was distracted at the patient’s head by the monitors; intravenous drugs lying along the med cart ready for infusion.

The surgeon realized that he should not be doing this case, what with the close personal attachment to the patient. He was on call however, and at a teaching institution there was no one else. Besides, he concluded, would he trust the exploration of this abdomen to anyone else? Lee W., confident but very anxiously, decided he could not.

The prep nurse now finished, backing away and leaving the patient supine on the operating table. The abdomen was brown and shiny, having been prepped with betadine soap. The surgeon adjusted the operative field lighting. “Condom,” he always thought of a condom when he moved the lights; the central handle covered by a sterile clear plastic disposable envelop as in a prophylactic. The plastic reminded him of a condom, ironic given the nature of this case. His mind returned to the case as he asked for drapes. The scrub nurse handed four folded sterile towels, one by one, to the man who placed them sequentially. The towels outlined the intended midline abdominal incision, each secured with a shiny towel clip. He was then handed the paper laparotomy drape; placed it over the wound and unfolded it to cover the patient from head to foot. Tubing and sucker were next, followed by the bovie electro-cautery unit; each clipped securely to the patients left side.

“Scalpel,” instructed the surgeon to whom the scrub nurse handed a gleaming ten blade and handle. He looked to the anesthesiologist at the patient’s head, confirmed the patient as asleep, and began the incision.

Gunshot wounds to the abdomen are generally examined through a midline incision beginning at the symphysis-pubis, the lowermost extent of the belly, and ending just below the sternum. The abdomen is like a large black box, nooks and crannies everywhere; perfect sites for succus or pus to hide, making such traumatic wounds unpredictable. Owing to the uncertain nature of such injuries; the large midline incision allows unfettered access to the abdomen. With this incision the entire abdominal contents and hidden spaces may be examined, and any and all injuries repaired.

In such a fashion the skin was divided from symphysis-pubis around left of the umbilicus and continuing to the xyphi-sternal junction. Electro-cautery was used to divide the subcutaneous tissue and muscular rectus fascia. The peritoneum membrane was then tented up between forceps and incised sharply. Moist towels were applied to the wound edges, and a Balfour self-retaining retractor placed exposing the abdominal cavity.

The chief resident, the surgeon, stood on the patient’s left while the attending assisted from the right. “This patient has a gunshot wound to the left upper quadrant of the abdominal wall,” Lee W. Hickok said. “There evidently was a struggle in which a gun discharged at a very oblique angle just entering and exiting the left upper quadrant. Here, you can see the entrance,” he said pointing to a small puncture wound with slightly raised edges to the left of the incision in the upper left corner of the abdomen. “Let me have that probe,” the man said to the scrub nurse. He then probed the entrance site showing its exit just further to the left. “Ya … see with the probe it’s not clear whether it entered the abdominal cavity or whether the projectile went in and out just through the abdominal muscles.”

Gunshot wounds to the abdominal region must be assessed as to whether they violated the peritoneal cavity or just the abdominal wall. In the first case, abdominal exploration is necessary. In the latter many times it is not. Physical examination and other tests are used to make this distinction.

The surgeon looked up and made eye contact with the attending over his mask. He went on to present the case to his superior. “You see, on exam however, there was marked guarding and cough tenderness in the left upper quadrant suggesting the belly was violated, and the blood pressure was significantly down at about eighty systolic. So I did a quick paracentesis which was just the slightest pink. I couldn’t see newsprint through the effluent. It could have been a bloody tap, but with the blood pressure and peritoneal signs on exam of the area, I felt we needed to explore the belly. We might not find anything.”

The attending responded. “I agree, it is best to explore any gunshot wound with a chance of penetrating the peritoneal cavity. To not explore a case that has had the belly violated by the gunshot leaves the patient in a mortal situation. You did a paracentesis? I haven’t seen that done in years. Good, how did you do it?”

“I infiltrated some lidocaine just below the umbilicus. Then with a 20 gauge spinal needle, I tapped the abdomen. I ran a liter of Ringers Lactate into the belly through the needle, left it to soak for a while, and then drained it. Like I said the return fluid was slightly pink. When I covered some print from the newspaper with the paracentesis fluid, the letters were not readable. So that is a positive tap, right?”

“Ya that is a positive tap. It suggests the peritoneal cavity was violated by the projectile. I think we will find something,” the attending said as he began packing the abdomen. “Ya, this was the right thing. We will find something, I’m sure.”

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Chase did not sleep well that night; he knew he was not ready for the neurology exam. Medical school was a nightmare, and a poor grade on this test might end his career. The dean had warned him of this, but now it was inevitable. Chase closed the door to his room behind him, crossed the courtyard with the algae green swimming pool filled with a champion collection of water bugs, and exited the old fraternity house building on 606 University Avenue.

The number 606 was one of historical irony, an inside joke for the Zeta of Phi Chi fraternity members. Built at the turn of the century, the first UTMB fraternity house on University Avenue in Galveston was numbered by the medical students of the era in jest, referring to the first systemic therapy for syphilis, Salvarsan 606. While the drug was eventually made obsolete by penicillin, the number 606 remains; a testament to history and more so to the sexual forays witnessed at the fraternity through the last century. Chase thought of the number that morning, its significance reviewed in his mind with sadness.

The young, discouraged, man began his four block walk to school, the sky a cloudless dull blue; the overwhelming heat of the gulf coast just beginning. Seagulls circled above with caws tossed down from the sky. In his state of mind however, the harmless birds might just as well be ones of prey.

The man was immediately covered in perspiration, but he would be sweating today even if he was back in the perfect weather of Southern California, his native home; his mental status so compromised. The humidity in Galveston did not help however, it being overwhelming as always. It left the air heavy with moisture and a continual moldy smell that sickened him.

Chase forced his thoughts away from his discomfort, but no pleasant thoughts replaced them. He barely made the grades necessary to become a sophomore, and now in the second year things were especially bleak. The dean warned him of this, placing him on probationary status; it was his last chance. His fate depended upon passing each exam this semester; the mid-terms were rocky, and now neuro-anatomy would likely do him in.

If honest however, the young man would have to admit to not studying like he should. He partied like in undergraduate school, but then medical school was much more difficult. Long all-nighters the night before the exam bought him great grades in college, but medical school was a whole different thing. Parties at night with beer were consistently a bad decision, but what ruined him was his introduction and increasing dependence on narcotics. He had stopped and changed his partying ways, but then she came into his life and one thing led to another, and he found himself out of luck walking to school and his fate. Chase reached in his pocket finding one last white oblong tablet, threw it in his mouth and swallowed it dry, catching partly on its way down his parched throat. He knew that it would relieve some of his anxiousness; nothing could stop his sweating however.

A blast of air conditioning met him as he entered the medical center and took the elevator to the fourth floor classroom. A group of hospital employees passed him, dressed as was popular for some reason, in stretchy surgical hats pillaged from central supply. Once in the classroom he sat in the usual back row seat, reached down to his right and slowly unfolded the wooden table aware of his fate. He had that sick feeling, the one of doom that followed him continuously. Neuro-anatomy was the last thing he wished to focus on. As he searched for something to divert his growing terror, another upsetting vision entered his mind. Looking to the ceiling, Chase closed his eyes trying to blot the woman from his brain.

She was a third-year student now, with long-curly blonde hair cascading down onto her shoulders. With green piercing eyes; she had the most beautiful smile he had ever seen. She was a Texan from Dallas, a native to the state that was so foreign to Chase. Her southern drawl did not help, so slow and seductive that he now found himself just hoping to hear her voice each day. After that first exhilarating meeting, her subsequent rejection haunted him.

He noticed her immediately, across the darkened fraternity house that night. She was talking quietly to a few of his fraternity brothers, and they made eye contact across the room. Chase forced himself to talk to her, refusing to let his usual shyness prevent their meeting. He was enchanted with her laugh and she carried their conversation so easily. A fraternity brother had some cocaine and they shared a few lines, after which their relationship began to whirl out of control like the drug. When the rain started down she grabbed his hand and pulled him outside. Soaked to the skin they slid into the shadows next to the main house and kissed passionately. Chase then led her to his room. When finished, they lay and laughed in a casual embrace. Chase was so happy, he thought they would live together forever; a memory that soon was destroyed.

The next morning she quietly rose and left before he was awake. The girl tormented him from that moment on; she not really considering their meeting as a special time, he now obsessed with the girl. Her denials ever since destroyed the young man. She now was too busy for him, always on the ward draped in the short white coat of the clinical med-school years. Chase couldn’t get her out of his mind, the last thing he needed during this semester when he had to concentrate and be straight.

The TA’s passed out the written exam to each row from the edge of the room. The stack of exams thinned out as each student took one and handed them along to their left. He knew he was in trouble from the first question. Cross sectional views of the brain flashed on the screen ahead, each with a black arrow identifying a neurological structure. On the exam, five choices were listed, the student to choose the correct one. He was sure that the first slide was a transverse section of the cerebellum, but was the arrow pointing to the dentate or the uncinate nucleus? Was the next of the cerebral peduncles and the substantia nigra? The exam went on and by the fiftieth question Chase knew he had failed. In the icy room a chill overcame him, his sweatshirt now drenched with sweat. Was he hot or cold—he really could not decide. As he walked along the row and handed his exam in, the young man was in a deepening gloom.

Chase retraced his steps after the exam, blowing off the next class to return to his lonely room. The sun in the sky was high overhead and there was a slight breeze from the gulf, but the young man noticed only an atmosphere of doom. His belly was aching as it had been all week. Stepping out off a curb, he stopped with a jolt as the car blasted its horn and swerved to avoid him. Thoughts turned to his last visit with the dean. The man was very clear; his probation depended upon a passing grade in each of the next mid-term exams. The physiology exam had not gone much better than this morning’s neuro-anatomy, but he may have passed it. This last test was definite, not a chance in the world for anything better than a D.

Chase stopped at the Gerlands grocery store to use the payphone outside. The store was a graying yellow color, chipped, and needing maintenance for years. That muggy smell from the humidity was especially heavy, coming from the air conditioned building. A grocery employee came out of the store to his left. The man was grinning as he held a huge rat by the tail. “I found it on the bread aisle,” he said; as if he expected Chase to find this amusing. Not waiting for Chase’s response the man bashed the rodent with a shovel, turned and returned to the store. Chase stared at the man with an empty expression, the scene not registering on his brain.

The med-student dropped a dime into the slot and dialed the number from memory. She would be at home but sleeping after all night call on internal medicine last night. He was surprised when she answered on the second ring, that cute voice so positive until she recognized his. She was busy of course, and tried to get off the phone as soon as she could. When she told him she did not want to him to call again, the world looked like the watery stools he had been passing of late.

“Molly, how could you say that? What is wrong,” Chase wondered?

“I don’t have feelings for you Chase, and you’re really, well you’re really bugging me. It’s weird, stop stalking me,” she said as the phone clicked dead.

Anger pounded in his temples as he stood at the payphone with a silent receiver in his hand. Her response destroyed any positive feelings forgetting the exam might have done for him. He looked to the dead rat on the ground almost with a sense of envy. He was anxious, jumpy; he did not know what he could do to give himself some relief. A prescription bottle in his room flashed into his mind.

Back at the frat house he ran up the single flight of stairs to his one bedroom above. Chase wasn’t one to cry, but he felt himself sobbing as he rifled through his sock drawer. The bottle was nearly empty, the label glaring with an accusatory stare. He downed the last two pills with a swallow, throwing some water into his mouth from the bathroom sink. One more refill he remembered, but something told him he wouldn’t need to call it in.

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The surgeon turned to the abdominal incision. “Moist lap,” the surgeon said, receiving a warmed saline-soaked cloth pad. With this he turned the incision edge out and examined the under surface of the wound. A small tear with peripheral bleeding could be seen. With the probe the surgeon proved that it communicated with the tract of the gunshot.

“Ya, it entered the belly here,” the attending said pointing to the tiny rent. “Harrington,” he said. The nurse passed a hand-held retractor to the man, which he used to lift the wound’s edge.

The abdomen was then systematically examined. In the two upper quadrants the spleen and liver were intact. The stomach had a small ecchymosis on its anterior edge just next to the entrance site but its surface was totally intact. Pulling the wound edge over the stomach, the surgeon was convinced that the anterior wall of the stomach was just next to the wound tract, and that the lesion represented just some bruising. The transverse colon was inspected and intact. The ascending and descending colon, as well as the sigmoid colon, was without pathology. In the lower abdomen no pooled blood or visual signs of trauma were seen.

“We’ll run the bowel now,” said the surgeon to the attending. Inch by inch the small intestine was inspected from its origin at the duodenum, along the ileum then jejunum, and to its end at the colon and the ileo-cecal valve. In the proximal ileum, they found a small puncture wound. The two surgeons resected the traumatize piece of bowel, the re-anastomosis done with the GIA and TA stapling devices. They then removed their sponges, confirmed that the instrument and sponge counts were correct, and closed the wound with a number one vicryl running suture and skin staples. Given the clean nature of the bowel injury, they chose to not use retention sutures.

In the recovery room the chief resident finally had a moment to think. He sat at the nursing station and absent mindedly wrote post-op orders. When finished, he glanced at the patient, then turned and walked to his tiny office just outside of the OR. While unlocking the door he stared at his name engraved in black plastic: Lee W. Hickok, MD. The surgeon dropped into the chair and sat at the desk, covered with patient charts. He mindlessly picked up the Zeta of Phi Chi Medical fraternity coffee cup and sipped old cold brew. What had happened that day? He knew the brief story of a gunshot wound, but not much else; the other details had had to wait. The man picked up the phone and spoke to the emergency room physician who had met him before surgery in the trauma room. He asked for more details after the usual pleasantries. Ingesting the story was mortifying as he realized what it meant.

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Lying on his unmade bed and staring at the ceiling, Chase dozed off for a troubled few minutes. Dreams of meningeal membranes, cortical lesions, and gastric hydrogen pumps filled the air. Chase jumped up startled, and turned to look at the clock on the wall. When he awoke he was high, that warm feel just next to nausea pressing upon him. With the opiate in his blood stream, he felt confident; she could not do this to him. He decided that she would still be at home. In his stupor he reached into and rummaged around the back of the closet floor. The 22-caliber pistol was in his hand and loaded; he was out the door before he knew what he was doing.

She lived on Seventh Street, next to the Gulf, over by the sea wall. He made the six blocks without any awareness. The air was stationary, heavy and full of overwhelming humidity. The sun was at the horizon, it was cooler, but Chase was not thinking about the weather. When he stood in front of her house he did not remember walking there.

She lived in a two floor shotgun house, built in the forties and turned into double occupancy apartment. The first floor looked out over the front porch, the upper floor entered from a door to the right of the porch and up a flight of interior stairs.

The young man looked across the road at the stagnant gulf. That warm feeling in his belly was beginning to leave him and he knew the nervousness would soon begin. He was sure that this was her house, but did not know which floor was hers. Turning to the mail box out along the road, Chase read the names hoping for some recognition. Apartment one belonged to someone named Jones; above this a hyphenated name referred to the upstairs apartment. The young man closed his eyes trying to think. The name on the mailbox was Molly’s. The name was hyphenated; not an address with two names, but hyphenated. He recalled that she had mentioned her full name once as Molly Taylor, but the second of the two hyphenated last names was familiar as well. Betrayal flashed into his mind. The meaning here was clear, anger overtook him, and he was frantic now to confront the girl.

She answered the door with reluctance; he assumed after seeing his image through the eyehole. Her face said it all as she unenthusiastically ushered him in. Upstairs the girl was brutal. “You have to leave now, Chase! It was a mistake, you’re bothering me. I am going to call the cops on you!” She was furious, stomping her feet and using language so atypical for her. Chase felt the pressure of the gun in his sweatshirt pocket over his right hip. He had the gun in his hand before he knew why. Now she went ballistic, grabbing at the gun and cussing at him. She reached and struggled pulling on the gun barrel. Her angry face and vicious voice was all he remembered before it went off.

The gun discharged with a deafening sound. She dropped to the floor before him, her face distorted in pain. Chase looked down realizing that the gun was in his hand and he had shot her. She yelled and cussed repeatedly, clutching her hand to her abdomen, blood oozing between her fingers. “You fool,” the girl yelled with nastiness. “You shot me, ass-hole!” She lay back and closed her eyes, hyperventilating. “Oh … you idiot, I can’t believe you did this!” Looking up at Chase she grimaced and spit out an explanation with malice. “I am pregnant you dumb bastard!”

He stood above her and stared with an empty expression. His whole life tumbled before him. Chase looked down; realizing that the gun was in his hand, he dropped it to the floor. Turning, he moved down the hallway to the yellow phone on the kitchen wall. The floor was covered with cockroaches which scattered as he turned on the lights. The number 911 was dialed before he could think. “There has been a shooting at 100 Seventh Street, the second floor. You better come soon, she is screaming, hurt, and…I shot her,” the conversation ended with Chase dropping the phone.

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Lee W. Hickok had fallen asleep. Leaning back in his chair, his booted feet were up on the desk, one with a disposable paper cover, the other without. A cigarette burned unattended in the ash tray. The knock on the door startled him awake. What time is it he wondered, as he got up and opened the door? The recovery room nurse was standing there, very sorry that she may have disturbed the doctor.

“Dr. Hickok, here are the labs from the gunshot wound patient who is post-op.” Hickok stared back at the nurse with an empty expression. The nurse frowned; she was actually wondering if the man was not sure who she was talking about. “You know, Ms. Taylor … er, you know, Ms. Taylor-Hickok,” she said apprehensively. “There are some labs that I thought you might be interested in,” the girl said hesitantly. She smiled sadly at the chief resident but said nothing else.

The surgeon took the yellow carbon sheet from the nurse, thanked her and shut his office door without waiting for a reply. Standing at his desk he scanned the lab results. Two thirds of the way down the list was a startling finding. A urine pregnancy test drawn pre-op was positive! The significance hit him square in the gut, and he had to sit down. An angry scowl crossed his face as he realized that he had operated on a pregnant woman. Lee W. reached down and opened the bottom left drawer of his desk, extracting a bottle of Jack Daniels whisky. He grabbed his Zeta of Phi Chi mug and angrily emptied the old coffee into the trash can next to his desk. He stared at the cup for a moment, then poured and drained two fingers of the burning liquid. He then threw the mug across the room to crash and explode against the wall. In anguish, the man pounded his fist on the desk top. He had operated on a pregnant woman! He knew that the decision to explore her was the correct one however, especially given the perforated viscous. The laboratory details completed the story that was devastating to the man. Lee W. was twice married, the first ending in divorce because of her infidelity. On the rebound from wife one, he sadly had a vasectomy; a simple operation that made it impossible for him to be a father. He had operated on his pregnant wife who, as his first wife before, had been unfaithful to him. Worse yet, she was shot by her lover who obviously was the individual who impregnated her. That lover appeared to be his little fraternity brother, Chase Thomas. Lee W. was then betrayed by both his wife and a so-called friend.

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One of Galveston’s finest, Officer Willie Washington, sat outside the Mario’s Flying Pizza on Seventh Street. The man was sipping a bottle of Lone Star beer and waiting for his to-go pizza dinner. As he drank, he hid the bottle in his huge black hands, covering up the label and hoping no one would notice. The officer knew he should not be drinking while on duty. Whatever he thought, nothing ever happened during his boring shift and besides, the heat was overwhelming. When he heard the gunshot, he actually spit the brew out of his mouth over the bottle that he was cupping to his mouth. The blast had come from the shotgun house directly across the road from the restaurant. He stood, tossed his beer into the overflowing trashcan scattering seagulls as they fought over debris, and quickly walked across the road. Willie Washington decided he would get his pizza order later.

When he tried the door he realized it was just a screen door, the inside door standing ajar. The officer entered, drew his gun, and ascended the interior stairs to the floor above. A woman lay on her back, moaning quietly. Her bloody hand clutched the upper part of her abdomen; a revolver lying on the floor at her feet. As he looked down at the woman, a young man in a brown hooded sweatshirt walked silently down the hallway towards them. The man stopped at her side and stared down at the scene with an empty expression.

“What happened here, son,” the officer asked?

Chase looked up at the policeman. He was finally sweat free, strangely liberated from any concern. The oxycontin was on board now; it was pleasant and left him unafraid. Staring at the man the tragedy of that day coursed through his brain. His life was over now, a failure at school; medical school his lifelong ambition. Chase had shot the wife of another man; a woman he had slept with who then shunned his attentions. She was pregnant; he had not bothered to inquire by whom, but he had a bad feeling. Molly Taylor-Hickok was the spouse of his fraternity big-brother; a man he looked up to, and a brother that trusted him. He was an addict and an alcoholic. When he took the pills he couldn’t think, when he did not the restlessness was unbearable. The disappointment would never go away. He was sure he had killed someone, maybe two that is. The young man was humiliated and disheartened beyond relief. He blinked several times while staring at the policeman. Quietly he answered the officer with a simple, “I shot her.”

After the ambulance had taken Molly away, Officer Washington escorted the medical student down the stairs and placed him in the back of his squad car. There were plenty of policemen around now, the sun was setting, and it was finally cooling down. In the back of the vehicle Chase Thomas felt strangely relieved.

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