Getting Out

Drew’s phone vibrated off the top of the nightstand and fell to the floor. Before his buddy Fred had introduced him to the recreational potential of the anesthesia cart, Drew’s on-call dreams had revolved around forgetting to check on a patient and ordering the wrong medications, but now he was trimming delicate mucosa with Metzenbaum scissors on one of Dr. Eric Xavier’s complicated vulvoplasty cases. The phone started its St. Vitus dance again and Drew cursed the helpful intern who was calling to remind him they were starting morning report. He could have sworn he’d set an alarm when he’d crawled into the narrow call bed forty-five minutes ago. The Old Bastard would be pissed.

Drew rooted around for a clean set of scrubs and settled for a top one size too small. At St. Basil’s Medical Center, a few miles from the watchful gaze of William Penn atop City Hall, the solution to linen theft was to consistently fail to provide anything worth stealing. He brushed his teeth with the spit-flavored toothpaste the hospital inflicted on patients who hadn’t time to pack their own and ran a wet, ward-issue comb through his hair.

Drew apologized to the Old Bastard for being late, and fearing certain retribution, kept his head down through rounds and clinic. While he rushed to sign out his team and crawl home, the call came from the surgical scheduling desk: the Old Bastard needed him to assist on a case.

Dr. Xavier who’d finished his residency three years ago, wanted Drew’s help too. He’d opened his own surgicenter and had offered Drew a job as soon as he finished. “You tighten this, you tighten that, and the best thing of all,” Xavier typed, “it’s all self pay.” Drew was in the process of getting licensed to practice medicine in California: he’d filled out the forms, submitted photographs and fingerprints. The confirmation email from the medical board had included their most recent newsletter, and Drew had been bored enough one night on call to read through the roll of physicians variously reprimanded, their licenses suspended and some revoked. A familiar name caught his eye: Dr. Eric Xavier was on probation.

Two hours after reporting to operating room nine, Drew stood, gowned, gloved and angry, across the table from Dr. Owen Bates. Patients and the medical board called him Dr. Bates, but everyone else called him the Old Bastard, or OB for short. He’d been at St. Basil’s since before Hippocrates and claimed he’d been too close to retirement to jump ship when the head of obstetrics and gynecology had moved the department’s talent to the medical Mecca across town. Rumor had it the OB hadn’t been asked to go.

“Ever see anything like it, Dr. Spight?” the Old Bastard said.

Drew tensed his hold on the retractor. “No, Dr. Bates, I haven’t,” he said for at least the tenth time while the OB trained the CO2 laser on a vulva the size of a cauliflower.

Drew shook his head and wondered when he was ever going to get out. The OB had started by sawing at the worst case of condyloma acuminatum any of them had ever seen with scalpel and cauterization before switching to the laser to annihilate the widespread lesions.

Drew flexed his right trapezius until the seventh cervical vertebrae cracked. Dr. Frederick Yee, the anesthesiologist, shot him a sly look that seemed to say he had something for that. Fred Yee had something for just about anything in his pharmacopoeia including something to help him forget the last thirty-six hours.

The Old Bastard poked the wart-encrusted labia majora with a gloved finger and waved the hand with the laser to get the anesthesiologist’s attention.

“How many babies did you say again, Fred?” the Old Bastard said.

Fred looked up from the Friday crossword puzzle. He liked to do them in red pen. “G6P5,” he said. Six pregnancies, five births. Fred took the opportunity to glance at his watch and survey the patient’s solid vital signs before he ticked off the box for another fifteen minutes of high risk anesthesia time.

Drew watched Fred crack open another vial of fentanyl, and he inclined his surgical mask ever so slightly in that direction. Researchers sampling OR air claimed they had found minute amounts of aerosolized narcotics, enough, they postulated, to prime some surgeons and anesthesiologists so inclined to seek more of the same.

“Don’t see how anyone got his pecker past this once let alone six times,” the OB said.

Drew averted his eyes. He remembered examining the patient in clinic the day he’d confirmed she was pregnant again. Her vulva had only grown stiffer with the thick, warty growths, and there was no way she was going to deliver a baby through the rock-hard concretions that surrounded her vagina. Even worse, any infant delivered through genital warts could inhale the virus and develop lesions on the vocal cords that could occlude the airway.

“Better exposure,” the OB barked.

Drew repositioned and the Old Bastard wielded the laser again. “Set phasers for stun,” the OB said.

Drew held the retractor, his arm motionless, his breathing even and perfectly measured behind his surgical mask. He wasn’t about to talk and risk breathing in any more of the fried stench than he had to. The aerosolized live virus was a risk to every airway in the operating room.

The OB sliced at the tissue and wisps of infected smoke rose from the surgical site. “Not likely to see this in a fancy-pants private practice,” he said. “But you won’t be working on the pretty pussies next year, will you?”

The scrub nurse discreetly pointed the suction catheter in the direction of the effluent. Drew breathed slowly, controlling his anger. He wasn’t going to let the Old Bastard bait him today. It was Friday, and this was the last case. He was post-call and had the rest of the weekend off.

The OB laughed. For any other case, they would have scrubbed in with an intern and a pair of medical students. But as soon as Fred had anesthetized the patient, the OB kicked them out along with everyone else who’d seen the cauliflower case on the OR schedule and wanted to observe. Drew knew the OB didn’t care enough to worry about exposing the entire department to the virus, and he wondered why he’d been called in since the OB wasn’t even pimping him with petty questions about anatomy and physiology.

Still, it was nice without the medical students tripping over themselves trying to be helpful and cheerful while doing everything absolutely wrong. Their grades, their futures, depended on it, and that was the first place Drew had gone bad. He’d never been bright eyed and bushy tailed, and trying to suck up bullshit never did much for his mood. Private practice could be like this: one surgeon, one assistant, an anesthesiologist, and two nurses: one to scrub, one to circulate. A very private party.

“You’ll be leaving us after this year,” the OB said.

Drew couldn’t decide if it was a question or a statement.

“I wanted to tell you that I’ll be writing your recommendation letter,” the OB said, his voice low.

Mirroring his own reaction, Drew felt the patient’s abdominal muscles tense against his hands.

“I’m not getting muscle relaxation” the OB said.

Fred connected the patient to the anesthesia bag and demonstrated that the patient had so much medication on board that she made no spontaneous respiratory effort.

“Relax her,” the OB barked.

Fred injected something into the IV and flushed the line.

The air conditioning kicked on and Drew shivered, glad for his surgical gown. The nurses kept the OR cold so no one melted under the intense overhead lights. During deliveries and most surgeries, Drew kept warm wielding instruments and sweating a few technical decisions, but the Old Bastard was having too much fun decimating the warty nooks and crannies to hand Drew the laser. At the head of the table, Fred pushed up the sleeves of his scrub jacket before putting red pen to paper again.

Conventional wisdom held that anesthesiologists who never showed their arms had something to hide. In Fred’s case, that was true, but he was careful to stock fine gauge needles and never reuse them. Why should he? He’d shown Drew scanning electron microscope pictures of needles, the tips of their beveled ends barbed like a fish hook after a single trip through skin and vein. Trained to rotate their injection sites like good diabetic patients administering insulin multiple times a day, neither of them left tell-tale needle marks.

Drew had been tracking how many days the new circulating nurse wore her scrub jacket with the knitted cuffs. Most nurses, hot to show their tits or tattoos or whatever else it was they thought they had, didn’t. Drew hadn’t decided if the new nurse was in the club or just cold.

The OB put down the laser and manually retracted the labia majora and minora to expose the introitus. “Open, Sesame,” he said. “Bet it won’t be long before she gives it a spin.”

Drew didn’t want to look anymore. The raw vulvar tissue looked like it had been pressed onto a heated waffle iron. He stripped off the surgical drape and grudgingly admitted to himself that the OB was right: a significant proportion of St. Basil’s patients were loathe to obey the edict of six weeks’ pelvic rest after surgery and childbirth.

The circulating nurse elbowed past him to reinforce the cloth tape that held the catheter tubing to the patient’s thigh: she’d had a bitch of a time spreading the gnarled, inflexible labia to catheterize the patient’s urethra, and she wasn’t about to lose her prize. After she’d affixed a thick sterile pad to the vulva with more tape, the anesthesiologist extracted the endotracheal tube from the groggy woman’s throat. She gave a weak cough then mumbled something, her voice hoarse and low.

It was after seven o’clock and the last case was finally over. In a proper hospital, the doctors walked to recovery, wrote orders, and retired to their lounge. But this, Drew was fond of telling the medical students, was St. Basil’s. And at St. Basil’s, they practiced a different kind of medicine. He grabbed the sides of his gown, popped the paper ties across his neck and back, and pulled off gown and gloves in one smooth motion before snapping on another clean pair of gloves from the box on the wall. He left his mask on.

Here there were no orderlies and no cushy lift team. Drew rolled the gurney in from the hallway and parked it beside the operating table. The medical students had been smart enough to bolt when the OB banished them, so he stood on the far side of the gurney with Fred and they pulled the white sheet beneath the patient towards them to slide her from OR table to gurney.

The patient’s head lolled to one side, but Fred brought her chin back to midline and repositioned the mask of one hundred percent oxygen that was washing all the good drugs out of her system. Her breath would reek of the chemicals while her liver worked to break the bonds that had held her, immobile and insensate, during the procedure to raze the field of warts.

Fred lifted the patient’s one arm, then the other and rolled her side to side, checking for pressure marks or redness that might have been caused by improper positioning or padding of her generous hips and ass during the procedure. He documented that there were none; the nurse initialed his sheet.

“Getting out?” Fred said. He’d already written his orders for post-operative pain medications.

“Yeah,” Drew said, “pretty soon.”

Getting out was important, but timing was everything lest he cross paths with the OB again. Drew looked at his watch. The OB would still be holed up in the single stall of the doctor’s lounge. He didn’t want to hear the Old Bastard bearing down into the Valsalva maneuver, willing his stream past a prostate engorged with age.

Drew punched orders into the computer system’s ancient amber monitor in recovery. He picked up the phone and dictated the case. He’d learned not to obsess. The OB would criticize and correct it and make him dictate it again. But that would be later. He padded to the lounge and dialed the combination on his locker quietly. He wanted out of the contaminated scrubs, but when he heard OB’s clogs scuff toward the bathroom door, he grabbed his clothes and bolted. He didn’t want to hear about sticks or pricks or holes or whores for the next sixty hours.

Drew was out. It didn’t feel like autumn, but then every patch of dirt that had once fronted the row houses on his block had been replaced with cement decades ago and not a single tree or bush grew. He returned to his ground floor room in the three story row house he shared with Fred and a social worker to shower. The envelope to pay for his California medical license was on top of the pile on his desk. A thousand dollars was a lot of money. Upstairs, Fred had left the deadbolts for the second floor door unlocked. Drew entered the narrow kitchen and heard his housemate call from the small front room that overlooked the street.

“I already ordered,” Fred called. “Come help yourself.”

Drew slumped onto the couch. The walls were covered with printed pages of school ID pictures that dated back to Drew’s first year of medical school. Some of the names beneath the indistinct black and white faces had been underlined in red.

“Long day,” Fred said pushing the pizza box at Drew. “I’d been doing pediatric cases up until the OB pulled me for your papilloma party,” he said working his second slice. “I love kids. I had all my drugs drawn up for a tonsillectomy, but when someone wasn’t watching, the kid grabbed a handful of jelly beans in pre-op.”

Drew chalked up one cancelled case and waited for Fred to swallow.

“Then another kid wouldn’t go for the rectal Valium his local doc had prescribed as a sedative, and I assured the mother I’d dispose of the medication safely,” Fred said. “We can’t have kids getting their hands on drugs that depress the respiratory system.” He bit into his third slice thoughtfully.

“Great cases,” Drew nodded. He tallied Fred’s take for one day: a little ketamine, the Valium, some fentanyl, maybe even some propofol, and grinned.

Fred toasted the air with his beer bottle. “Fuck the days of the giants.”

After the pizza was gone, they prepared to pleasure themselves with Fred’s private crash cart, and Drew reminded Dr. Yee he that he wanted to remember some of his weekend. Fred pulled open the bottom drawer of his red tackle box and removed a handful of thirty gauge needles, two tourniquets, and a well-worn cardboard box that contained a prefilled syringe of naloxone, the antidote in case of an overdose.

While Fred laid everything out, Drew quizzed himself on the naloxone dose and found he still remembered 0.4 to 2 milligrams every two to three minutes as needed. Then he got up and closed the window. Winter was coming, and if Fred left next summer, so would the drug supply. Drew would have to be enterprising. He stood and stretched before the wall of photos until Fred signaled he was ready for his last case of the day. Drew took the syringe of fentanyl Fred handed him and decided he’d have to make notes before Fred took the ID photos down. Some of the people on the wall still had to be at St. Basil’s or at least in the city. They would have contacts.

No stranger to difficult IV starts, Drew had no trouble injecting a plump, healthy vein inside his ankle. Then he leaned back to appreciate all the pharmacology he’d learned: how synthetic opiates bound to the brain’s receptors, concentrated deep in the area of pain and emotion. How the dopamine levels rose in the reward center to create euphoria and relaxation.

Fred tossed both syringes into a sharps container. “I got my letter,” he said. “Penn’s taking me for a cardiothoracic fellowship.”

“Choice,” Drew said. “Congrats.” He’d never had any doubt that Fred would rectify the great injustice done when he’d been matched to St. Basil’s for residency. Fred had attended a swank college on a scholarship and attended the University of Pennsylvania for medical school but then his luck ran out. Fred’s mother said it stemmed from his refusal to wear the red outfit she’d bought him for the new year when he was sixteen. 

“It’ll be a shame to leave all this,” Fred said waving an arm at the stalactites of damaged plaster hanging from the ceiling, “but I’m looking to trade up to something in west Philly that hasn’t been condemned.”

Fred could have bought himself a house on the Main Line selling the narcotics he’d appropriated with his various waste scams, but he’d been careful not to draw attention to himself while atoning for the shame his residency had caused his family. Even Drew was tired of hearing Fred’s father tell the story of how he’d eaten tree bark to survive after escaping his village to emigrate to the United States.

“You weren’t planning on renewing the lease, were you?” Fred said.

“Don’t know where I’ll be,” Drew said. “You’re coming out of anesthesia, a great department. All those excellent trauma cases, gunshot wounds to the chest, the head, the abdomen, not to mention all the bread and butter appendectomies on the garden variety poly-substance abusers. Everyone wanted you because every case you’ve ever done is high risk.”

“St. Basil’s Ob-Gyn department still has a great reputation outside of Philadelphia,” Fred said. “Only the attentive know the best attendings left.”

Drew knew he’d damaged his marketability last year when they’d called him in to cover for someone stuck in traffic on the Tacony-Palmyra bridge before he was capable of remaining vertical, but any recommendation letter from the OB would be carefully worded to decimate whatever status he might have enjoyed having trained at St. Basil’s. Their former department chair hadn’t been stupid enough to damage her program by exposing a resident with a drug problem before her grand exit: it reflected as badly on her as it did on Dr. Andrew Spight. She’d put him in the medical staff’s diversion program that forced him to submit to random drug tests. So far he’d aced them, but stealing urine samples from the basket of outgoing labs on pediatrics was getting to be a real pain in the ass.

Fred slapped Drew’s arm above the red line left by the tourniquet. “You show the Old Bastard!” he said. “Put your head down, work hard. Get out of here. Plenty of places looking for young docs with a broad experience base.”

Drew snorted. Broad experience base. Sometimes Fred cracked him up. He watched the anesthesiologist prepare two new syringes. Pity the poor losers stuck sucking fentanyl patches.

St. Basil’s hadn’t been Drew’s first choice for residency either, but unlike Yee, his father had only escaped Philadelphia for the suburbs where he serviced fire extinguishers. Four years of state school and four years of mediocre performance in medical school had left Drew little chance of trading up.

Drew injected again and slipped to the floor where he stared up at the pattern of the thumb-print sized faces, the unsullied slurpers and ass-kissers interspersed with the users of marijuana, methamphetamine, ecstasy, and more whose names Fred had tricked out with a thin, red line. Sure, recreational drugs were illegal. But it was even more risky to use drugs and practice medicine. Never mind the patients, they could lose their licenses. With that in mind, Fred had carefully cataloged the users. They were deemed safe to speak and party with: they all had something to lose. 

“With your indulgence,” Fred said, “I think my fellowship warrants something special.”

Drew nodded, his gaze fixed on Fred’s hand as it disappeared into the hinged box. The fifty milliliter bottle he withdrew had the coveted baby blue label. Propofol. Fred held the glass vial to the light between thumb and forefinger. The liquid, ten milligrams per milliliter, was cloudy white like the diluted formula some patients fed their babies to make it go farther when they sold their WIC vouchers to support their own habits.

Fred dealt and they pushed the plungers on their respective syringes. Drew felt warm and safe and happy. The textbooks barely scratched the surface when they enumerated propofol’s effects: a sense of well being, hallucinations, and sexual fantasies. With the first flush of dopamine bathing his brain, Drew felt a sense of purpose. He would ask the OB about writing up the nasty condyloma case, get it published, and find himself a decent job. Maybe even do his own fellowship.

As he slowly exhaled, the blurry face of Dr. Eric Xavier smiled down at him. The room darkened and the presentation on reconstructive gynecology that Dr. Xavier had sent him commenced with Netter’s famous illustrations of the perineum with its anterior and posterior triangles. Photographs of the vulva followed: the labia majora and minora, the introitus with and without hymeneal remnants, the clitoris. There were testimonials from women who said they lacked confidence to wear string bikinis, tight pants, and skimpy thongs. Women who required pubic liposuction and lift, labia majora remodeling, labia minora reduction, clitoral hood reduction, and clitoropexy. The pursuit of the aesthetic pussy was everything. And for the women who regretted pushing babies the size of bowling balls out through their vagina, there was vaginal rejuvenation. Dr. Xavier guaranteed that his technique could make a woman tight as a virgin again, and the accompanying photo showed him holding a ruler beside one of his newly post-operative creations. Drew clapped twice before blacking out.

The next morning Drew woke and scratched before padding to the bathroom to stand on the crusty hexagon tile in front of the toilet and piss away the degradation products of the previous night. He was still fascinated by science and the mysteries of the human body. He hadn’t meant to be a horrible, drug-addled obstetrician-gynecologist; there was just so much he hadn’t anticipated: delivering a woman with a toxicology screen that had come back positive for everything, coning a cervix riddled with cancer, watching 300 grams of red, gelatinous miscarried fetus expire. As fast as he learned, he wanted to forget, and now, just months from finishing, he was afraid.

Fred knocked hard on the door.

“If you don’t get out, they’re going to start calling you the new bastard,” Fred said.


The following June, on his last night on call at St. Basil’s, Drew sat, feet up in the nurse’s station, reading the latest report from the medical board. One physician had diverted controlled substances for personal use. Another, who practiced in southern California like Dr. Xavier, had been on probation for lewd conduct. Drew pictured a consultation room with palm trees waving outside the window. He imagined patients with smooth, shaved vulvas, too beautiful to have genital warts. While on probation, this doctor had been found guilty of having sexual relations with patients: license revoked.

Fred had moved out the week before, and maybe that was a good thing. Drew, broke as usual, found himself limited to alcohol.

The charge nurse blew by and knocked his clogged feet off the counter.

“Delivery,” she ordered.

The cracked vinyl pinched the back of his thighs through the thin scrub pants. Drew pushed himself up. Next week the new interns would arrive and he’d get no rest until they demonstrated basic proficiency. He still couldn’t believe that after writing him a crappy recommendation letter the OB had offered him a position at St. Basil’s providing obstetrical and gynecological care to the tsunami of patients on public assistance. Why they were going to let him near residents and medical students was anyone’s guess, but then again, what choice did the skeleton department have? Last year’s exodus had left bitter, overworked attendings desperate to fill the ranks. Drew had been too embarrassed to tell Fred about the job or that he’d renewed the lease.

The pregnant patient had been moved to the surgical delivery room because her blood pressure was elevated. Drew reviewed the chart and chatted up a new nurse who was wearing a scrub jacket covered with red roses.

Drew gowned and gloved then asked the nurse to adjust the light. He examined the patient’s vulva and checked the pelvic proportions. Her pendulous labia majora was already swollen and her labia minora were as thin and wide as bat wings. No, the OB was right, he didn’t practice among the pretty pussies.

The patient bore down and the baby’s head crowned against the pitted, scarred skin. Drew ticked off the months on his fingers and glanced at the name on the nurse’s handwritten notes. It had to be her, the patient whose genital warts the OB had burned off. He remembered talking with Fred that night. What had he done about getting out?

The head delivered easily, and the next contraction propelled the rest of the baby into the world. G6P6. Drew leaned in to secure the baby in the crook of his right arm and pinned its slippery movements against the texture of the disposable gown. He looked at the bawling baby. Another girl. Someone he’d be delivering in thirteen or fourteen years. God, let him not be here. Let him get out.

L. M. Asta has published fiction in The Battered Suitcase, Inkwell, and Schuylkill, as well as having been previously published in Philadelphia Stories. Her essays have appeared in Hippocrates and the Journal of the American Medical Association. "Getting Out" is from Report From the Medical Board, a novel that tracks the physicians who come to the attention of their state medical board and are variously reprimanded, put on probation, have their licenses suspended, and sometimes revoked. She is a graduate  of Temple University School of Medicine and did her residency at St. Christopher’s Hospital for Children.


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