| Diary Serial |

On Call — Chapter 14: The Best of Doctors   

 I’ve noticed that these experts range from the appropriately modest to the ludicrously arrogant


Ican do this. I think.

The patient, an unconscious 87-year-old man suffering from septic shock, is oblivious to my indecision. My attending instructs me to place a central line in the man’s jugular vein, running through his neck. I know the theory cold, but actually doing it to a living, breathing person is another matter.

“Insert the needle into the jugular…” drones my attending, and ignoring my clammy palms, I slowly follow her instructions. Trying to thread the wire through the needle, into the vein, I sense resistance. Breathe. Rotate the wire carefully. Ease it in. Breathe. The patient’s still alive. Breathe. I’m sweating by the time I’ve finished. It’s time for the routine X-ray to ensure the catheter is properly placed, something we always do when central lines involve the neck.

Scanning the black-and-white image, I suddenly notice that the attending is stifling an unprofessional chuckle.

“We don’t see that every day,” she informs me, pointing to the scan. I can see the length of the central line. Somehow, instead of reaching my patient’s heart, I’ve inserted the wire Into. His. Brain.

It’s not my finest moment.

Thankfully, there was no lasting damage, but my spectacular beginner’s luck was a good reminder of how much I had to learn. Now, as I enter my third year of residency, I’m grateful for the knowledge I’ve gained from multiple doctors in various medical fields — but I’ve noticed that these experts range from the appropriately modest to the ludicrously arrogant.

Dr. Nathaniel Morton is one of the latter.

And he’s furious. At me.


“We’re bringing in a patient!” The ambulance line, which I’ve been trained to use since second-year residency, crackles to life. “An older male from the airport. He was waiting for a flight when he started complaining of severe back pain. He told us he has a history of severe cardiac issues, and we suspect he’s dissecting.”

I acknowledge the call, and we set up a room for the patient, nurses scurrying around frantically. A dissection is when the inner layer of the aorta — the body’s largest artery, attached to the heart — tears. When this happens, blood leaks into the outer layers of the artery, and the loose flap of artery traps it, causing dangerous clots and narrowing the passage for the remaining blood. Lack of blood flow damages smaller arteries, cutting off the blood supply to the rest of the body. “Serious” doesn’t explain what’s going on; try “life-threatening.”

When the paramedics bring in the patient, I begin my examination. Jerry, the old man, is writhing with discomfort, and as I go deeper into his history of heart issues, I know it’s time to act. The nurses quickly insert multiple IV lines, and we start him on esmolol, an ultra-fast-acting medication to lower his heart rate and blood pressure. We need to stop the dissection from worsening. While the nurses work, I quickly put in the order for a CTA, a specialized scan in which contrasting dye is forced through the arteries, so we can see every detail of the blood flow.

It’s not long before I receive a call.

“It’s a large dissection.” When I look at the image, the tear in the aorta’s inner layer stretches from the aortic arch, in the chest over the heart, and descends all the way to the man’s legs. I wonder if Jerry can survive, but one thing is for sure: He needs a surgeon’s expertise.

Who am I going to call?

Every hospital has politics, and ours includes an artificial division between the cardiothoracic and vascular departments. A surgeon from either department can repair dissections, but there’s a catch: Type A dissections include arteries near the heart, while Type B dissections don’t involve Type A arteries. In our hospital, a thoracic surgeon who deals with the chest area might refuse to do Type B surgery, since the arteries are not as close to the heart. Type B dissections go to the vascular guys, who deal with any problem involving veins and arteries.

What type of dissection is this? Is part of the tear in Jerry’s aortic wall close enough to his heart to be considered a Type A? I’m not sure, and every moment counts.

“I’m not a CTA tech,” I tell my attending. “But part of the dissection looks pretty close to the heart. Should I call Dr. Morton at home to look at the images?” It’s Sunday, but I know Dr. Morton is on call. He’s the head of thoracic surgery, and he can save this man’s life.

The attending nods. “Call Dr. Morton and see what he says.”

The phone rings a few times before I hear the deep, commanding tones of the man himself.


I quickly explain the situation.

“Send the CTA scan over, and I’ll take a look at it,” he orders.

I refrain from saying, “Yes, sir!”

A few minutes later, my attendant’s phone rings.

I don’t have to ask who it is. I hear the deep voice bellowing from across the room.

“Why are the residents acting unsupervised?!”

“I’m not sure what you mean,” my attending answers Dr. Morton, clutching the phone.

“I just had a resident send me a CTA scan of a dissection!”

“Is that a problem?”

“When it’s a Type B dissection, it’s a problem! You know that only the vascular surgeons take care of that.” He spits the words out, enraged. “I’m on call at home, but what if I was having dinner, and I had to waste my time looking at images that don’t matter? What if I was at Home Depot, and had to race home for nothing, leaving my purchases behind?”

“Are you at Home—”

“That’s not the point! I’m calling the residents’ program director, and we’re going to straighten this out!”

When he clicks off abruptly, there’s a deep silence.

“We still need to call a vascular surgeon,” I venture softly. “Or the patient will die.”

We transfer the patient, but inside I’m reeling. I don’t know if Jerry will undergo surgery (with the correct surgical department) and survive, especially since we’ve wasted precious time on Dr. Morton.

I do know the mishnah, “Tov rofim l’Gehinnom — The best of doctors go to Gehinnom.” I’ve often wondered about it. Is it about the mistakes doctors inevitably make? They’re human, after all. Now I know it’s something deeper. When there’s no humility, when a doctor thinks a patient’s life is less important than a run to Home Depot or convoluted hospital politics, when arrogance blinds him to Who truly heals, he’s headed down.

But it can be easy to forget where the skill comes from after all our hours of training and learning and doing. Dr. Morton wasn’t always an arrogant department head — I know that he was once a resident, just like I am.

I print a simple sign, black on white in a plain black frame. It sits in my cubicle, a silent reminder of who I am and what I need to remember. Tov rofim l’Gehinnom.

An experienced neurosurgeon once told me: “Medicine humbles you.” For the best doctors, it does.

The characters in this series are composites; all the stories are true.


(Originally featured in Family First, Issue 901)

Oops! We could not locate your form.