Dedication

To Justin and Annabel,

the best chapters of my life

Epigraph

War is the only proper school of the surgeon.

—HIPPOCRATES

Contents

Cover

Title Page

Dedication

Epigraph

Preface

The Step-by-Step Guide on How to Become a Doctor

Introduction

One: The Man in the Tuxedo

Two: Academic Weapon

Three: The 50 Percent Club

Four: Glasses

Five: Once a Champion, Always a Champion

Six: What Am I Going to Tell the Family?

Seven: The Intern versus the Hamptons

Eight: It’s Not the Crime That Kills You, It’s the Cover-Up

Nine: Dr. Jane

Ten: The Boys’ Club

Eleven: The Price of Being a Female Surgeon

Twelve: When You Roll the Dice, Sometimes You Lose

Thirteen: The Runaway

Fourteen: The Secret Patient

Fifteen: The Day the Dicks Came Down

Sixteen: So You Want to Be Chief?

Seventeen: Life in the Grey

Eighteen: How to Play the Game

Nineteen: The Best Revenge Is Massive Success

Epilogue

Acknowledgments

Notes

About the Author

Copyright

About the Publisher

Preface

I’ve been thinking a lot about imprints, moments in life that are fleeting, but leave an indelible mark on your soul. Some people call them canon events. I think of them as the moments that made me who I am. And there was never a more concentrated period of imprints than during my time in surgical training. Residency is the awkward teenage years of being a doctor. You’re not a kid (medical student) and you’re not an adult (practicing physician). You’re in the in between, given some freedom and responsibility, but still under the watchful eye of your parents (attendings). You test boundaries, make mistakes, stay up way too late, and think you know everything.

I have performed over five thousand surgeries and taken care of tens of thousands of people. I have worked at over ten different hospitals in five different states across my career. The stories in this book are a compilation of my time at all these institutions. In order to best respect my patients’ and colleagues’ privacy, some names have been changed and certain details have been altered or experiences combined.

Taking care of patients in their most vulnerable time of need is the utmost privilege of my life, and working alongside the other physicians, nurses, therapists, and techs has been an honor. This book is about the people who shaped me, who lifted my voice in the conversation, and who led by example, for better or for worse.

These are my imprints.

The Step-by-Step Guide on

How to Become a Doctor

While every doctor’s journey is unique, I’m going to outline the steps most doctors go through in order to don one of those revered white coats.

The first step is to complete four years of college. You can get into medical school coming from any college, but the more prestigious your college, the more likely you will be accepted into a prestigious medical school. The same thing goes for residency programs. Technically, yes, you can get into any residency program coming from any medical school. But you will be more likely to match into a higher-ranked residency coming from a more prestigious medical school.

While you’re in college you are allowed to major in any major you wish. Biology or a science major are obviously more common, but you could be a music major, an economics major, a French major, et cetera. The only requirement is that you complete a set of premed required courses. In general, this includes multiple years of biology, chemistry, organic chemistry, physics, and their accompanying lab courses (which for the most part are universally despised). So these courses are in addition to your regular course load.

Just in case you thought it might be a good idea to pad your GPA with some gut courses, the admissions committee separates out the science GPA so they can try to compare apples to apples. Additionally, you have to get at least three letters of recommendation from science teachers, the same ones who are teaching these five-hundred-person classes who you’ve probably never spoken to on a one-on-one basis but somehow have to write a whole letter about how scoring well on two exams in one semester means you’re qualified to be the next Miranda Bailey.

Then there are the “unspoken” requirements for your application. In order to prove that you’re serious about becoming a doctor (forget about all those extra voluntary classes), they want to see your research. And not just that you participated in research (i.e., gave up hundreds of hours of your free time to work for free to do research for someone else’s project), but that this research was important enough to be published in a journal that you had absolutely no control over.

Did you immerse yourself in volunteer work at the hospital to get “exposure” to the field? Did you sacrifice enough of your free time shadowing physicians, so you had a complete understanding of what it was really like to be a doctor? Did you do charity work to show your commitment to helping others by sacrificing your time?

In the middle of all this, you must prepare for the MCAT: a test that’s supposed to be based on the information learned from all those voluntary science courses you took. But because there is no standard curriculum, you have to spend hundreds of hours learning materials and you have to pay thousands of dollars to Kaplan and the Princeton Review to have the privilege of spending every Saturday for months trapped in a testing center taking practice tests. Then you spend another three hundred dollars and eight hours taking a test that literally makes you sick to your stomach.

What are you doing in the summers? Working a normal job that could help pay for all these courses and fees? Of course not! You’re doing more unpaid internships in a hospital, learning how to be a scribe (a glorified stenographer), transporting patients through a maze of hospital corridors like Pac Man, and, if you’re lucky, getting to stand in a corner being completely ignored while you watch an interaction between a doctor and a patient who really didn’t want you in the room but felt compelled to allow it so they didn’t seem like an asshole when the doctor awkwardly asked if a student could shadow them.

You’ve made it to senior year. (This is for students who complete all the requirements during the four years of college. I’m not even going to go into what happens if you have to do a post-baccalaureate program—more school after you’ve finished college because you didn’t know you wanted to be a doctor when you were a child, so there is a special school just to complete the requirements!) Time to enjoy your last year with your friends and make special memories—psych! You will be busy filling out medical school applications (the average number of schools people apply to is sixteen, but many will apply to more than thirty, costing over a thousand dollars). After spending the time and money submitting the primary application, each school will then send you a secondary application, with different questions and fees (let’s tack on another one to two thousand dollars and thirty hours).

For those lucky enough to score an interview, the applicant is expected to take time off from school and then cover the cost of travel, accommodations (although you’re too cheap to pay for a hotel room so you hit up your random friend from summer camp on Facebook), and food, which can be anywhere from another two to seven thousand dollars.

It will all feel worth it ($15,000 worth it?) when you open that life-changing, life-validating acceptance letter to medical school. But funny enough, that letter does not include the cost of acceptance: $65,575 yearly average tuition to attend that school of your dreams. Once you pay to relocate to a completely different city, far away from your family and friends, you finally get to start medical school.

Now if you thought that was a ludicrous amount of time and money spent chasing after your dream, just wait until you realize you have to do that same exact cycle for residency, fellowship, and your first job! Hundreds of hours “performing research” where you give up your precious free time for unpaid labor in order to prove how much you “really want” to be in a certain specialty. Crisscrossing the country speaking with doctors who are trying to judge you in five minutes whether or not you’ll be a good “fit” for their program. In a sense it’s like an educational Ponzi scheme where we, the people who are voluntarily choosing a career in service to others, have to pay with our money, time, and sanity.

Now, who’s ready to become a doctor?

Introduction

It is a truth universally acknowledged that in a hospital, the first week of July is a shit show. On my first day at Lenox Hill Hospital, I was chosen to start as night shift. This meant I would be there overnight, basically on my own, unless I had to call in more experienced doctors for backup. Working at a hospital overnight instead of sleeping isn’t normally ideal, but I was flattered to be chosen. It meant the chief residents believed I was the least likely to screw up while taking care of patients on my own.

Well, mortally screw up, anyway.

Getting ready to go to the hospital, I couldn’t believe that I was only two generations removed from my grandfather, who had installed the asbestos for the pipes in the then brand-new Shea Stadium; now, I was about to be part of the team of doctors who treated those professional athletes. I was ready to claim my new identity as Dr. Erin Nance. I’d been working toward this sleepless night for years. I felt pretty confident all I needed to do was avoid distraction . . . and that usually came in the form of my family.

PLEASE DO NOT TEXT OR CALL ME TONIGHT! I AM STARTING NIGHT SHIFT AT THE HOSPITAL AND NEED TO FOCUS.

But the family wasn’t exactly paying attention. Mom had already called me twice to make sure I was drinking enough water, my dad was giving the play-by-play of the Mets game and why they stink this year, while Sean and Kevin, my two oldest brothers, were gloating, blowing up the family text chain with pictures of their Hamptons share house (the ones that were safe for parental eyes). Walking across Park Avenue, I fiddled with my still-creased scrubs and sent one final text to the family.

PLEASE, I MEAN IT.

With that, I figured the distractions had been successfully eliminated. I put my phone in my pocket, and flashed a grin at the security guard that could only come from someone who had absolutely no idea what the hell she was in for.

IF YOU’VE EVER SEEN GREY’S ANATOMY, OR ANY POPULAR medical show, you know that the doctors’ lounges are anything but relaxing. Leisure? Never heard of her. There are usually at least twelve people yelling, crying, and fighting over three dinosaur-era desktop computers, which are hard to see over the mounds of energy bar wrappers and half-empty coffee cups. But it’s better to look at that than over at the bins of scrubs stained with bodily fluids, most of which you do not even know exist.

When I walked into the lounge for the six p.m. sign-out, Joon was physically hitting the printer and cursing in Korean; Craig, the newly appointed chief resident, was scolding Peter for losing the EKG printout necessary for Mrs. Foster’s pre-op clearance; and Isabel was just sitting in a corner hugging her knees while pages of half-written consult notes stuck out from every pocket imaginable. I locked eyes with Katie, the PGY-2, or second-year resident. She gave me the Let’s get the eff out of here look, and we slipped out the door quietly together.

“Looks like a hot mess in there,” I muttered to Katie, who gave me an apathetic shrug.

“It’s not their fault. Craig has instituted this new ‘Chief Resident Reign of Terror,’ and all the interns are too scared to even look at him.”

I MET KATIE DURING OUR INTERN ORIENTATION. SHE WAS A second-year general surgery resident, and you could tell immediately she was the alpha resident in her class. She quietly did all her assigned tasks, no matter how menial. She didn’t gatekeep her secrets for how to interact with even the most challenging attendings. While most people in general surgery residency were plotting how to position themselves to score the best fellowships in areas outside of general surgery like plastics or cardiothoracic, Katie put her nose to the grindstone and perfected everything from inserting NG tubes (the tubes that go down your nose into your stomach) without making a patient gag to piercing an ABG (arterial blood gas to get the best snapshot of how much oxygen is being delivered throughout your body) through the radial artery on the first shot. I respected her tremendously and gave her a lot of credit for trying to work with people, like me, who were from other fields like ortho, radiology, and urology, just passing through gen surg trying to learn how to keep people alive in the unlikely event someone in our relatively cushy fields took a turn for the worse.

“Know of any disasters I’m walking into tonight?” I asked, not really wanting to know the answer.

“Right now, there’s just Mrs. Foster’s pre-op clearance that needs to get done ASAP since she’s first on the add-on list. Craig must have a hot date tonight because he wants this case done yesterday and doesn’t want any paperwork holding it up. Anesthesia will boot us to the back of the line if we don’t have everything ready. So, I’d just find Peter and see what needs to get done stat and then come back for sign-out. No one’s leaving any time soon.”

“Thanks. What’s the world record for fastest time for an intern to complete a pre-op checklist?”

“Whatever it is, I hold the top ten times,” Katie said with a smirk. “Please just rescue Peter so Craig can find someone else to terrorize.”

PETER LOOKED LIKE HE HAD JUST GONE TWELVE ROUNDS with Mike Tyson. Cheeks burning, shoulders slumped, scrubs wrinkled and untucked. Internship is humbling for everyone, even for someone as accomplished as Peter, who was on his way to Johns Hopkins for radiology. And what had poor Peter done to deserve this verbal and psychological assault from Craig? Let a patient die? Started a fire? Nope. He just couldn’t find the EKG printout among the hundred pieces of folded-up patient lists, consent forms, and consult notes that were overflowing from his scrub pockets.

“Hey, Pete, just give me Mrs. Foster’s pre-op checklist and I’ll do the EKG myself and have everything ready. Don’t worry, I got you. Finish up whatever else you gotta do to get out of here.”

Peter looked up at me with his big, overwhelmed eyes and said, “Thanks, Nance. I owe you one.”

And with that I grabbed the checklist and headed for 5 Wollman, which was where most of the stable pre-op patients were waiting. They were all part of what’s known as the add-on list at a hospital, which is a list that no one even knows exists until you find yourself in a position of needing an emergency surgery and then it’s as if you’re trying to get to the front of the line at Marquee. Only instead of a bouncer, there is a really cranky pre-op nurse who is immune to all forms of bribery. And only instead of queuing up for drinks, it’s . . . emergency surgery. The nurse will not release any helpful information except to say that she will call you when your patient is next, which could be thirty minutes or thirty hours. So it’s imperative that when you receive the magical phone call from her stating your patient is next, you have everything ready to go. Otherwise, the vultures from neurosurg will start circling trying to bump their patients up the list.

I quickly glanced down at Peter’s pre-op note to see exactly what Mrs. Foster was on the add-on list for.

Pre-op Diagnosis: Appendicitis

Surgery Planned: Appendectomy

Okay, so that shouldn’t be too complicated. This was a classic surgery, and Peter had done a great job: he’d had all the labs drawn, medical clearance note completed, and consent form filled out. The chest X-ray was already in the system, so she just needed a repeat EKG, and her pre-op would be complete.

Since it was now after hours and all the technicians who normally performed the EKGs were already done for the day, I had to take matters into my own hands and steal an EKG machine from the critical care floor. “Sorry I’m just borrowing this for a quick sec!” I said to no one in particular as I raced into an elevator with the bulky equipment, hoping no one saw me. Then I rolled it all into Mrs. Foster’s room to quickly do the EKG.

Only as I started explaining the procedure to her, my phone started buzzing—and it wouldn’t stop. I glanced down at my phone . . . Mom . . . are you kidding me? I told her to stop calling! Click. The one distraction I thought I could avoid.

“So, if you don’t mind, I’m just going to place these leads”—bzzz-bzzz—“on your chest and I’ll be out of here”—bzzz-bzzz—“in a jiffy”—bzzz-bzzz. “Sorry, do you mind? I’m just going to answer this call about another patient, and I’ll be right back,” I said hastily as I walked into the hallway ready to explode.

“HELLO? ER?”

“MOM! How many times do I have to tell you DO NOT CALL ME when I am in the middle of work!” I yelled at her with the disdain of a preteen girl whose mom had volunteered to chaperone the middle school dance.

“I’m sorry. Er, it’s just . . .” Her voice was shaking, and I could tell she was nervous, something I hadn’t picked up in my initial whirlwind of annoyance.

“It’s Kevin . . . I got a call from one of his friends who he was with in the Hamptons . . . He said he hit his head in the pool,” she said meekly.

“Is he all right?”

“There was bad cell phone reception so I couldn’t hear much, and it sounded like he was okay, but they were going to the hospital just to check things out.”

“Well, if he calls back tell him to make sure that an attending radiologist reads his head CT. It’s the first week of July. You know there are going to be brand-new residents reading these films tonight and they’re probably going to miss something.”

“Okay . . . I’ll let them know . . .”

“Mom, I have to get back to my patient, I’ll check in once my shift is over in the morning, ’kay? Bye.”

Click.

Typical Kevin. Scaring Mom half to death. I wasn’t surprised a group of guys at a summer house was going to get into some trouble, but at least he was with a bunch of jocks who had experienced enough concussions to know it was better to be safe than sorry. I figured that’d be the last of it.

I checked the on-call pager: no message from pre-op asking if Mrs. Foster was ready. I went back into the room and started placing the sticker leads on Mrs. Foster’s chest.

“Do you know when I’ll be going in for surgery?” Mrs. Foster asked anxiously. “I was warned that if I waited too long my appendix might burst!”

“We’re not going to let that happen, but unfortunately I can’t give you a specific time. We’re in a bit of a holding pattern right now,” I explained as diplomatically as possible.

“But as soon as I get this”—bzzz-bzzz—“EKG done”—bzzz-bzzz—“Excuse me again, this may be the surgery desk calling about your surgery.” I walked outside, closed my eyes, and took a deep calming breath.

Ryan, my youngest and most responsible brother.

Wait, what was Ryan calling me for?

“Er, it’s Kev, he—”

“He bumped his head in the pool, I know. Mom already called me, she said he’s fine and going to the hospital to get checked out . . .”

“No, Er, you don’t understand, Kev can’t move.”

“What do you mean he can’t move?”

“One of the girls was picking up trash by the pool when she saw a body at the bottom of the deep end. She dove down and dragged Kev out of the water. He’s in a helicopter on the way to Stony Brook. Mom and Dad are on their way right n—”

Click. I reflexively hung up the phone, I couldn’t listen anymore.

I STARED IN SILENCE FOR WHAT SEEMED LIKE AN ETERNITY.

I felt the vibration of the on-call beeper tickle my stomach, but I didn’t reach for it.

I heard, “Dr. Nance? Dr. Nance?” come from Mrs. Foster’s room, but I ignored it.

I slowly retraced my steps back to the gen surg lounge.

I opened the door to the lounge; nothing had changed in the thirty minutes since I first arrived. Joon was still cursing at the printer; Craig was yelling into the phone at the pre-op nurse about being bumped from the add-on list; Isabel was furiously scribbling consult notes that should have been posted during the day; Katie was refilling the wound cart for tomorrow’s rounds; and Peter was packing up his bookbag, desperate to have this day end.

I walked like a ghost into the middle of the chaos, silent and transfixed.

“Nance, what’s wrong?” Peter asked, genuinely concerned.

“I can’t do Mrs. Foster’s pre-op,” was all I could muster.

“Nance, what are you talking about?” Craig sighed in disgust.

With tears welling in my eyes, I squeaked out, “I’m sorry, I just can’t do the pre-op.”

Peter came over and put his hand on my shoulder. “Nance, is everything all right?”

“It’s my brother, Kevin”—sob, hiccup—“he hit his head on the bottom of the pool”—sob, hiccup—“and now he’s . . . he’s . . . he’s PARALYZED!”

The moment the word came out of my mouth I knew I couldn’t take it back, and everything had indeed, become real.

I violently dropped down to my knees and all the paperwork came flying out of my pockets like a medical ticker tape parade.

Katie cradled my head, while Isabel and Joon rubbed my back. Everything was blurry through the hot tears, and a searing headache split my brain. The room was collapsing in on me and I had no space to breathe.

Then out of the corner, a commanding voice rang out.

“Katie, stand Nance up. Isabel, pack her bags. Joon, you’re off tomorrow during the day so stay late with Jane until things settle down. Peter, go back to Mrs. Foster’s room and get me that EKG ASAP.” Craig was doing what a chief resident was supposed to do: crisis management.

He came two inches from my face and said, “Go home, Nance. Katie will make sure you get home safely.”

I bit my trembling lower lip hard because I was already so embarrassed for ugly crying in front of the entire gen surg team, but at that moment all I could do was throw myself into a bear hug around this jerk.

I DON’T REMEMBER MUCH ABOUT THE TWO-HOUR DRIVE from the Upper East Side to Stony Brook. I sat in the back seat with the windows rolled all the way down to blow away any of the tears I had left. There was not going to be time for tears when I arrived at the hospital.

The emergency department waiting room smelled like sunscreen and stale beer. Two dozen sunburned, sheepish boys all looked up at me with relief and sighed. “Kev’s sister is here! She’s a doctor, she knows what to do!” Mind you, I had been a doctor for all of fifteen minutes, but it didn’t matter, they were all looking to me for the answers. And I was determined to find some.

Before pulling back the curtain, I took a deep breath, closed my eyes, and tried to crystallize my image of Kevin before this accident: sandy brown hair, tanned skin from caddying all summer. He had just graduated from Duke University; a Division I track star who had competed for Team USA in the steeplechase. A truly phenomenal athlete. But he was also stubborn and hotheaded. Like a typical middle child, he sparred with my parents and hated being told what to do. If I had to pick one of us kids who would be best able to handle a catastrophe, he wouldn’t have been my first choice.

But maybe there had been a mistake? Maybe he was going to be okay?

I pulled back the curtain to see Kevin propped up like a porcelain doll with his arms and legs supported by mountains of pillows. He had a Miami J cervical collar on, which was one of those real-deal hard plastic exoskeleton-looking neck braces, not the soft, just-for-show neck braces that people wear on Judge Judy.

Mom was sitting next to him, perched on the edge of her seat, stroking his limp arm, and keeping her eyes glued to the EKG monitor on the screen above the bed. Dad was pacing like a madman, the wheels in his brain spinning so furiously they overran any rational thoughts. The beeping of the various pumps, drips, and monitors, while completely discordant, provided a comforting background noise.

Kevin’s eyes were still completely closed when he whispered, “What took you so long?”

“Oh, you know, the LIE was jammed as usual, so we got off on the Northern State and then picked it back up at the Sagtikos.” I fell into one of our favorite pastimes of complaining about Long Island traffic patterns.

“Erin, I’m so glad you’re here!” Mom rushed over, took my face in her hands, and gave me a never-letting-you-go hug. I squeezed her back and looked at her face, then looked at Kevin looking at me.

I’d only been a doctor for one day, and was scared out of my mind, so I’d have to channel the doctors I’d seen. Like my chief resident that night, I was in crisis management mode. Steeling myself, I said, “Kev, tell me exactly what happened.”

“Honestly, I don’t even know. Everyone was inside the house just hanging out. I went outside to get some fresh air and decided to take a quick dip in the pool. I dove in and remembered hitting my head on the bottom of the pool where the shallow end slopes toward the deep end. And just like that, poof, it felt as if someone pulled the plug out of my body. You know when you’re watching TV during a storm and then, suddenly, the cable goes out and the picture turns to fuzzy black and white? That’s how my body felt in an instant. I tried to scream and move my arms and legs, but I just sank further down. And then I realized, holy shit I’m drowning and I’m going to die. Mom is going to kill me!”

I blurted out a laugh and caught the death stare from Mom, so I pretended to cough instead. Only Kevin could crack a joke at a time like this.

“So, I just closed my eyes and asked God to send a message to Mom and Dad that it didn’t hurt, the dying part, it didn’t hurt.”

Mom squeezed his hand so hard that his knuckles turned white, but Kevin didn’t seem to notice.

“And right after I closed my eyes, I heard a huge splash, and before I knew it, Laura was pulling me up out of the water and I took the biggest breath I have ever taken in my life. Like when the Little Mermaid takes that huge breath when she first becomes human and explodes out of the water. Laura was shaking my arms and screaming for someone to call 911. After that, I felt really tired and don’t remember much about the helicopter ride or coming to the hospital . . .” He trailed off.

“That’s okay, Kev, just rest for now. We will handle everything.”

My mom pulled me over to the corner and whispered, “Well, what do you think?”

Seeing the flicker of hope in her eyes that I would be able to tell her the medical magic bullet to make everything better just destroyed me.

Gently, I told her, “I don’t know how bad it is, but it’s not good.”

Her face scrunched up in anguish and I put my arm around her shoulders.

Swish. The curtain swung open.

“Hi, I’m Dr. Williams. I’m the orthopedic spine attending on call tonight. Are you”—looks down at the chart—“Kevin McDermott’s family?”

Dr. Williams did not look like an orthopedic surgeon. He was short, and schlubby, and nerdy looking; not like the chiseled, overconfident jocks that I was used to dealing with.

“Yes, doctor, I’m Mary McDermott, this is my husband, Mike, and this is my daughter, Dr. Erin Nance, she’s also an orthopedic surgeon.” Mom really emphasized the “doctor” part. She thought if he knew I was part of the tribe I would be privy to extra-secret information that doctors don’t normally discuss with plebian family members.

“Nice to meet you all, where do you practice, Erin?”

“Well . . . I’m actually an intern at Lenox Hill . . . today’s my first day . . . I’m supposed to be on night float.” I fidgeted and looked down at my new Dansko clogs. There was no patina of dried blood or IV fluids or whatever else accumulated on the shoes of hardworking residents. Just a shiny new doctor in her shiny new shoes, as useless as a scalpel in a gunfight.

Dr. Williams must have sensed this radiating feeling of inadequacy and he offered to review Kevin’s MRI with me in the radiology room. I jumped at the suggestion and followed him back to the dark cave that was illuminated by black-and-white images of broken body parts.

“Here, I’ll let you drive,” he said, handing me the mouse to let me scroll. I went straight for the money shot: the sagittal T2 images that would show where the most damage had taken place.

As I gently scrolled down and saw the images progress, I saw flashes of Kevin leaping over the steeplechase hurdle, splashing into the water pit. They were shielding me from what I knew was coming: shattered bone and high signal splashing through the spinal cord and the precious strands of nerves that were needed to control his arms and legs. You did not need to be an orthopedic surgeon to realize this was a catastrophic-looking MRI.

I turned my head away from the monitor and gave a small nod to Dr. Williams. He patted me on the shoulder, and we walked solemnly back to the trauma bay.

“Kevin is lucky to have such a great support system; he’ll need it to recover. I’ve already examined him, and his MRI came back consistent with the level of deficits that he’s showing. He has a C6 burst fracture and a severe spinal cord contusion. That’s why he’s unable to move his arms or legs. Luckily, the nerves that control his diaphragm don’t look like they’ve been affected, and he can breathe on his own. We will need to perform a spinal stabilization surgery in the front and back of his neck to provide rigid fixation. This will be a long surgery but necessary to provide the support in his neck.” Dr. Williams explained everything clearly and matter-of-factly.

Mom, who had been hanging on every word that came out of Dr. Williams’s mouth, exhaled, and said, “Thank you so much, doctor.” She looked at Kevin, who was fast asleep, exhausted from the day’s physical and emotional trauma. “Do you think”—sniff—“he’ll ever”—sniff—“walk again?” The words stumbled out of my mother’s mouth.

Dr. Williams grasped both of her hands and told her honestly, “I don’t know.”

The unknown gave us what every family needs in these critical moments: hope. Hope that your son may be the one to defy the odds. Hope that your brother will go back to his carefree life as a twenty-something living in Manhattan for the first time. Hope that your family can withstand this devastating punch and lean on one another to stay positive, keep fighting, and not give up.

“Will he be having the surgery tonight?” Dad went back into fact-finding mode.

“He’s on the add-on list but my sense is that we will wait until the morning when we have a fully rested OR team. His vital signs are stable and there is no need to rush him into surgery just yet.

“He’ll stay here in the trauma bay overnight for observation. Though I suggest that you get some sleep because tomorrow will be another long day and a big test for Kevin.”

“But someone needs to watch him and make sure he’s breathing, and his heart is still beating and . . .”

“Don’t worry, Mom,” I reassured her as I gently swept back the dampened hair on Kevin’s forehead with my fingers. I finally understood my purpose after all those years of preparing to be a doctor. “My night shift . . . starts now.”

Chapter 1

The Man in the Tuxedo

Close your eyes and remember what you wanted to be when you grew up. A teacher! A firefighter! An orthopedic surgeon specializing in the field of sports medicine! Wait, what? It’s not one of the usual career paths, I know; people are always shocked when I tell them I made the decision to become an orthopedic surgeon at seven years old. “How could you know what you wanted to be so specifically?”

Well, I owe it all to a man in a tuxedo.

WHEN YOU ARE ONE OF FOUR CHILDREN IT IS EASY TO GET lost in the shuffle. I had the distinct advantage of being the only girl. It was always Erin and the boys. The boys and Erin. In fact, my mom used to just scream “SeanKevinRyan” in one breath, as if they were a three-headed monster. Which, depending on the day, they could be.

At a very young age I recognized that my dad was an important person. I knew this to be true because he had a beeper. And when that beeper went off, he would disappear only to be seen the following night at bedtime. If you asked second-grade Erin what my dad did, I would tell you that he was a lawyer who helps doctors, and that he worked at a hospital in the City. Growing up on Long Island, Manhattan already seemed exciting and mysterious—and more so because Dad worked as a medical lawyer at Lenox Hill. What I knew as a kid was that it was a very fancy hospital that treated very fancy people. The men wore serious, dark suits and the ladies wore tweed skirts and perfume that made a little kid gag. The fanciness didn’t impress me much, since working at that hospital required him to leave in the morning before I woke up and come home only a few minutes before I had to go to sleep. His days were filled with crises, like dealing with doctors who had accidentally operated on the wrong body parts (it happens!) and patients eloping from the hospital.

My days were less dramatic, filled with school and sports. All three brothers and I were obsessed. On any given weekend in our little town on Long Island, you could see towheaded McDermotts running all over the soccer fields, basketball courts, and baseball fields. Quality time at home between the six of us was a rare occurrence, so I remember the circumstances exactly before the accident occurred.

It was an early Sunday evening, one in which we had all eaten a civilized, sit-down-kitchen-table dinner together, not at the Burger King drive-through next to the soccer field or a slice of pizza in between basketball games. We finished dinner so early, we didn’t know what to do all together that didn’t involve running, jumping, or tackling one another. When Dad hid a board game behind his back, this prompted the boys to scale his body in an attempt to be the first to uncover what was going to hold our attention for the rest of this special evening.

I wouldn’t say the Scattergories reveal was met with the greatest of enthusiasm (the boys were two, four, and six at the time), but I was salivating. I was a precocious second grader; this was exactly the type of game I could use to show off my word prowess. As we tore open the box and assembled the pieces of the game, I noticed one key element was missing: the pencil. I popped up and announced that I would bring up the essential pencil from the basement so we could start the game. I ran down the stairs with such alacrity, I didn’t pay attention to the length of my nightgown. My baby giraffe-like legs skipped steps two at a time, and I tripped at the bottom, causing my arm to land awkwardly on the hard basement floor.

Ow.

Pretend it didn’t happen, I thought, not wanting to ruin family game night. But it hurt and I wasn’t much of an actress. When I slunk back upstairs cradling my arm, my parents knew right away that something was wrong.

When I locked eyes with my mom, I couldn’t hold it in any longer, and the tears started to flow. My cheeks were hot with embarrassment.

Sobbing and hiccuping and snorting, I explained the situation: “I was running down the stairs . . . and I tripped . . . and fell.”

“Oh honey, come here.” As she held me, I could see her mouth the words to my dad, “Do you think it’s broken?”

He looked at my splotchy tearstained faced, then at my arm, and said, “Let me make a call.”

Minutes later he walked back into the living room and announced, “We’re going to Lenox Hill.”

WHAT FOLLOWED NEXT WAS A BLUR OF ACTIVITY. SOMEHOW my neighbor made his way over to our house to watch the boys, and before I knew it, I was in the car with my parents, on my way to the City.

When you are a kid who grows up on Long Island, the City is a mythical place that is both exhilarating and terrifying. It’s the place you go to the week before Christmas to see The Tree and watch the ice-skaters fall down in Rockefeller Center. My mom always prided herself in knowing where the best public restrooms were (the Plaza) and on never spending a dime on parking, even if it meant circling around for what seemed like an eternity to a child. But New York City was also big and scary. I still remember the fear every time the car braked at a stoplight and an aggressive squeegee man would forcibly rub a dirty rag on our windshield and demand a tip. And if you didn’t fork over cash, they would start banging on the windows or hock a loogie all over the car.

What I learned that night is that when you have a broken arm, every minor bump in the road feels like a ginormous pothole. You could tell something was wrong because there was an angle in the middle of my forearm, an otherwise straight bone. The soft tissues kept swelling more and more and the throbbing increased even though my mom told me that the bags of ice would help (they did not). I laid my head in my mom’s lap in the back seat while she brushed my hair off my face and attempted to keep me comfortable. I tried to be brave but sometimes no amount of “It’s going to be okay” makes a difference. When we finally reached the hospital, my dad flashed his badge to the security guard who led us into an unmarked doorway. This jived with my already preconceived notion that my dad was an important person around here, and we skipped all the usual ER waiting room unpleasantries.

“Mike! What are you doing here so late?”

“Mike! Is this your little girl? She looks just like you.”

“Mike! Did you see the Rangers won in OT last night? They’re looking pretty good this year.”

All types of people, nurses, guards, lab techs, doctors, kept coming up to my dad, shaking his hand and giving him a pat on the back. My dad would ask them how they were doing, how their family was, and they would chitchat for a bit. Then they would realize that he was here for a personal matter and offer to do whatever they could to help make the process as painless as possible.

It was only until I, myself, became a doctor that I understood my dad’s true role. My dad was the hospital fixer. If some complication happened during surgery with one of the patients, the doctors came to my dad. If one of the nurses made a medication error, they came to my dad. If one of the techs labeled something incorrectly, they came to my dad. If security couldn’t find a patient because they had escaped from the psych ward, they came to my dad. All those emergency beeper calls that stole my dad in the middle of the night, it was these people! And it was this moment when I learned there is a time and place where you get to cash in on all the goodwill you have built.

But my focus was on the room.

It was cold and quiet, the fluorescent lights burning all the way into the back of my eyeballs. The walls were stark white, there were no Mickey Mouse decals or kid-friendly games to keep me preoccupied. I noticed that every time someone opened the door a rush of beeping, moaning, and clanging would flood the room, sending a shiver down my spine. An aide handed my mom a kid-sized hospital gown, still two sizes too big for my diminutive frame, and I looked like I had two toothpicks sticking out of the arm holes, with one slightly bent.

The first person to speak with us was a nurse, who had very frizzy hair, crumpled scrubs, and probably was supposed to end her shift an hour ago. She asked me the basics: what happened, where did it hurt, did anyone see you fall? After we localized the pain to my forearm, she told me to sit tight, and the X-ray technician would come get me soon.

A few minutes later, a young man with different scrubs wheeled a gurney into my room and told me to hop on. I looked up at my dad to make sure he was okay with this and I wasn’t being abducted, and he nodded and said he would be right behind me the whole time. I hopped onto the gurney and wheeled past people who were throwing up into pink buckets, people who had blood dripping down their towel-wrapped hand, people who were asleep and looked like they were having a bad dream.

We rolled into the radiology room and the tech helped me hop off the gurney and gingerly placed my crooked arm onto the cold exam table. He told me to hold still and promised that this would not hurt. He walked over to the alcove off the side of the room and closed the door behind him, leaving me all alone. My eyes started to frantically dart across the room looking for escape exits, when I heard a tapping coming from a glass window. It was my dad who had been watching from the viewing room. He gave me a thumbs-up and I let out a big, deep breath.

After I finished taking the X-rays (which did hurt, by the way), we rolled back into the room, and we waited. And waited. And waited until the pain of boredom overtook the pain of my arm. It was late at night for a seven-year-old and I started to look like one of those sleepy cartoon characters with the heavy eyelids and exaggerated yawns.

“Knock-knock,” someone said, entering the room.

“Thank you so much for coming, I owe you one.” My dad rushed over to the man and clasped his hand.

“Not a problem at all, Mike. Now, who is this young lady?”

I rubbed my eyes with my one good hand. Was I dreaming? Was this for real? Did a man in a tuxedo just come into my room? Who was he? What was he doing here?

“This is Erin,” my dad said, patting my head, reminding me that I was, in fact, not dreaming.

“Hi Erin, I’m Dr. Alexiades, I’m the bone doctor. I help kids when they hurt their bones.”

Wait, this was the doctor? I thought he was some movie star who got lost in a hospital and entered my room by mistake.

He crouched down so that he was on my eye level and asked, “Can you tell me what happened?”

I looked at him, then I looked at my parents, then I looked down at my arm, and without taking my eyes off it, I mumbled, “I tripped down the stairs and fell onto my arm.”

“That must have been really scary.”

I nodded, keeping my eyes glued to the arm in question.

“Can I examine your arm?” He reached over, but I drew my arm closer to my body.

He pulled back and said, “I know your arm must hurt so badly, but I promise, I’m going to do everything I can to make it better. Do you trust me?”

I looked at Dr. Alexiades, I looked at my dad who was nodding his head enthusiastically, I looked at my mom who was biting her lip and furrowing her brow, and I looked back at Dr. Alexiades.

“Okaaaay,” I agreed tentatively.

He asked my mom to hold my hand while he squeezed my elbow, then squeezed my wrist. Then somehow, he managed to squeeze the spot on my forearm so precisely it was as if his fingers had a magnet to the broken ends. I yelped in pain, and he said, “I’m so sorry, that will be the last time I have to touch your arm, you were so brave.” I flopped back into the bed and my mom gently brushed my bangs off my forehead.

“Erin, would you like to see the special pictures from the X-ray you took earlier tonight?”

I was interested in the pictures. I didn’t know what they were supposed to show but I knew in my gut these pictures held the key to my future.

Dr. Alexiades reached down into his bag and pulled out a large manila folder. He thumbed through the folder and picked out what looked like a see-through sheet of black construction paper. He then lifted the sheet above his head under one of the overhead fluorescent lights, and looked up at the image.

“You see this long white bone? This is your radius. And do you see the other long white bone next to the radius? That is called the ulna. Now normally these two bones are supposed to be straight like an arrow. But do you notice anything different about your bones?”

I nodded silently.

“Your bones are bent but not broken.”

What?

“Have you ever picked up a branch that’s fallen off a tree?”

I nodded.

“Well in the winter, when the branches are old, the inside of the branch is white, when the branch falls, you can snap the branch in two.” He pantomimed a big snap with his large hands. “But if the branch falls during the spring, the branch is very young and it’s green inside. And when the branch falls, the branch bends but doesn’t break.”

This made sense to me.

“Your bones are still very young, and so when you fell, the bones bent and did not break all the way. That is called a ‘greenstick fracture.’”

Hmmm.

“Now, here’s where the magic comes in.”

I leaned in closer, eyes wider, ears open.

“Because your bones are young, they have special powers, and they can actually heal themselves!”

Well, that sounded cool.

“And all we have to do is put a cast on them and let your body do the rest.”

Huh, not bad.

“So will you let me put a cast on your arm?”

Dr. Alexiades looked like he was asking his dog if he wanted to go outside and play fetch. I looked at my parents who were looking very relieved and I knew this was the right thing to do.

“Yes.” I smiled for the first time since I had the brilliant idea to be the one to grab that damn pencil.

AS I THINK BACK TO WHEN DR. ALEXIADES STARTED TO WRAP my arm with the ticklish fuzzy cotton roll and then overwrap it with the soupy white plaster, there were so many things I did not realize had happened behind the scenes. At the time, the fact that this doctor in a tuxedo showed up seemed like magic. I’d later find out that Dr. Alexiades was not the orthopedic surgeon on call that night. He had been enjoying a date night with his wife at the opera when my dad paged his beeper. And as I have had to do many times to my own spouse, he’d apologized profusely, exited abruptly, and left them hanging.

Honestly, I didn’t know much at the time. I certainly had no idea about the challenges I would face in my own recovery. How only five months later I would take a disastrous fall playing Red Rover at my First Holy Communion party, and suffer a compound fracture of those same bones requiring surgery and an additional three months locked up in a cast—the last two weeks being tortured with unscratchable chicken pox inside the world’s stinkiest cast.

And of course, I had no idea how my paths would cross with Dr. Alexiades again. How immensely proud I would feel to be able to scrub in with him as one of his surgical trainees twenty years later. How he would offer me a professional lifeline when my dream job was snatched out of my hands. But most importantly, he taught me about the magic in medicine, and I would spend the next thirty years of my life chasing that feeling.

Chapter 2

Academic Weapon

Once I publicly announced my intention to become an orthopedic surgeon, there was no turning back. I knew that kids were allowed to change their minds, but I was stubborn, and I needed to plot a twenty-five-year plan. The first step was to rule at school.

I loved school and I was really good at it. Honor roll, student of the month—you name it. Any challenge that school offered was one I was game for.

Given how much I loved school, my parents decided to wait until the day before fourth grade started to inform us that we would be going to a new school in a different town. Presumably they waited until the very last day so they wouldn’t have to hear us whine and complain about missing our friends all summer. But the small Catholic school we attended had shrunk in enrollment, the good teachers had bolted, so they made the difficult choice to make the switch.

Funny enough, the two schools had identical Catholic school uniforms, except for one small detail. At Saint Thomas all the girls had to wear this little bolo-type tie that matched our plaid jumpers. At Saint Anne’s, you didn’t. Which I found out upon arriving in my old Saint Thomas uniform, sticking out like . . . well, the only girl rocking a plaid bolo tie.

Starting a new school is an exercise in identity politics. Who you align yourself with in those early days can set up your entire year for better or for worse. I certainly had a couple things working in my favor: I had double ear piercings (which was pretty badass for a ten-year-old), and I could kick a kickball farther than any girl and most of the boys. But I didn’t have a subscription Tiger Beat or get dELiA*s catalogs, so I wasn’t hanging out on the curb ogling pictures of JTT or Prince William. My lunch consisted of a bologna sandwich and some grapes, so not a lot of lunch capital to work with; nobody wanted to trade for those things. And I took the short bus home, consisting of a mishmash of students from far away towns, none of whom got to play in the leafy, tree-lined kid central streets of Garden City or Stewart Manor.

But hey, I knew I was going to be an orthopedic surgeon one day.

I eased into my role as the studious, polite, inquisitive, and respectful girl. I would raise my hand confidently but not aggressively. I received my perfect test scores without fanfare and was eager to move on to the next challenge.

Fourth grade was the year we started changing classrooms for subjects, and Mrs. Donegan, the toughest, strictest, hardest teacher in the whole school, was the math and science teacher. She wore sweater knits, a long heavy skirt, those stockings that came in a shiny cardboard box, and sensible beige flats. She had short, brown curly hair that never moved, and of course she wore glasses. I think the most terrifying thing about Mrs. Donegan was that she called students at random.

“Miss Zecconi, what is seven times eight?”

Erica abruptly stood up and started uncomfortably fidgeting with her hands, eyes darting around the room.

“Uh . . . uh . . . fifty-two?”

“You’ll be writing the seven times tables ten extra times tonight, Miss Zecconi.”

“Mr. Moran, let me see your signed math quiz from yesterday.”

Colin slunk down into his seat, trying to become invisible.

“I . . . uh, forgot to bring my math notebook home last night . . .”

“Please see me after class, Mr. Moran, I’d like your parents to sign an extra-special note from me.”

Busted.

Up until this point, I never had any problems being called on. I always knew the answer. I always had my assignments completed on time. So, I never had any anxiety or sense of dread when I was called on.

“Miss McDermott, please tell me the definition of ‘photosynthesis.’”

I gulped. This was the longest vocabulary definition I had ever come across so far. I gingerly pushed back my seat so I could stand up slowly, buying some time to think.

“Photosynthesis. The way in which green plants trap the sun’s energy . . .”

I hesitated and Mrs. Donegan tilted her head and narrowed her eyes in response.

I took a deep breath.

“Photosynthesis. The way in which green plants trap the sun’s energy and . . .”

Mrs. Donegan walked right in front of my face, daring me to spit out the rest of it.

“I’m sorry . . . I don’t know the rest,” I whispered in embarrassment.

Mrs. Donegan did not look mad, she did not look disappointed, but rather curious.

“Photosynthesis. The way in which green plants trap the sun’s energy and use it to change carbon dioxide and water into a simple sugar,” she stated confidently.

I sat down in defeat.

“Miss McDermott, please tell me the definition of photosynthesis.”

I looked around the room, I was confused, why did she want me to say the definition again if she knew I didn’t know it the first time?

I stood up awkwardly.

“Photosynthesis. The way in which green plants trap the sun’s energy and use it to change . . . carbon dioxide and water . . . into a simple sugar?” I stated meekly.

“Again.”

“Photosynthesis. The way in which green plants trap the sun’s energy and use it to change carbon dioxide and water into a simple sugar,” I repeated a little louder.

“Again.”

“Photosynthesis. The way in which green plants trap the sun’s energy and use it to change carbon dioxide and water into a simple sugar,” I said louder and faster.

“Again.”

“PHOTOSYNTHESIS! THE WAY IN WHICH GREEN PLANTS TRAP THE SUN’S ENERGY AND USE IT TO CHANGE CARBON DIOXIDE AND WATER INTO A SIMPLE SUGAR!”

With slack-jawed faces, twenty-two pairs of eyes were watching a teacher’s pet become completely unhinged.

Mrs. Donegan simply smiled and said, “Good, you may take your seat.”

WHEN I ARRIVED AT SAINT ANNE’S, THERE HAD ALREADY been an established academic pecking order. There was an honor roll that was displayed in the hallway of the school so every student, teacher, and parent that walked inside could see a student’s standing. I was flying a bit under the radar—that is, until I snagged the final spot to represent the fourth grade in the math bee.

The math bee consisted of four students each from fourth, fifth, and sixth grade. John Puswald, the defending champion, was a sixth grader and the odds-on favorite to repeat. Danny Marotta, the smartest boy in my grade, was presumed to be the one to give John a run for his money, and then the rest of the field was wide open.

The auditorium stage had a sticky, lacquered hardwood floor that was framed by musty faded green velvet curtains. As I sat down onto the cold metal folding chair, the one inch of the back of my thighs that was exposed sent an electric chill up my spine. As Mrs. Donegan, the moderator, asked each student a question, I closed my eyes and attempted to answer the question as if it were my own, building confidence and psyching myself up.

“Next contestant?”

I can still hear my knees knocking while standing up at the microphone waiting for my question.

“Six times five . . . divided by ten . . . plus four . . . equals?”

Mrs. Donegan’s voice sounded like a National Geographic narrator: slow, deliberate, anticipatory.

I went through the operations in my head one by one, and after arriving at the same conclusion three times before the five seconds ran out, I blurted, “Seven???”

I panicked as I scanned the faces at the judges table, flipping through the answer sheets, waiting for the sound of the mortal ding of the bell.

But there was no ding only a drawn-out “correct” from Mrs. Donegan.

I exhaled and scurried back quickly to my seat.

When John Puswald and Danny Marotta answered their questions, they didn’t answer it back with a question, they answered it back with a statement.

“Six times six . . . divided by nine . . . minus two.”

“Two.”

They did not exhale. They did not scurry back to their seats.

As the rounds went deeper, and the attrition accelerated, the three of us could not be stopped.

“A hundred and thirty-two divided by eleven . . . times eight . . . plus twenty-four.”

“A hundred and twenty???”

“Correct.”

“Forty-six plus three . . . divided by seven . . . times eight.”

“Fifty-six.”

Boom.

The rounds kept going until we exhausted all the “regular math bee” questions and had to go into the “super difficult bonus math bee” questions.

First up: the dark horse, representing the girlies and all the kids who had to take the short buses from outsider towns . . . Erin McDermott!

“Eighteen times fifteen . . . divided by ten . . . plus sixty-three.”

Shit, this was hard.

I definitely hadn’t memorized any multiplication tables beyond twelve. I tried to remain calm, do some on-the-fly estimating, and right before the five-second buzzer rang, I blurted out, “Ninety???”

There was a longer than normal pause (or at least it felt that way), and as my face was contorted into a grimace preparing for the shrill sound of the ding, I was met with an impressed (and quite frankly surprised) “correct” from Mrs. Donegan.

The crowd broke into an unexpected thunderous applause, and I could see parents nodding and mouthing to each other, “Who is this girl?”

I smiled nervously, then ran back to my seat. I felt something new in my chest: it was the belief that I could win this thing.

Next up was Danny Marotta.

“Seventeen times fourteen, divided by seven, plus eighteen.”

I could see Danny furrow his brow ever so slightly. Then after the full five seconds he coolly answered, “Forty-eight.”

My eyes darted over to the judges’ table, and I saw Mrs. Donegan shake her head and reluctantly tap on the bell.

There was an audible gasp from the crowd, and Danny hung his head and flopped down into the metal folding chair.

“John, you’re up next. If you answer incorrectly, Erin will be our champion.”

I blinked repeatedly just to make sure I wasn’t dreaming. Erin, the champion? Erin, the little fourth grader who could?

John sauntered up to the microphone.

“Twelve times fifteen, divided by eighteen, plus twenty-four.”

What?! That wasn’t hard at all!

“Thirty-four.”

“Correct. John and Erin, you will continue to our final round. Danny, you can leave the stage.”

As Danny walked off to polite applause, I spotted my mom in the audience, beaming with pride, giving me a fist pump, encouraging me to believe in myself.

John and I battled for four more rounds, each equation upping in difficulty and elevating the stakes.

HERE’S WHAT HAPPENED: I DIDN’T WIN THAT MATH BEE. I messed up one of the multiplication parts and couldn’t think fast enough before time ran out to answer the question. John was solid as a rock and was a worthy repeat champion.

The students all went back to their classrooms, and I stayed behind to take some photos with Mrs. Donegan. I watched my mom shake hands with the principal, and she gave me a big hug and told me what an awesome job I’d done.

When I walked back into my homeroom one of the kids shouted, “Erin’s back!”

They all swarmed me and patted me on the head, took turns hoisting my second place trophy, and congratulated me for “taking all those older kids down.” I became a fourth-grade legend that day, and I learned the only thing that could stop me was me.

Chapter 3

The 50 Percent Club

Fun fact: I’ve been rejected from Stanford four times. I was rejected for college, medical school, residency, and fellowship. That’s right, Stanford really doesn’t want me.

Which was a problem, because I really wanted Stanford. I was eight in 1992, and big on swimming. This was the same summer as the Barcelona Summer Olympics, and all the Olympic swimmers went to Stanford: Janet Evans, Summer Sanders, Lea Loveless, Jenny Thompson. These women were powerful, beautiful, and smart. They would wake up before the sun came out to swim and leave the pool after the sun had set. So I made up my mind I absolutely had to go there.

But Stanford didn’t want me. (As I had to find out four separate times.)

These soul-crushing rejections were the basis of the most important skill a doctor can have: resilience.

For anyone who has gone to college, chances are you have met a premed dropout. In fact, you may even be one yourself. If you are, you are in good company: over 50 percent of college students drop premed within their first year, and a whopping 83.5 percent never make it into medical school. So, what is it about that 16.5 percent that allows them to take one of the most rigorous course loads in college, dominate an eight-hour exam, and schmooze their way through interviews that give them that golden ticket of med school admission?

This is the story of how I became a premed dropout . . . almost.

THE MOST IMPORTANT ACADEMIC DECISION I EVER MADE was not whether I went to the Mayo Clinic or the Hospital for Special Surgery for fellowship, or if I should pursue a dual MD/JD degree at Georgetown or go to Brown. It wasn’t even the decision to turn down Princeton for undergrad (take that, Stanford). No, the most important decision I made was a choice I didn’t even know existed.

At Saint Anne’s I noticed that in each graduating class, the valedictorian (who was almost always a boy), got to go to a school called Regis. Regis is an all-boys Catholic school, that only the smartest boys from all over the tristate area can apply. Then, like a nerd Hunger Games, those boys are weeded out with a grueling exam. But if you make the final cut, the reward is you get to go to the most prestigious private school in the City for free. Imagine a school where being the smartest kid you know is just a prerequisite. A large portion of the boys go on to attend Ivy League schools, thereby setting themselves up for a lifetime of continued success. Colin Jost and Dr. Anthony Fauci are two of the more recognizable alums.

“Mrs. Clarey, what happens if the valedictorian is a girl? Where does she go to school?”

“Oh, well, there are some lovely schools: Sacred Heart Academy, Kellenberg, Our Lady of Mercy.”

She was right, these were lovely schools, and great schools for my area . . . but they were not REGIS.

I had a new mission in life, and it was to find Girls Regis.

But this was 1996, I had to go to the library and look through the periodicals section and education books the size of the Bible to look for something I didn’t even know existed. And then one day while visiting an older cousin, I heard my mom and my aunt discussing a girl who was a brilliant artist whose father worked for the Long Island Railroad, and she went to school across the street from the Metropolitan Museum of Art.

This was the first break in the case of finding Girls Regis.

The school was called Marymount. The first time my parents dropped me off to take the entrance exam I was mesmerized. Three Fifth Avenue mansions, with their signature green oxidized copper rooves, the fluted Ionic pilasters, carved stonework, and filigreed wrought-iron doors, made it feel like I was walking into Buckingham Palace. I had never seen a chandelier before in real life, certainly not in the bathroom.

As luck would have it, the nuns that taught at Marymount were in the same order as the nuns that taught at Saint Anne’s. There is no stronger recommendation than a nun-to-nun recommendation. After the exam and an interview with the admissions counselor, Mrs. Alvar (who loves to tell people that she plucked me out of obscurity like a model being discovered in a mall), on a cold, snowy day in January, I received a phone call congratulating me for winning the Butler Scholarship and welcoming me to the class of 2001.

I was ecstatic. I was going to be the first girl from my school in Long Island to go to school in the City. Now at the time, I didn’t realize that would mean I would have to wake up at 5:30 a.m. to be dropped off at the 6:28 a.m. Garden City train. I stood alone on the platform with my ginormous forest green L.L.Bean backpack, my Britney Spears–esque pleated skirt, and my Doc Martens. I sat down sandwiched between bankers carrying their Wall Street Journals and construction workers carrying their lunch coolers.

I insisted on taking the early train just in case there were delays or a subway wasn’t running, or the bus skipped our stop. In fact, the nuns would watch me shivering outside the large glass door until the clock struck 7:30 a.m. on the dot, and only then would they unlock the heavy wrought-iron door and let me defrost inside.

But beyond the world-class education, Marymount gave me a place to be unabashedly me. It was a place where it was cool to be smart. A place where people celebrated if you were ambitious and had goals. Most important, it was egalitarian; it didn’t matter that I didn’t live on Park Avenue or belonged to a fancy club. If you worked hard, tried your best, and didn’t give up, you could succeed. And learning how to function on only a few hours of sleep a night served me very well into my medical career!

During COVID-19, when I started to lean into the creative part of my brain after so many years of scientific and academic pursuits, I remembered a line from Mrs. Alvar: Marymount was a place for girls who were curious and not afraid to take risks throughout their lifetime.

But sometimes when you’re in a predetermined path like becoming a doctor, any deviation can feel like a full-blown derailment.

WHEN I STARTED COLLEGE, LIKE EVERY HYPER-SCHEDULED, overachieving highschooler, the newfound freedom was probably the biggest learning curve. As luck would have it, there were plenty of openings for 8:00 a.m. classes (lol), and as someone who was used to waking up at 5:30 a.m. every day, how hard could it be? As part of the premed curriculum, every aspiring doctor had to take the same intro to chemistry class. And while I doubt any teacher would admit it, they are actively trying to weed out the pretenders from the contenders.

The first Friday 8:00 a.m. class was when I realized, Oh wait, kids don’t actually show up to all the classes. There isn’t a parent shaking your shoulders telling you to get your butt out of bed. And guess what? No one is taking attendance. The first time I missed a Friday 8:00 a.m. class I probably did honestly forget to set an alarm and woke up in a panic, scrambling to kick off my sheets and throw on a polo dress and run the half a mile to class in my Rainbow sandals. But when there’s no consequences, you get lulled into thinking, “Well no harm no foul.” And the little voice inside you that tells you to be a good responsible girl becomes quieter and quieter.

The other major difference between high school and college is how tests are designed. First, there’s only two or three of them over the course of the semester so the stakes are much higher with each individual exam. The next is that only a minuscule number of students achieve the highest grades, while the majority are lumped in the mediocrity of the middle, and then some truly fall off the cliff.

As soon as I read the first question on the midterm, I knew I was in trouble. I remember it had something to do with calculating the amount of water that would melt from ice cubes on a cross-country flight. (To this day I am still haunted every time I see a cup of ice on a plane.) I remember reading each question thinking, Am I even in the right exam room? I would skip a question I didn’t know the answer to, but then realized I hadn’t been answering any of them.

When I came home for Thanksgiving break, I was burning with shame. It was officially my lowest test score ever: a forty. A fucking forty. I was so embarrassed that I couldn’t even talk about school, punting every question about how school was going, how I was liking my classes. Why were they even asking me? Wasn’t it totally obvious that I was a loser? Sitting at the kitchen table, I was so mad at myself; I wished I hadn’t skipped those classes, that I’d tried just a little bit harder.

Later that night, my mom came into my room, finding me as a total lump in the comforter. “What’s up, honey?”

I poked my chin above the blankets.

“I don’t think I’m going to be a doctor.”

“What are you talking about? You’ve wanted to be a doctor your whole life.”

“I got a forty on my chem midterm.”

“Okaaay.”

“No, it’s not okay, I’m not going to pass, and I’ll never have a GPA high enough to apply to med school, it’s over.”

Now that I had put into words what I had kept bottled up inside me, it felt like the final nail in the coffin. I had completely ruined my plan to become a doctor.

“Erin, it’s just one test. One bad test doesn’t mean you don’t get to be a doctor.”

“Really?” I blubbered through snotty tears.

“Of course, honey!” She wrapped her arms around my shoulders and rubbed my back, just like she used to do when I was a little girl home sick from school.

And in that moment, the weight of that veil of perfection was lifted, and I could breathe.

Looking back at the kids who were in that intro to chemistry class, I do believe the weeding out process brings some clarity to those who were premed for the wrong reasons. If you were there because your parents wanted you to be a doctor, or because you thought being a doctor was the only way to get ahead in life, you realized it wasn’t a smooth path. In fact, the path to becoming a doctor was full of so many unnecessary hardships and hurdles that almost everyone who was looking for an out could find one pretty quickly.

If what you want is to be in medicine, there are so many different ways to serve people in the healthcare field. You could do anything from becoming a physician assistant, EMT, speech therapist, social worker, public health professional, or even being a healthcare investor or lawyer. It actually wasn’t until I was an adult that I learned that my dad was a biology major in college.

Had he always wanted to be a doctor? I’d had no idea.

I mean, I didn’t know many lawyers who majored in the sciences. Turns out his family could not afford to send him to medical school, and he accepted a scholarship to law school where he studied health law. His job as the general counsel for Lenox Hill Hospital was one of his first major jobs right after he graduated, and he worked at many different hospital systems all over the country during his career.

He worked alongside the young doctors he once envisioned himself to be, which to me sounded pretty cruel, but for him, he was happy to be in a position where he could be present for his young family. But his story always felt a little bit sad to me, that the career he wanted wasn’t feasible just because of money. It caused me to question the way things were done, why they were done this way, and who got to do them. Most doctors I’ve met told me they became a doctor because their dad was a doctor, or their grandfather was a doctor, but they would up the ante. Like if their father was a cardiologist, they became a cardiothoracic surgeon. So, if you didn’t have that head start, how would you ever end up at the same place?

In the end, you need both types of support, the steadfast “You’re sure you want to do this” and the sympathetic “You’re sure you want to do this?” to prop you up when you need the support but also allow you to fall, and instead of picking you up, let you dust yourself off and decide if you want to try again.

ONE OF THE OTHER CONCEPTS I HAD YET TO UNDERSTAND was how the curve works, and that forty was actually one of the highest scores in the class. I got an A in chemistry that semester and ended up being chosen as the John K. Crispell Memorial Lawn Room recipient, the highest honor for a pre-med student at the University of Virginia. But none of that would have been possible if I didn’t have someone give me permission to fail—and I needed the reminder that if you want something, you really do have to give it 100 percent. I think of all those other 50 percenters who might have continued their journey if only they had someone tell them it was going to be okay. I’m here to tell you, it’s going to be okay. You’re going to be okay. And screw Stanford.

Chapter 4

Glasses

As a medical student, you want to see everything. You want to be in every room, every procedure. The last thing you want is to miss something.

That’s what I thought, anyway, until I realized that the worst thing that can happen isn’t missing something . . . it’s messing something up.

Sure, I’d learned it was okay to fail, but I was still terrified of failure. As someone suffering from eldest daughter syndrome, the only thing worse than making a mistake is the anxiety that comes with the never-ending hypervigilance of not letting that mistake occur in the first place. But perfectionism takes a toll, and while you may be smiling as your head remains above the surface, your legs are paddling furiously down below. And when your muscles have given out and you think you’re going to drown, only then do you finally submit to the water. Yet instead of drowning, your feet touch the floor, and you realize you’ve been in the shallow end this whole time.

Each year, I tell rotating medical students that there are three keys to success:

Show up on time.

Be helpful.

Don’t be annoying.

Now these rules may seem pretty simple, but you would be surprised how difficult it is to master all three at once. Take the first episode of Grey’s Anatomy: Meredith is late, Karev is incapable of helping anyone but himself, and Cristina is a total know-it-all.

What separates a good student from a great student is their ability to be seen without being seen. When rounds are efficient because the student prepared the correct wound supplies in anticipation for each patient’s dressing change. When the attending asks what the patient’s temperature was overnight and the med student answers it without missing a beat because they have pre-rounded to have the information at their fingertips instead of painfully waiting for someone to log on to a computer, search for the correct patient, and scroll through hundreds of data points. When the student knows the correct angle to hold an abdominal retractor, so the attending has the best view of the anatomy because they understand what part of the anatomy is critical for each step of the surgery.

While these may seem like small actions, they are noticed by those who matter. Trust breeds interest, and interest breeds opportunity. Getting a question wrong is never fun, but for a medical student, the worst possible scenario isn’t being asked a question you don’t know the answer to, but rather, not being asked any questions at all. If nobody is asking you questions, you don’t have the opportunity to prove yourself.

That starts in medical school, where you spend the first two years mostly in the classroom, building the foundation of medical knowledge. You learn a new language with vocabulary such as “bradykinesia,” “dysphagia,” and “choledocholithiasis.” Then, in your third year, you start getting practical experience as you begin working on clinical rotations: you go from the books to the hospital floors.

Spotting a medical student in the hospital is easy if you know what to look for. They are the ones who look like lost toddlers, with panicked expressions and wandering eyes. They have pockets exploding with cheat sheets, never used otoscopes, and snacks that have long since expired. And if you can’t see the fear (or into their pockets), there is one more sign: a short white coat.

“HEY BIGGS, I GRABBED MY GLOVES, CAN I PUT THEM ON THE table?”

“You can put them right on top of the gowns and I’ll take care of them,” Biggs said, nodding in appreciation. Simple things like picking out your own sterile gloves before surgery started instead of making the OR nurse go searching for extra gloves showed that you had an awareness that surgery is not about you. You are a guest in the surgical team’s house. Everyone in the operating room, from the scrub tech to the surgeon, plays a critical part in the ultimate success of a surgery. For those who haven’t seen much of Grey’s Anatomy, let me give you a brief rundown of the cast of characters in the OR.

The circulating nurse. Anyone who thinks the surgeon is running the room has never stepped foot in a real OR. The mood of the OR nurse sets the tone for the entire case. The nurse is the one to bring the patient into the room, who holds their hand, drapes the warm blanket over their bodies, and lets the patient know everything is going to be all right while they drift off to sleep.

The scrub tech. This person is a technical assassin. Surgeons spend more than half of their time out of the OR while scrub techs do case after case, day after day. I have always marveled at their ability to hold their tongue when they see a resident or an attending struggle, because they have seen how other surgeons get it done. The scrub tech can be your greatest ally. A good scrub tech will hand you what you ask for. A great scrub tech will hand you what you need. Do not grab anything off their instrument tray unless you are prepared to lose a finger.

The surgeon. The most difficult part of any surgery is the mental load. We are simultaneously cutting while supervising while anticipating while correcting while teaching while performing. It was not until I became an attending surgeon myself that I understood the intricacies of this coordinated dance. There are so many things that can go wrong during surgery, the patients put their trust in the one who holds the scalpel. In the end, it is the surgeon who speaks to the family members and loved ones about the surgery outcomes. The surgeon is the person that bears the ultimate responsibility for the success of a surgery, and heavy is the head that wears the crown.

The anesthesiologist. Everyone in the room takes for granted that this person is literally keeping the patient alive. Sometimes the surgeons don’t even know who the anesthesiologist on a case is, since by the time they walk into the room the patient is already prepped and the curtain is up. People may joke about the amount of time they spend doing Sudoku or executing stock trades, but when shit hits the fan, all eyes are on the person behind the curtain. Plus, someone has to be the DJ.

The resident. Training is based on a “see one, do one, teach one” method. There is a constant push and pull of wanting surgical independence and understanding the critical point during surgery where it is in the best interest of the patient to have the attending take over and do the procedure. Good judgment cannot be taught but it can be emulated. The best resident does not flinch when a bleeder squirts uncontrollably. The best resident measures twice and cuts once. The best resident allows the med student to shine because they have prepared them for this moment.

The med student. There is really only one rule for med students in the OR: don’t touch anything. They tend to be placed in the corner of the room, far enough away to not be any real threat to contaminating the surgical field, head bobbing from periodically falling asleep while standing. When the nurse asks if med students can see, they nod their head politely, even though they can’t see shit, because they don’t want to disrupt the flow of the OR. Having a med student in the room always feels like throwing a joker in the deck: you never know when they’ll blow up your hand.

“DID YOU LOOK OVER YOUR ANATOMY LAST NIGHT? HALPERN loves to pimp students about anatomy.”

I was assigned to follow Nick Stewart, Stewie, the PGY-2 resident for the entire week. Since he felt that the preparation of the medical student was a reflection on his ability to teach, he wanted to make sure that I would not embarrass either myself or him in the OR.

“Yes, I read all about the approach, the blood supply, and a couple of articles about common complications following anterior approaches to the spine.”

“What are you trying to do, jinx us?! Don’t talk about complications, plus Halpern doesn’t have complications, he’s super slick. Talk to Laura, see if there’s anything she needs. I’m gonna run down to the caf and eat something before the case starts, text me when the patient’s in the room.”

This was really the resident’s job: to make sure everything was ready to go. You were supposed to check that the pre-op exam had been completed, consent forms were signed, and all the instruments needed for the case were already in the operating room. Nick was happy to delegate the grunt work to med students. He loved to preen and show off his surgical skills in the OR, but he didn’t care enough about the less glamorous (yet still essential!) parts to making a surgery successful. Positioning the patient on the table properly wasn’t sexy work, nor was prepping the scrub tech for all the necessary sutures and bandages for closing, or even displaying the critical images of the MRI on the OR computer screens that could help jog a surgeon’s memory. But it is all critical.

I dipped into the bathroom to splash my face with some cold water. I had been up for twenty-six hours and was exhausted. My breath stunk, my scrubs were wrinkled, and my eyes looked like a raccoon’s. My contacts were so dry they felt like they were going to invert themselves and pop off. I decided to switch into my glasses so I could resist the urge to rub my eyes and contaminate myself during surgery.

I had a few minutes before the surgery was supposed to start, so I popped into the room to see if Laura, the circulating nurse, needed any help.

“Oh my God, that would be amazing! Could you run down to central sterile and get this retractor sterilized? Biggs realized Halpern’s favorite retractor was missing so I had to find it, but it needs to be flashed.”

“No problem, be back in a jiffy.” I tucked the retractor under my arm and slipped out the back door.

The basement of a hospital is terrifying: it’s dark, with no glaring fluorescent lighting down there; it smells, like if sulfur and chlorine had a baby; and it’s hot, steamy even.

Morgue . . . no . . . pharmacy . . . no . . . laundry room . . . no, where the hell is central sterile? I thought as a wandered through the maze of unmarked corridors. Finally, I spotted the tiniest, most unassuming sign for central sterile. But when I pleaded my case to get the retractor flashed stat, the attendant pointed to the mountain of tools also waiting to be flashed stat and didn’t seem interested in helping me bump my retractor to the front of the pile.

“Listen, I’m not sure if you’ve met Dr. Halpern before, but if he doesn’t get this special retractor then I’m going to look like a failure, and I really want to match into this residency program, I want to move back home to New York and be with my fiancé and be closer to my family and . . .”

“All right, give me the thingy already.” Listening to a twenty-something girl whine and complain was not what the attendant signed up for working in the basement of central sterile.

“Thank you!” I wanted to lean over and plant a big kiss on him but quickly decided that was not appropriate med student behavior.

Fifteen minutes later I was handed a steaming hot tray wrapped in thick blue towels. I carried it triumphantly into the OR and Laura unwrapped it like a wife opening up the last tiny box on Christmas.

NOW THE SURGERY COULD FINALLY START.

“Are there any patient-specific concerns?”

“No.”

“We have collectively and independently verified the patient’s name and procedure, you may begin.”

Nick locked eyes on Biggs and held out his hand to accept the scalpel.

Biggs, knowing better, waited for a cue from Dr. Halpern.

“Dr. Stewart, what were Ms. Cranston’s physical exam findings that were consistent with her MRI imaging?”

Stewie had not taken the time to put up the images (that was me) or review them (like I had), nor did he take the time to interview Ms. Cranston in pre-op holding (her final straw was when she lost all her strength to lift her foot, which caused her to trip over her feet and fall into a display of free samples at Costco).

“I . . . I didn’t have time to examine Ms. Cranston in pre-op, I was busy . . .”

“Scalpel.”

Dr. Halpern placed his hand over the patient’s abdomen so Biggs could slide the scalpel directly into his grip without taking his eyes off the incision.

Nick reluctantly picked up the suction, annoyed at being relegated to assistant status.

I slipped out the doors to start scrubbing, and when I came back Biggs gave me a This is going to be a looong case look as he put on my gown and gloves. I took my place behind Biggs and Stewie, catching periodic glimpses of the surgery when Biggs would reach for something or Stewie slumped his shoulders because he could not feign interest anymore.

“Erin, what structures make up Calot’s triangle?”

Whoa, this was coming out of left field. I was scrubbed into a spine surgery and was getting pimped with liver questions. But I didn’t waste my Saturday nights hanging out in the library with a pile of textbooks and flash cards for nothing.

“Cystic duct, cystic artery, and . . . common hepatic duct.”

Dr. Halpern did not look up, he did not pause the rhythmic motion of his pickups and tenotomy scissors, he did not offer any words of affirmation.

“Laura, get a stool for Erin so she can actually see something.”

Laura looked at me, beaming like a proud mother, and rummaged under the surgical desk to find a stepstool. She placed it behind Biggs so that I could watch Dr. Halpern dissect through the deep abdominal cavity.

It was like my textbook was coming to life. I was fascinated. Blunt dissection through subcutaneous fat to the anterior rectus fascia. Divide transversalis fascia to get into the retroperitoneal space. Blunt dissection down to the psoas. Retract medially along the left ureter. Those Saturday night study sessions had nothing on watching it happen in real life.

I was shook from my reverie by the surgeon asking, “Erin, can you tell me which vessels these are?”

They were so deep into the cavity I had to stand on my tiptoes in order crane my neck over Biggs’s shoulder. I leaned in so that I could have a direct view of the structure he was pointing to and that’s when the unthinkable happened.

Just as I was about to triumphantly name the iliolumbar vessels, I felt something slip off my face. I watched in blurry horror as my glasses landed straight on the patient.

If it were a Grey’s Anatomy episode, this would be when the music crescendos and the camera pans in on the Drama. Honestly, it was like that in the OR as well. Laura gasped. Biggs’s eyes looked like they were going to pop out of his head. Stewie almost dropped the retractor onto the floor. Even the anesthesiologist peered over the curtain to see what all the fuss was about. And I stood there. Frozen. Too scared to even blink. Everyone waited to see what Dr. Halpern would do. I figured he’d kick me out, yell, tell me I’d never become a doctor.

But none of that happened.

“Biggs, pick up Erin’s glasses, place them on the counter and then change your gloves. Laura, get me a huge piece of Ioban. Stewie, do not move your retractor, we have a perfect view. Erin, step away from the table.”

As I gingerly took a step backward off the stepstool, I picked up my glasses, and walked out the double doors. I ran through the hallway to the nearest bathroom, cheeks burning red, eyes welling up with tears. I had never been so embarrassed in my whole life. Why did I have to wear my stupid glasses, I hated these glasses, I never even wore them to work before. As the soapy water washed over the frames, I prepped myself for becoming the laughingstock of the ortho department. It was hard enough to infiltrate this boys’ club as a girl, now I was going to become a joke.

After spending a few minutes sulking behind the scrubs dispenser I realized my white coat and all my stuff was still inside the OR, and I was going to have to show my face again at some point. So I slipped back into room 4 hoping no one would notice me.

“Your gloves are on the table,” Dr. Halpern said without taking his eyes off the patient.

Wait, did he want me to scrub back in? I thought I was exiled. I looked at Laura and she motioned for me to go outside to scrub my hands.

I scurried outside and put on a face shield (there was no way we were going to have a repeat of that catastrophe) and scrubbed my hands until they were red and raw. I backed into the room and a table had been set up for me to self-gown and glove.

After I finished putting on my gloves, Laura tied my gown and I settled behind Stewie with my hands crossed over my chest. I was going to stand still and make sure that nothing I did would further disrupt the surgery. Then Dr. Halpern motioned for Biggs to move the instrument tray to the bottom of the field.

Biggs moved to the foot of the patient, and I realized what Dr. Halpern was doing: he was making room for me to stand right next to him.

Under my mask I bit my lip and my nostrils flared. My chest tightened and it took every ounce of willpower to not spill any tears. I took a deep breath in as Dr. Halpern placed the special Langenbeck retractor in my hands.

And then I exhaled.

“Now, what are the names of these vessels again?”

DR. HALPERN GAVE ME A PRECIOUS GIFT THAT DAY: THE knowledge that mistakes are inevitable. What matters is our response to the mistake. Do you stay cool under pressure? Can you think on your feet? Do you publicly show support for your team members? A surgeon once told me, “Confidence comes from our ability to fix our mistakes.” I was lucky to have learned this lesson early in my career, so I could have a better perspective on how to forgive myself for an accident, and later, help other medical students learn that as well. And of course I stopped wearing glasses in the OR.

Chapter 5

Once a Champion, Always a Champion

We are all one phone call away from our lives being irrevocably changed. Kevin’s accident was proof of that.

Only you don’t know the days that are going to change your life forever.

JUST A COUPLE MONTHS BEFORE, THINGS WERE GOING QUITE well. I’d married my husband, Justin, in a beautiful ceremony surrounded by our friends and family. I graduated from Brown University’s Warren Alpert Medical School and officially became Dr. Nance. I moved into Justin’s apartment in the City, truly palatial living compared to the standard resident housing for interns who were not married to an investment banker.

It’s a beautiful moment in time the month before residency starts. You already have a secured spot for the next five years (hopefully in a city that has some good late-night pizza options) and you don’t have to start repaying that mountain of debt for the hundreds of thousands of dollars you took out for the privilege of going to medical school . . . yet.

The day of Kevin’s accident started off like most others: I took a long walk in Central Park, watching the tourists climb the giant bronze mushrooms of the Alice in Wonderland statue, listening to the sounds the Ancient Playground filled with the squeals of children and the gossip of the nannies sitting on the benches. These simple mornings were about to be replaced by the caustic sounds of sirens, the harsh fluorescent OR lights, sneakers screeching to rush to the next code, and the smell of vomit and death. I knew there would be plenty of emergencies, I just didn’t expect the first one would be in my family.

Kevin’s accident caught me by surprise, as most accidents do. No twenty-two-year-old kid wakes up one day thinking this will be the last time you can open a can of soda, tie your shoelaces, or write your name. Kevin was an incredible athlete, but he didn’t become a Division I track star and member of Team USA just because of his athletic skills. No one wanted it more than Kevin. He was tenacious. He had grit. It didn’t matter if his opponent was twice his size, he would find a way to get to that finish line first. If you walked into his bedroom, you would see the walls covered with running bibs with his record-setting times written in Sharpie marker, newspaper clippings about all the races he won, medals stacked by the dozens, and championship trophies from baseball, basketball, roller hockey, and of course track.

He was a specialist in the three-thousand-meter steeplechase, the most grueling and exhilarating race in a track meet. It’s the event where in the middle of the track they have to jump over high hurdles and a water pit. A Steeplechase event is must-see TV because of how exhausting the race is; inevitably someone slips on top of the hurdle and lands face-first in the pool of water, causing a chain reaction of runners crashing into the pool, making it as close as possible to a contact sport in track. Little did he know that being an elite athlete, both in mind and body, is what saved his life when he could not even move a muscle.

When I made that trip out to Stonybrook Hospital the night of July 5, 2009, I had no idea this would now be the before and after date for the entire McDermott family.

After that first vigilant night in the ER, Justin had arranged a hotel room near the hospital for me to get some sleep. When I woke up after about four hours, Justin was quietly tapping on his computer, and there was a Gatorade and bagel on the nightstand. Just for a moment I allowed myself to pretend like I had woken up from a dream. My teeth were glazed with that horrible fuzzy film from going to sleep without brushing them, my hair was in a massive knot from sleeping in a messy bun, and my contacts were so dry they felt like they were about to shatter into a million pieces.

Justin looked up from his computer; I probably looked like one of those weird silent horror movie dolls. He rushed to my side. “Your dad called. They haven’t taken him back to the OR yet.”

I flew off the bed, “What?! They still haven’t taken him back? I gotta get over there. I mean he is at minimum a level two add-on. I can’t see what else could bump him, and he should have priority over any of the elective cases . . .”

“You need to eat.”

“I’m not hungry . . .”

“You haven’t eaten since yesterday.”

“I’m fine.”

“Eat this now.”

He shoved the bagel into my hands, and I took a bite under duress.

As I rummaged through my work bag looking for some type of gum so that I wouldn’t offend anyone when I went back to the hospital, Justin plopped a duffel bag onto the bed. It had fresh underwear, socks, and a shirt I would never pair with workout pants, but I appreciated the effort immensely.

“There’s a toothbrush in there and I grabbed some of your contact stuff.”

I leaned over and kissed his forehead.

I doused my eyes in artificial tears and threw on the clean clothes.

“I’m going to head over there now. Plan on me staying at the hospital overnight.”

“Again?”

“Someone has to be with him at all times and my parents need more rest than I do. So I’m going to be the night person.”

“Do you need me to tell your job?”

Shoot, I totally forgot about Lenox! I grabbed my phone and skimmed through all the hundreds of unread texts. Alex, my orthopedic surgery co-resident, had messaged me five minutes ago.

Sorry to hear about your brother. Dr. Hershman asked me to switch with you, so you can start on Internal Medicine and I will do Gen Surg. Praying for you and your family.

It’s hard to describe to someone who has never been through surgical training the impact this simple switch had on my ability to continue with residency and be there for my family when they needed me most. General surgery internship is the most grueling, intense trial by fire that exists in our healthcare system. It’s where you learn what to do when a patient crashes; how to close a complex wound in the OR; how to keep people alive in the most challenging circumstances. It’s why all of the surgical specialties (neurosurgery, orthopedic surgery, vascular surgery, et cetera) require their trainees to start in general surgery first.

WITH THAT TAKEN CARE OF, I WAS ABLE TO FULLY FOCUS ON my brother. When I arrived at the hospital, Kevin had not moved from his spot in the trauma bay, and it sent me into a fit of rage. Why is he still lying here? He’s freaking paralyzed, doesn’t anyone realize how critical he is? Where is the intern on this case? Did they speak with the OR charge nurse directly? ’Cause I’ll march right into that OR desk and make him next on the add-on list.

My dad, knowing how things really functioned after working in hospitals for over twenty years, reassured me that the surgeon had been in contact with them, and that Kevin would have his surgery today.

So we waited. And waited. And waited until I, the designated night watch person, started to nod off. And then finally the ER nurse, exasperated by my constant hounding, told us it was time. We said our goodbyes and good lucks, patted him on the head, and he was wheeled off down the long corridor and into the cavernous patient elevator.

THE FIRST POST-OP NIGHT TAKING CARE OF KEVIN I LEARNED just how needy someone without any use of their arms or legs could be. The surgery was a massive four-hour-plus procedure to fuse the bones in his cervical spine that had been crushed by the diving accident. And because he still had feeling in his neck, he required large amounts of narcotics to help keep the pain managed.

Now most patients when they have a massive spine surgery are put on something called a PCA, a patient-controlled anesthesia device. This allows the patient to hit a button and a small dose of narcotic is injected into their IV to deliver immediate pain relief. The patient is therefore able to control how frequently they need pain medicine.

But in Kevin’s case, he could not hold a pain button, so he needed someone to ask the nurse to get him pain medicine throughout the night. This doesn’t sound like such a big deal except if you have never been in an ICU, the nurses are constantly busy keeping people who are teetering on the verge of dying alive and don’t have time for “requests.” And don’t quote me, but if you ask an ICU nurse, they will probably tell you they prefer working with unconscious patients.

In addition, Kevin had not eaten in over thirty-six hours and his mouth was so parched from not drinking water as well. So, I would hold the big pink water pitcher with a straw under his mouth so that he would sip it, one gulp at a time, throughout the night. I took it as a personal failure if I saw his urine bag was too dark and I would make him drink until my arm got tired of holding the pitcher.

An unintended side effect of the pain medication was that it made him extremely itchy, but on the only part of his body he still had feeling: his face. So, if you peeked into his ICU room in the middle of the night this is what it would sound like:

Er, you up?

Yep, what do you need?

Can you scratch my face?

Sure, where?

Right under my nose?

Okay.

No, not that side, the other side of my nose.

Okay.

No, underneath that part of my nose.

Okay.

You’re not itching hard enough.

How hard do you want me to itch?

No, now you’re scratching me.

Deep breath. Kevin . . .

Sorry, that’s fine, I’m good.

Five minutes later.

Er, you up?

THERE WAS ANOTHER CRITICAL REASON WHY SOMEONE needed to be with him at all times, because as I already knew as an intern, we like to do all of our rounds at the crack of dawn when there is no family around and the patient is too groggy to ask questions. That’s the only way we can efficiently check on patients before we are physically tied up in the operating room all day.

The junior resident came first around 5:00 a.m. to gather the overnight vital signs and asked Kevin if he noticed any changes in his strength.

“No new voluntary upper or lower extremity movement,” I chimed in.

The intern looked at me like I just declared Chicago deep dish was superior to a New York slice.

He looked back at Kevin.

“Anything new?”

“Nope.”

He nodded his head and dashed out before I could even open my mouth to ask when the attending was coming.

“The team,” as the pack of doctors and assistants that round together is affectionately known, has an almost identical structure no matter what specialty it’s composed of. Leading the pack with an air of importance that is greatly inflated is the chief resident. They like to take credit when things are running smoothly and are quick to blame a junior when anything goes wrong. Next is the attending, who is the person usually looking the least stressed out of everyone. They are not furiously typing on the rolling computer, their hands are not filled with patient lists or buckets of wound supplies, and they listen when the overnight nurse tells them something important that the junior resident forgot to ask.

The junior resident has the most pressure on them as they are the ones responsible for gathering and interpreting all the information and then synthesizing it for the entire team that shows 1) you are thorough; 2) you actually know what you’re talking about; and 3) you, too, one day will have the confidence to be the team leader. The med students generally are the clueless-looking ones carrying buckets of supplies and cheat sheet books weighing down the pockets of their short white coats. The NPs and PAs bring up the rear wheeling the mobile laptops, feverishly trying to convert all of the verbal plans set out by the attending into the web of order sets and medication alerts and notifications necessary to set the plans into motion for each patient.

There’s no knocking in the ICU, so the gaggle of medical professionals stormed into Kevin’s room unannounced.

“Kevin McDermott, twenty-two-year-old male, C6 burst fracture, C7 ASIA A Quad, post-op day one status post C5-T1 posterior spinal fusion, no overnight events . . .”

“Actually, his pain was not controlled with PRN morphine and he had a significant histamine reaction causing severe itchiness, which, when you can’t scratch yourself ’cause you’re paralyzed is a really big deal,” I couldn’t help saying.

The attending looked at me and cracked a faint smile.

“Switch him to Dilaudid.”

I gently nodded in appreciation.

The NP furiously clacked away on the laptop.

The junior resident, my new foil, cricked his neck and continued speaking, “Vital signs stable . . .”

“Jenson, what’s the triad of neurogenic shock?” the chief resident barked.

The junior resident gulped.

“Hypotension . . . hypothermia . . . and . . . and . . .”

Bradycardia.

“Hypotension, hypothermia . . . and . . .”

Dude, it’s bradycardia.

“Bradycardia, Jenson, don’t just say someone’s vital signs are stable if you don’t even know what we’re looking for. Read a goddamn book.”

Okay, now I felt a little bad for the guy.

“Kevin, how are you feeling this morning?” the attending asked as he walked over to the head of the bed, trying to distract from the temper tantrum his residents were throwing.

Kev’s voice was so hoarse from the intubation tube that had been down his throat for so long during surgery, he could only whisper.

“It hurts a lot but I’m okay.”

“Glad to hear it, I’m just going to do a few tests if you don’t mind.”

Kevin ever so slightly shook his head within the confines of the Miami J exoskeleton brace that encased his neck and torso.

The attending asked him to squeeze his fingers.

Nothing.

He asked him to push down on the gas pedal with his feet.

Nothing.

Then he motioned for the medical student to come next to Kevin’s feet.

“Have you ever seen a positive Babinski?”

This is one of the key tests for paralysis. Basically, if everything in your body is operating as it normally would, tickling the bottom of a foot leads someone to curl their toes downward. It’s reflexive, something you wouldn’t even think about. When you have a spinal cord injury and perform this same test on the sole of the foot, the big toe shoots up straight, extending proudly.

The attending put his hand into his white coat pocket, you might have thought he was going to pull out a leprechaun, that’s how much anticipation was in the med student’s eyes.

When he pulled out the reflex hammer, he was holding it upside down. He lifted Kevin’s foot in the air and gently used the sharp, pointy end of the hammer to scratch a large C shape on the outside bottom of his heel, along the lateral border of the foot, and across the ball of his foot toward the big toe.

Sometimes when the spinal cord is just bruised and not transected, the patient can go into a period called “spinal shock,” which is a temporary loss of spinal cord function below the level of injury. It’s like God playing a game of Gotcha! and what you thought was a catastrophe turned into just a blip on the radar. Deep down inside I was hoping that the injury was not that serious, that it would blow over after a few weeks of rest and therapy.

All I could hope was that Kevin would curl his toes, but he didn’t. Couldn’t. Seeing the look of wonder on the med student’s face told me all I needed to know.

BEFORE MY FOURTH NIGHTSHIFT STARTED, I WOKE UP TO visitors in my hotel room.

Mandy, Caitlin, and Moira: my three bridesmaids.

“Aww, thank you guys for coming, did you go to the hospital already to see Kev?”

“Er, it’s your birthday. We’re taking you out to dinner.”

I stared at them blankly. It had not even dawned on me that today was my twenty-sixth birthday.

“That’s really nice of you guys but I’m not very hungry.”

“Justin told us you haven’t eaten for days.”

Which was the truth, I couldn’t argue with them.

“I just don’t have any appetite.”

“Well, we’re having a birthday dinner and you’re coming.”

They dragged me out of the hotel room and brought me to the fanciest restaurant within walking distance of the hospital.

I sat, motionless and mute for the entire dinner, while the girls tried to cheer me up with tales from the New York City dating scene and good gossip about our classmates. And I appreciated everything they were trying to do for me. I just wasn’t in a place to process and accept the love. I was in survival mode. I didn’t even have the breath to blow out the lonely birthday candle.

THE WEEK IN THE ICU BLEW BY FAST, WHICH IN RETROSPECT was hard to believe when the patient alarms would go off every three to five minutes for some sensor that became askew or vital sign reached dangerous levels. When the day came for Kevin’s transfer to Burke Rehabilitation, his home for the next six months, I was nervous to leave the security of those monitors, those alarms. But, as we would soon learn, in the discomfort is the growth.

When we arrived at Burke we were introduced to Kevin’s roommate via his nurse, because Francis, a teenage boy with a traumatic brain injury, couldn’t even speak.

The first night at Burke we settled into our normal routine of scratching, dabbing, and rolling. The night passed uneventfully. The next morning my mom pulled me aside.

“Er, we think you should go back to work.”

“Go back to work? No, Kevin needs me here. I’m good.”

The thought had crossed my mind of quitting residency altogether and just help Kevin full-time, but I couldn’t say that to my parents. I knew they’d never go for it.

“You need to live your life, and you need to become a surgeon. I can’t have two kids shatter their dream.”

This hit me hard. I knew no one had ever asked me to sacrifice anything to help take care of Kevin, but I wasn’t thinking of the implications this was having on my career, on my brand-new marriage. Something needed to change. We decided as a family that we’d make a calendar with rotating shifts, so that someone was always with Kevin overnight, and he wouldn’t be alone.

I went back to my apartment for the first time in nine days; I slept like a bear in hibernation.

When I finally did wake up, Justin showed me a six-month calendar with every night filled in with the name of a person who had volunteered to sleep over with Kevin. Friends, cousins, caddies he worked with, former teachers, even an ex-boyfriend of mine, had all signed up. I immediately started sobbing.

THE DAYS AT BURKE WERE LONG, BUT THE WEEKS FLEW BY. Each week that passed without regaining any function meant it was less likely that he was ever going to regain any function. I started back to work on internal medicine with an attending straight from heaven. After morning rounds together with the team, she would shoo me out the door so that I could visit Kevin in the afternoons and get home in time to be ready for another day.

One crisp, sunny, fall afternoon, my mom and I wheeled Kevin to a garden outside to get some fresh air. He had hardly any lung capacity, but I believed the cool air would do him good. I found a warm blanket (he had no feeling, but I still felt it was important to keep him warm) and as I was placing the blanket on top of him, I saw it. It would be imperceptible to anyone else, but I was positive, I saw his right big toe move a millimeter.

“Kevin! Your toe! It just moved! I saw it!”

I grabbed my mom by the arm and pulled her down to look at his feet.

“There it is again! It’s moving! Are you moving it?!”

Kevin bit his lip, and I saw his eyes start to water.

“I didn’t know if I was really moving it or if I was imagining it. I didn’t want to get my hopes up . . .”

The three of us hugged in a circle while my mom and I jumped around while Kevin tapped his big toe like he was sending a message in Morse code. The most powerful drug is hope.

KEVIN MADE PROGRESS BEYOND OUR WILDEST DREAMS AT Burke. Even as an orthopedic surgeon, I was unaware of the recovery that someone with a spinal cord injury could make. Most people are familiar with Christopher Reeve’s story, Superman, the ultimate hero, who became a quadriplegic and a leading advocate for spinal cord research and medical advances. The man who once leaped over buildings was confined to a power wheelchair, dependent on a series of plastic tubes and oxygen tanks to keep him alive.

I had no idea that a person could recover some, and in some super rare instances, almost all of their pre-injury functions. Whenever we asked Kevin if he wanted to speak with someone who had his same injury, he always said the same thing, “I only want to speak to people who made a full recovery.” He wasn’t interested in learning how to live with a spinal cord injury, how to use the catheters, the adaptive silverware, the leg braces. He only wanted to speak with people who were cured, so he could learn the secret from them, how they did it, how they beat it. But it doesn’t work like that. A spinal cord injury is not like cancer, you don’t beat it. No matter how badly you want to, you learn that this is an injury where the recovery is out of your control, no matter how cruel that may be.

As time went on, he regained some strength in his upper arms, his forearms, and his wrists (his fingers and fine motor control were still painfully weak). He was even able to stand on his own and take a few steps with the help of his physical therapists. One day the six of us were crammed into his room, bored and getting on one another’s nerves. He was growing increasingly frustrated with trying to maneuver his big clunky motorized wheelchair around his room in tight spaces. I had never heard him complain, not even once in the three months since the accident, but he was being a bit whiny.

“Get up,” my youngest brother Ryan told him.

“What?” Kevin made a dismissive motion with his hand and acted like he didn’t hear him.

“I said, ‘Get up’ and get out of that chair.” Ryan looked him dead in the eyes.

Kevin looked back at him and realized he was not playing.

“Get out and into that manual wheelchair. I don’t ever want to see you in that chair again,” he said resolutely.

The manual wheelchair had no electronics, no aides to help propel the chair forward. It would be up to him to push the chair by himself if no one was around. Not only did this require a significant amount of arm strength, but also required lung endurance and was a cardiovascular workout. No one had challenged him like that before. Up until now we all just tried to be positive and encouraging and inspirational.

Ryan put the walker in front of the power chair and held it in place while my dad helped lift him under his armpits to get him into a standing position. Once he felt like he had an adequate grip on the hand bars he straightened his spine. I forgot he was five inches taller than me.

My mom pressed the control button to move the power chair from behind him and Sean rolled up the manual wheelchair right behind his thighs. He held tightly onto the back hand rails of the manual chair to brace for when Kevin fell back into the chair to sit, which he did, landing like a hundred fifty pound Weeble Wobble.

Once he was able to position himself into an upright seated position, I flipped open the brakes on the wheels and he began to push himself. It took every ounce of strength to move those wheels, and slowly but surely, he inched past the bed, then out the door, then down the corridor and past the nurses’ station where I saw his battle-ax nurse crack a smile. He rolled up and down the hallway, feeling the slightest breeze he created for himself, and never sat in that motorized chair again.

“HEY KEV, YOU GONNA DO THIS TODAY?” I BROUGHT HIM A flyer from the front desk for the Burke Olympics. The staff was throwing a competition for all the residents of the rehab facility like a grammar school field day.

“Nah, I don’t think so,” he said, brushing it off.

“Come on, it will be fun!” I tried to hype it up.

“No, I’m good,” he repeated curtly.

It didn’t occur to me that encouraging him to compete in any type of competition in his state was insensitive and probably made him grieve for the athlete he once had been.

“Well, let’s go outside and cheer the other people on.”

My whole family joined us, and we went outside to watch people recovering from strokes, traumatic brain injuries, Guillain-Barré syndrome, and spinal cord injuries compete in mini races around the track. They had decorated the field with race flags and people were cheering with pompoms and whistles. Some people were using walkers, other people were using canes, and some people were racing in wheelchairs. It was a raucous atmosphere as a few of the races were quite close and the crowd really got into the competitive spirit.

“Hey Kev, the last event is a hundred-meter dash for people in wheelchairs, you should do it!”

“I can’t do that.”

“Sure you can. You can take a break if you need to, I can help give you a push if you want, but I think you could do it.” I was giving him some positive needling.

“Okay fine. I’ll do it.” I think he just wanted me to shut up.

We rolled over to his physical therapist, Marie, who loved to give him shit, and I wouldn’t be surprised if she had some side bets on these races. She positioned him on the track and then placed the biggest, dorkiest, oversized helmet on his head.

“Sorry, dems the rules,” she said as she quickly clipped the helmet on before he could change his mind.

Kevin was lined up with five or six other wheelchair racers, mostly in their seventies and eighties, people with dentures and hip replacements. Only four months ago he was racing in the NCAA championships.

“Take your mark . . . go!” A gun went off and the octogenarians burst off the line. They were surprisingly coordinated and not holding back. They jockeyed among one another for the lead back and forth, back and forth, until they finished in a flurry across the red winner’s tape.

Then I looked back, and there was Kevin. He was barely past the starting line, moving like the tortoise, with his head hanging low under the weight of the helmet. Each revolution of the tires required about six pushes, requiring an immense amount of effort. He tried to use every ounce of voluntarily muscle movement in his body to help propel the chair forward.

With all the racers finished, the crowd’s entire attention was on Kevin. At first, I was mortified. Why did I push him to do this? It must be so embarrassing for him. Imagine being one of the fastest people in the world now reduced to moving at a snail’s pace.

But then the energy from the crowd started to grow and grow. And I could see the determination on Kevin’s face, that same grit he showed splashing into the steeplechase pool, passing others who would stumble out of the pit.

That hundred-meter dash might have been the slowest hundred-meter dash ever recorded, but once he crossed over the finish line there was a roar as loud as if this were the real Olympics. My family surrounded him, slapped him on the back, and congratulated him.

“How’d I do?” He was panting heavily and looked up at me with that ridiculous helmet.

“You won Kev, you won.”

Chapter 6

What Am I Going to Tell the Family?

Patients die. We all know that. In fact, my very first morning back to work after Kevin’s accident, the first patient I went to check on was dead in his bed. Dead-dead. Like, dead as a doorknob. After a momentary freak-out and cry for help that woke up the entire floor, the nurse rushed into the room, made sure I wasn’t having a heart attack, and calmly pointed out the bright purple “DO NOT RESUSCITATE” bracelet on his wrist.

There’s a reason I chose to become an orthopedic surgeon: we get to put people back together. It’s like Humpty-Dumpty, but with better success rates. Other surgical specialties—like cardio or neuro—have much higher mortality rates, and the patients are generally pretty sick. Orthopedic surgeons treat mostly healthy people who injure themselves.

Patient deaths are a rare occurrence on the ortho service. Most of the time, a patient may already be very sick, have a fall, and die as a combination of the injury and being ill. Or a patient is injured so catastrophically, like they were literally hit by a bus, that they cannot survive the trauma. But patients who are otherwise healthy and die because of an elective orthopedic surgery are very rare.

After finishing three months of mostly elective rotations (internal medicine, ER, and anesthesia) where the attendings looked the other way while I mostly spent time supporting my family and helping Kevin’s recovery, it was time for the main event: the ortho service.

“Eight-thirteen: Post-op day three status post total knee replacement, looks good, on coumadin, home today.”

Check.

“Eight-nineteen: Post-op day two ACDF, finally peed overnight, get him out ASAP.”

Check.

“Eight-twenty-two: Post-op day one tibia IM nail, make sure PT gets him up on crutches, he has to be able to walk to go home.”

If you’re noticing a theme to weekend rounds it is get the patients home as soon as possible. The hospital even has a name for this practice: throughput. You see, when a patient has surgery, let’s say a total knee replacement, the insurance company only pays the hospital a set amount of money, no matter how many days the patient stays to recover. So the hospital gets to keep more money the less amount of time the patient stays in the hospital. As the intern, you have no idea about the economic factors that drive medical decision-making. You are just trying to survive and keep your patients alive—and get them home so your list of patients becomes smaller.

Sign-out for the rest of the forty-five patients on the list sounded the same, and then the bomb dropped.

“Heads up about eight-forty-seven, the nurse was paging me all night. Her heart rate keeps going up, I bolused her a bunch of fluids, her blood pressure keeps dropping, too. She’s complaining of belly pain, but she’s only post-op day two from a front to back spine fusion so she’s gonna have pain. I upped her PCA and put in for some rescue doses. Then this morning her O2 sats started to drift and her alarms are going off like crazy. If I were you, I would get a CBC, BMP, chest X-ray, and ABG STAT.”

Trouble first thing in the morning is never a good sign.

“Okay, does the attending know about all this?” It was considered a sign of weakness if you couldn’t figure out a problem on your own, but I had a sense this was going to be above my pay grade.

“He never comes in on the weekend and he hates to be called overnight. I guess you can let him know what all the labs show when they come back. I gotta bounce, I’m exhausted, you good?”

“Sure. CBC, BMP, chest X-Ray, ABG, got it.”

And with that, I was on my own.

Before I started putting in the hundreds of computer orders that were needed for all the patients that were solely my responsibility, I thought the best first thing to do was meet Ms. Weston.

When I walked up to the room, I heard screaming from the inside; I braced myself for what was coming.

“Are you my doctor?!” A woman unhinged with pain was writhing around. She reached out toward me, and I was worried she would suck me into her bed if she got ahold of me.

Startled, I took a few steps back.

“I’m sorry, I’m actually here to see your neighbor”—I pointed a shaky hand to the calm woman across the room—“I’m sure your doctors will be here soon.”

I sped past her and threw the curtain between the two beds closed so fast I gave myself whiplash.

Phew.

“Hi, Ms. Weston, I’m Dr. Nance, I’m the orthopedic surgery resident on call for the next twenty-four hours, nice to meet you.”

She tried to push herself to sit up straight causing her to wince and I told her just to relax.

“Nice to meet you too, Dr. Nance.” She smiled and took some deep breaths.

“I heard you had a rough night last night.”

“Well, not as bad as others.” She nodded toward her neighbor who had not stopped screaming.

“Do you mind if I take a look at your incisions?”

“No, not at all.”

I pulled the comforters up to just under her waist to keep her covered while I lifted her gown above her stomach. As I peeled back the bandages, the wounds looked clean and there was no redness or signs of infection. I pressed on her abdomen around the wound and there were no masses. When I gently rolled her on to her side to look at the back wound, she felt winded and had to take a moment to catch her breath. The back wound looked clean as well, so I turned her back to her original position.

“Well, so far looks like everything is healing the way that it should. I would like to run some tests to see why your heart rate is a little higher than normal and figure out why your oxygen level is running a little low.”

“No problem, I feel like I’m a human pin cushion at this point.”

“I need to get some supplies for a special test, be back soon.”

I ran past the screaming neighbor and slid into the nurses’ station to put in the orders. The CBC, BMP, and chest X-ray would be performed by the techs, but the ABG was a doctor-only test.

ABG stands for “arterial blood gas.” If you’ve ever had your blood drawn, you’ll recall that the nurse or technician will tie a rubber band around your arm and then stick a needle into one of your veins. This is called “venipuncture,” and it allows the lab to measure certain cells and electrolytes in your body. But to measure the true oxygenation of your blood to see if your body is getting the proper amount of oxygen, you have to draw the blood from the artery. In order to draw blood from the artery, we will stick a large needle into the radial artery of your wrist. This is a higher-stakes puncture since damage to the artery can lead to catastrophic problems.

The other difference when drawing an ABG is that the vial of blood has to be kept on ice for the results to be accurate. After gathering all the supplies, I went on the hunt for ice. Hmmm, where would the ice be? After a cursory look around the nurses’ station and a bunch of shrugs from the secretary and nurses’ aides, I went up and down the hallway, multiple floors with no luck. Then a lightbulb went off: the cafeteria! There would certainly be ice there. I ran down the stairwell, through the dining room, and looked for the soda fountain. A measly scribbled note on a piece of looseleaf was taped to the machine.

OUT OF ORDER

Crap, this isn’t supposed to be the hard part of doing an ABG!

I saw one of the post-call gen surg interns eating a slice of cold pizza.

“Hey! Any idea where I can get some ice for this ABG?”

“Did you try PACU (the post-op recovery room)?”

PACU! Of course, why didn’t I think of that?

“Thanks, man. Get home soon.”

By the time I returned to Ms. Weston’s room, the neighbor was screaming even louder and Ms. Weston looked even more uncomfortable.

“They just took the labs and did the chest X-ray.” Her breathing sounded increasingly labored.

“Great, I’m going to do this procedure on your arm to take some blood that’s running through your artery, hopefully this will give us some more clues as to what’s going on in your body.”

Thankfully I got the ABG on the first shot and was able to send the lab off in time before the ice melted.

While I waited for the results, I answered the two hundred pages from the nurses who were waiting on discharge orders, pain medicine orders, physical therapy orders, and diet orders.

Then the results started rolling in.

CBC: Normal

BMP: Normal

Chest X-Ray: Normal

ABG: Normal

Seriously?! This didn’t seem right. I was missing something. I had to go back to see Ms. Weston.

When I went back to her room the neighbor had been wheeled off to a test, so we had a moment of peace and quiet. I noticed the beautiful flowers on her windowsill.

“I’ve never seen flowers like that before, they’re so lovely.”

“Oh, thank you, it’s an amaryllis. My daughter sent them to me. She’s about your age and you remind me of her. She’s always worrying about me ever since my husband passed away. She didn’t want me to get the surgery, thought it was too risky. I told her she wasn’t the one who had to live with this back pain every day.”

I gave her a sympathetic smile.

“Well, the good news is that all the tests came back normal. The bad news is I still don’t know what’s wrong with you.”

She laughed but the act of laughing caused her to recoil in pain, and that set off alarm bells in my head.

“Do you mind if I examined your stomach again?”

“Why not?” She winced.

This time when I pressed on her abdomen it was rigid, stiff like a board. And she would shield her body when I tried to press down, a defense mechanism called “guarding.”

Something was not right at all.

“I’m going to call your spine surgeon to give him an update, and I’ll let you know what the plan is as soon as possible.”

“Thanks, Dr. Nance.”

“Don’t worry, we’ll get to the bottom of this.”

CALLING ATTENDINGS ON THE PHONE IS ONE OF THE MOST stressful parts of being an intern. It’s the last thing you want to do, really, if there’s any way to avoid it. There are three rules: 1) There better be a good reason to interrupt someone during the weekend or night. 2) You must explain succinctly what the problem is and how you want to fix it. 3) Make sure there’s a reason you need them to weigh in. If you make it seem like you’ve got everything under control, they will judge you for calling them for no reason. If you make it seem like the patient is on fire, they will judge you for being an intern who doesn’t know how to do their job.

When I got the attending on the line, I could practically feel his eyeballs rolling from the other side of the line. I explained the situation and that I was concerned she was having an unusual amount of pain. He said she just had surgery.

Well, duh.

I was a bit flustered, but continued, “Yes, I know, but the pain is more abdominal in nature and not related to the surgical site. The pain has been unresponsive to her PCA and her vitals have been off since this morning despite multiple fluid boluses and O2 nasal canula.”

I paused to see if he had any comments or questions, but then the pause turned into awkward silence, so I kept going.

“I’ve already run a new CBC, BMP, chest X-ray, and ABG and everything is normal. But her abdominal exam has changed in the past fifteen minutes, and I’m concerned that she might have an acute abdomen. I’d like to consult general surgery if that’s okay with you.”

More silence.

“Did PT see her yet? Has she gotten up out of bed?”

“I don’t think she’s going to be able to get out of bed, she’s having difficulty breathing when she laughs or coughs.”

“Okay, fine, have gen surg see her, but I want her out of bed today.”

“I’ll do my best . . .”

Dial tone.

Well, that wasn’t horrible. I mean, he’d hung up on me, but it could’ve been worse.

Now to find Katie, the gen surg consult resident on call today. I had seen her in the hallway earlier and felt so relieved I could run this by her. I sent her a page and texted her to meet me in room 847.

When I walked into the room, I was shocked to see Katie already there.

“Hey! I just texted you, are you here to see my patient?”

She pointed at the screaming neighbor. “Sorry, this one’s got a perforated bowel. I’m wheeling her up to the OR right now. We’ll be back in a few hours.”

A few hours, shoot.

I looked at Ms. Weston, there were beads of sweat on her forehead, her heart rate was up to 115, and even though she wasn’t screaming in pain like her neighbor, I knew she was having an emergency too. I just didn’t know what it was.

“I’m ordering an abdominal CT,” I yelled at Katie as she wheeled the neighbor into the patient elevator.

She gave me a thumbs-up and the doors closed shut. I ran back to the nurses’ station and put in the abdominal CT order stat.

Then I waited, and waited, and waited for patient transport to wheel Ms. Weston to radiology until I just couldn’t wait anymore. I grabbed the chart, flipped up the brakes to the bed, and pushed Ms. Weston down to radiology myself.

Ask for forgiveness not permission, my mom’s voice rang in my head. And after being chewed out by the radiology tech for skipping the line, I pleaded that my case was more urgent than any of these other people who seemed fine to me.

Once Ms. Weston was safely in the radiology suite, I hustled back up to the ortho floor to answer two hundred more pages about this patient doesn’t like Percocet and wants Vicodin, this patient needs a kosher diet order, and this patient hasn’t pooped in three days and needs a laxative.

After about an hour I got a page from radiology. I called and they told me to come down to the reading room stat. It is never a good sign when the radiologist needs to speak with you in person.

I ran back down the stairs into the dark cave illuminated by the bright white computer screens. The radiology attending motioned for me to stand next to him. His index finger rolled over the wheel of the mouse and the images flashed like a horror movie.

The superior mesenteric artery, which provides the blood supply to the intestines, was blocked. This meant that the intestines had no blood supply, and they were dying. And the dying intestines were killing Ms. Weston.

I walked out of the radiology room and found Ms. Weston’s chart. I thumbed through the pages until I found the emergency contact information.

I took a deep breath, then dialed the number.

“Hello?”

“Hi, is this Ashley, Ms. Weston’s daughter?”

“This is she? Is there a problem?”

“We haven’t met, but I’m Dr. Erin Nance, I’m the orthopedic surgery resident who has been taking care of your mom all day. I need you to listen to me very carefully. Stop everything that you are doing and come to the hospital. Your mom has had a complication, and she needs to have emergency surgery as quickly as possible. You’re going to want to say goodbye before she goes into surgery. Please hurry.”

“Oh my God . . .”

Dial tone.

I called the vascular surgery on-call attending myself and explained the situation since Katie was still in the OR. I spoke with the spine attending who still didn’t seem that concerned.

After I wheeled Ms. Weston to the pre-op holding area and was filling out more paperwork, I saw her daughter run out of the elevator and embrace her mom. Ms. Weston was right, she did look like me. I watched her hold on to her mom’s hand until the last fingertip was torn out of her grasp by the nurses wheeling the bed into the operating room.

I SAW KATIE IN THE CORRIDOR AND OUR BACKS SLID DOWN the wall until we landed like a puddle on the floor.

It wasn’t supposed to be this hard, I thought, and we closed our eyes until the sound of the beeper told us it was time to get up again.

Ms. Weston never woke up. She died three days later in the ICU. The dead bowel put her body into septic shock and all her organs started shutting down like dominoes. I have replayed that day many times in my head, second-guessing my decisions, wondering why I couldn’t figure out what was going on sooner. It took me a long time to realize that while I couldn’t save Ms. Weston, I did give her daughter a gift, the gift of being present in the last moments of her mother’s life. And being there for that fingertip moment, the last moment she was truly alive, meant more to her than I’ll probably ever know.

Chapter 7

The Intern versus the Hamptons

Like most jobs, medicine is a hierarchy. Where you are on the chain determines a lot: who has to clean up the vomit, who has to sit in the front row of morbidity and mortality conference, and who has to cover call shifts on holiday weekends. When you are the intern, it is a yes, sir, no, sir environment.

Disimpact someone who hasn’t pooped in five days? With pleasure!

Take an extra night shift after you’ve already done two in a row? Nothing I’d like more!

It’s a true “thank you, sir, may I have another?” system. Little interns at the bottom of the pile are in no position to challenge the players at the top for fear of being ostracized, penalized, or straight-up fired. And so, we put our heads down, we keep our mouths shut, and we don’t rock the boat.

But sometimes when an injustice is so egregious, you don’t just rock the boat, you tip it right over. This is the story of how, as an intern, I cursed out an attending.

MEMORIAL DAY WEEKEND IS THE UNOFFICIAL START TO summer in New York. The streets in Manhattan get less crowded as doctors and lawyers go off to their vacation homes upstate or in the Hamptons. Interns, of course, don’t get that privilege. I had already worked Thanksgiving and Christmas that year, so I wasn’t exactly surprised that I was on the call schedule to cover another holiday. It was late Friday afternoon and in anticipation of another nonstop night of hip fractures and exploding abscesses, I thought I’d treat myself to the most indulgent thing an intern has time for: a frozen yogurt.

I sat on the wooden bench outside the Butterfield grocery store and watched the girls in their strappy sundresses and boys in their boat shoes line up to take the Hampton jitney. I looked down at my oversized, wrinkled scrubs with iodine and plaster stains all over the pants. Those stains were a badge of honor, because they showed that I had been operating and fixing people’s broken bones all day. But to the people passing me on their way to their summer share houses, I just looked like a hot mess. I scraped up every last shred of toasted coconut, imagining that I was one of the people off for a long weekend at the beach.

Instead of walking along the surf, I trudged back inside the hospital. Inside the ortho lounge was a junior resident, giddy with excitement over the prospect of having three full, uninterrupted days off.

“Ready for sign-out?”

He looked like a deranged golden retriever, only instead of a ball he was ready to catch some sleep. He told me he was heading to a friend’s parents’ place in Southampton. “Plus, he knows the bouncer at Talkhouse so we can get in any night. Booga Sugar’s playing all weekend!”

Okay, I was a bit jealous.

After we signed out all the information for the fifty patients on our service, I asked him, “Hey, do you know this Dr. Shuler that’s on call this weekend? I’ve never worked with him before.”

“I scrubbed in, like, one case with him. Don’t know much about him, but I did hear that he’s the official orthopedic surgeon of Sapphires.”

“You’re lying.”

He winked at me. Sapphires was the local strip club where every ortho night out ended. Then he tossed me the pager like a hot potato. “Good luck! And, Nance? Don’t call me!”

“See you Tuesday.”

And right on cue, the beeping from the pager pierced my eardrum. The frozen yogurt treat suddenly felt like a long time ago.

“THIS ONE’S BAD.”

When the overnight ER PA who has seen everything says that to you, you know it’s serious.

“Whatcha got?”

He pulled up the XR on the computer screen and I reflexively winced as soon as I saw the image. The tibia, or the shin bone, was snapped in half and you could see the bone protruding through the soft tissue shadow on the screen.

“It’s open?”

“The whole thing’s sticking out. Mom almost vomited when I took off the bandage to take a look.”

“It’s a kid?”

“Teenager. Was playing lacrosse and got pushed from behind. Leg hit the metal cage and snapped the bone right in half.”

An open fracture is when a broken bone breaks through the skin. Because the bone is exposed to the outside environment, it is at increased risk of developing an infection. Because of that infection risk, these injuries are considered emergencies and should be operated on within the first twenty-four hours. Any longer than that creates unnecessary risk for the patient.

“KNOCK, KNOCK,” I SAID AS I OPENED UP THE DOOR TO THE pediatric procedure room. A fourteen-year-old boy, still baby-faced with no facial hair, lay flat on the stretcher. He had a grass-stained Riverdale jersey on and his pads were swallowing his neck and shoulders. He reminded me of that Life cereal commercial when the guy takes a bite of the cereal, and he transforms into a little kid wearing the same supersized adult clothes.

“Jack? I’m Dr. Nance. I’m the orthopedic surgery resident on call tonight, I’m going to be taking care of you.” I put my hand on his shoulder pad and gave a nod to his mom.

“Can you tell me what happened?”

“My teammate had the ball behind the goal. I made a cut in front of the net and as soon as he passed me the ball, I felt a stick push my back into the goal and I fell forward. I heard a crack sound, and I knew right away this was bad. Everyone on the field started freaking out, I couldn’t really see or feel anything, but I knew I couldn’t get up and walk. Coach told me to lie down and keep my head back and I kinda blacked out after that.”

“Well, I’m guessing you already know you broke your leg.”

“Yep. Do you think I’ll be ready if we make the playoffs?”

Poor kid had no idea his season, maybe his lacrosse career, might be over.

“We’re going to take things one day at a time. The most important thing we can do for you is get you into surgery as soon as possible because the bone is sticking out of your leg. The longer the bone is sticking out, the greater chance you could get an infection, and we don’t want that.”

He nodded like he was following along.

After I examined him, washed out the wound, and covered the bone with an iodine-soaked bandage, I spoke at length with him and his mom about the risks and benefits of the surgery and the urgency with which the surgery had to happen. I told them that I would speak to the attending on call for the weekend and update them with a tentative plan for when the surgery would be taking place.

“Can I get something to eat? I’m starving!”

Definitely a teenage boy.

“I’m sorry, dude, until we know when you’re having surgery you can’t eat or drink anything. That’s the anesthesia law and if you break it, I’m in big trouble.”

His head flopped back into the pillow in disappointment, and I mouthed “sorry” to his mom who nodded back in understanding.

“I’ll be right back,” I told them as I slithered out of the procedure room and made my way up to the ortho lounge.

I SCANNED THE LIST OF ATTENDING PHONE NUMBERS AND found Dr. Shuler.

Ring-ring . . . ring-ring . . . ring-ring . . . ring—“HELLO?!”

“Hi, Dr. Shuler?”

“WHO IS THIS?!”

I didn’t know why he was shouting but there was a lot of background noise on the phone. Okay, I figured, time to shout.

“THIS IS ERIN NANCE, THE ORTHO INTERN. WE HAVE A FOURTEEN-YEAR-OLD BOY WITH A GUSTILLO TYPE TWO OPEN TIBIA FRACTURE. I WASHED OUT THE WOUND AND STABILIZED THE FRACTURE WITH A LONG LEG SPLINT. HE’S MEDICALLY CLEARED FOR SURGERY AND I ALREADY PUT HIM ON THE ADD-ON SCHEDULE.”

“WHAT DID YOU SAY?!!”

“I SAID I PUT HIM ON THE ADD-ON SCHEDULE.”

“I’M IN A CONVERTIBLE ON MY WAY TO THE HAMPTONS!”

Okaaay, well, that’s gonna take some time to get back. I figured he’d just let me know how long it would be, and if we needed to push the surgery.

Silence.

“FIND SOMEONE ELSE!”

What? Find someone else? It was a holiday weekend, there was literally no one else.

“SIR, IT’S MEMORIAL DAY WEEKEND. YOU’RE ON CALL, THERE IS NO ONE ELSE.”

More silence.

“FIGURE IT OUT.”

“But—”

Errrrrrrrrrr . . .

The dial tone blared in my ear.

What the hell? Talk about interns being at the bottom of the food chain. I mean, this guy was supposed to be on call and not only was he completely abandoning his duties, but now I was the one that had to clean up his mess. I texted a couple of the younger attendings who I thought might be in town and they all told me some version of, “Sorry, I’m away,” or “Sorry, I’m leaving tomorrow for vacation,” or “Sounds like you’re in a real pickle.”

A little while later I got a text from Dr. Shuler.

Dr. Nickerson’s gonna cover for me, you can give him a call.

Okay, well at least this was promising. I didn’t know Dr. Nickerson either and I had to scan the list of names and phone numbers.

Ring-ring . . . ring-ring . . . ring-ring . . . ring—“HELLO?!” The music was blaring, and people were shouting in the background.

Okay, it’d be another opportunity to practice shouting.

“HI, DR. NICKERSON? THIS IS ERIN NANCE, THE ORTHO INTERN. DR. SHULER TOLD ME HE CONTACTED YOU ABOUT THIS ADD-ON CASE FOR TOMORROW. THE KID WITH THE OPEN TIBIA?”

“LISTEN, I’M AT THE ROLLING STONES CONCERT AT THE MEADOWLANDS, CAN I CALL YOU BACK TOMORROW MORNING?”

“HE’S ON FOR 7A—”

Dial tone.

Seriously? What was wrong with these people? When the first doctor answered my call and told me he was on his way to the Hamptons, I was so naive I thought he’d say, Thanks for letting me know so quickly, I’ll turn back right away, instead of just dumping this problem of conjuring a surgeon out of thin air in my lap.

But no matter what the messy backstory was, my main job was to prepare this patient for surgery, and that meant instilling in him trust and faith that we would do everything in our power to help him get better. Me seeming panicked would definitely not help.

“I just got off the phone with Dr. Nickerson, one of our trauma surgeons, and he will meet with you tomorrow morning before surgery to go over any final questions.”

“Oh, thank goodness, you’ll be able to put the bone back in place?”

“He’ll have a metal rod down his shin, but he should be all healed up by the time fall tryouts come around.”

I could tell that this disappointed him, but I assured him that athletes tend to heal really well. They want to get back out on the field as soon as possible so they usually follow all of the instructions that the physical therapists give them. This seemed to help a bit, but I could tell his mom was still worried.

“What happens if something goes wrong?” The mom asked a very wise question.

“Well, the number one risk, because of the open wound, is developing an infection, which is why you’re going to the operating room as soon as possible tomorrow morning.”

“Should he be having surgery tonight?”

Another wise question.

“The literature supports operating on open wounds within the first twenty-four hours, and as long as there is no threat of losing the limb from a lack of blood supply, most surgeons prefer to operate during the day when they’re the most well rested.”

Nowhere did I mention that the current surgeon on record was getting down to “Jumpin’ Jack Flash” in a stadium in New Jersey.

The mom nodded and I told them that I’d be popping in and out throughout the night to get all the tests and paperwork done for his case tomorrow, but in the meantime to try and get some sleep.

The rest of the night, thank goodness, was quiet, because if there was a true level-one emergency, I’d be totally screwed. But at least I’d solved the issue at hand.

Or that’s what I thought, anyway.

WHEN 6:30 A.M. ROLLED AROUND I WENT UPSTAIRS INTO THE pre-op holding area and saw Jack lying anxiously with his mom. They looked so tired and weary; they obviously had not slept at all. I remembered the black circles under my mom’s eyes that looked like they had been permanently tattooed during Kevin’s hospital stay.

I leaned into the OR front desk’s window and spotted the nurse in charge.

“Have you seen Dr. Nickerson yet?”

“Nope, I was just gonna page you, the consent’s not signed and I don’t know where your surgeon is.”

My face burned with crimson.

“I’ll be right back.”

I made my way down the long corridor into the empty women’s locker room.

Ring-ring . . . ring-ring . . . ring-ring . . . ring—“H-h-hello?” creaked a voice that sounded like it had chain-smoked an entire pack of cigarettes in one night.

“Hi Dr. Nickerson? It’s Erin Nance, the ortho intern. The OR front desk is waiting for you to sign the consent for our seven a.m. add-on, the kid with the open tibia . . .”

“Yeah, I’m not going to make it in, sorry . . .”

Years of covering for men’s bad behavior, of doing what I’m told to do, of being polite, and respectful even when that respect had not been earned, flashed before my eyes. And before I knew it, it was as if the Holy Spirit of fed-up female surgeons possessed my body and took over.

“I HAVE A FOURTEEN-YEAR-OLD KID WHO NEEDS EMERGENCY SURGERY AND YOUR NAME IS ON THE CHART. SO, YOU’RE GOING TO GET YOUR FUCKING ASS DOWN HERE AND DO THIS CASE, DO YOU UNDERSTAND ME???!!!”

Silence.

More silence. I didn’t know if an intern could be fired on the spot, but I figured there was a first time for everything. I looked down at my dirty white coat. It would probably be the last time I ever wore it.

And then, I heard a gulp on the other end of the line.

“I’ll be there in thirty minutes.”

Dial tone.

I straightened my scrub shirt, tightened my ponytail, and checked off the little box on my pre-op checklist: confirm Dr. Nickerson available for surgery.

THE FRACTURE WAS TRICKY, AND DR. NICKERSON HAD difficulty threading the guide wire across the broken bone fragments. But after a few attempts the wire nestled inside the fragment down by his foot and his leg was reconnected inside of his body. He would make it to varsity football tryouts after all. And I, it seemed, wouldn’t get fired.

From the time girls are in kindergarten, we are rewarded for sitting still, following directions, and raising our hands. We aren’t taught how to raise our voices, which turns out, is just as critical a skill to master. I still believe in respecting authority and conducting oneself with grace and civility. I’m sure there was another way to get my point across without dropping an F bomb. But at that moment, that was all I had to get his attention. It took an out-of-body experience to get someone to listen to me and change their view.

Many old-school attendings complain there has been a shift in the attitude of residents toward work since the adoption of the eighty-hour work week. And it is true: I would never go home until everything that my patient needed was either completed or buttoned up. This was often to the detriment of my sleep, diet, friendships, physical health, and mental health. It made me fiercely protective of my patients because they were mine, they weren’t just a person who was shuffled from shift to shift. But what I’ve learned is that the number of hours that you work has nothing to do with the sense of accountability for a patient. It has more to do with the character of the doctors themselves.

I THINK THIS WAS PART OF WHY I SNAPPED AT DR. NICKERSON. I was outraged that the people supposed to be in charge were the most irresponsible. Dr. Nickerson was the one who bore the brunt of my outburst, but he wasn’t even the person who was responsible for being on call and taking care of Jack in the first place. I started to feel a little bit guilty at my misdirected rage. But his non-acknowledgment of me in the room confirmed he knew I was correct, and I was the only one who was doing right by the patient. And I tried not to curse at another human being again in my life—well, maybe at those people who talk too loudly on their cell phones on the jitney.

Chapter 8

It’s Not the Crime That Kills You, It’s the Cover-Up

My dad’s office had a shelf full of metal instruments: retractors, scissors, clamps. He called this “the most expensive shelf in the hospital” because while it looked like regular tools to me, there was a bigger story there. The shelf was full of instruments that were mistakenly left in patients’ bodies.

Like, inside them.

When I was young, I was fascinated by the stories my dad would tell me about his job. I didn’t have a good idea of what my friends’ dads did for work, but I was pretty sure they dealt with more normal problems—not babies being stolen from the nursery or nurses injecting paralyzing agents into bags of saline. As a lawyer for many different hospitals in New York, my dad spent his days wrestling with ethical quandaries—what to do when a Jehovah’s Witness parent refused a lifesaving blood transfusion for their child on religious grounds, or when a longtime partner of a patient dying of AIDS could not legally make any end-of-life medical decisions because they weren’t allowed to be married. Or, you know, how to tell a patient that a set of clamps had been left in their abdomen during surgery.

Every day, he grappled with huge decisions, and there wasn’t always an obvious right answer. Sometimes mistakes were made. But one story always stuck out in my brain as the most important lesson I could ever learn: it’s not the crime that kills you, it’s the cover-up.

IF YOU’VE HAD SURGERY IN THE PAST TWENTY YEARS, THEN you know that the side of your body where your surgery will be—left or right—will be written and confirmed one thousand times. It’s a way for doctors to make absolutely certain that, yep, they’re operating on the right side (okay, or left). There’s even a surgical time-out—the moment right before the surgeon picks up the scalpel—in order to confirm they are operating on the correct patient and the correct side of the patient. Everyone, including the surgeon, the scrub tech, and the OR nurse must stop everything that they are doing to focus on the time-out. They confirm the patient’s name, date of birth, and, of course, what exactly they are operating on.

Only after the time-out is successfully completed can the surgery begin.

The surgical time-out was modeled after the aviation checklists that pilots do to ensure the safety of the plane. It helps prevent errors, improve communication between staff members who may have never worked together before, and ensure patient safety. And while harm done to a patient through a procedure, surgery, or medication may seem like an unfathomable error, an adverse event happens in 1 out of every 100,000 patients.¹

In the United States, each year over 250,000 people will experience an adverse event, and 100,000 people will die because of that adverse event.² While doctors are legally required to report these adverse events, and they are often the subject of the morbidity and mortality conference (anyone who has ever watched Grey’s Anatomy knows about M&M), the overwhelming majority of mistakes occur in the near misses. These are errors that occur but, thankfully, don’t cause any significant injury or harm to the patient, are severely underreported, and are happening every day at every hospital.

IT STARTED WITH THE FIVE DREADED WORDS: “MIKE, WE have a problem.”

That is never what you want to hear when you are the hospital attorney.

The chief of oncology shifted uneasily between his feet, equal parts embarrassed and enraged.

“Tell me e-v-e-r-y-t-h-i-n-g.”

The chief plopped down in the uncomfortably hard chair across from my dad’s desk, just like he was being called into the principal’s office.

The patient was Mrs. Jones, a lovely middle-aged woman who found herself in the unfortunate position of being newly diagnosed with a brain tumor. But lucky for her, the team of doctors were confident they could treat the tumor with a much less invasive approach: targeted radiation therapy to her brain. By doing so, they’d be able to avoid surgery and chemotherapy. And so, she started her daily trips into the cold and sterile radiation oncology ward, armed with the belief that this magical laser beam would save her life.

Only after the first six weeks, scans showed that the cancer wasn’t shrinking. Somehow, it was growing.

Her oncologist was baffled as he looked at the images. They’d implemented the correct treatment protocol. They’d taken an aggressive, smart approach. It didn’t make any sense that the tumor would be progressing despite the daily, high-dose radiation.

Puzzled, he decided to bring her case up for larger review with the entire department to try and figure out why this tumor was growing. When he presented Mrs. Jones’s case, the patient’s radiation oncologist, the doctor who was in charge of actually performing the procedure, happened to pass by. She listened to the oncologist describe the images.

“As you can see the tumor in the left parietal lobe has grown twenty-five percent since the patient’s last scan.”

Wait, did he say left parietal lobe? The radiation oncologist had just treated Mrs. Jones that morning, and she was almost positive she had treated the right side of her brain.

She ran down to the radiation suite and furiously flipped through the procedure notes.

3/2: Right parietal lobe

3/3: Right parietal lobe

3/4: Right parietal lobe

3/5: Right parietal lobe

Fuuuuck.

Now in this moment, the radiation oncologist had a choice. She could run upstairs to the oncology conference and share with everyone she knew why Mrs. Jones’s tumor was not shrinking: they were treating the wrong side! She would have to admit that a medical error took place, and they would have to bear the responsibility for this negligence.

But this is not what the radiation oncologist chose to do.

In a move to shift the blame from the radiation oncologist to the oncologist, the radiation oncologist found the original paper order form, which contained the instructions for the radiation including the location: the “left” parietal lobe. And with the stroke of her pen, she crossed out the word “left” and wrote the word “right” on top.

I will let that sink in with you for a moment.

AFTER THE CONFERENCE ENDED WITHOUT ANY CONSENSUS as to why the radiation wasn’t working and whether or not they should change her treatment protocol, her oncologist decided to review the original order to make sure that the dosage and parameters were inputted correctly. When he found the original order, his mouth dropped.

I didn’t cross this out! Who did this?!

And so, the great oncology inquisition began.

“HAS ANYONE TOLD THE PATIENT YET?” EVEN THOUGH MY dad’s job was to protect the doctors in the hospital, his number one priority was always the patient.

“No, I literally just found out. I didn’t know what to do, so that’s why I came to you.”

As a kid I watched my dad’s hair slowly fall out of his head until he became completely bald. Now I understood why that happened.

“All right, we need to see this chart.”

So, my dad and the chief made their way into the radiation oncology suite.

“I’d like to see Mrs. Jones’s chart, please.” The chief drummed his fingers impatiently on the receptionist’s desk.

After a few minutes of painstakingly inefficient searching, the secretary handed over the chart to the chief. They huddled together in an empty exam room and began flipping through the hundreds of pages until they saw the form.

“See, I told you, someone crossed out ‘left’ and wrote ‘right’ to make it look like whoever ordered the test ordered the wrong side to receive the radiation.”

“Are you sure the oncologist didn’t do the crossing out?”

“Absolutely. We don’t do cross-outs. If you mistakenly write something in an order you throw away the form and start fresh. We would never do that.”

“Can you show me a fresh form?”

The chief looked around the receptionist’s room to find some blank order forms.

“Here. This is where we write the location, the dosage, the frequency.”

He handed the form over to my dad. My dad held the form in his hands, looked at the place where the location, the dosage, the frequency was to be written down, and then the paper separated in his fingers.

The form was not just one piece of paper. There was a white piece of paper on top, then a piece of black carbon paper, and then a pink sheet of paper on the bottom. He had not seen any pink sheets in the chart.

My dad looked up at the chief and then looked back at the secretary.

“Excuse me, where do you keep these pink sheets?”

“The pink sheets go into the radiation tech logbook, that’s how they keep track of all the patients who come through here.”

“Where do you keep that logbook?”

The secretary, the chief, and my dad went into the belly of the radiation treatment room and located the logbook. A massive three-ring binder with thousands of bubblegum-pink papers inside, which they began skimming for evidence.

E. Jones, F. Jones, M. Jones. Turns out a lot of people with the name Jones get radiation therapy. But eventually they found the correct Mrs. Jones’s pink sheet with the original order written clear as day: left parietal lobe. The chief locked eyes with my dad and they shook their heads in unison. Of all the possibilities of why a treatment wasn’t working, altering medical records to cover up a medical error was the most sickening.

My dad’s job was to defend doctors when they were accused of malpractice. Mistakes happen all the time. But there are certain circumstances where there is no doubt that the doctor and the hospital are in the wrong, and these cases go straight to settlement or “give them whatever they want” type money. Admitting to the patient that they made a mistake by giving her radiation to the wrong side of her brain would have been bad enough, but disclosing that they uncovered a cover-up was monumental.

One day a junior resident told me he had to run back to the floor to erase a post-op check he did on one of the total knee replacements. He thought he remembered the guy had his right knee done, but it was really the left. I grabbed him by the shoulders and told him the story about how my dad had to fire a radiation oncologist for altering the chart. How honesty is the most critical part of the unspoken trust patients have in doctors. I told him we all make mistakes, we’re human. But the truth always comes out, and you don’t want to be on the wrong side of that pink sheet.

Chapter 9

Dr. Jane

In a hospital, you’ll see the people you work with more than your spouse, your parents, your kids, or your friends. They come from California and Canada. They come from Harvard and state schools. These are the people who are hopping on top of a patient’s bed furiously applying CPR while you are shouting “Clear!” before you deliver the electrocuting shock. These are the people you catch stealing an unopened juice box from a patient’s discarded lunch tray. These are the people who hold the suction perfectly still so you can place the last stitch to seal a ruptured artery. We are family, and if you learn one thing, it’s to never go against the family.

THE FAMILY BEGINS DURING INTERN YEAR, AND LET ME TELL you, a lot is determined during that first year. There is a very nuanced pecking order within an intern class, and that year says a lot about how your subsequent years in medicine will go. In order to understand this invisible hierarchy, you have to understand how medical training is organized. Let’s start at the beginning. If you graduate medical school as an MD (allopathic medicine) or a DO (osteopathic medicine), you are a doctor. While in your fourth year of medical school, you will apply for a residency program in a specialty. There are forty specialties you can apply for: internal medicine, general surgery, radiology, dermatology, et cetera. The first year of residency training is called the internship year: you are an intern. If you go into internal medicine, the intern year is part of the three-year internal medicine residency program. If you go into general surgery, the general surgery internship is part of the five-year general surgery residency program.

Now here is where it gets confusing. Certain surgical programs like orthopedic surgery or plastic surgery will make their trainees complete their intern year as a general surgery intern in the same program. So as a Lenox Hill orthopedic surgery resident, I completed the first year of residency as a general surgery intern at Lenox Hill. Other specialties like radiology or ophthalmology will allow their trainees to choose to do a medical or surgical intern year, and they can apply to do their intern year at a completely different hospital than their specialty residency program. For example, a few of my med school buddies who matched in radiology decided to do an internal medicine internship in Hawaii. If you’re going to go through hell, you might as well be tan doing it.

So, when all the general surgery interns meet one another for the first time, we are sizing everyone up, understanding that each of us will have a different motive that drives our performance as an intern. For the interns who are here for just one year and then poof, vanish, never to be seen again, they tend to approach work differently than the general surgery intern who is trying to impress her preceptors who will be guiding her along a five-year odyssey.

I had never met someone who was transgender until I started my internship. Dr. Jane was one of the general surgery interns while I was passing through general surgery as the ortho intern. She must have been six four, so her scrubs were always a bit too short. She had an Adam’s apple and her voice was at least an octave lower than mine.

Even if her appearance was different from some of the other female surgeons, there was no question about her talent. Jane came from one of the most prestigious medical schools in the country and had lights-out boards scores, top-of-the-class grades. When you apply to a residency, the first gatekeeping step is to submit your Step 1 score, grades, and all the letters of recommendation from your preceptors. In it they describe: your work ethic (were you the type of student who voluntarily stayed after work to help residents just for the sake of learning?); your medical acumen (did you know the answers to questions that showed you did outside reading?); your technical capabilities (had you been practicing your knots so on the off-chance the attending would let the student close the wound the sutures didn’t unravel?).

Based on that first cut, you are invited for an in-person interview. Jane snagged a ton of interviews. She flew all across the country, went to the welcome cocktail parties at the fancy university clubs, answered all the rapid-fire questions attendings throw to try and rattle the students to see how they handle pressure, and schmoozed with all the residents at the after-interview bar nights. But despite all the positive feedback, the sterling résumé, the winks and strong handshakes, she was not exactly surprised when she didn’t match with a single program.

This meant she had to enter the Scramble.

The Scramble is what happens if you don’t match in a program during your fourth year of med school. That spring, in mid-March, all the med students around the country gather at 12:00 p.m. Eastern Standard Time, open a letter (or email) to find out where they will be spending the next three to six years of their life.

The contents of that letter are derived from a computer algorithm that simultaneously orders the rank lists of every single med student with the rank lists of every single residency program across the country and matches the student with a program. So, for example, I ranked Lenox Hill orthopedic surgery number one on my rank list. If Lenox Hill also ranked me number one on their list, then there’s an instant match. But, if Lenox Hill had ranked someone else ahead of me, the computer would first check to see if that person ranked Lenox Hill first and match them instead. (The moment I opened my letter and saw the words “Lenox Hill Hospital, New York, NY” on the middle of the page, the reality of reuniting with my fiancé after four years of separation hit me in such an unexpected way I almost passed out.)

But there is one important step before Match Day. The Monday before Match Day is known as “Did I Match Day?” You are sent an email notification to find out if you matched with any of the programs you interviewed with. You don’t know where you’re going, but there is just a sigh of relief to know that you are definitely, in fact, still in the running to be a neurosurgeon, or a pediatrician, or a urologist, et cetera. But for the students who find out that they did not match, it feels like an arm reached out through that computer screen and physically punched you in the gut. Imagine you have just spent four years working as hard as you can, taken out loans for $200,000, sacrificed going to your best friend’s bachelorette party in Nashville so you could carry a pink bucket to catch puke all night, just to read a message on a computer screen that says, “Nope.”

But you do not have time to wallow in self-pity because there is one sliver of hope: the Scramble. It is officially known as “SOAP” or Supplemental Offer and Acceptance Program, but it will always be the Scramble to me. The Scramble is an opportunity for an unmatched student to match into any unfilled program in any specialty. So if you went unmatched in anesthesiology, and all 1,600 anesthesiology resident spots were filled, you could interview for an unmatched spot in emergency medicine in Kentucky.

The Scramble is completely different from the earlier interview process. Your entire career hangs in the balance of frantically calling programs who have a coveted unmatched spot and making your case over the phone. Now while most people would feel that a phone interview would not be the best way to present yourself, Jane was salivating at the chance to be seen without being seen. For while the Scramble is a chance to save some incredibly worthy residents who just slipped through the cracks, let’s call a spade a spade: Jane was discriminated against because of what she looked like. She was scooped up immediately and offered a spot at Lenox Hill. And so, on Match Day, Jane had the dignity of opening up her match letter just like all her other classmates, and celebrate her acceptance, as she deserved.

You don’t learn these match stories on day one of internship, rather, you learn about them over beers at the end of a long call weekend. I learned that Joon had newborn twins that she’d left in South Korea so that her parents could raise the babies while she focused on her training. Left her babies in another country! I couldn’t even imagine that kind of sacrifice. I met many of the intern spouses . . . not all would last through the five years.

I don’t know what I would have done without Justin. Sometimes when I would come home and collapse on the couch next to him, we would just sit in silence. I’d throw on Real Housewives on the TV, and let the stress of the day evaporate off my body. I would tell him my stories, not that he understood much of what I was saying, but he was there to be present and listen to them.

Jane did not have a partner. Did not have a roommate. Did not have a pet. I never heard her talk about her family or friends. I have to imagine it was very lonely for Jane, in so many different ways. I think this is why she never stopped working—and her work ethic, like her talent, was unmatched. If her shift was over, she was helping the overworked on-call resident in the ER. If she had a day off, she was in the surgical skills lab: she could take out a gallbladder in three minutes on the simulator. If I couldn’t get a blood draw on one of my patients, she could get it on the first stick. If a case needed to be presented, she volunteered to put together the PowerPoint and present in front of the entire department.

But just because you are a rock star among your peers, doesn’t make interacting with the public any easier when you don’t look exactly like everyone else. And in a place like New York City, where many of the patients were WASPy Manhattan socialites . . . it definitely wasn’t easy. The first person I ever treated in the ER was a seventy-five-year-old woman who was dragged down Park Avenue by her standard poodle. Jane couldn’t really escape the judgment and scrutiny that came from seeming different, and yet, every day she kept showing up.

On my last night of general surgery internship, Jane and I were night float together. Usually, one of us would be assisting in the OR while the other focused on the mundane pre-op clearances and pager duties. Because Jane was going to be a general surgeon, I typically would let her scrub in on the cases. The life ahead of me was made up of bones and joints, not squishy organs.

“You should scrub, it’s probably the last time you’re going to touch an appendix,” Jane said, laughing.

“I never want to see another appendix again in my life,” I said, snorting back. “Have you met your new interns for tomorrow?”

“Yeah, they’re all wide-eyed and bushy-tailed . . . I give them two days.” We laughed again.

I could not believe an entire year had passed. A year since Kevin’s accident. The night I’d left abruptly, Jane was on night float with me. She covered the entire service by herself that night. There was no one who could have done that but her.

“We’ll be running the hospital next year,” I told her. People think that chief residents run the service, but it’s not, it’s the PGY-2s. We are the senior junior people, the ones who are doing the consults, taking care of fires on the floor, responsible for getting people in and out of the hospital. I was proud of us.

Beep-beep.

“All right, I’m gonna head up to room four, this appy shouldn’t take too long. We have a boatload of pre-ops for tomorrow and the day shift didn’t even get labs for any of them.”

“They only had three hundred and sixty-four days to figure this out.”

“Don’t get me started. I’ll find you when I’m done and we can knock these out together.” I started walking backward to the service elevators.

“What are you going to name it?”

“What?” I shouted as I moved farther away.

“The appendix?”

“Jane. I’m going to name it Jane.” I smiled as the elevator doors closed.

WHEN I WALKED INTO THE ROOM THE PATIENT WAS ALREADY under anesthesia and they were waiting for me to start the prep. So, I took the Betadine-soaked sponges and started in small circular motions, cleaning the surgical area and then widening the circles to cover the entire abdomen. Then I carefully laid the layers of blue sterile paper sheets in an overlapping pattern to only reveal a small square of the surgical field. It is an incredibly vulnerable moment for the patient. They are completely naked, cold and exposed, while a stranger washes their body.

Only in this case, it wasn’t a stranger. While I was handing the top corners of the sheets to the anesthesiologist to cover her face, I looked at the young woman with a tube down her throat and recognized her immediately. I had gone to high school with her! I walked over to the chart, this girl had a very particular name, so I knew it was her all right. The coincidence sent a shiver down my spine. But there was no time to be weirded out, this girl deserved everyone’s full attention, and I was determined to make sure she had the smoothest operation possible.

The attending who was covering the case was one of my favorites. He always let me do a ton of surgical skills, even though I was the ortho intern, because he knew I wouldn’t mess it up.

“You’re starting on the Dark Side tomorrow,” he said, goading me.

“They’re not so bad,” I replied, even though it wasn’t totally untrue.

Orthopedic surgeons have a reputation for being dicks. Cocky and obnoxious, they walk around like they are God’s gift to medicine (the fact that they’re typically the best-looking people in the room doesn’t do much to bring their egos back down to earth).

“Well, you did a really good job on gen surg, I wish we could keep you.”

“Thank you.” I blushed. Honestly, I think that was the first piece of feedback I’d heard all year.

THE CASE WAS A BREEZE. I LEARNED TO ENJOY OPERATING like you are playing a video game, which is essentially what laparoscopic surgery is. You place these tiny cameras, the size of a pen, into a patient’s abdominal cavity, and then while looking up at the screen, you move your hands in space and maneuver your instruments to gently push aside the delicate organs. Finding the appendix is like a treasure hunt, only the treasure is a beefy, inflamed, fingerlike protrusion. We use the mini tools to cut and cauterize the offending appendix and then pull it out of the body like a magician pulls the rabbit out of his hat.

Gotcha, you little troublemaker. Once I took it out, I poked the appendix, which was slimy but hardened, nothing like how the bouncy, spongy appendage was supposed to feel.

As I flick my gloves off into the garbage can and tear off my gown, the noise from my pager pierces my ears. Literally, I cannot get one second of peace. The callback number is for the gen surg floor with “911” attached—that is not good. I push the patient into the post-op bay and promise the cranky-looking PACU nurse I will be back to put in the orders: I have an emergency on the floor.

When I get to the floor there is no nurse in sight, but I do hear a commotion coming from room 506. I peak inside and I see a sixty-year-old man snarling at the end of his bed, seething with disgust. Then I see Jane, six-four Jane, cowering in the corner.

I make eyes with Jane, I look back at the patient, and I say, “Sir, is there a problem?”

He turns his reddened face and beady eyes toward me and shouts, “I don’t want him touching me. I don’t want him as my doctor.”

I look back at Jane. It’s not fair. All the late nights in the lab. The hours poring over anatomy textbooks. The thousands of rectal exams, being thrown-up on, the exploding pockets of pus. But none of that matters. No one sees all the sacrifices she has made. All they see is what they can’t get past seeing.

I walk over to the patient and look straight into their eyes.

“She is your doctor. She is the best damn resident in the whole hospital, so show her some respect!”

Jane and I never spoke to each other about this incident. It would have been easy to just switch off with Jane and take care of this patient myself, but that wasn’t the right thing to do. I’m positive this wasn’t the first time someone had said something like that to Jane. But it might have been the first time someone publicly stood up for her. Because in the end, it’s the family that matters, and for us to take care of you, we have to protect each other. And in the end, the patient got the best possible care as a result; he was lucky to have her.

Chapter 10

The Boys’ Club

The first rule about Boys’ Club is you do not talk about Boys’ Club. That is, until you have finally made it to the point where you don’t have to look over your shoulder anymore.

The majority of surgeons are men. What does it look like to be a female surgeon? On the surface, not much different: we wear the same boxy scrubs, stuff all our hair into a cap, and remove all our jewelry. Women wear dark suits and comfortable (i.e., hideous) footwear when presenting at grand rounds and going to residency interviews.

I have never worn a suit in my entire life (except for the one time I had to interview at the Mayo Clinic and it was minus twenty degrees and I broke down and bought an itchy gray wool suit from Theory). When we picked out designs for our custom head-to-toe OR lead aprons, I picked out a bright blue paisley pattern, so I knew no one would dare steal it. You could hear me coming from a mile away in the hospital hallways, because I always wore stiletto heels that thunderously click-clacked when I had to present for grand rounds, adding that extra three inches of confidence.

For most women, surviving in a world that was not designed for you means adapting. The reason why I’m most conflicted about pulling back the curtain on my own tribe, is that I excelled within this culture. I loved my training. I loved my co-residents. I loved my mentors. But as my classmate Neel Shah likes to say, a bad system will beat a good person every time. A lot of these stories were hilarious to me when they happened in real time. But if I step back and imagine inserting my daughter into those same scenarios, I would be horrified. And so, it is through that lens that I look back on my time and present to you, the ultimate Boys’ Club.

THE FIRST INTERVIEW I EVER HAD FOR ORTHOPEDIC SURGERY was at my home program at Brown. I was pleasantly surprised at the number of female orthopedic surgery residents in the program, which proved to me that they valued women as trainees. They even had a few female attending orthopedic surgeons, an even rarer occurrence. Women make up around 10 percent of the orthopedic workforce, the lowest percentage of female physicians in any surgical subspecialty.¹ Critical to succeeding in the field is to understand how to play the game, how to get papers published, pick the right people to write your letters of recommendation, find the person who will speak your name in the rooms with closed doors. For me, that person was a man who not only recruited me to come to Brown but laid out the blueprint to get to where I needed to be.

The morning of the interview all the candidates were gathered together in a small conference room. I was the only female, as usual, which didn’t bother me. In fact, I always saw it as an advantage. When, out of the corner of my eye, I recognized someone. A muscled-up guy in a suit that was too tight and shaggy hair with ends that curled up along the back of his neck—there was no doubt, this was a typical UVA frat boy. But wait, no. Was that . . . ? I started blinking at him like he was a mirage. Could it be possible that this guy, who I literally used to step over at the bar because he was passed out on the floor, was at the same place as me? I massaged my eyebrows in an effort to remain calm and focused on the task at hand.

“Hey! Erin! Is that you?”

“Heeeey, how are you?”

“Great! You go here? What’s Dr. Ehrlich like? Is it true he wrestles all the candidates?”

Dr. Ehrlich had been at Brown since I was learning my multiplication tables. He looked like an old football lineman whose body had betrayed him in old age and he lumbered around the hospital, grunting and grimacing. He ruled the department with an iron fist and was never spotted without his signature bow tie. He was gruff and intimidating to all the students and residents. He was also beloved by his patients and dedicated to research that transformed their lives.

“I don’t know if that’s a real thing, I mean, he’s really old and not exactly a spry guy.”

McDermott!

“That’s me, gotta go, good luck.”

I followed Dr. Ehrlich’s secretary into his office. It looked like what you would imagine a chairman’s office would look like: big mahogany desk, a swivel chair with the quilted leather buttons on the back. Stacks of research journals piled up on the desk. Framed diplomas lining all the walls. Pictures of dignitaries and famous patients. A library of thick and heavy textbooks, some with his name on the spine.

He did not look up from the interview packet when I sat down in the chair facing his desk.

“Don’t I know you?” he grumbled, still not looking up from the packet.

“Yes, sir, I’m one of the Brown medical students, I did my sub-I rotation in the spring.”

“And you come to grand rounds.”

“Yes, sir, I do research with Dr. Weiss, and he invites me to observe grand rounds.”

“Do you want to come here?”

“I’ve really enjoyed learning from Dr. Weiss and working with all the residents in the ER. And the super chiefs tackle the most complex trauma cases I’ve ever experienced.”

“I asked you if you wanted to come here.”

I took in a sharp breath.

“No.”

He finally put the papers down on the desk and leaned forward.

“Why not.” It wasn’t a question; it was a statement.

“I want to go home to New York and live in the same city as my fiancé.”

He stared at me uncomfortably. I couldn’t tell if he was impressed with my honesty or thought I was committing career suicide.

He picked up my packet again.

“Where do you want to go?”

I exhaled slowly.

“I want to go to Lenox Hill Hospital.”

He slammed the packet back down on the desk.

“You’re coming from an Ivy League institution, why would you want to go there?” he said, sneering.

Okay, now he was definitely judging me.

“I have a lot of history there and they do more volume of surgeries per resident than any other training program in New York. Plus, when I rotated in the summer, the residents were the ones performing the surgeries; it’s not just an academic place where you write a lot of papers but don’t get to operate.”

He knew that was a thinly veiled dig at some of the more prestigious training programs in the City and he smirked.

“Good luck to you.” He stuck his hand out but did not get up from his seat.

“Thank you, sir.” I shook his hand and scurried out the door.

The rest of my day was filled with meetings with surgeons I had spent time in their ORs and in their research labs and we mostly chatted about interesting controversies in orthopedic treatments or fascinating cases I had been part of during my away rotations. When all the interviews were over, the candidates gathered together in the same conference room.

The room was abuzz over who got the best of Dr. Ehrlich in their wrestling matches. The rumors were true. When the frat boy asked if Dr. Ehrlich tried to wrestle me, I just shook my head and smiled. I would have felt better had Dr. Ehrlich even tried to wrestle me (not even a thumb war?). Less than half of med students match into their number one program, so it shouldn’t disqualify them from being ranked highly from any of the programs they apply to even if it’s not their first choice. But for me, the girl, I only had one shot, and I chose to be honest. I thought about the rest of the women interviewing across the country and I felt sad. It was not even a question of a level playing field, but rather you weren’t even invited onto the mat.

WHILE MATCHING INTO ORTHOPEDIC SURGERY IS THE FIRST hurdle, staying in orthopedic surgery is the next. Women are more than twice as likely to unintentionally leave orthopedic surgery residency.² The next glimpse into the orthoverse features one of my favorite senior residents, who will go unnamed due to the highly embarrassing nature of this story, but one that so perfectly sums up a day in the life on the ortho service. One morning before lecture started, the chief resident was showing the other senior residents pictures of X-rays on his phone of a particularly challenging ankle fracture that had come into the ED that night. The bone was splintered into tons of tiny fragments, and a pit grew in their stomachs as they knew this fracture would be, for lack of a better word, a “bitch” to put back together.

Suddenly the chairman walked into the room, curious at the crowd who had gathered around the chief resident’s phone.

“Whatcha got there?” The chairman grabbed his phone and started scrolling through the X-ray pictures.

“It’s a pilon, going to the OR today, as long as they pass medical clearance . . .”

The chairman abruptly stopped scrolling and pushed the phone back into the chief’s hand and walked away in silence.

We all looked at one another in total confusion until the chief’s face drained of all blood as he looked back at the last image the chairman had up on the screen. Staring him in the face was a picture of a mini-mountain of pubes he had manscaped and was so proud of his accomplishment he felt the need to document it on camera.

THIS WAS ACTUALLY TAME COMPARED TO WHAT HAPPENED during my first dictation. That’s the moment after surgery when every surgeon—or the resident working with the surgeon—records themselves detailing the op note. The op note is a very important document as it describes all the important findings that happened during surgery. Which implant was used. How much blood loss occurred during surgery. No detail is too small to be included. Insurance companies comb through the op report to decide whether or not to pay the surgeon and hospital based on the procedures they claim they performed. It is a legal document that is often dissected during malpractice trials.

I was understandably nervous about recording this first dictation, as I hadn’t practiced being able to put into words all the steps and findings of a two-hour procedure. But the time had come and the particular surgeon I had operated with that day demanded that the residents dictate all his cases for him. (Once I became an attending surgeon, I always did my own dictations. I never wanted someone else to read my mind about what was critical to a surgery.)

It was late evening and all the ortho residents were gathering in our lounge to finish up notes and dictations. I grabbed one of the landline telephones and punched in the codes to start the dictation.

“This is Dr. Erin Nance dictating a case for patient Erica Smith, medical record number 534466, date of birth 06/25/1963. Pre-operative diagnosis—”

“Auugghhh!!” A deeply pitched woman’s moan rang in my ear.

What was that?

“Pre-operative diagnosis—”

“Ahhhhhhh!!!” Now a high-pitched squeal pierced my eardrum.

Who was she?

I spun around and there were three senior residents, one with his phone next to my head playing a porno. They were dying of laughter as I scowled at them and gave them a Are you freaking kidding me right now? look.

I turned back to the landline.

“Pre-operative diagnosis: knee osteoarthritis—”

“Oh! Oh! Oh! Yes! Yes! Yes!”

I shot them a nasty glance.

“Guys, cut it out! I don’t want that to be picked up on the dictation!”

But my protests were pointless, and they proceeded to keep playing the porno in my ear for the next ten minutes while I painfully tried to describe the barbaric practice of taking a power saw to the ends of a knee and hammering in cold metal implants.

Looking back you might say, “Erin, why didn’t you report this behavior?” The truth was that in a very warped way, me being included in this type of behavior meant that I belonged. That I was someone who could take a joke, could hang with the cool kids. It was like I was being asked to wrestle in the interview with Dr. Ehrlich. But what I realized later, was by going along with this culture, I made it that much harder for someone else to stand up to it.

THE PIÈCE DE RÉSISTANCE OF BOYS’ CLUB BEHAVIOR occurred during my next cycle of interviews, this time for a hand surgery fellowship. This was 2013 mind you, not 1953. It got off to a calamitous start. After flying cross-country, I woke up at 4:00 a.m. to shower and start the hour-long drive to the medical center.

It was a Saturday morning, and I was the only car on the freeway. As I was driving, I had an inauspicious thought: I don’t think I put my license back into my wallet after I took it out for the TSA agent back at the airport, I’m pretty sure I left it in the front pocket of my luggage.

I was relying on Google Maps to guide me on the route, but I couldn’t read the next exit, so I picked up my phone to see where to get off. At the exact same time that I placed the phone back into the cup holder I was looking at a pair of eyes staring straight at me from a police squad car. He flipped the siren in Pavlovian response, and I almost choked on my own gasp.

Since there were no other cars on the freeway, I had been caught literally red-handed with a cell phone. I gave him a little deferential hand gesture and pulled over to the side. Here I was driving in a car that was not my own, without a driver’s license, while committing a violation. Panicking over the thought of calling the fellowship director from jail to explain why I was late, I had to remind myself that I was dressed like an insurance agent and not your typical grand theft auto hooligan.

“License and registration.”

“You know, officer, this is a really funny story. You’re going to laugh . . .”

He did not look like he was going to laugh.

“Right before you pulled me over, I just realized that I never took my driver’s license out of the front pocket of the luggage I was carrying for my plane trip. And I thought, Okay, now, don’t go getting pulled over while you don’t have your driver’s license, and then, BOOM! you show up. Isn’t that, like, a crazy premonition?”

Strike one.

“Registration.”

“Funnier story, so, I’m actually traveling here to go on an interview for hand surgery. I’m a doctor, that’s why I’m on the road so early, no one else is crazy enough to be on the road this early on a Saturday. See, I’m all dressed up for my interview, got my blazer on and dress . . .”

“Registration.”

“This is my aunt and uncle’s car. I have no idea where any of that stuff is.”

Strike two.

The gears in my brain were not in synch.

“My uncle is a cop in New York, and he told me to show this card in case I ever got pulled over.”

I tried to hand him the “friends and family” card to which he immediately pushed back my hand through the open window.

Strike three.

“I’m so sorry about using my phone, I swear to God I wasn’t texting, I was just trying to make sure I got off at the right exit. See, I’m from New York, and I’m trying to make this hand surgery interview on time, I’m really sorry.”

The officer had no time for excuses or crocodile tears, and after fifteen minutes waiting for him to come back to my window, he handed me three tickets.

“I’m sorry, officer.”

“Don’t touch your cell phone while driving,” he scolded me one last time.

Shit. So now I had to memorize the rest of the route, speed without getting caught to make it to this interview on time, and act hunky-dory when I got there.

Thankfully the parking lot was still empty by the time I pulled into the hospital and I started running with my sling-backed heels. The security guard was absolutely no help in directing me to the ortho conference room, and with one minute to spare I slipped into the room, wiped the beads of sweat off my forehead, adjusted the strap on my shoe so it wouldn’t pop the newly created blister on my heel, and threw my offending cell phone into my purse.

The chairman of the department walked into the room and all the interviewees began to introduce themselves.

“Such a pleasure to meet you sir, I’m Erin Nance from Lenox Hill Hospital.” I reached out to shake his hand.

“Look at that ring! What does your husband do for a living?”

I reflexively drew back my hand like Vivian in Pretty Woman.

Was I being punked?

I looked around the room, still the only female in sight.

I let out an awkward laugh and murmured, “Finance?”

He slapped me on the shoulder. “Smart girl . . .” he mused and then continued jawing with the other candidates.

You’re telling me I worked twenty-four hours straight, hopped on a six-hour flight, slept on an air mattress that deflated overnight, got pulled over by the cops, and almost arrested to deal with this?

Somehow it got even worse.

As soon as the door closed after walking into the fellowship director’s office, I knew the vibe was off. He didn’t stand to greet me; he didn’t offer a handshake. He just sat back in his low-lying chair with his knee crossed over the other and stared at me intently.

Spotting the empty chair across from him, I sat perched over the edge, ready to escape at a moment’s notice.

I looked at him looking at me, now feeling increasingly uncomfortable with each passing silent second.

Finally, he licked his lips and spoke.

“Tell me a dirty joke.”

I blinked blankly at him. Really? Really? This was a job interview. Now what I should have done was stand up and walk out the door. But I couldn’t risk being labeled a difficult applicant, that would spread like wildfire and guarantee I would be blackballed. So, I told him my joke (I did just spend four years being surrounded by ortho bros) and I finished the interview. I had a long six hours on the plane to think and a really expensive police ticket burning a hole in my pocket.

When I walked back into my apartment, I pulled up my electronic rank list on my computer. If I was going to spend an entire year entertaining some horny middle-aged man who got off on making young girls squirm while he sat perched in his position of power, it was not worth it to continue. I left off the California program completely. I’d rather go unmatched and switch specialties than subject myself to working with that creep every day for a year. I still see him at conferences giving podium presentations and speaking on panels, and I wish I had the guts to call him out.

Years later, a medical student reported one of the attendings I used to work with for inappropriate behavior in the OR. To my shock, the attending was suspended (albeit for a short period of time). I was so proud of that student for doing what I couldn’t, and putting her own career at risk so that other women wouldn’t find themselves in that same position. But knowing what I know, blackballing is still a very real threat and I hope she was able to find a home. Because Boys’ Club continues to exist if no one speaks out about Boys’ Club, and bad behavior thrives in the shadows. But guess who has the megaphone now?

Chapter 11

The Price of Being a Female Surgeon

Put a finger down if you always sat in the front row, raised your hand high, never missed a class, did all the work for the group projects, and had a perma-smile plastered to your face while doing it. I was raised with the belief that a girl can do anything! A girl can be president! A girl can be an astronaut! A girl can be an orthopedic surgeon! I was raised with a no-limits-outlook on life. But for a female surgeon charting their life course, our paths are not only full of roadblocks, they’re littered with roadkill.

There are two main types of female surgeons. The first is the alpha girl. If I could amalgamate their features, they would be a five-foot-eight, stick-thin, butter-blond, pointy-elbowed viper. Their hair is pulled back into a sleek low ponytail under their scrub caps, and they wear heels that are physically impossible to walk around in twelve hours a day, but they’ve trained their feet for the pain. These women will cut your Achilles and then step on top of you to get an advantage. They are laser-focused on their goals and don’t have time for incompetence or mediocrity.

The next type of female surgeon is the busy beaver. Her scrub pants are always too tight, her roots are showing, and she hasn’t changed her style of glasses in fifteen years. These women are so busy doing all the work for the entire department to the detriment of their own education and preparation. Women are generally given more administrative tasks, which do not add to their visibility in the department or the ability to advance, gain prominence, and generate wealth.

Throughout my career I have been both types of women. And I am friends with and respect both types as well. Outsiders may try to pit us against one another, but besides fighting against the systemic sexism that exists in our field, we have one common enemy: time.

FEMALE SURGEONS HAVE TWICE THE RATES OF INFERTILITY as the general population. Why? Well, most people who apply to medical school spend about two years of additional research after graduating from college, so they are entering med school around the age of twenty-five. After four years of med school, five years of residency, and one year of fellowship, they are thirty-five years old. For women, if they decided not to get pregnant during training and to wait until after fellowship, it’s considered a geriatric pregnancy. Of course, there is nothing written in stone about women not being allowed to have children during their training, but it’s definitely not encouraged.

That brings me to the most feared woman in Rhode Island.

When I was a med student, I was taking overnight call with the ortho intern named Jake. If you looked up “ortho bro” in the dictionary, there would be a picture of Jake: huge biceps, gelled-back hair, definitely on the gym, tan, laundry spectrum.

It had been a busy night full of ER consults, post-op checks, and putting out fires on the floor. By 3:00 a.m. we had a moment of silence and decided to try and catch an hour of sleep. Back in those days, the students earned major street cred if you took a night of call and then just continued to work the entire next day but, you know, not mention that you had been up for over thirty-six hours straight.

No more than five minutes had passed when the piercing, panic-inducing sound of the pager was rattling on the desk next to the bed. I shot up like a Pop-Tart from the toaster, completely disoriented after achieving deep sleep in ninety seconds. Jake was groaning in the bed above and wasn’t moving fast enough in my opinion to shut off the head-splitting noise coming from the pager. I watched his feet swing off the bed and dangle in front of my face before he leaped off and fumbled with the pager buttons for a few seconds before pressing the right one that would stop the madness.

“ER . . . shit . . . let’s go.”

I threw off the paper-thin blanket, put on my white coat and followed Jake to the emergency room where a very concerned looking ER doc walked up to Jake.

“You guys ortho?”

“What’s the story?” Jake made a beeline to the PACS machine where he started scrolling though the X-ray images of our soon-to-be patient.

“Sixty-two-year-old male, had a total hip done a couple years ago. Bent down to take off his socks before bed and felt his leg give out from under him. Can’t move the leg at all.”

“McDermott, what type of dislocation is this?”

I gulped. “Posterior hip dislocation,” I murmured in a gravelly 3:00 a.m. voice.

“Get him ready for sedation, McDermott come with me.”

When we pulled back the curtain to introduce ourselves to our middle-of-the-night consult, I could feel the patient’s discomfort radiating through the room. His leg was awkwardly rotated and pointed in an unnatural way. His white knuckles were gripping the sheets in bunches, and he had beads of sweat on his forehead.

And while Jake was supposed to be listening to the patient describe how this happened, he could not take his eyes off the patient’s giant leg. He looked like he could wear Shaq-sized sneakers. I think I even saw a shiver go down his spine.

After the anesthesiologist sedated the patient so that there would be no fighting back from the muscles surrounding the hip, Jake went to work and started pulling on the giant leg. He pulled, and tugged, and twisted, and pulled some more. He lifted the leg high into the air, he dropped the leg below the table, but after each attempt, the leg would revert to that twisted, unnatural position. Jake’s scrub top had rings of sweat on it, and I could see the muscles in his forearms twitching and cramping.

After about ten minutes of futile yanking, he yelled to the charge nurse, “Page Will, if he’s not in the OR tell him I need him in the ER now!”

Will was the PGY-2 resident on call for surgical emergencies. Calling a more senior resident into the ER was seen as a sign of weakness, but Jake had no choice. The giant leg was winning.

After a few minutes, a shorter but wider ortho bro walked into the room. His biceps were twice the size of Jake’s and surely the two of them would have the strength to pull this hip back into its socket.

After greeting Jake with a death stare, Will grabbed ahold of the patient’s leg while Jake hopped on top of the patient to steady the pelvis. Will was huffing, and puffing, his face turned fire-engine red, and the veins were bulging in his neck. He switched arms, squatted lower to get better leverage, and almost pulled Jake off the bed. When he finally let go and the leg rotated inward into the same dislocated position it had started in, Will and Jake locked eyes and turned toward the charge nurse.

“Page Appleyard,” Will muttered in defeat.

A small gasp was let out and there was rustling among the nurses and techs in the room.

Who’s Appleyard? I thought. I mean if these two jacked guys couldn’t pull this leg back into place, then who on earth would be able to do it? I imagined a guy double the size of both of them, the apex ortho bro.

When the curtain swooshed open five minutes later, standing there was Chief Resident Deb Appleyard, standing five foot nothing, eight months pregnant with twins, and rudely woken at 3:30 a.m.

The nurses parted ways as Deb approached the patient. She looked at the position of the leg, looked at Jake, looked at Will, and simply stated, “You couldn’t get it in?”

“It’s impossible!” an exasperated Jake pleaded with her.

“Something must be blocking the joint,” Will stated with an undeserved confidence that could only come out of a man’s mouth.

Deb pushed past Will and placed her hands on the patient’s ankle.

“Mind if I . . . give it a try?” Deb raised her eyebrows.

Will and Jake shut their mouths, backed away from the patient, and raised their hands in the air to signal “good luck.”

Deb took the ankle with both hands and pinned it between her armpit and her side. She flexed the knee and started to gently rotate it, like she was dancing an intimate samba with the giant leg. After a few twists and turns and gyrations around her massive belly, there was an audible pop! and the leg relaxed into its natural position lying on the bed.

The boys’ jaws were on the floor, and the nurses nearby were beaming. Even I watched with glee as Deb waltzed past Jake and Will and said, “Better luck next time, boys.”

What a legend.

I was still new enough in my career that I figured that she would become the head of ortho, win every award, et cetera. And yet, Deb did not get to ride off into the sunset as a hero deserves. In fact, when I reconnected with Deb fifteen years after our first fateful meeting, I was shocked to hear that she was no longer operating. She hadn’t operated in years. She told me that having four children during training made her a pariah, and she was punished. After serving six grueling years at the same residency, her own home program passed on her when she applied for fellowship. She couldn’t even get a job in the United States and had to practice in a foreign country. What bullshit.

At the time, I didn’t even realize how much of an anomaly Deb was for having children during residency. She was actually the only one of the female orthopedic surgeons I’d met who’d had children. And the ones who were attendings? Well, they’d either chosen not to have children, or their biological clocks timed out and made the decision for them.

During one of my away rotations, I worked with a female attending in her early forties. The best word to describe her demeanor was depressed. She was skipping lectures and bailing on morning rounds. I wouldn’t say she was any resident’s favorite attending to work with. One slow day in her clinic, I asked her if she had any feedback for me. It’s always helpful to understand if my suture technique needs improvement or I’m not interpreting the XRs correctly.

She looked down at my finger.

“You’re married?”

I responded puzzled, “Yes?”

“Get pregnant tomorrow,” she said and walked away.

As with Deb, I just didn’t understand the feedback in the moment. I didn’t understand it acutely, anyway. It wasn’t until many years later when I myself felt that bitterness of secondary infertility, that I could look back and empathize with her. She was great at her job; those missed rounds and lectures were because she was doing IVF at 6:00 a.m. for months. And while I don’t know her specific journey, I know countless female orthopedic surgeons who have had miscarriages and continued to work as if nothing ever happened, with literally no one to talk to. We’re much more likely to experience infertility, and while there are many theories at play, one fact is obvious: female surgeons have their first pregnancies later in life.

“I’m going to make a baby tonight!” I yelled across the bar to my best friend while techno music blared in our ears.

“What?!” She laughed partly because of how ridiculous a statement that was to yell publicly in a bar.

“I graduate fellowship exactly forty weeks from today, if I get pregnant now then I won’t miss any time off from work and I’ll have a full month before I have to start an attending job, since those start in September.”

“You’re crazy, but cheers to making a baby!” We toasted with a Bud Light and I went home on a mission.

THE NEXT DAY WHILE WORKING IN CLINIC WITH MY FELLOWSHIP director, I tapped him on the shoulder, “Dr. A, can I talk to you?”

“Sure, what’s up?”

“Em is doing an elbow fracture dislocation case from fellows clinic, do you mind if I leave office hours a bit early to help her?”

“Of course! Phew, for a minute I thought you were going to tell me you were pregnant!”

I painfully smiled and let out an awkward laugh.

“Nope! Not pregnant, just working!”

He smiled and sent me on my way.

TWO WEEKS AND THREE POSITIVE PREGNANCY TESTS LATER, I was reviewing the case list for my next day at work.

Case #1: Ray Amputation.

Case #2: Soft tissue forearm sarcoma excision.

Case #3: Humerus unicameral bone cyst excision with cement fixation.

Shit. Cement.

In orthopedics there is a component to the cement called methyl methacrylate (MMA), which can be toxic to developing fetuses if the fumes are inhaled.

I tapped Dr. A on the shoulder once again.

“Dr. A, can I talk to you?”

“Sure! What’s up?”

I crossed my legs and was fidgeting with my hands, “Well, I wanted to let you know that I’m pregnant.”

He looked at me and blinked and I held my breath for what seemed like the longest three seconds ever.

“Erin, that’s incredible news! Congratulations!”

I audibly exhaled and started to tear up.

He gave me a big hug and sat me down.

“How far along are you?”

“Two weeks.”

He let out a chuckle. It was kind of ridiculous to be telling your boss you were pregnant before you even confirmed it with a doctor.

“I saw the cement case on the schedule, and I just wanted to be safe and let you know that I need to scrub out during that part of the case.”

“There are going to be plenty of times when you might feel uncomfortable, or you don’t feel good, or you’re too tired and you never need to ask for permission to do whatever you need to do.”

Now the tears started to flow.

“Make sure you go down to radiology to let them know.”

“They’re next on my list.”

Another hazard of being a pregnant orthopedic surgeon is the level of radiation we’re exposed to due to the constant X-rays and fluoroscopy during our surgical cases. During a fracture case we may take ten, twenty, thirty radiographs. So out of an abundance of precaution, many of us will “double lead,” which means that we will wear two lead aprons that wrap around our chest and pelvis each weighing ten pounds. So, imagine the weight of being pregnant and then adding a twenty-pound metal jacket while standing for hours at a time.

To monitor the amount of radiation we wear a dosimeter badge on the outside of the lead. Whenever someone is pregnant, they must report to the radiation department so that the exposure can be monitored more closely.

The following week before one of my fracture cases I threw on my lead and went to grab a snack in the lounge while the anesthesiologist intubated my patient. I noticed some of the nurses and techs whispering and not so discreetly looking at me. Finally, one of the seasoned Filipina nurses pulled me aside and whispered, “Congratulations!”

How could they possibly know that I was pregnant?

“How did you know?”

She pointed to my badge and winked.

I looked down and next to my regular dosimeter badge was a second badge with a picture of a cartoon fetus.

“Cat’s out of the bag.” I laughed and then lumbered over to the OR like the Tin Man.

Thirty-seven weeks and five days later I stood on the graduation stage, two days from my due date after achieving everything I set out to do. I did not miss one day of work. I never took one less call shift than anyone else. I did fourteen-hour brachial plexus surgeries in my third trimester. I scheduled all my OB appointments on days where clinic didn’t start until 9:00 a.m. so I could still round on patients, go to lecture, go to my own appointments, and then be back to see patients in the clinic and operate.

And it was exhausting.

There were two thirty-nine-week pregnant fellows on the stage that graduation and I remember overhearing someone say what a coincidence that was. Let me tell you, that was no coincidence. That was intense planning and immense consideration for everyone else in the program. I didn’t plan when having a baby would be best for me, but rather when would be the least inconvenient time for everyone else.

I am forever grateful for an uncomplicated pregnancy and a healthy baby girl. But the fact that I was able to reverse engineer a perfectly timed birth led to a false sense of how easy it was to have a baby. And the years that followed were filled with the heartbreak that is all too familiar for many women trying to get pregnant, but especially female orthopedic surgeons.

There is no “right time” to have a child. By the time I had my daughter, my parents had moved to California, and I was relying on a full-time nanny as well as the goodwill of my New York friends who I used to bribe with access to a Peloton if they would agree to sleep over so someone would be waiting for the nanny while my husband was traveling and I was in the OR at 6:00 a.m. Every parent has to figure out their own logistic gymnastics, but after that first year I realized why so many of my male co-residents had stay-at-home wives: it just seemed impossible any other way.

I think back to Joon who had to leave her twin babies in Korea with her parents. I think back to one of my chief residents who had to hire an au pair to watch her infant—who has the money to hire an au pair when you are making less per hour than the cashier at McDonald’s? Not to mention all the opportunities you get passed over like presenting research at conferences, not because people didn’t think you were worthy but because they assumed you wouldn’t be available or interested in leaving your children for a weekend—a concern never brought up with the men who had children in residency. Not to mention the resentment that builds because your program has to “cover” for the time missed during your maternity leave, which for the women who came before me was often just a week if you were lucky. And I think of how unfair Deb was treated, stripped of having a genuine shot at establishing a practice as payback.

How do you win?

As a female surgeon, you spend your whole young adult life trying desperately to not get pregnant, and then when you feel you are finally ready, every time you see that drop of blood it is a dagger to your heart. And with every passing month you question all those X-rays, those thirty-six-hour call shifts, the toxic Bovie and cement fumes, and the anger and resentment grows. And when the window has closed and the time is up, you finally understand the true price of being a female surgeon. You feel robbed, only you can never replace what was stolen.

Chapter 12

When You Roll the Dice, Sometimes You Lose

Springtime in Central Park is when the jewel of New York City shines brightest. On a warm day in May, tiny cherry blossom petals dance in the breeze. A jazz band holds court for families out for a walk while the sounds of children squealing on a tire swing punctuate the melody. Couples splay out their blankets on the Great Lawn only to have their not-so-discreet cups of rosé knocked over by an errant soccer ball. The elm trees tower overhead and cast shadows over the tulips lining the pathways.

While all of those are lovely, the most fascinating part of Central Park for me has always been . . . the dogs. Hear me out, the dogs rule Central Park. Whether it’s a proud dachshund strutting his stuff, or a pack of exuberant goldendoodles begging to be taken off leash so they can chase squirrels, there’s something special about seeing them escape the concrete jungle and enter this verdant oasis.

Truth be told, I’ve had a complicated history with dogs. My family never had one. Whenever I asked my dad if we were ever going to get a dog he always said that he had three boys and that was enough. One time when we were visiting my aunt’s house, all the cousins were playing tag in the front yard. Tag with six or seven middle school kids is a chaotic scene, and somehow in the midst of the chaos, my aunt’s golden retriever decided to join in the fun and chase me, only in that moment it felt like I was being hunted. After trying to evade him by circling around some trees and weaving in and out of the bushes, I felt a sharp pain that caused me to stumble. Luckily the dog kept running past me and I could catch my breath and take stock of what just happened. I felt the back of my shorts and they were wet with goopy saliva. I had just been bit on the butt.

From that moment on I had a fear of dogs, and the dogs knew it. They could always sense the hesitancy and awkwardness whenever I would try and pet a friend’s dog, like a teenage boy giving their random great-aunt a hug. I couldn’t understand how people would get their face right up into a dog’s face and playfully scruff up their necks. And whenever I saw a dog off leash my body would tense ever so slightly, preparing to make a break for it if I needed to.

WHILE CENTRAL PARK COULD BE THE SOURCE OF SO MUCH fun, it was also one of the main drivers of patients to the hospital. First-time Rollerbladers tripping over tree roots breaking a wrist. Bicyclists colliding with pedestrians crisscrossing the loop around the park. Kids falling off the monkey bars breaking their elbows (why are monkey bars still legal in this country?).

When I got called down to the ER, I figured it was a case like that, but I was sent right to the procedure room to meet my patient.

The door to the procedure room was cracked open and I heard a soft whimpering coming from inside. But the crying didn’t sound like the typical agitated wail of someone in physical pain; it sounded emotionally painful.

The patient was sitting in the edge of the bed with his head hanging low, cradling a blood-saturated bandage around his right forearm. His eyes were bloodshot, and he had deep scratches across his face and the front of his legs.

“Can you tell me what happened, Mr. Davidson?”

He rocked his head back, closed his eyes, took a deep breath in through this nose, pursed his lips and breathed out.

“It was a beautiful day so my wife said we should take Teddy for a walk in Central Park. Teddy is my toddler; he loves to watch the toy boats in the boat pond.”

I loved the boat pond too. There was always something magical watching grown adults turn back into kids when they’re handed a remote control and a little toy boat. Some people bring fancy toy boats from their home with flashy colors and elaborate sails. The kids stand just close enough to the edge to make the adults worry they may fall in, and they root and cheer for the boats with their favorite colors.

“He saw another kid with an ice cream cone so of course he wanted one. My wife got him one from the vendor and I sat down next to him on a bench so that he wouldn’t drop the ice cream.”

I noticed what looked like a big chocolate splotch on his T-shirt.

“Then out of nowhere, this huge dog comes rushing up to my son. He leaps in the air, and I throw my body in front of him.” He pantomimes the scene.

“I tried to push his snarling face away with my arm, but he clamped down on it and wouldn’t let go.” He thrashed his bloodied forearm in the air. “The dog was deranged; his eyes were wild, and he smelled . . .” He couldn’t even finish the sentence.

“My son was screaming, my wife was hysterical, begging for someone, anyone, to help us.” He bit his lip in pain and looked toward the ceiling.

“Finally, the owner wrestles the dog down and I’m holding on to my son so tightly, my heart is racing a hundred miles an hour and I want to throw up.”

“And before I know it, the owner and the dog are running away. Straight-up fleeing the scene. The crowd that had gathered around us tried to stop them, but I have no idea if anyone ever caught them.”

I sat down on the stool next to the bed.

“I’m so sorry, that sounds terrifying. Is your son all right?”

“Thank God he’s fine, not one scratch on him, if he had one scratch you don’t know what I would have done.” He was seething.

I put my arm on his shoulder and started breathing with him.

“Well thank God he’s okay, let’s take a look at your arm since it looks like that took the brunt of the attack.”

I put on some gloves and started to unwrap his bandage. The damage was extensive. The lacerations were not only deep, they were ragged and chewed up. There was fat from the deep tissues protruding through the wound and you could see some shiny tendon edges from where the tendons were torn. The most important part of the exam was to make sure there was no neurovascular compromise of the arm. That meant checking all the major nerves and blood vessels that run through the forearm. And miraculously, his pulses were strong and all of the major sensory and motor nerves were working properly.

Next came the painstaking task of checking each flexor and extensor tendon in his forearm and hand, which involved checking that every little joint moves up and down, side to side as it’s supposed to. And even though there were some small partial tendon tears, everything was intact.

“I know you don’t want to hear this right now, but you were extremely lucky today. I don’t know how his teeth missed all your major vessels and nerves, but once we clean the wounds and stitch you back up, you’re going to be okay.”

“I can’t believe I was so stupid!” He made a fist with his good hand and clenched it tightly.

“Sir, it was an accident, you were so brave to protect your son.”

“You don’t understand . . . I don’t have any insurance,” he said so softly, so that no one would be able to overhear.

Now up until this point I was not even thinking about his insurance or his ability to pay. And that’s probably largely because he did not look like someone who wouldn’t have insurance. He had on a polo shirt and khaki pants, leather loafers and a nice watch.

Because I looked confused, he went into more detail.

“I got laid off from my job a couple months ago. But I didn’t pay for the COBRA. I thought, I’m super healthy, I can get by without it . . . What an idiot!”

For those of you who don’t know what COBRA is, it stands for the Consolidated Omnibus Budget Reconciliation Act. It basically allows people to temporarily extend the health insurance they had while employed in the event they stop working. However, it can be very expensive because you have to cover the entire premium without any help from your former employer.

“Mr. Davidson, I have to administer your rabies shot.” A nurse walked into the room and started to set up an injection on the Mayo stand.

“Rabies? You think I could have gotten rabies?”

“Well, we don’t know if the dog that bit you was up-to-date on all his shots, so we give a series of rabies vaccines to anyone who was bitten by an unknown dog.”

“A series of shots? How much is that going to cost me?”

“Oh, I have no idea, sir. You’ll get a bill with all of the procedures listed on it.”

I watched the blood drain from his face, and I had him lie back down on the stretcher.

I spent over an hour irrigating, debriding, and suturing his forearm. The wounds were difficult to close because his forearm was so swollen from all the trauma. But I didn’t want him to have to go to the OR and make this an even more expensive problem, so I used all my suture tips and tricks to put him back together again. After I wrapped his forearm up in fresh white gauze and put him in a sling, I prescribed him some antibiotics to take at home and told him to follow up in the ortho clinic in a week.

I SAW MR. DAVIDSON A COUPLE WEEKS LATER TO CHECK ON his wounds and take his stitches out. Thankfully he never got an infection, the wounds were healing beautifully, and he could move and feel all the parts of his hand. But when I saw him, he was so melancholy I was worried that I was missing something.

“Do you know how much those rabies shots were?”

“I have no idea actually.”

“Fifteen thousand dollars.”

“What?! No, that can’t be.” I didn’t know much about billing at that point, and I had no clue how much the hospital charged for my services, but that just didn’t seem right.

“I’m screwed. I don’t know what I’m going to do.” His eyes started to water up and I scrambled to find a tissue.

Here was a man who was protecting his son from being viciously attacked, and now had to worry about going bankrupt because his health insurance was automatically terminated when he lost his job. It made me think of other people who lacked access to health insurance. It wasn’t until 2010 when President Obama signed into law a provision that young adults could stay on their parents’ health plans until age twenty-six. Before that many young adults who recently graduated from college had no health insurance safety net whatsoever and started their adult lives saddled with medical debt. And still today, young adults have the highest rate of uninsured individuals of any age group and also the lowest access to employer-based insurance.

The fact that access to health insurance is so integrated with employment by a large company puts so much power into the hands of these corporations. And more and more corporations are avoiding the responsibility of providing these benefits and shifting the responsibility to the individual. The Affordable Care Act did at least give people more options when there really were almost none. But ask most people who use those insurances, and they will tell you they can’t get in to see any doctors because so few of them will accept the low reimbursement rates.

I dated my husband for eight years before we got married. My dad had one rule: you’re not allowed to get married until you have your own health insurance. Even though he said it as a joke, looking back it was probably one of the wisest things he’s ever said to me. Health insurance is one of those things you have no idea how valuable it is until it’s gone.

Being uninsured is more than just having to pay a shit ton of money for uncovered medical expenses—in America, it’s one of the biggest possible threats to your well-being. If you’re unemployed or even freelancing or taking a job in the gig economy, the price of private insurance can be prohibitive; but if you take the gamble to live without it, then you’re staring down the paralyzing fear of getting into an accident and being responsible for hundreds of thousands of dollars that you will never have. Or the threat of debt collectors screwing up your credit score so you’ll never be able to buy a house or get a loan. It’s the kind of fear and uncertainty I wouldn’t wish on my worst enemy. And when I’m on a walk through Central Park with my own daughter and I see a dog off leash, I hold her a little closer and think how lucky we really are.

Chapter 13

The Runaway

Bias in medicine usually comes in two flavors: conscious and unconscious. I have rarely come across conscious biased medical judgment or decision-making. More frequently I witness bias that patients experience due to a medical provider’s unconscious bias that negatively affects a patient’s treatment. Meaning stereotypes that exist in our subconscious and can involuntarily affect the way we think and act. But what happens when unconscious bias leads you to judge someone in a positive light? A blindingly positive light, in fact?

Well, sometimes your patient will end up on the cover of a tabloid magazine.

AS A MED STUDENT THERE ARE MANDATORY CLINICAL rotations: internal medicine (everyone has to learn how to treat pneumonia); general surgery (everyone has to learn how to take out an appendix); pediatrics (everyone has to learn the developmental milestones); OB-GYN (everyone has to learn how to deliver a baby); and psychiatry (everyone has to learn how to treat a mental breakdown).

Psych was my first clinical rotation after spending two years in the library learning about the carbon skeleton oxidative catabolism for carbohydrates (aka the Krebs cycle). What I can tell you for certain is that nothing about memorizing the anatomy of a nephron will help you when they send the med student to interview a patient in the psych ER.

“Can you tell me why you came to the ER?”

“My brother and I were minding our own business at McDonald’s when all of a sudden someone comes up behind us, grabs my brother, throws him in an oven, and cooks him into a cheeseburger!”

I looked at the patient quizzically.

“So, your brother’s a cheeseburger?”

He lunged straight at me, causing me to fall and become entangled in the exam curtain.

“How come no one else is upset that my brother is a cheeseburger!”

As soon as I got my feet back under me, I ran into the physician lounge. I recited the entire cheeseburger kerfuffle to the senior resident who nonchalantly typed “acute psychosis room three.”

One time the psych attending asked for a volunteer to perform a full psychiatric evaluation on a patient in front of all the other students. I raised my hand, confident after studying all the different components to a complete interview.

The patient was a young man, still in college. He was the son of a celebrity, apparently hospitalized in an out-of-state institution to avoid word getting out to the press.

“Hi, I’m Erin McDermott, I’m a medical student, I’d like to ask you a few questions.”

“Fire away.”

“What brought you to seek mental health treatment?”

He leaned back in his chair, stretched out, and crossed his legs.

“To be honest, I don’t know why I was brought here, I’m the most normal person I know.”

I leaned forward, undeterred.

“Do you have any symptoms of feeling sad or anxious?”

“I’m as happy as a clam.” He smiled with a flash of his pearly white teeth.

“Have you ever been diagnosed with a mental health disorder before?”

“No, I just snort Adderall for fun.”

“Does anyone in your family have a mental health history?”

“Well, if being pathological liars counts . . .”

“Any history of schizophrenia, depression, anxiety?”

“If you’re asking if they’re crazy the answer is yes.”

I let out an irritated puff of air.

“How does your mental health affect your daily life?”

“Well, the voices are pretty annoying.”

I perked up. Maybe I was getting to an actual psychiatric problem.

“You hear voices?” I leaned even farther forward.

“All the time, especially at night when I’m trying to fall asleep.”

“What do the voices say?” I was at the edge of my seat waiting with bated breath for the answer.

He looked side to side, then leaned forward to talk directly into my ear.

“They tell me to . . . ‘pour some sugah on meeeeee!’” He jumped up and started playing air guitar like he was Def Leppard onstage.

“That’s enough.” The psych attending stepped in to save me from any more embarrassment. I walked dejectedly back to the group sitting in the observation room. I had been thoroughly played.

THE NEXT DAY THE HEAD PSYCH ATTENDING INFORMED ME that I would be sitting in on a family meeting for one of the young female inpatients. This was a woman who was brought in against her will for acute postpartum psychosis. And after the previous day’s shenanigans, I was not buying it. First of all, I had seen her multiple times in the psych ward and every single time she was reading a book. Most of our patients were trying to cut off their arm or scream until the staff couldn’t take it anymore and silenced them with Haldol. They weren’t leisurely reading Jane Austen.

Next, she looked like she walked straight out of a J.Crew catalog. She had beautiful long blond hair usually kept in a neat braid, certainly nicer than the messy bun I rocked each day, and she wore a casual dress with a cardigan and cute flats; again, much more put together than my wrinkled scrubs and bloodstained Merrells. As far as I could tell, she was totally fine.

The meeting took place in a large conference room with no windows and harsh lighting. The attending shook hands with the mother, father, and husband.

“This is my medical student, Erin, do you mind if she observes our meeting?”

“Sure, I guess,” the husband consented. We all sat down at a long table, the attending and I on one end, the family on the other.

“Thank you, now I know this is hard to talk about, but we all want the best for Ava. And for me to be able to treat her properly, I’m going to need to know everything about her behavior for the past three months and why it alarmed you.”

The family all gave looks to one another and nodded.

“It started with the wedding dress.” The husband plopped his elbow on the table and started to rub his eyebrows.

“One day I come home from work, and I see something sticking out of the trash bin because it’s so large it won’t fit in. I go over to the bin, open the lid, and there’s her wedding dress stuffed inside the garbage can. Just mixed in with the banana peels and dirty diapers.”

You could tell that he formed a smell association with that moment, which brought him right back to the scene.

“What did you do next?”

“I went inside, I could hear the baby hysterically crying upstairs but she was just sitting on the couch staring blankly at the TV like a zombie. I said, ‘Ava, is everything okay, where’s the baby?’ She shook her head like she was snapping out of it and told me she just put the baby down for a nap, she hadn’t slept all day.

“‘What’s with the wedding dress in the garbage can?’ I asked her. ‘Oh, I wanted to make extra space in the closet, and I thought I didn’t need that anymore, so I just tossed it.’”

Now I have to admit, that was weird. I don’t think I’d just throw a wedding dress straight in a garbage can, but did that make you “crazy”?

“Were there any other odd behaviors?”

The husband looked at the parents who gave him another nod letting him know that it was okay to be talking about these private stories.

“Another day I come home from work, and I find her sitting on our couch cutting her face out of our wedding photo. I freaked out, I said, ‘Ava, what are you doing!’ But it was as if she didn’t even register me yelling, she just kept cutting with those large scissors and I could hear them slicing through the photo paper. Then I looked around the room and she had cut her face out of all the family photos in the house! Like, what the hell!”

He was shaking at this point, and I felt really bad for him. His mother-in-law put her arms around his shoulders, and he began to sob.

The behavior was bizarre, but I still wasn’t convinced that throwing out your wedding dress and cutting yourself out of some pictures meant you had to be locked up in the psychiatric ward of a hospital.

“Don’t forget about the Bible,” the mother chimed in.

“That’s right, out of the blue she started reading the Bible constantly and going to church, like every day. We’d never been to church together besides our wedding day, so it made no sense to me why all of a sudden, she was super into religion.”

I could tell he was at a loss and mourning the woman he used to know. They were all sad and frightened at the same time. And with that, the attending said that we would continue our observation, and let the family file out.

Once they were gone, the attending turned to me. “So, what do you think?”

I furrowed my brow and fidgeted with my fingers.

“I’m not convinced she’s psychotic.”

“You don’t think the out-of-character behavior fits the pattern?”

“I know she just had a baby, but what if she really just didn’t want her wedding dress taking up space and was having a bad day and made an irrational decision to cut herself out of her photos, I just don’t see how that makes someone psychotic,” I said, stating my case.

“And what about the hyper-religiosity?”

“I don’t know, are people not allowed to get really into a religion? I mean I don’t know many twenty-year-olds that go to Mass every day, but just because you do does that mean you’re psychotic?”

He digested what I said, closed his eyes, and said, “I hope you’re right, let’s see how she does in the program.”

I continued to watch her each day I had left on my rotation, and each day, she was a perfect patient. She attended all the mandatory group therapy sessions, she never acted out or made any demands. Her family would come to visit her, never with the baby (would that be triggering?), and I started to think: she never even mentioned anything about having a newborn. If I had just had a child and was forcibly separated from them, I imagine I would be kicking and screaming to see my new baby, but she was cool as a cucumber. Even in therapy sessions, she seemed calm and even-keeled.

On my last day on service, a patient tried to kill themself and had to be transferred to the medical floor. In all the commotion with the medical team infiltrating the psych ward, Ava grabbed my arm and whispered, “I have to get out of here.”

“You’ll be home soon. You’ve made so much progress in all our therapy sessions. I’m sure they’ll talk about a discharge plan at your next family meeting,” I assured her.

What did I know? I was a measly med student who spent six weeks on a psych rotation and could now diagnose all my friends’ personality disorders.

I gave Ava a pat on the shoulder and swiped my card key to exit the ward, making sure to close the door tightly behind me.

Months later, I left the hospital to stock up on my diet of cereal and Lean Cuisine. As I pulled my cart into the cashier line, my eyes were drawn to the stacks of tabloids lining the checkout aisle. “Brad and Angie!” “Britney’s Psych Hold!” “Heath Found Dead,” and, wait . . . Ava?!!!

Staring at me was a picture of the J.Crew girl from the psych hospital, looking anything like the prim and polished girl I thought had been wrongly hospitalized. I put my basket on the floor, grabbed a copy of the magazine, and found a quiet corner in between the deli and the bakery. Turns out she had eloped from the hospital shortly after I had finished my rotation and made a cross-country trip to San Francisco where she quickly deteriorated and was found by her family homeless, wandering the streets, in a complete state of full-blown schizophrenia.

My face turned bright red. Poor Ava. How could I be so wrong? All along I had this voice inside of me that just said, Does this look like someone who’s psychotic? And that was the problem, because she looked “normal” I assumed she was, and sought ways to prove how everyone else was wrong. If I’d instead objectively looked at the warning signs that were there all along, I would have checked my biases at the door. In this case, my bias was a huge disadvantage to a person who was depending on me to help her.

At the end of the article was a quote from her husband who said that they shared their story so that other families would recognize the symptoms of postpartum psychosis and get new mothers the support they needed before it was too late. In their gut, they knew something was wrong, and they did the hardest thing they ever had to do: turn their own loved one in to a psychiatric facility. It took a tremendous amount of bravery to risk alienating themselves from Ava. And even after they did the right thing, it turned into a bigger nightmare than they could ever imagine. How scared they must have been not knowing where she was and how they were ever going to find her. I was so relieved to find out that she was able to be treated again and that she had completely recovered. Not all stories like these end up with a happy ending.

It’s never too early for a doctor to be served a slice of humble pie. Honestly, I’m lucky it happened to me so early, because it changed how I approach conversations with the family forever. I think about Ava whenever I sense a disconnect between patients and doctors, and I’m reminded that as doctors we only get such a small glimpse into a patient’s world. The patient and their families are the ones who really know what’s going on. If a spouse ever accompanies their partner to their appointment, I often ask the partner follow-up questions because nine times out of ten, the patient downplays their symptoms. And if they tell me something is wrong, even though I can’t see it or the labs are negative, I believe them. If someone looks too young or too healthy to be having significant health problems, I believe them. It’s important to check your bias at the door and keep looking for answers, even if you briefly think nothing is wrong. It’s easy to think that way, but you can’t ignore the signs of a bigger issue. And whenever I see those magazines on the grocery checkout line, I think of Ava and hope she’s found peace.

Chapter 14

The Secret Patient

One of the best parts of being a surgeon is fixing someone’s problem. It’s a feeling of satisfaction with such a powerful aura, it’s easy to get addicted to it. You feel like a firefighter carrying a baby out of a burning building or like a cop chasing down a burglar and slapping the cuffs on him. For surgeons, it’s the feeling that you get when you tell a patient, “You’re cancer-free,” or “You’re going to walk again.” Everyone deserves to have that moment at least once in their life.

Yet while that high can feel like you’ve just scaled Mount Everest, there is a low that we don’t talk about, that almost no one else in the world experiences. Because the other side of that power is the chance we make someone worse, take a life instead of saving one. And the guilt we carry when that happens is just as intense as the pride we feel when we save a life.

NO ONE IS BORN A SURGEON. THE MANTRA IS: SEE ONE, DO one, teach one. Technical skills are developed over thousands of hours of meticulous repetition. If you look closely at the drawstring on the pants of a surgical intern, attached to the large knot you will see wispy strings of suture with tiny knots, sliding knots, surgeon’s knots, one-handed throws, two-handed flat knots, that we practice when we have a precious minute of downtime.

If you ask a surgeon where their happy place is, they will tell you it’s the OR. There’s no place we’d rather be. There are church-like rituals that provide a sense of calming familiarity. I could be in New York or Nashville, and the scrub process is always the same. Take off the wedding rings, slide them on your necklace (never tie them on to your scrubs unless you want to be digging in a pile of dirty scrubs at the end of a scrub chute), tuck your ponytail under the bouffant scrub cap, try to not fall over when you put on your shoe covers, and tie your mask tightly to cover your face.

Tear open the scrub sponge, use your hips to give a little push to start the scrub sink faucet, use the fingernail pick to clean all that grubby dirt from under your fingernails, then rhythmically scrub your fingertips, down to your palms, up your wrist and forearms just till under your elbows. Then you place your arms in a ninety-degree angle under the running water so that the soap is rinsed off your fingers and down your forearms so there is no contamination. You walk backward toward the OR, push the door open with your butt, and are greeted by a scrub tech who will now go through the next ritual of gowning and gloving.

With your hands still sticking up in the air, the tech places a blue towel into your palm, which you dry hands first, then wrists, then forearms, then drop into the cupped hands of a nurse. Next, the tech holds an unfurled sterile gown into the air, and you walk like a zombie with your arms straight in front of you into the gown so that it is draped over the front of your body. The nurse then stands behind you and grabs two small paper strands on the inside of the gown and ties a knot at your waist and closes a Velcro tab at the nape of your neck.

With one hand still inside the sleeve of the sterile gown, you pinch the sleeve of the opposite arm so that the hand can poke through when the tech stretches the sterile glove over your fingers (newbies always get multiple fingers stuck in one finger hole). You repeat the process for the other hand and then pull the tab for a card attached to a long string. You hold on to the small end of the string, then you slap the card into the hand of the scrub tech while you do a pirouette until the string is wrapped around your body. The tech hands you back the card, which you tear off and use the free end of the string to tie to the shorter end in your other hand.

I have gowned and gloved for thousands of surgeries with hundreds of other physicians, techs, nurses, and students. Everyone has their own flair and idiosyncrasies (I appreciate a snazzy pirouette) but it is the consistency and predictability of the ritual that has always put me at ease.

When you are in training you are constantly observing. You observe how attendings introduce themselves to the patients and their families, you observe the language they use to explain how the procedure went: Do they go into technical detail? Do they just say, “Everything went great”? Do they stick around to answer questions? Do they personally check in on the patients? Do they speak with the PACU nurses to explain potential concerns? Do they hide out to do dictations and catch up on paperwork? Or do they hang out in the lounge chitchatting with the other surgeons? There are no right or wrong ways, but there is always your own personal gold standard.

There is no physician I have come across that inspires more confidence and trust from patients, other physicians, nurses, and techs, more than Dr. Ed Athanasian, Dr. A for short. I first met Dr. A during a rotation on the orthopedic oncology service at Memorial Sloan Kettering. Dr. Athanasian had the unique distinction of having dual appointments at the most world-renowned cancer center in the country and the most world-renowned orthopedic program, the Hospital for Special Surgery.

Before I met him, I knew of him by his reputation. My mentor at Lenox Hill, Dr. Steve Lee, tells the ortho residents the same story every year so that we understand that there will be times in our career when we don’t know what to do, and to not be afraid to ask for help. Dr. Lee had just graduated fellowship and was a new attending taking call. He was paged in the middle of the night to see a patient who had a painful, red rash on his arm, which might indicate an infection. But even in the short time it took Dr. Lee to see the patient himself, it was clear that this was no ordinary infection. The forearm was becoming more swollen by the minute and the discoloration was rapidly creeping up and turning into a mottled, purplish hue. The pain was excruciating, his heart rate was racing, and his blood pressure was tanking.

“I’ll be right back,” he told the nurse and called his senior partner.

“Hello?” Stephen Nicholas answered groggily.

“Steve, I think I have a case of nec fasc, you ever seen one of these?”

“No, you sure it’s nec fasc?”

Necrotizing fasciitis is the most serious, life-threatening infection that exists. It’s also known as “flesh-eating bacteria.” The scary part is that in the beginning, the infection seems innocent enough with some mild redness and swelling, but then it quickly morphs into an aggressive, all-encompassing wave of destruction killing every cell in its path leading to death in a matter of hours.

“What should I do?”

The phone was silent for few seconds, “Call Ed Athanasian.”

“Who’s that?”

“He’s my college roommate, smartest person I know. He trained at HSS, he’ll know what to do.”

“But he doesn’t know who I am. He doesn’t even work at this hospital.”

“Call him; he’ll tell you what to do.”

So Steve Lee called Ed Athanasian, who picked up the phone immediately.

“Hello?”

“Um, Ed, hi this is Steve Lee, I work with Stephen Nicholas over at Lenox Hill, and I wanted to know if I could run something by you.”

“Of course, what’s going on?”

“I have a guy in the ER, I think he has nec fasc, vitals are tanking . . . to be honest I’ve only read about nec fasc, I’ve never seen a case in real life.”

“You sure it’s nec fasc?”

“Yeah . . .”

“You amputate the arm.”

He was afraid he’d say that.

“The whole arm?” Steve painfully questioned.

“You amputate the arm, you save a life.”

“You’re right . . .”

“Steve, call me anytime.”

Dr. Lee ended up amputating the entire arm that night, and in doing so, saved the man’s life. I had heard Dr. Lee tell that story at least three times before I met Dr. A during my first stint at Sloan Kettering. The first thing I noticed about Dr. A is that he is a walking medical encyclopedia.

“Patient is a three-year-old male with a two-month history of a soft tissue mass in the hypothenar eminence. Per the patient’s mom the mass does not bother the child, but she believes it has been growing in size recently,” I said, reporting the history to Dr. A.

“What’s the exam?”

“Mass is about one centimeter by one centimeter, soft, mobile, no overlying skin changes.”

“Does it transilluminate?”

Shoot, I forgot to check that.

“I don’t have a pen light on me, sorry Dr. A.” I looked away sheepishly.

“What’s your differential diagnosis?”

“Well, it could be a ganglion cyst.”

“Is that a common location for a ganglion cyst?”

“Well, it’s not the most common location.”

“What are the most common locations?”

“Uh . . . dorsal ganglion cysts and volar radial cysts?” I winced.

“Have you ever heard of an ectomesenchymoma?”

Gesundheit, I thought to myself.

“No, sir, I haven’t heard of that.”

“It’s a malignant tumor in children that has ganglioneuroblastic, rhabdomyosarcomatous, and chrondrosarcomatous elements.”

I gulped.

The mass turned out to just be a ganglion cyst, but Dr. A’s point was to make sure I was aware of potential zebras. There is a saying in medicine that if you hear hoofbeats, think horses, meaning the most common and obvious diagnosis is usually the right one. But it’s important to consider all of the possibilities. For some people, those hoofbeats may be coming from a zebra, and if we don’t think of those zebras, we’ll miss them completely.

One day during a full slate of complex surgeries, Dr. A disappeared for an hour. I just figured he had a meeting with another surgeon or was perhaps catching up on paperwork. Then the next day he disappeared for an hour during his office hours. When he disappeared for a third day in a row, I wondered if maybe I did something wrong to not be included in whatever was clearly a very important meeting.

I popped by his secretary to check in. “Ro, where is Dr. A sneaking off to every day around lunch?”

The telltale sign of a respected surgeon is how long their secretaries have been with them. Behind every successful surgeon is a devoted secretary who protects them from the barrage of inquiries and requests, reminds them they have to finish up by 5:30 p.m. to get to their kid’s concert in time, and sneaks them snacks during clinic so they won’t pass out. They are the gatekeepers to the doctors, and if a resident is smart enough, they know that the key to a successful rotation is making sure you make the secretary’s life as easy as possible.

As reserved and straitlaced as Dr. A was, Ro was his boisterous comic relief. To work in a job where every day you have to deliver cataclysmic bad news, Ro was a breath of fresh air. She treated people like they were her own family members, and her thick Italian accent endeared her to patients and surgeons alike. I would watch her call a patient to reschedule a long-awaited appointment because Dr. A had a surgical emergency, and by the end of all the sweet-talking, the patient would be laughing and thanking her.

“He’s taking care of Leo.”

“Who’s Leo?”

“You know, Leo, the one with the humongous open wound on his shoulder.”

I was surprised. Wound care was not generally the purview of the surgeon, they are so busy with surgeries and evaluating new patients that they simply don’t have the time to do basic tasks like dressing changes. The residents typically change all the wounds while rounding on patients at five in the morning so that by the time the attending sees them, they can focus on speaking with the patient and formulating a plan to get them home. It was something I should be doing.

“Hold on a sec . . .” She stood on her tippy-toes thumbing through a bunch of patient charts filed in the wall cabinet. “Got it! Here you go, hon.”

The chart was as heavy as a brick and the color of the manila folder had faded over time. I looked at the date of the initial visit; he must have been one of Dr. A’s first patients. There were hundreds of notes detailing the office visits, operative notes, pathology reports, and radiation logs to treat his shoulder cancer. I skipped to the last page and saw a handwritten note with “post-radiation sarcoma” underlined.

Oh no.

Post-radiation sarcoma is an extremely rare cancer that is perhaps the cruelest of them all. It is an iatrogenic cancer, meaning that the same treatment used to treat one cancer is what causes a different form of cancer. For anyone who has had cancer, then you’re familiar with the general forms of treatment: surgery to remove the cancer; chemotherapy to chemically kill the cells; and then radiation to physically kill the cells. However, in rare instances, the effect of the ionizing radiation alters the cells, causing long-term damage that can take up to ten years to manifest as a new cancer.

It is a devastating late complication, and because of the aggressive nature of the disease, the soft tissues start to decay, leaving what looks like acid-drenched skin. I had never seen a post-radiation sarcoma in real life, only read about it in the textbooks.

“Do you know where Dr. A is right now?”

“He’s probably still with him in the first-floor exam rooms, he said it takes about forty-five minutes to change the bandage.”

“Thanks, Ro.”

I made my way down to the ortho clinic, and even before entering the room, I could hear the patient whimpering.

I was taken aback: first by the smell and then by the sight. The gentleman looked like a kind, gentle grandfather, and his entire shoulder was rotting flesh. It looked like a shark had taken a bite out of him and then fleas had infested the fat and muscles to make it look like putrefied chum.

Dr. A could see I was holding back my lunch and returned his attention to the patient. I had never seen a dressing change like this before. I could only imagine how painful it must be and wondered how the patient was even tolerating it without anesthesia.

“I can assist however you’d like, even just to help clean up, it’s not a problem at all,” I said, while trying not to breathe through my nose.

“Thank you. Leo, this is Dr. Nance, she’s one of the ortho residents who’s helping me this rotation.”

Leo looked up at me with wounded eyes. He knew I was there to help but was already anticipating the pain I’d be an accomplice to.

“Pleasure to . . . meet you,” he stuttered through gritted teeth.

Dr. A was trying to peel back a layer of bandage that was glued onto the tumor without ripping the surface of the tumor, causing more bleeding and yellow, soupy oozing and immense pain. He placed his hands so gingerly on the skin to try and apply enough pressure to separate the bandage, but every time he would make progress the bandage would be snagged in a different area and Leo would yelp in pain.

“Let me get some more fresh saline.” I had a bright idea and ran out into the supply closet. I closed the door and took a deep inhale in and then choked out a cough. If the bandages were wet they would soften the scabs that had formed between the soft tissue and the gauze and maybe that would give him some relief.

It was humbling to see Dr. A, the chief of hand surgery, the world expert, be so gentle with this man. And while I knew that Dr. A did not cause this cancer, and Leo knew that Dr. A did not cause this cancer, I couldn’t help but be overcome with the wave of guilt emanating from that room.

We spent another twenty minutes meticulously cleaning Leo’s wound, covering it with layers of antibacterial ointment and soft absorbent gauze and a compression dressing to provide some support and cover the wound from any unsuspecting gaze. The five-year survival rate for radiation-induced sarcoma is only 40 percent, but I could tell from Dr. A’s determination that he was not going to let Leo become part of that statistic. Dr. A wasn’t hiding this patient so that no one would find out about the complication. He was doing everything he possibly could to take personal responsibility and ownership of the complication. A true hero.

For Dr. A, it wasn’t about the surgeries, or the clinics booked with back-to-back patients from around the world, or the groundbreaking research studies he authored; it was about the patient right in front of him. No matter if they required an eight-hour microsurgery, or a simple Band-Aid, he placed his patients’ needs above his ego, and taught me that above all else, we are in service to our patients. That our responsibility to them does not end if there is a complication or a bad outcome, in fact, that’s when the true mettle of a doctor-patient relationship is tested. And while no one is born a surgeon, we get to choose every day how we show up for patients, one bandage change at a time.

Chapter 15

The Day the Dicks Came Down

If you asked any of my ortho co-residents to close their eyes and tell you what was inside the ortho lounge they’d tell you one thing: dicks.

That’s right.

Physical dick cutouts taped up all over the room, oftentimes inserted into the mouths of a printout of an attending’s face (typically a popular attending; this was a sign of being respected, that they could take a joke). In my lounge, there was even a three-foot-long cardboard cutout of a dick that was hanging over the whiteboard. Literally, no one would bat an eye when they would write out the eight types of osteogenesis imperfecta on the board under a giant dick.

There was a swimsuit calendar with girls in skimpy bikinis, which was our official calendar of educational lectures, anatomy dissections, and skills labs. The lockers on the side of the wall each had our nickname taped up and were decorated with—you guessed it!—dicks. I don’t remember who had a Maxi pad taped under their name, but I don’t think it was any of the girls. One had a printout of the Throckmorton sign, which to enlighten the general public, is when someone has such a large and dense penis that the shadow of the penis shows up on an X-ray. (Google at your own risk.)

In the four years since I’d started at the hospital, not much had changed in the lounge. Maybe a few more dicks had gone up. Besides that, the difference was that I was returning to the lounge as chief resident. The chief resident is the most senior resident, or group of residents, in a department. My residency was five years long, so when you reached the fifth year you became the chief resident. The chiefs are responsible for making sure the program runs smoothly. They assign the daily coverage for surgeries. They are in charge of granting vacations so we’re never short too many residents to cover the 24–7, 365 days of orthopedic surgery coverage for the hospital. They determine who’s on call every night. They organize the educational lectures. They set the example of leadership among the junior residents.

When I got to the ortho lounge, James, one of the interns, was busy scribbling on one of the green consult notes; he had about seven in his back pocket already.

“Busy night?”

“The ER is trying to kill me.” He leaned back and smothered his face with his hands.

We’ve all been there. Whenever my friends and I went out to a bar or a concert or a game, I never got up to go to the bathroom, no matter how many beers I had. I joked that I had an iron bladder because I used to go twenty-four hours on call and not go to the bathroom once because there was simply . . . no time.

But there was something else that was off about James. He’d done a great job as a med student. He was hardworking, he knew the answers to the pimp questions (the rapid-fire questions senior residents and attendings hurl at junior residents to try to trip them up), he always stayed late to help the overnight intern in the ER or volunteer to assist in the late-night add-on cases. The residents were pumped when he matched at Lenox. We only have two residents per year, so we really can’t afford a dud.

“Have you been scrubbing in on a lot of cases?”

Juniors take the brunt of the scut work. This means doing all the unglorified paperwork; holding the pager answering calls from the floor nurses; putting in orders for all of the seventy-year-old attendings who never learned how to use the computer. You think you’ll be hands deep in someone’s pelvis putting bones back together like a jigsaw puzzle, instead, you’re hands deep disimpacting someone who hasn’t had a bowel movement in five days.

“I just finished spine.”

“Oh, so a lot of Two for Tuesdays,” I joked.

Two of the spine attendings listened to the classic rock station Q104.3, which on Tuesdays would play back-to-back songs by the same artist. My dad loved classic rock and he controlled the radio in the car, so I knew every Beatles, Eric Clapton, and Eagles song by heart. Even my wedding song was an obscure Billy Joel song from the seventies that none of my friends had heard before. After the first song would play the attendings would have everyone guess what the next song would be. I had a feeling James didn’t know his CCR from his AC/DC.

“Yeah, Tuesdays were long for sure.”

He didn’t sound angry or sad; the worst part was that he sounded like he just didn’t care.

I could tell there was more going on with James than just feeling like he didn’t fit in because he had different taste in music. Although he never said anything, and I never heard anyone else talk openly about it, I knew that James was in the closet. I don’t know when it happened, but James went from being the ortho junior to the gay ortho junior. And if I thought it was bad being among the only 6 percent of females in orthopedic surgery, I could not even identify one openly gay male orthopedic surgeon in the country.

I am positive there were other gay male orthopedic surgeons, but I certainly had never met someone who openly identified as one. That just didn’t happen. I mean, some of my residency interviews ended up after hours at a strip club; it wasn’t exactly an accepting environment.

“Life gets a lot better when you’re a senior resident, and you never have to do three months of spine again,” I said, trying to cheer him up.

Beep-beep . . . beep-beep.

James winced as he peeked at the number on the pager. X7888 meant it was coming from the floor, probably just a quick Tylenol order to put in the system. X3079 was the ER, which could be anything from a broken hip admission to a complex elbow dislocation. Just his luck . . . it was the ER. He put his forehead down on the table and stretched his arms all the way out to his fingertips, trying to release some agitation.

I patted him on the back, “Sorry, man. Good luck, I gotta do the schedule and then I’m out. Chapman is the senior on call if you need any backup.”

We both knew he would never call in a senior resident for junior resident work, but I wanted to let him know in theory the option did exist.

“Thanks, Erin.” He picked himself off the table, gathered all the consults into his scrub pocket, and walked out the door.

No one in ortho called me by my first name; I was Nance. All the girls were called by their last name. In fact, I think some people in the hospital thought my name was Nancy and people were calling me Nance as a nickname. The fact that James called me Erin humanized me, and it felt like he was trying to connect with me.

I went over to the desktop computer where the next day’s OR printout was lying on top of the keyboard so I could email the OR assignments to the team, my first official act as chief resident. As I was typing out the assignments:

Carter: Dolan TKA x 3

Daniels: Kang CTR x 2, DR ORIF x 1, Olecranon x 1

Rodgers: Anderson ACDF, PSF

Something didn’t seem right, and it felt blindingly obvious when I looked around the room.

All I saw were the dicks staring back at me. The dick on the lockers, the three-foot cardboard dick above the whiteboard, the dick attached to the attending’s mouth. What must it feel like for James to enter this room day in and day out? We all knew what we were signing up for but that didn’t mean it had to stay that way.

I had walked through that door thousands of times before, but it wasn’t until I saw the impact on James that I realized something needed to change. I wasn’t going to let one more day go by where someone was made to feel unwanted or uncomfortable. Residency could be close and fun without making people feel self-conscious about their identities. And me participating in and tolerating the culture was making it harder for anyone else to speak up and make a change.

And something inside me just snapped: the dicks were coming down. I ripped up all the paper dicks, peeled the Maxi pad off the locker, pulled down the swimsuit calendar, stood on a chair and yanked down the massive dick and stuffed it into the trash can. I was out of breath; it was hard trying to erase fifty years of misogyny.

I don’t remember when James officially came out to the other residents and the attendings, but I do remember meeting his boyfriend, who was also a resident at Lenox Hill, at his graduation three years later when I was a first-year attending. It made me so happy to know that he felt safe and proud enough to bring his partner.

When I met my husband for dinner that night at JG Melon, I was about an hour later than I’d promised. I squeezed past the crowd of preppy banking interns and fashion girls to sit next to him at the bar.

“What happened?” he asked sympathetically. “You get pulled into a case?”

“Nope, I took all the dicks down.”

He looked surprised. “Even the ginormous one?”

“Yep, this is the Nance era, and we’re done with the dicks.” I took a huge bite of my cheeseburger, a swig of beer, and had never been more pleased with myself in my life.

Chapter 16

So You Want to Be Chief?

When you are a junior resident, you tend to bitch . . . a lot. You bitch about the number of call days, holidays on call, vacation days (or lack thereof). You bitch about holding the pager, covering the ER, presenting the cases, and rounding on a never-ending stream of patients. You bitch about holding the retractor for four hours straight and being stuck in resident clinic. Then one day you wake up and you are now the senior resident, the chief resident even, and you’re the one making the schedule, telling people where to go and which holiday to brace their family to not expect them home for turkey dinner.

We ask them to do Herculean, inhumane tasks. We sacrifice our time, our energy, our relationships, all in the name of learning and having the honor of taking care of people. But becoming a doctor is not just about learning medical facts and perfecting surgical skills. You must learn how to become a leader. A leader among your peers, a leader in the operating room, a leader in your community. You learn that you cannot control the actions of other human beings. Maturity as a surgeon is understanding that it’s how you respond to those actions that makes all the difference.

“ROB, WE’RE ROUNDING AT SIX A.M. TOMORROW MORNING. I know it’s your birthday tonight. I don’t care what you do or who you do it with, just be in the lounge at six a.m. sharp.”

It was Friday night and a bunch of the residents not on call were busy swiping on Tinder and spraying copious amounts of Axe body spray on themselves. It was enough to make you choke on the scent.

“Oh yeah, I’ll be there, no problem, Chief.” Rob flashed a mischievous smile.

“I have an add-on case first thing in the morning, we can’t be late with rounds.” I wanted him to understand the stakes.

“Rob, you coming?!” yelled a bunch of his ready to tear-up-the-night co-residents.

“Six a.m. Got it.” He grabbed his coat out of the locker and ran out of the lounge to catch the rest of the guys in the elevator.

I looked at the intern on call for the night.

“There’s no way he’s making it to rounds on time,” he scoffed.

“He wouldn’t dare,” I corrected him. I had the reputation of being a strict but fair chief resident. I instilled just enough fear for the residents to stay in line but also want to grab drinks after work together. Rob might want to party tonight, but no way he’d be irresponsible enough to miss work.

WONK! WONK! WONK! WONK! THE 5:30 A.M. ALARM NEVER GETS easier to hear.

Justin looked at the clock. “This seems early for a Saturday.” He rubbed his eyes and snuggled back under the cozy comforter.

“I have an early case and we have over forty patients to round on.” I put my hair up into a high pony and got out of bed.

“I love you.” I peeked under the comforter and gave him a peck on the forehead before heading to the bathroom to splash some cold water onto my face.

I walked the familiar fifteen blocks in the pitch black, lit by only the stop lights and the neon signs from twenty-four-hour convenient stores. I swiped my ID into the ER entrance and made my way to 14 Black Hall.

5:55 a.m.

“Hey man, anything else come in besides that hip fracture you texted me about?”

“Just a bunch of distal radiuses and some crap consults.” Tom was flipping through his green sheets to make sure he had finished writing them out before he dropped them in all the charts like a little ortho fairy.

“How many people on the list?”

“Forty-two.”

“All right, you take eight Wollman, I’ll do eight Lachman, and Rob can do the rest.”

6:00 a.m.

I looked down at my watch and flared my nostrils. I texted Rob: “You’re late” and stuffed the phone into my scrub pocket. I was annoyed but figured best to get started on the day.

I took the most complicated patients to round on since I knew I’d be the fastest. I changed all the most complex spine bandages and wrote orders for the ICU and step-down patients. I went over the plans with the overnight nurses to relay to the day team, and made my way through the stacks of charts writing barely legible, but still legible, notes.

7:30 a.m.

After I finished rounding, I went back to 8 Wollman to see if Tom needed any help finishing up with his patients. There on the counter was the untouched patient list meant for Rob.

That motherfucker.

I texted him again. “You better get your ass over here now.”

I spotted Tom in the hallway. He could tell immediately by the look on my face what was going on.

“Take the patients on five Uris and I’ll get all the rest. I’m gonna kill that kid,” I said, steaming.

8:00 a.m.

Tom met me back in the ortho lounge to sign out all the patients. Unfortunately for Tom he wouldn’t be going anywhere until either I finished my case or Rob strolled in.

“This case should be fast, it’s a hip pinning. I’ll get you home soon, sorry.”

“It’s not your fault,” Tom pointed out.

10:00 a.m.

As Murphy’s law would have it, the add-on case took twice as long as it should have. On the weekend the OR crew is not exactly moving with a pep in their step. For the nurses and OR techs and anesthesiologists, they are stuck at the hospital for the entire day, no matter how many cases they do. For the surgeons, we leave as soon as the case is over because we don’t get any off days. We still have to show up at our offices full of waiting patients even if we were operating all night long.

After I transferred the patient to the PACU, dictated a quick op note, put in all the orders into the computer, and stole a juice box from the patient fridge, I made my way back up to the ortho lounge. Tom was splayed out on the conference table, pager lying on the desk, papers scattered all around him.

For a moment I thought, what if something actually happened to Rob? I mean he hadn’t answered any of his texts; should I check the ER board or call the local jail?

10:07 a.m.

I smelled Rob before I saw him slinking into the room with a hoodie pulled over his head. I kept on writing notes.

Rob put his bookbag in the locker and then sat across the table from me.

We all sat in silence.

Painful, awkward silence.

“Aren’t you going to say something?” Rob finally broke first.

I took a deep breath to compose myself.

“What the fuck am I gonna say to you?! You obviously don’t fucking care what I have to say or what I tell you do to!”

Okay, that was as composed as I could be.

“I’m sorry . . .”

“Don’t tell me you’re sorry. Get sign-out from Tom who’s been waiting for you so he can fucking go home.” I was beyond disgusted at this point; I had crossed over into apathy.

“Are you gonna do anything?” He looked at me like he was ready to receive corporal punishment.

I looked him in the eye so he could feel what I was about to tell him.

“Oh, I’m not gonna do anything, I’ll let Weiner decide what to do with you.”

Dr. Weiner was the residency director. The guy was five foot five and built like a tank. Everyone in the hospital was terrified of him. The less he talked, the angrier he was at you. For those who were in his good graces, he was absurdly fun to be around. But if you were in trouble, watch out.

Rob gulped and shook his head. I grabbed my bag out of the locker and left Rob to cover probably one of the most painful twenty-four-hour calls of his life.

Truth be told, I never told Weiner about Rob. The fear of me telling Weiner was enough to keep Rob in check.

LATER IN THE YEAR I FOUND MYSELF IN ANOTHER PREDICAMENT over patient safety, and I chose a different route.

I was finishing the last week of my final rotation with Dr. Jose Rodriguez, or JRod, as he was affectionately called by all the residents. Because it was toward the end of the year, and the fellows had spent twelve months dedicated to doing total joint replacements under his watchful eye, they were given increasing amounts of surgical autonomy. The fellow and I usually split rooms so each of us would have the chance to be the lead surgeon trainee, but my last case happened to cancel so I offered to assist JRod’s Fellow, Charles, during the surgery.

The beginning of the surgery was uneventful. Charles cut through the incision, dissected through the fat, and pushed aside the large muscles in the front of the thigh. He had reached the stage where he was supposed to expose the three sisters, the branches of the lateral circumflex vein. But something didn’t look right to me. The veins were supposed to be bluish and compressible. The retractors weren’t pulling the muscles at the same angle I was used to seeing, almost as if they weren’t placed in the correct muscle interval.

“Charles, are you sure you’re in the right spot?” I didn’t want to embarrass him but I was worried that something about the anatomy was off.

“I’m in the right place, I’m sure of it,” he responded confidently. He continued to dissect into the small open window in the hip.

I gave Kenny, the scrub tech, a look and he gave me one right back. He was like a surgical bouncer. He would not let you pass go if he thought you were going to fuck something up. We gave a micro shrug to each other and placed our attention back to the wound.

“Mets.” Charles called for the scissors to dissect around the veins. Kenny slapped the handle into Charles’s hand, and he began to dissect with the blade.

I tilted my head to get a better view of what he was cutting when all the sudden, WHOOSH, WHOOSH, WHOOSH! A stream of bright red blood was squirting across the field, splattering my white gloves. I knew he wasn’t in the right place. He’d cut the goddamn artery.

I looked at Charles, his hands were frozen, and his eyes were darting around the room.

“Lap pad!” I called out forcefully, but not in a panic.

Kenny handed me a lap pad, which I used to put pressure on the wound. It soaked up all the blood in less than five seconds.

I looked over to Charles, he still hadn’t made a move.

“Get me another lap pad, Bovie, tonsil!”

Kenny handed me the items in succession. I swapped out the soaked lap pad for a new one and used the tonsil forceps to try and clamp down on where I thought the bleeding was coming from. I buzzed the Bovie on the tonsil to see if maybe it was a small bleeder that could be cauterized easily.

It could not.

“I need more lap pads, there’s too much blood, I can’t see where it’s coming from.” My heart rate was quickening and I felt beads of sweat begin to form on my forehead.

“The vein shouldn’t be bleeding this much,” Charles muttered into space.

I took my eyes off the wound for a second to look directly at him. “Charles, you were too medial, you cut the artery.” Now was not the time for denial.

Then in an incredible act of manifestation, JRod opened the back door to pop in on us.

“Everything going all right?” he asked innocently.

Charles looked at me.

“We’re fine,” he answered nonchalantly.

JRod nodded his head and turned back around to leave.

I looked back at Charles. Liar.

“We’re not fine!” I said defiantly. “We cut the artery and we can’t control the bleeding.”

JRod whipped his head back around and made a beeline to the OR table.

“I’ve been putting pressure on the bleeder, but it must have retracted proximally. I can’t find the source,” I said, defeated.

JRod made a face with his pursed mouth, like he wanted to say something but had the maturity to hold it inside.

“Don’t move your retractors. Nance, keep your pressure on the wound. I’m scrubbing in.”

He forcefully pushed the front door open and went to quickly scrub outside the OR.

Charles leaned forward toward my face. “Why would you say that to him? I would have figured it out,” he said in a scathing, hushed voice.

I shot him a nasty look.

“You didn’t even know what the problem was! I’m not letting the patient lose their leg because you can’t admit you made a mistake,” I huffed.

JRod was back in a flash. Kenny gowned him up in world-record time. He walked straight over to Charles’s spot at the table and pushed him down toward the legs.

“Scalpel.” He placed his hand in the ready position to receive a loaded scalpel and Kenny inserted it perfectly. He lengthened the incision with one smooth sweep of the blade.

“Bovie.” He clamped down the small bleeders with his pickups and cauterized along the way.

“Mets.” He dissected a clear path to the anatomy in question and within two minutes had identified the proximal source of the bleeding.

“Tie,” he called out to Kenny, but instead of taking it in his hand he called out, “to Nance.”

Kenny and I swapped; he held the pressure while I took the tie in one hand.

I looked at JRod who had not taken his eyes off the offending bleeder.

“Right angle hemostat,” I called out.

My hand was shaky, but Kenny slapped the hemostat with authority into it; he knew I could do it. I placed the end of the tie into the mouth of the hemostat and gently used the angle to sweep under the vessel edge to place the tie around the gushing artery. Then I took the two free ends in both hands and just like I had practiced for thousands of times with sutures on my scrub drawstrings, I laid a perfectly square two-handed tie around the vessel, and with one gentle but firm pull, the bleeding stopped instantly.

I exhaled but did not displace my hands one millimeter. I caught a glimpse of a smile from Kenny out of my peripheral vision. Then I switched the direction of my throw to lay down a second perfect square knot that locked it into place. I did another one, and another one, and one more for good luck.

“Scissors,” JRod called out, and he snipped the ends of the suture like any good assistant would.

The whole time, I was thinking about what would happen after the surgery—how mad JRod would be at us. I didn’t know how to stop the bleeder and I was certain the fellow didn’t know either.

We finished the rest of the surgery without any further drama and I pushed the patient to the recovery room and signed out to the PACU nurses. JRod was waiting for me in the hallway. Moment of truth.

“That was brave, what you did,” he said, placing his hand on my shoulder.

He could see I was confused.

“The sign of a good surgeon is knowing when to ask for help,” he explained. “And the sign of a great surgeon is knowing when to speak out when the safety of the patient is in danger, no matter who it is.”

I smiled and my body relaxed for the first time in three hours. “Thank you, sir, I appreciate it.”

I had gone against the training hierarchy and ratted out a fellow. Not a good look. But I knew what the right thing to do was. I made my choice, and I had to live with it.

IN ROB’S CASE, I LET MY ANGER CLOUD MY JUDGMENT AND let him flounder in a situation where he had no business taking care of people. I was hellbent on punishing him, showing him that there was a right way and a wrong way to conduct yourself. That your consequences have actions. But part of being a good leader is to understand how much rope to give someone: enough that allows them to learn from their mistakes, but not hang themselves. It’s how my dad described what it’s like trying to be a good parent. A constant push and pull of observing and intervening. You can’t make the choices for the people you’re leading. But you can lead by example, know when to give grace and know when to take action. And trust that one day when they are in the same position, they will think of you and know what to do.

Chapter 17

Life in the Grey

As a premed student watching Grey’s Anatomy for the first time in 2005, I was entranced. Not because of the superrealistic cases, or the behind-the-curtain peek into a resident’s life, or even the McDreamy factor (okay, that was part of the reason I never missed an episode), but because of the moral ambiguity of the characters.

The greyness of it all.

Should Izzie be falling in love with her patient, knowing full well about the imbalance of the power dynamic between doctors and patients? Should she have “stolen” a heart for Denny to get him the transplant he needed? Was there a way to stop it from happening? I didn’t have all the answers. The show brought new dimension to medicine, which had always seemed very black and white to me. There was a right thing to do, and a wrong thing to do. There was a right way and a wrong way to do things. But what if the right thing to do had to be done the “wrong” way?

FELLOWSHIP IS THE LAST STOP ON A SURGEON’S PATH TO independence. Technically we’re fully licensed and able to treat patients on our own, but the vast majority of surgeons opt for an additional year of hyperspecialized training to master a particular field. In my case, I chose a hand fellowship. The hand is an incredibly complex part of the body. It is one of the most highly evolved parts that makes us human. The interplay of tendons, bones, joints, nerves, and soft tissues allows us to do everything from climb a mountain to power-type a scathing Yelp review.

One of the responsibilities of the hand fellow is to manage the calls from the emergency department. This can be anything hand-related, running the gamut from a simple fingernail infection from a manicure gone bad to a fingertip smashed in a doorjamb to a broken forearm from a fall off the monkey bars. The junior residents are capable of taking care of about 90 percent of the injuries, but sometimes they have to call in the fellows for backup.

Bzzz-bzzz . . . bzzz-bzzz.

There is an unstudied phenomenon that if you are on call for the night, the moment you think things are quiet and you go home, the moment you step foot into your apartment, you will get a page, sucking you back to the hospital like some sort of super magnet.

“So sorry to bug you, but I think you’re gonna want to come in for this,” the junior resident warned me.

Moments later ten pictures pinged on my phone, each one more grotesque than the other. (I never minded any of the injury photos, but my husband and I shared an Apple ID, and he had made it clear he could go without the stomach-churning photos flooding our photo album. Which . . . fair.)

“What the heck happened to this guy?” I was stunned. New York City has a very light trauma load compared to other areas of the country where they are used to dealing with explosive industrial injuries at factories or catastrophic farm equipment accidents. The biggest threat to an investment banker might be a papercut.

“You know that huge tower they’re building across the street?”

“The one with all the scaffolding?”

“Yeah. So this guy is one of the construction workers. Apparently, he lost his balance and fell off the top of the scaffolding.”

“Holy shit, that has to be like ten stories! How is he alive?”

“He used his hand to grab on to one of the poles to slow him down as he fell until his clothes got caught on one of the posts and saved him from going splat on the pavement. But he basically burned a hole through his entire palm and every single tendon is cut.”

“Is it even viable?” Without immediate blood flow, the soft tissues would start to die in a matter of hours.

“That’s the crazier part, all the vessels stayed intact, even the nerves are in decent shape. But the tendons are ripped to shreds and the palm skin is a huge flap hanging on by a thread.”

“Okay, I’ll be there in ten minutes. Give it a good wash in the meantime; it’s got to be filled with metal debris and who knows what.”

I made my way down York Avenue, walked through the revolving doors, and swiped my card to enter the back of the ER. I scanned the board to see who was in the procedure room: there was no name, just an ID number. I knocked on the door and let myself in knowing the junior resident would be busy washing out the wound.

“Hello, I’m Dr. Erin Nance, the Hand Fellow on call tonight.”

The patient looked at me blankly.

“Soy Doctora Nance, soy la doctora de tu mano.” I sounded like Mike Bloomberg speaking Spanish at one of his press conferences.

“I speak a little bit English,” he responded through gritted teeth. The resident was using the equivalent of a squirt gun to wash away the dirt and grime of that pole, and clearly, he was in a lot of pain.

“Okay, great then. Your hand will need surgery to fix it, we have to repair los tendones.”

“No, I cannot stay for surgery.” He shook his head furiously.

“Sir, you need surgery, your hand could become seriously infected, you may even lose your hand if we don’t take care of it soon. Plus, none of your tendons are connected, you won’t be able to move any of your fingers.” I spoke very directly; I wanted him to understand the seriousness of the situation.

“No, I need to go home.” He continued to shake his head, and I could see tears welling up in his eyes.

“Sir, we’re here to help you, you won’t get any better if you just go home.” I tried to get a good read as to why he might be refusing to have surgery on such an obvious injury.

“No.” He began to cry and wiped away the tears with the torn-up sleeve of his good arm.

The junior resident looked at me, I looked at him. I didn’t know what to do. It wasn’t as if I could force this person to get hand surgery, but it literally looked like his hand was falling off his wrist. The junior put a big fluffy Kerlix bandage over the hand like a mitten, and we stepped outside.

“Get the interpreter and explain the risks and benefits of surgery with him. Maybe he doesn’t understand what I’m trying to say. I’m gonna go back home and get some rest in case we do the surgery tonight. Keep me posted.”

For the first time in my life, I was disappointed when I got an uninterrupted full night’s sleep. The next morning when I showed up to round with the junior resident, I asked him what happened.

“He left AMA before the interpreter even got there,” he explained. “AMA” means “against medical advice.” It’s usually a pejorative term for someone who is willfully going against the doctor’s instructions.

“Look up his phone number in the computer, we should give him a call.”

“That’s weird, there’s no phone number or address in the system.” The junior was clicking away at a bunch of different tabs trying to find some clues.

“I have an idea. Sign out to the day shift and tell the clinic I may be a little late,” I hollered as I made my way to the exit. If he wasn’t going to come to me, then I was going to come to him.

OUTSIDE THE NEW BUILDING TOWER WAS A FLURRY OF activity, twenty men in hard hats lifting, pulling, pushing, soldering, jackhammering. Did any of them know that someone literally almost died here last night?

“Hello?!” I yelled, catching no one’s attention. “¿Hola?” I tried another approach, still getting no one’s attention. “Does anyone know the guy who fell last night?!” It was as if I was screaming into the abyss. I caught one older looking burly guy walking from one job site to the other and I pulled him into an alcove where we could at least barely hear one another over the noise of the construction equipment.

“Excuse me, do you know the guy who fell last night?” I asked hopefully.

“No speaka English, lady,” he said, trying to brush me off.

“I’m trying to help him. He was in a terrible accident last night.”

“He doesn’t want your help.” He pushed past me and kept walking to the external elevator that was going to take him up to the same spot where my patient plummeted last night.

Okay, I give up. I don’t get it, I tried, I thought to myself as I turned to go back to the hospital.

“You looking for Jorge?” rang out a voice from a younger guy who looked about Jorge’s age.

“Yes, I saw him last night in the hospital before he ran away,” I explained.

The guy couldn’t have been older than eighteen or nineteen years. He grabbed me by the arm and pulled me in close to his mouth.

“He’s afraid.”

“I know surgery’s scary for a lot of people . . .”

“No, he’s afraid he’s gonna get caught and get sent back home.”

“Get caught by who?”

The young guy rolled his eyes at me.

“We have no IDs, we have no papers. We’re like ghosts. This is the only place we can work.”

I was so naive, what an idiot. Of course that’s why he didn’t want surgery.

“He got injured on the job; he’s entitled to workers’ compensation.”

“You think this boss has us on workers’ comp?” He laughed incredulously. “Do you think we’re gonna risk getting deported if someone finds out who we are?”

I felt the fear in his voice and his concern for his friend. I thought for a minute.

“What if I could get him into surgery without anyone knowing who he was.”

The friend looked at me skeptically.

“Tell Jorge I will be in that clinic right across the street, the one with the staircase going down into a basement. If he doesn’t get the surgery he could lose his hand, he could even die if he develops an infection.” I didn’t want to scare him, but these were the real stakes.

The friend nodded, and I thanked him for coming up to me. I walked back across the street to the hospital OR booking desk. I knew what I had to do, but it was a huge risk.

“HI! I WANTED TO BOOK AN ADD-ON CASE FOR LATER TODAY, please,” I said in a sugary-sweet voice that would melt the heart of even the coldest OR nurse coordinator.

“Who’s the patient?” She looked down at the add-on list.

“They’re not in the system yet, he’s coming over from the ER across the street.”

Her eyes looked up over a pair of glasses that had slid down to the end of her nose.

“What’s the insurance?”

“No insurance whatsoever. It’s a clinic case.” I smiled with a Cheshire cat grin.

The nurse raised her eyebrows and started to tap her pen annoyingly.

You see, the Hospital for Special Surgery is probably one of the most profitable hospitals in the world. They operate on celebrities, professional athletes, even royalty. And trust me, they charge a pretty penny. But they are also a teaching institution, filled with med students, residents, and fellows, and in order to allow the trainees to get some hands-on experience, they allow us to run a clinic where people from all different types of backgrounds and insurance status can book appointments and even get surgery with us. It’s a little-known secret that you can get world-class treatment from the best doctors-in-training. Kind of like getting a severely discounted haircut from a beauty school.

“I’m not going to book your case if the patient’s not in the system.” The nurse turned over the booking sheet and shooed me away.

Shoot. Okay, next move.

I clenched my fist and brusquely walked back toward the ortho clinic.

When I entered the clinic one of the medical assistants stopped me.

“Dr. Nance, there’s a patient waiting in the hallway for you. He didn’t have an appointment, but he said he was told to meet you here.”

“Thanks, I’ll find him.”

I walked around the corner, through the physician work lounge, and there was Jorge and his huge bloody bandage mitten. I could tell he hadn’t slept all night and was in tremendous pain.

“Jorge!” I checked my excitement and switched over to hushed tones. “I’m so glad you came; I have a plan.”

He let out a pained smile.

“I know you don’t want anyone knowing who you are, I get it now. There is still a way we can operate on you. You will just have to trust me that I can get it done.”

Jorge gave me a long look. This was a gamble. Trust some random person who claims they can protect you when you know they cannot and potentially be deported or lose your hand. What a choice.

He looked at his hand, he looked at me, he looked back at his hand and sighed. “Okay, let’s do it.”

“Let’s do it.” I nodded my head and patted him on the shoulder.

“All right, stay in this exam room until I call for you, and don’t eat or drink anything!”

“I won’t.” He winced, cradling his hand.

I RAN BACK ACROSS THE STREET FROM THE CLINIC TO THE attending private offices. Dr. Paul was the supervising attending on call that week so technically the case would be under his supervision. I was going to need some heavy-duty backup.

“Dr. Paul, I have a hand degloving injury with multiple tendon lacs that needs to go to the OR today. He fell multiple stories from the construction site across the street.”

“Tough case, all right, put him on the list.”

“There’s a slight problem . . . he doesn’t have a name.”

“What do you mean he doesn’t have a name?”

“Well, he does have a name, but he doesn’t want anyone to know he exists. He’s here illegally and he’s afraid he’s going to be picked up and sent home,” I explained.

Now Dr. Paul gave me a long look.

“I was hoping you could book the case as a John Doe?” I gave him my best pretty, pretty please face. I had done John Doe cases before but usually in trauma situations where a person arrives unconscious and there is no identification on him, or once a patient was involved in a severe blast injury and he could not be recognized by his face. But I had never done a case where we were trying to purposefully conceal someone’s identity.

Dr. Paul scratched his head and I watched him do the mental gymnastics of all the scenarios of how this could come back to bite him in the butt. After an eternal minute he said, “Let me see what I can do.”

I reflexively gave him a hug (I did not normally hug my attendings), and told him, “He’s NPO, I’m gonna do the case with another fellow, you don’t have to stay, thank you!”

I was giddy, thrilled with both the prospect of helping Jorge and beating the system. I’d seen what had happened to people without insurance before, like the man I’d treated for the atrocious dog bite, but I had never considered the idea that simply by being a patient could put yourself at risk and jeopardize your life in the US. I felt a heaviness and sadness that there were probably millions of other people that were sick and needed help, but because they lived in the shadows, they were never going to be able to get that help without fear that doing so would alter the whole course of their life.

I’m not a politician, and I don’t know all the laws and procedures about coming to this country legally and through the proper channels. But I am a doctor, and I know that the Hippocratic Oath does not stop because of where someone came from. And I get that there are legal liabilities and economic burdens that make these decisions a much more nuanced problem than just doing what’s right and what’s wrong. But in the end, I did not think someone deserved to lose their hand over politics. I did not think someone deserved to lose their hand because it was going to make some people uncomfortable with what we were doing. I was going to save this man’s hand.

The case was tough. I had never done so many tendon repairs in one surgery, and even though my co-fellow was suturing at the same time, we were running against time. In surgery we use something called a tourniquet, which cuts off all the blood flow below so that the field is clean and bloodless. But you can only cut off a limb’s blood supply for so long before causing serious damage, and our time was almost up.

“FDP and FDS of the index and middle are done, how’s the pinkie looking?”

“The FDP was so ratty I had to graft it with palmaris, so I’m still working on it.”

“How much time’s left on the tourniquet?”

“Fifteen minutes.”

“Crap, we still have the thumb and ring finger to do.” My voice was a little shaky, betraying my confidence that we could get this done.

“You guys need some help?”

It was Dr. Paul. It had to have been after 10:00 p.m. and he had stayed all this time, intentionally stayed out of the room to give us that surgical independence and decision-making, and then offered to swoop in to save the day just like an attending is supposed to do.

My co-fellow and I looked at each other. “Yes please,” we said in unison.

We managed to save Jorge’s hand that day and even more miraculously, he returned to work after just three months. I would see him on the job site from time to time and get nervous that one of the tendon repairs would snap, but he recovered beautifully. Seeing his progress made me happier than almost any other patient I had ever operated on. What I learned is that every doctor develops their own set of morals and ethics, and those morals and ethics can evolve over time. And when someone has a different set of morals and ethics, it doesn’t necessarily mean that one person is right, and the other person is wrong. Is it really possible for doctors to remove our own sense of justice to operate within the rigid structures of the system we live in? Where is the line between hiding a patient’s identity and cutting the LVAD wire? Turns out medicine is not all black and white, and the humanity lives in the grey.

Chapter 18

How to Play the Game

When you’re a resident your world is very small. You interact with the same doctors, nurses, and techs every day. You work together to make sure the patient gets the right medication, the right splint, the right MRI or CT scan. Whatever it will take to make the patient better, that’s our ultimate goal. But what you don’t realize is that you are a small part of the much larger healthcare ecosystem: hospital administrators and health insurance companies and pharmaceutical executives and board members. And while these people are generally not doctors, they have an outsized influence on how healthcare is actually delivered. It’s a game of power. And for a resident, realizing you’re in the game, is the first step.

Whenever I was on-call for the emergency room, my favorite was to get a call from Larry. Larry was a forty-year-old bespectacled ER PA with the energy of a rabid squirrel who worked the overnight shift as his second full-time job. He was a jack-of-all-trades who could handle lacerations, projectile vomiting, and a LEGO stuffed up a kid’s nose. Most ER docs and PAs when they see a fracture that needs to be reduced, i.e., pulled back into place, will call the ortho resident to do it, not because they don’t know how to do it, but they are usually just so busy that they have to have us come in and take care of it. But Larry went the extra mile whenever he could. I remember many early mornings while scanning the overnight XR queue, I would find images of beautifully reduced distal radius fractures that came in at 3:00 a.m. that were taken care of by Larry so I could get some precious moments of sleep.

Beep-beep . . . beep-beep . . . beep-beep.

I was woken by the familiar glow and vibration of the beeper. Nobody enjoyed calling a surgeon this late at night, which meant it had to be bad. Sure enough, the apologetic voice on the other end of the line was Larry’s. “So sorry to bother you, but I got a really bad forearm fracture, you’re gonna want to come in.”

“It’s okay, I’ll be there in a few minutes,” I whispered, trying not to wake up Justin. I knew if Larry couldn’t take care of it himself it must be pretty bad.

I slipped on my Merrells, brushed my teeth, splashed some cold water on my face, grabbed my ID, and slipped out the front door. For the city that never sleeps, I can tell you that on Wednesday at 2:00 a.m., everyone is sleeping. The streets are quiet except for a few roaming taxis and a couple of club-goers scarfing down a slice of pizza. The lights from the bodega signs dot the sidewalk and some doormen are quietly asleep at their perch. I buzzed myself into the ER, walked past the group of revelers sleeping off their hangovers, and made a beeline to Larry, whose face immediately showed his relief.

He pulled up the films on his computer, and I could see why he called me in.

“Ouch!” I winced, looking at bones that should look like parallel railroad tracks but instead resembled the letter X. “What happened?”

He told me that the patient was a homeless woman, and a creep had assaulted her and pushed her down the stairs. Some people cannot catch a break, I thought. As if it wasn’t bad enough to not have a proper place to sleep, you had to have your head on a swivel just to try and survive.

She was waiting for me in the procedure room, in many layers of clothing even though it was the middle of summer. She was wearing all of her possessions, I realized, and I felt a pang in my heart. She looked up and smiled sweetly, revealing that she had no teeth. She seemed familiar, somehow, like we’d met before.

“HELLO?” I SAID CAUTIOUSLY. “IT’S DR. NANCE, THE BONE doctor, I’m here to help you.”

I couldn’t tell if she was paying attention, though. She was sitting up on the exam table, swaying, dancing to a melody inside her head.

“Can you tell me what happened?” I asked.

She paused, and tilted her head, wondering if she could trust me. I dragged a chair next to the table so I could sit down and be on her level.

“I live across the street, right there on the church steps.” She motioned in the air.

“I was minding my own business when all of the sudden someone comes up from behind me and tries to steal my purse! So we’re wrestlin’ back and forth and I rip the bag back into my arms ’cause no one is stealin’ my stuff!” She tried pantomiming the scenario, but winced at the pain it caused her arm. She cradled it instead, going on to say, “And then he just pushes me down the steps and I land ‘crack,’ right onto this arm and I knew right away something was not right and I had to go across the street to the hospital.” She looked down at her dangling feet and shook her head in the same rhythm.

I stood up and reached my arm over to her shoulder and patted it gently. “I’m sorry that happened to you. Did you hit your head at all?”

She shook her head from side to side.

“Okay, good.” I reached out my hand toward her broken arm. “Can I see your arm?”

She recoiled and shielded the injured arm with her good one.

“I’m not going to hurt you, I just have to take a look,” I said slowly and gently, trying to ease any fears about what was going to happen next.

She didn’t take her eyes off me, but she did uncover her arm. Like a baby bird with a broken wing, she let out a soft yelp as she tried to lift it. It was as bad as I thought, if not worse. She had abrasions over her elbow, that were filled with dirt and dried blood. The middle of her forearm was swollen and angulated, with a piece of bone dangerously close to piercing the skin. I asked her to raise her thumb, make an okay sign, and spread her fingers out wide, which she followed along like we were playing “Simon Says.” She passed the test, meaning that she had no nerve damage. But it wasn’t an injury that would heal on its own.

“I’m sorry to tell you this, but you need surgery.”

“Whaaaatt?!” She gasped and nearly fell off the table. I could see I whole new wave of worry wash over her face.

“I’ll be back to talk about the details in a moment, I just have to talk to Larry first.”

Now here is where the American healthcare system really sucks. While my patient presented to the ER with a broken bone that needed surgery, it wasn’t technically an emergency surgery. Confusing, right? For something to qualify as emergency surgery, there needs to be a time-sensitive risk. If you came into the ER with appendicitis, there is a risk that the appendix might burst, which could kill you—so that’s an emergency. If you went skiing and blew out your ACL, you’d need surgery, but your life isn’t at stake; you can go home and schedule the surgery as an elective procedure for another day. You may think that elective surgery means getting a nose job, but to an insurance company, it’s a whole different set of rules.

No hospital is allowed to turn anyone away who needs an emergency surgery. This is because hospitals are granted tax-exempt status by the government (i.e., they don’t have to pay any taxes on the revenues that they generate) and in return they have to provide community benefits, which is generally interpreted as running an ER that is open to all and providing emergency services to all. But elective surgeries have to be preauthorized, meaning that the requests have to be cleared by insurance companies, hospital finance committees, and administrators.

The problem was that if I sent my patient home to the church steps, no doctor would take her as an elective patient. She wouldn’t pass any financial or insurance check that the hospital runs for its elective cases. So unless she were to come into a lot of money or get insurance, that’d be that . . .

No one was watching.

I could send her home, and basically sentence her to life with a painfully broken, wonky arm. But the right thing to do—I was sure of it—was to get this woman the treatment she needed and deserved.

So, I lied . . . sort of.

“Larry, I gotta admit her. I’m worried about compartment syndrome so we gotta fix it tonight.”

Larry looked at me with a twinkle in his eye and said, “You’re the boss!”

Now, compartment syndrome is a real complication. It’s when the pressures inside a muscle compartment become so high that it cuts off blood supply to the limb and the limb dies—scary stuff. It’s a rare complication but nobody (i.e., any hospital administrator) would argue with you that immediate emergency surgery is the only course of action. So while I might have used the concern for developing compartment syndrome as my ticket to the OR, if that meant she was able to have surgery, then so be it. I should have never had to justify why this woman deserved to have surgery, but knowing how to play the game is something you learn after spending years in the medical system.

The surgery was a beast. In just a few hours, her forearm had swollen to the size of a butternut squash. The anatomy in the middle of the forearm is booby-trapped with the most essential nerves and vessels that control every movement of your hand, and they’re hard to identify in an undisturbed field. But when the middle of the forearm looks like a right angle and throws off all the spatial relationships, it makes the surgery even more challenging and the stakes get much higher. Besides the mental gymnastics and total focus required, the physical part of reconnecting the bony ends was tricky, and I relied on all the strength the overnight scrub tech had to give to hold the bones perfectly still while I drilled the sixteen screws and two plates into her forearm.

I took the time to wash all the Betadine off her arm and wrapped the perfect post-op splint. One of those things that feels important: patients only get to see the outside of a bandage, so I always make sure it looks good, so they have confidence that the work inside is high quality as well. She was fully awake by the time she arrived in the PACU, and was already asking for some post-op treats. “Let’s start with some ice chips,” the PACU nurse said with a laugh as I dictated the op note as quickly as possible into the PACU phone.

It was 7:45 a.m. I only had fifteen minutes before my first patient for the day at eight, so I ran back to the ER to finish all the paperwork from the original admission so she could go home when she was ready.

“Tough case?” Larry was furiously packing his backpack, trying to extricate himself from the ER after working sixteen hours straight.

“I’m glad we did her tonight; she might have been in real trouble if we waited any longer.”

“She might have been in real trouble if I didn’t call you.”

I blushed.

“Good night, Larry.”

“Have a good day, Erin.”

I closed my eyes, took a deep breath, and then reopened them with purpose. Time to start the day, again.

SHE CAME TO SEE ME IN MY OFFICE ONCE TO TAKE OUT HER stitches, but she never followed up afterward. There was no good way to get in touch with her, so every few weeks I would swing by the church steps to try and catch her and check in to make sure she was doing okay. I couldn’t get an XR or anything, but at least she would know I was thinking about her and wanted to make sure she was healing properly.

The reason why I wrote about this is because while I was writing this book, almost ten years after the incident, Larry texted me late at night again. He asked if I could see a colleague’s family member urgently, which I was happy to oblige. The next morning, I woke up to a text that said:

Very few residents are both thorough and affable let alone ortho residents! 2.25 full-time jobs for twenty-five years I’ve met a lotta practitioners. I knew you were the real thing from day one.

To which I responded with an eyes welling up with tears emoji.

I could tell by you caring for Jeanine and doing a post-op check at her “residence” by the church! Didn’t know you were being watched did ya!

I couldn’t believe he remembered her name after all those years. And I couldn’t believe he noticed me checking in on her on the church steps, making sure her arm was regaining the strength it needed to. I have seen Jeanine on the streets a handful of times, and every time she calls out, “That’s my doctor!” I smile, and wave, and am very proud she’s my patient. We played the game and we won.

Chapter 19

The Best Revenge Is Massive Success

Everyone loves a resident. We will hold a retractor for six hours straight without moving a muscle; we will dictate hours of office notes; we will answer calls from your patients in the middle of the night; we will write hundreds of prescriptions for people we’ve never even met. But when the time comes for us to transition from training—aka essentially free labor—to potential competition, the chumminess between the attendings and the residents disappears.

Let me rephrase: everyone loves a resident . . . until they need a job.

The hiring process is also completely shrouded in mystery. While there are many things to complain about the residency match system, the biggest advantage is that the process is transparent. Jobs, however, are often brokered behind closed doors, between men who trained together and trust one another. It’s not unlike the office dynamics portrayed on the TV show Mad Men. Only this wasn’t the 1950s, it was the early 2000s.

This is the story of how I got fired before I was hired, and how one sixty-second phone call changed the course of my entire life.

A FEW WEEKS BEFORE I GRADUATED RESIDENCY, I GOT AN email from one of the heads of the orthopedic department, asking me to stop by his office. I didn’t know why I was being summoned; there hadn’t been any major screwups with the residents, and the service was running smoothly and efficiently.

When his secretary let me into his office, I realized I had never stepped foot inside before. I’m guessing that was a good thing, like I never got called into the principal’s office. So, it was a bit nerve-racking sitting in the hard wooden seat across from the big, tufted leather swivel chair behind the desk covered in charts, journals, and reports.

“Erin! Thanks for coming in, would you like a water?”

I hadn’t been offered a water in five years of giving my blood, sweat, and tears for this department.

“Sure, thank you,” I responded nervously, not wanting to disrespect the offer.

He signaled to his secretary who brought a glass of ice-cold water and handed it to me with a little Lenox Hill cocktail napkin.

It was the napkin that signaled to me I was not in fact getting in trouble . . . something else was happening. I was getting wooed.

“So, have you thought about where you might like to practice after you finish your fellowship?”

“I’ve been so busy studying for boards I haven’t given much thought to it. But . . . I’ve always wanted to stay in New York City. My husband works here, and my family is here, so, I’d love to find a position in New York.” I didn’t want to out myself and tell him it would be a dream job for me to practice at Lenox Hill, the hospital I practically grew up in.

“Well, I just wanted you to know that I think you’ve done a terrific job as a resident, really outstanding, and we would love to have you come back at Lenox after you finish your fellowship at HSS.”

I was shocked. Did I just get a job offer? Was it really going to be that easy? I couldn’t believe it.

A FEW MONTHS INTO FELLOWSHIP, MY CO-FELLOWS WERE traveling all over the country interviewing for jobs. I felt so fortunate that I had a position lined up in my hometown.

“Where are you going after HSS?” one of my fellowship attendings asked me during a particularly long case.

“I’m going back to Lenox,” I said proudly.

“That’s awesome. If you ever want me to look over your contract let me know. Nobody ever talked to me about things like noncompete clauses, productivity thresholds, so happy to help.”

Huh. I never actually got a contract, but I figured it would come in time. I mean, they asked me to come back on staff, so I was confident I’d get all that settled soon. But, maybe I should check in.

October 2014

Hi, hope everything is going well. HSS has been an amazing experience so far, I just finished my elbow rotation. I wanted to check in about the hand position and ask about some specifics about the contract. I’m around the Upper East Side if you want me to come in.

Thanks,

Erin

December 2014

Hi, I’m sure you’re busy, I just finished my tumor rotation at Sloan. I wanted to talk to you about the position and the start date. I’m three months pregnant so should be ready to start by the September start date no problem. I’m available anytime to talk.

Thank you,

Erin

February 2015

Hi, sorry to bother you, I just want to confirm that I will still be starting on staff at Lenox in September. It’s getting really late in the interview season, and I know you offered me a position before I left, but I’d like to go over the contract with you when you get a chance.

Thank you,

Erin

March 2015

Dear Erin, things have been crazy here. The system decided to hire two senior hand guys from another hospital to come on staff. There won’t be any room for a third hand surgeon. Wasn’t my decision. Hope you’re enjoying HSS.

I was shocked.

Are you kidding me? Are you for real? You ask me to work for you, then I get ghosted for months when I should have been interviewing for other available positions (that are now filled), and then “the system” hires two men from outside institutions instead of hiring one of their own trainees? I collapsed into a chair and hid my face in my hands. How embarrassing to tell everyone your home program called “backsies” on your job offer.

BY THIS POINT IN THE RECRUITMENT CYCLE, THE PROSPECTS were slim to none. All of the large ortho groups kept consolidating, leaving no open slots. A week later I got a call from an unidentified number; it was a recruiter. She said there was a job opening for a new hand surgeon in Queens. I had never heard of the surgeon who ran the practice, but the location was only twenty minutes from my apartment. So I arranged an interview at the office for later in the week and squeezed into the stretchiest interview clothes a six-month pregnant person could fit into.

As soon as I pulled up to the office, alarm bells went off. The office was packed with people in the waiting room who looked like they were casting for a personal injury lawyer commercial. The dark glasses, the neck brace, the cane, it seemed really sketchy.

The surgeon who I met with was really impressed with my background and offered me a job on the spot. When I got home and told Justin about how I was less than thrilled to take the job, he said, “You could be the Queen of Queens!”

I was distraught. Something felt off, and it wasn’t just that the job offer from Lenox had been rescinded. There was something about this one that didn’t quite sit right.

But it was the only viable option. I might have to become the Queen of Queens.

THE NEXT WEEK I WAS GETTING MY PREGNANCY CRAVING Philly cheesesteak lunch from the deli across the street when I ran into a device rep from Lenox Hill, Jim Wyzard, or the Wizard as he was known to the residents. Jim was a middle-aged man who looked like an accountant, not the typical stud athlete hot guy device rep that the nurses fawn over.

“Erin! How are ya?” Jim was eating his hoagie on his walk back to the hospital.

“Hey Jim, good to see you, I’m doing all right.”

“Where you going next year? Staying local?”

“It’s a long story, but Lenox basically screwed me over and I just have this job offer in Queens to work for this guy who has his own practice.”

“What’s his name?”

When I told him, Jim almost choked on the hoagie. He coughed to clear his throat and then put both his hands on my shoulders.

“Erin, if you took that job, I would call both your parents and tell them that you cannot take that job. That man is a crook, he’s a fraud, and he will ruin your reputation.”

Holy crap, the Wizard just saved my professional life.

So I wasn’t going to be the Queen of Queens. Back to the drawing board.

A COUPLE OF WEEKS LATER I RAN INTO DR. ALEXIADES, MY DR. Alexiades! I forgot that he had privileges at both Lenox Hill and HSS, I had just never run into him while I was a Fellow.

“Erin! How are things going? Looks like you’ve been busy!”

He was referencing my expanding abdomen. My pregnancy had been the least stressful part of this entire year.

“Oh, yeah, due at the end of July,” I said, blushing.

“What are you doing after HSS?”

How embarrassing to admit to the person who inspired me to become a doctor, tell him that I had no job lined up and no prospects.

“Unfortunately, a job at Lenox fell through and there haven’t been any other positions available in the City,” I admitted defeatedly.

“You know I was just having dinner with Dr. Freedman and he told me they may be looking for a new hand surgeon. Let me give him a call to investigate.”

“Oh my God, that would be amazing! Please let me know whatever I can do, thank you!” This was the wind I needed in my sail to carry me through to the end of the year.

Within a week I had an interview scheduled at one of the largest medical centers in New York City, and they were going to create a spot just for me! They weren’t even interviewing other people. I totally got the scoop! I spent all day speaking with the CEO of the hospital, the orthopedic surgery chairman, the chief of the hand service. They were really impressed with my training pedigree and knew my mentors well, often trading stories of times they got into trouble together as residents. At the end of the day, I was offered the job with a handshake.

“Be on the lookout for an email from HR with the contract next week,” the chairman told me. (I wasn’t going to count my chickens before they hatched this time.)

“Thank you so much, sir, I cannot wait to start.”

And with that I moseyed on back to my apartment, kicked my legs up, and cracked open a nice cold La Croix.

AS PROMISED, THE CONTRACT CAME VIA EMAIL ON MONDAY and it was a little . . . surprising.

And not for what was in the contract, but for what was left out of the contract. The contract itself was only three pages long. It basically just said that Dr. Erin Nance will be a hand surgeon at X Hospital starting in September. There was no mention of what my actual work duties were, how much time I’d be expected to work in a clinic versus operating room, no mention of call requirements, vacation time, or maternity leave policy. There was a noncompete clause with only one other rival hospital in the city. But basically, it told me nothing about what the job actually required of me.

It did, however, tell me that the salary was less than what the chairman quoted me during the interview. Like, a lot less.

The salary, that could be an error, but the fact that there was pretty much nothing else included . . . it seemed off. I figured I’d give my dad a call.

I was very fortunate to have a family member who happened to be an expert in hospital employment contracts; in fact, he was usually the one on the other end writing them. Most residents and fellows don’t want to spend the couple thousand bucks to hire a lawyer to review their contracts, because most don’t have that type of liquid cash to spend, although it could end up costing them hundreds of thousands of dollars in the long run.

“Listen, there’s really not much to this contract, so if you sign it, you don’t have a leg to stand on if you complain about it later. They could expect you to take call for every night of the year if they wanted you to do that. So, my advice would be to get these details negotiated in writing before you start this job.”

This was good advice, and even though there were a ton of things I should have brought up to clarify, I didn’t want to seem difficult, so I only focused on two. I responded to the email from the HR person and I said, “Thank you so much for sending me the contract. I’ve reviewed it and just have two main points that I want clarified. Number one, the salary in the contract is less than the salary the chairman told me it would be. And number two, I’d like to have in writing that I will take call for an average of one week every month.”

Now at the hospital where I currently worked, the attendings only took call one week every two months, so I wasn’t asking for some outrageously cushy call schedule. But knowing that I was about to have a newborn, I just wanted some protection in place so I wouldn’t be responsible for every hand emergency that came into the hospital each night indefinitely.

Two days went by, and I finally heard back from the HR person at the new company. Flooded with relief, I answered even though I was in the middle of a super busy clinic seeing patients. “Oh hi, thank you so much for calling me. I wanted to confirm that you received the comments to the contract that I made.”

“Yes, we did get your comments, and we’re calling to let you know that the position no longer exists.”

Crickets.

“What do you mean the position no longer exists? You just hired me two days ago and sent me the contract!” There was a red rash spreading along the side of my neck, and my shirt was feeling tight across my chest. I had to be misunderstanding her, right? There was no way I was hearing what I thought I was hearing.

“The position no longer exists,” she said simply and hung up on me.

I stood there, gobsmacked, and dropped the phone. As I bent forward to pick it up, I felt woozy and my eight months pregnant belly threw me off balance as I stumbled to the floor.

“Dr. Nance! Are you okay?” One of the senior nurses on the unit rushed to my side and offered me her arm as I tried to get back up. I was devastated. I mean, here I am, about to graduate from the top fellowship in the country, and I have no job. Or I had a job, but it had just been taken away.

We tell our girls to stand up for themselves! Know your worth! Don’t settle! But what does that get us? It gets us fired. It gets us passed up for promotions. It gets us labeled as entitled and difficult and ungrateful.

What should have been the happiest, proudest professional day of my career was one of my lowest points. On the day of fellowship graduation, the culmination of ten years of the most intense physical and mental training, all the fellows walk up onstage as the fellowship director announces where the fellow will be taking his talents to, kind of like the NBA Draft.

“Congratulations to Dr. Jones who will be joining the faculty at Harvard for total joint reconstruction.” “Congratulations to Dr. Smith who will be joining a multi-specialty practice in Dallas.” And then they got to me, thirty-nine weeks and six days pregnant, “And congratulations to Dr. Nance who is still looking for a job.” Mortifying, absolutely mortifying.

I ended up giving birth two days later back at Lenox Hill, on my due date (if there was one thing going for me it was my baby was the most low-drama, stress-free godsend) and I delivered a beautiful, healthy, perfect baby girl.

When I got home, I had tons of visitors who wanted to see the baby and check up on me. My two other female hand fellows were the first ones to come visit. They both had kids, and after just spending three days with my own I couldn’t believe how they did it while still in training. I thought back to Appleyard and her four kids and was, once again, blown away.

“How are you feeling?” they asked.

“Besides feeling like I sat on a grenade, I feel great.” I laughed.

“You know everybody keeps telling me, ‘Oh, enjoy this time with your baby, you’re so lucky to have all this time with your baby,” and all I can think of is, “Enjoy this time with my baby? I just spent sixteen years and two hundred thousand dollars to be the most overqualified unemployed person I’ve ever met.”

Looking back, I’m ashamed I was so absorbed in my job and how it was intertwined with my identity. I felt because I had failed to secure a job, I somehow was failing at life. And yet here I had the most precious gift literally sitting in my lap and I couldn’t appreciate the blessing I had created.

A month later a colleague of mine, an old resident friend, came to say hello and see the baby.

“How are you doing?”

“Dude, it’s awful. I had two jobs taken away from me, I don’t have any prospects, people have already started interviewing for the next interview cycle, and I don’t know what to do,” I said, throwing a little pity party for myself.

He looked me square in the eyes and said, “You are in a great spot.”

I looked back at him like he was out of his goddamn mind.

“What are you talking about? I’ve already missed out on the whole job cycle and now I’m behind on interviews for the next year. I don’t have any leads for new positions in New York City, nobody’s retiring anytime soon, and there aren’t any openings in the large groups or hospitals. What am I supposed to do?” I was out of breath.

“You could start your own practice.” Poof. He said it so nonchalantly, so effortlessly.

No one started their own practice in 2015. Fifty years ago, you would graduate from residency and hang your shingle . . . literally; that’s where the saying came from. You would hang your name on the door and patients would just come to your home. Now, it was impossible to compete with the hospital corporations and large multi-specialty groups as a solo doctor.

“I don’t even know how that would work.”

“Easy, you find someone who has an extra room in their office that you can sublease, malpractice is 50 percent off the first year in practice, and you can get on the call schedule and have patients right away.”

“I don’t know . . . I mean I never even considered it, but I guess . . . I guess it’s possible?”

“Think about it; I’m considering it myself.”

THOSE WERE THE SEEDS OF STARTING MY OWN OFFICE where I could practice medicine how I wanted. See patients for more than five minutes; get to know them; take the time to educate them and answer all their questions so they felt comfortable and confident in their doctor. So, I decided to run with the idea and start my own private practice: the only person to start a solo, orthopedic surgery private practice among the over seven hundred orthopedic surgeons I graduated with that year.

First item: find space. One of the surgeons who I used to work with at Lenox Hill had recently broken off from a large private group and just started his own practice on Fifth Avenue and Sixtieth Street, right across the street from the Plaza and Central Park: not too shabby for someone just starting out.

“Aruna, I heard you may have some extra space in your office, do you mind if I stop by to check it out?”

“Sure, you want to come by next week?”

“How about in an hour?”

“Umm, sure, I guess.” He was a bit taken aback by my urgency.

He was even more taken aback when I showed up with a two-month-old infant strapped to my chest in an Ergobaby. He was still in the middle of seeing patients, so I took the liberty of giving myself a tour of the new office. It was beautiful: cozy leather sofas in the waiting room, art that looked like it was part of someone’s private collection and didn’t come from HomeGoods, sleek lighting that had a soft glow, not the harsh fluorescence of most medical offices. As soon as Aruna finished seeing patients, I told him he had himself his first tenant.

The next step was to secure my voluntary privileges. Having voluntary privileges means you don’t work for a hospital, but you are able to bring your patients to that particular hospital in case they needed to have surgery or be hospitalized. And as luck would have it, one of the hospitals I needed to obtain privileges with was the one that had retracted the offer from me.

At this point, a new person was appointed chair of the orthopedic department, and I had to have a sit-down interview with them to answer questions about my background and confirm that I am a competent surgeon. After a few standard questions about my residency and fellowship training they said, “Do you want to know why we took the position away from you in the spring?”

I had not heard a peep from this department since that day in June (despite multiple efforts by myself and my mentors to contact them), so I said, “I would love to know why you took the position away from me in the spring.”

They looked at me and said, “We wanted you to know that you misrepresented yourself and gave off the impression that you didn’t want to work hard.”

Excuse me? I wanted to dig my fingernail into my ear and remove whatever wax was in there because clearly, I did not hear this person correctly. Misrepresent myself? Misrepresent myself? Did they think I was a foot-and-ankle surgeon and then found out I was a hand surgeon? Oh, and I didn’t want to work hard. That’s right, I’m sure working hard for over a decade had nothing to do with me matching into the number one orthopedic surgery training program in the country.

It took me seven years to realize what had happened in that room: they were gaslighting me. Just because I had the sheer audacity to try to set boundaries on responsibilities like taking call, they realized I was not a little sheep who was going to blindly do as they expected. That I was willing to speak out and protect myself from being unfairly taken advantage of. Make me look like the crazy one for pointing out a massive discrepancy in the salary offering. (Didn’t think I would actually read the contract, did you?)

So I looked them straight in the eyes and I said, “I’m sorry that you didn’t think an eight-months pregnant person could do the same job as a man. Now what do I have to do to get my privileges?”

The chairman’s face turned ghost white, and their mouth dropped to the floor. Even though I never had any intention of suing them, making them squirm and giving them a pit in their stomach was about as much pleasure as I wanted from the scene. And with that mic drop, I strutted out of the hospital, and never looked back.

After all the years of crafting this responsible, dependable, capable surgeon persona, I only had myself to rely on. And for all my meticulous planning, I ended up having Irish twins: Annabel and Nance MD Hand Surgery. Of course, only in hindsight could I understand that having my job offer rescinded was the best thing that could have ever happened to me. How it allowed me to build a career around my life, and not my life around my career. And I learned that your character isn’t built on all the good things that have gone your way, but rather, on how you respond to the challenging times when things go sideways.

That’s what I admired most about Kevin after his accident. His compassion toward others, his willingness to answer any question, no matter how personal, to any newly injured quadriplegic or their family, and his never-ending quest to find the cure for himself and others. I recently asked my dad when he knew that Kevin was going to be okay. He told me that one day in the ICU when he was in his peak morphine-induced itchiness, he whispered over to Ryan, “Hey Rye, scratch my eyebrow.” And Ryan would take a piece of white gauze and scratch his eyebrow. Then he said, “Hey Rye, scratch my nose,” and he would rub the gauze under his nostrils. “Hey Rye, scratch my chin,” and he moved gauze back and forth along the bottom of his face. “Hey Rye, scratch my ass.”

I can confidently say that Kevin is a better person after his accident. And his accident made me a better doctor, as well as all these other patients that have imprinted on my soul. I carry these experiences like a glowing North Star under my white coat, and when I’m waiting for my add-on case to go at 2:00 a.m. and questioning why I’m doing this, I think back to these moments and know I’m exactly where I’m meant to be.

Epilogue

Have you ever seen a movie or TV show where there’s an emergency on an airplane and the crew calls out, “Is there a doctor on the plane?”

Well, I’ve been that doctor.

We were on an international flight, hovering somewhere above the Atlantic Ocean, when a woman collapsed on her way to the restroom. She was sprawled out in the aisle and it looked like a crime scene. By the time I got there, a responder was already pulling an oxygen mask over her face and checking her wrist for a pulse.

The number one rule when you respond to any type of code situation is the first pulse you take is your own. You want to make sure you’re ready and not acting rashly. I took a deep breath and did a three-second survey of the scene. There did not appear to be any bleeding or severe injury. There were no dangerous hazards around her. And I could see her chest softly rising and falling.

“She has a pulse?” I asked the woman on the ground.

“It’s weak but it’s registering on her Apple watch.”

“Is anybody with her?”

“This is her son.” One of the flight attendants pointed out a tall adult man.

“Hello, I’m Dr. Nance. Can you tell me does your mom have any preexisting conditions?”

“N . . . none that I can think of right now,” he said with a shaky voice.

“How about any medications?”

“She takes losartan for her blood pressure, but that’s all I know about.”

“Does she have any allergies to foods?”

“No, nothing.”

“Before she passed out, was she complaining about any chest pain or headache?”

“No, she stood up from her seat to go to the bathroom and as soon as she took a couple steps in the aisle she went down, hard.” He was pacing back and forth in the tiny airplane galley.

“What’s going on?” a third responder joined the crowd.

“Sixty-year-old female, no significant medical problems, fell after loss of consciousness. She went from sitting to standing and passed out after a few seconds.”

“What are the vital signs?”

The woman who was taking the pulse piped up. “Her Apple watch is reading sixty-four beats per minute and her breath is steady.”

“Here’s the emergency medical kit,” one of the flight attendants said, pushing through the crowd. “I need to know who everyone is here, only a doctor can open the kit.”

“I’m a cardiologist,” the man said with authority.

“I’m a surgeon,” I chimed in.

“I’m a critical care nurse,” said the woman crouched down on the floor.

The cardiologist tore open the kit and the two of us rummaged through it to find the pulse oximeter and blood pressure cuff. We handed it to the nurse who placed it around her arm and finger.

“Ninety-nine percent pulse ox, sixty-five bpm, and 110/70 pressure.”

Phew, those were good numbers.

“Here’s the glucometer, let’s get a blood stick, make sure she’s not hypoglycemic.” I turned to the son. “You’re sure your mom doesn’t have diabetes?”

“No, she doesn’t have anything like that.” The son was biting his nails and in pain watching his mom get pricked and prodded.

The critical care nurse swiped her fingertip with an alcohol swab, punctured her fingertip, and milked a few drops of blood onto the glucometer.

“107.”

Okay, everything was looking good, we just needed her to wake up.

Then slowly, the woman opened her eyes and began to blink gently. Everyone crowded around her sighed in relief. We were in business.

“Hello, ma’am, can you hear me? Are you okay?”

Her eyes darted around for a few seconds, confused as to why she was lying on the floor, but then pieced together the moments that led up to her collapse.

“Yes, I’m okay,” she whispered weakly.

I put my hand on her shoulder to let her know she was going to be taken care of. I told her that her heart rate and blood pressure were completely normal, and her oxygen levels were good. “You might have had an event called orthostatic hypotension, it’s when a person goes from sitting to standing too quickly and your blood pressure temporarily drops causing you to faint.”

Ring-ring . . . ring-ring . . . ring—

The captain was calling the flight attendant to get an update on the situation and know if he needed to divert the plane.

The cardiologist and I looked at one another, we looked at the woman who was now sitting up comfortably, in no signs of distress.

“No need to divert, she’s conscious and comfortable, we have everything handled,” I explained to the flight attendant.

Soon after we helped the woman back to her seat, I walked up the aisle with the male doctor.

“Where do you practice?” I was curious.

“I’m from Egypt. What type of surgeon are you?”

“I’m an orthopedic surgeon.”

His eyes bugged out. “We don’t have any female orthopedic surgeons in Egypt,” he said incredulously.

I laughed. “I was hoping I wasn’t going to have to pull a MacGyver and do an emergency trach with a pen.”

He shook my hand. “Let’s hope you still don’t.”

ORTHOPEDIC SURGEONS SPEND TEN YEARS IN SCHOOL AND in training. We watch hundreds of surgeries before we ever lay a finger on a patient ourselves. We listen to thousands of hours of lectures and pore over surgical technique articles and anatomy textbooks. But there is one thing that cannot be learned, and that is the ability to care. What I left out of the story above is that the same woman passed out a second time on the plane, and this time it was more serious. She came to after some time but felt sick every time she tried to sit up.

“Is there nowhere else for her to go but on the floor?”

“It’s a full flight, there’s no space.” The flight attendant was racking her brains.

I took a second to survey the place myself and then came up with the solution.

“She can have my seat. I’m in business class, she can lay down in the bed.”

It was my first time traveling in any sort of special seat. It was my husband’s and mine’s fifteen-year anniversary, fifteen years after Kevin’s accident, and I never forgot all the kindness that was shown to us in our time of need.

“Are you sure?” The flight attendant was stunned, I don’t think she had ever come across someone who voluntarily gave up a business-class seat for someone else.

“She needs to lie down, otherwise they’ll have to divert the plane; I will be fine. Let’s get her over to my seat.”

The adult son came over, profusely thanking me. “You don’t know how much this means, thank you so much.”

“I’m happy to do it, she will be more comfortable and hopefully she’ll make it to London without any more problems.”

As we walked back up the aisle, past the privacy curtain, Justin looked a bit confused when I started plucking all my items out of the cubby holes.

“I’m giving up my seat for this woman so she can lay down for the rest of the flight.”

He knew I was serious from my tone and nodded that he understood. As we got the woman settled into the lie flat bed, I watched the son nervously pull the blanket over her and tuck her in. I tapped Justin on the shoulder.

“You’re going to give up your seat too for the son to sit next to her.”

He didn’t ask questions, he didn’t flinch, he just gathered his bags and stood up.

“You’re going to sit here so you can watch over your mom and be next to her,” I told the son. He clasped his hands together and started shaking his head. “How can I ever repay you?”

“You worry about your mom, she’s going to be fine. We just have to make it to the end of the flight.” I patted him on the back, and turned around unceremoniously to go to the back of the plane.

AN HONORABLE PERSON DOES THE RIGHT THING, AT THE right time . . . when no one is watching. There are so many moments in medicine when no one is watching. Do you admit to contaminating the surgical field if nobody saw it? Do you admit to administering a wrong dose of a medication if nothing bad happened to the patient? Looking back on twenty years, I’ve realized that there is just as much art as there is science in medicine. That spine surgeon didn’t have to take me back to the reading room to review Kevin’s films together. Dr. A didn’t have to change the bandages of the radiation sarcoma patient himself. We do these things because there is a way to preserve a person’s dignity, even in times when they feel stripped naked.

The night of Kevin’s accident, I learned that the most powerful drug is hope. Hope that you will be the one to beat the odds. Hope that the surgeon will know how to fix the problem. Hope that the recovery process will go smoothly. Hope that you will be able to live a fulfilling life no matter how many medical obstacles are thrown your way. And you learn that the best medicine is people: people who choose to sleep over and keep you company in the hospital, who bring enough food to feed an army, who keep you entertained with stories from the caddy shack. This is what gets you through the hard times and reminds you that life is still worth living, even if it isn’t how you imagined it.

If you are lucky, you get to see the fruit of that hope. Fifteen years after the accident, Kevin welcomed his beautiful daughter, Nina, into the world. I’m sure that that first sight of her wiggling all her ten fingers and all her ten toes was overwhelming. It was a testament to the fighting spirit that we all have within us to keep going, never give up, and never lose hope. Every one of us faces challenges in life, from being rejected from our dream school to losing the ability to walk. It is how we respond and how we help others respond to those challenges that is the true determinant of what makes a meaningful life. And just remember, this is not medical advice.

Acknowledgments

Three years ago I walked into a post-COVID networking event for moms in business. There were lawyers, architects, small business owners. Moms working full-time, moms working on side hustles, and moms just trying to figure it out. We sat around a huge oval table in a cold conference room and were asked to introduce ourselves and state an intention out loud. When it came to me, I said:

“Hi, I’m Erin, I have a kindergartener, I’m an orthopedic surgeon, and this year I’m going to write a book.”

Snaps all around.

The snaps felt good, but to be honest, I had never even thought of writing a book. I just knew that there was a story I needed to tell.

I wanted to tell the story of my brother’s accident from my point of view. How insanely ironic it was for an orthopedic surgeon on their first day as a doctor to be faced with their own brother’s catastrophic accident. How it transformed my view of medicine.

Then I did something really crazy and out of character . . . I joined TikTok. One of my most successful professional friends, Moira, who also has a shared love of reality TV and pop culture, insisted that I give it a try.

Little did I know that downloading an app would have as much impact on my career as the twenty years of medical education and training I had just finished.

I was transfixed by the realness and the rawness of people spilling their guts, sharing their most intimate fears and struggles. Not to mention the fact that people were funny as hell—much cleverer than the majority of doctors and supremely degreed people I was surrounded by all day.

I started watching TikTok in my “dead time”: waiting for the subway, waiting for the OR to be cleaned in between cases, scrolling while watching commercials on TV. I would pull the comforter over my head so my sleeping husband wouldn’t be startled by the stark white glowing screen.

Inspired by everyone else’s courage to share their true selves, I decided to start posting content about my life as a hand surgeon and some of the interesting cases I’d come across. But what I really wanted to do was share my story. But my story is not just my story, it’s about Kevin and his life. Sharing the story with one random mom from a networking event was not the same as sharing it with The Internet.

So, I texted Kev because I knew I would need his blessing to feel comfortable sharing our family’s painful history.

Hey! I’ve been doing these medical stories from my time in residency on TikTok. I wanted to do one about my first day at work (which was your accident), but wanted to make sure you were OK with that first.

I watched the bubble with the three moving dots under my text for a good minute before it revealed—

Absolutely.

I smiled.

Don’t blame me if you become TikTok famous.

Another text bubble with the three moving dots . . .

I want nothing more.

And that was how Little Miss Diagnosed was born.

I HAVE TO ADMIT, I USED TO NOT READ THE ACKNOWLEDGMENTS section of most books that I read. It’s like when I watch an Oscar winner’s acceptance speech and they rattle off a list of names of people I have no idea who they are or what they do.

But now, after writing a book, it’s my favorite part to read. It really is a love letter to the people who shaped the author who just brought so much joy to my life.

First and foremost, I want to thank my parents, Mary and Mike McDermott. One of the scariest statistics I ever read after Kevin’s accident was that the parents of a disabled child had a divorce rate of almost 80 percent. It was your love and support not only for Kevin but for each other that held us together as family. You are forever my biggest fans and making you proud is a drug I cannot quit. (And I’m sorry about all the curse words, I want to publicly state that you did not raise me that way, it is a side effect of surviving the culture of orthopedic surgery for so long.)

I want to thank my brothers, Sean, Kevin, and Ryan. Whenever someone questioned if I could cut it in orthopedic surgery, I would look them in the eyes and simply say, “I grew up with three brothers” (duh). I’m so grateful for having an intangible bond with people who can recite all the songs on our dad’s painful car mix, can picture exactly what our grandma’s secret candy bowl looks like, and can shut down a family wedding dance floor. You are all doing an amazing job raising your own families and you make me proud to be your sister.

Thank you to the doctors, nurses, techs, and patients who shaped me into the physician I am today. These stories are yours just as much as they are mine. I hope I have done you justice.

Thank you to Renske Gosselink-Tibosch for reading my first chapter when this was all a dream.

Thank you to Jenny Jackson for “getting me into the league” and to my agent, Mollie Glick, for driving this train to the right destination.

Thank you to my editor, Anna Montague, for sitting with me through my therapy, ahem, editing sessions, and for always encouraging me to stay true to my own voice.

Also at Dey Street Books, thanks to Chelsea Herrera, Kasey Feather, Anwesha Basu, and Carrie Thornton.

Finally, and most important, thank you to Justin and Annabel, for being my people. Writing a memoir is perhaps one of the most selfish things a person can do, right up there with training for a marathon or completing a surgical residency. Thank you for your patience and for giving me the space to write this book, for not making me feel bad about missing a soccer game or breaking out a laptop on the beach.

Annabel, I don’t know anyone else who loves reading as much as you do, and I hope when you’re older, this book will become as well-worn as your beloved Harry Potter and Enid Blyton books. And to Justin, none of this is possible without you. Thank you for always having my back and letting me shine. I got the best one.

Notes

Chapter 8: IT’S NOT THE CRIME THAT KILLS YOU, IT’S THE COVER-UP

1.A. Geraghty, “Incidence of Wrong-Site Surgery List Errors for a 2-Year Period in a Single National Health Service Board,” Journal of Patient Safety 16(1): pp. 79–83, March 2020.

2.C. L. Skelly, Adverse Events. StatPearls, August 2023.

Chapter 10: THE BOYS’ CLUB

1.Physician Compensation Report 2023, Medscape.

2.L. S. Harano, “Racial and Sex Disparities in Resident Attrition in Orthopedic Surgery,” JBJS, 2023 Apr; 8(2):e22.00148.

About the Author

DR. ERIN NANCE is a board-certified orthopedic hand surgeon who lives in New York City. She trained at some of the most world-renowned training programs including Lenox Hill Hospital, the Hospital for Special Surgery, Boston Children’s Hospital, Memorial Sloan Kettering, and Baltimore Shock Trauma.

She has run her own solo private practice hand surgery clinic for almost ten years on the Upper East Side of Manhattan.

She is known as the medical storyteller online for her viral TikTok account, @littlemissdiagnosed, where she educates people through patient experience stories, validating people’s feelings, and bringing awareness to commonly misdiagnosed conditions.

She is the founder and CEO of FeelBetr, a physician-run social media network that curates and customizes medical information based on a user’s individualized health needs and interests.

In her spare time, Dr. Nance loves to play tennis, one of the only sports you can have friends ranging from twenty to seventy years old. She is the number one cheerleader at all her daughter’s soccer games and is the default doctor on speed dial for all of her family, friends, friends of friends, colleagues, and most of TikTok.

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Copyright

Some names and identifying details of the individuals discussed in this book have been changed to protect their privacy.

LITTLE MISS DIAGNOSED. Copyright © 2025 by Erin Nance, MD. All rights reserved under International and Pan-American Copyright Conventions. By payment of the required fees, you have been granted the nonexclusive, nontransferable right to access and read the text of this e-book on-screen. No part of this text may be reproduced, transmitted, downloaded, decompiled, reverse-engineered, or stored in or introduced into any information storage and retrieval system, in any form or by any means, whether electronic or mechanical, now known or hereafter invented, without the express written permission of HarperCollins e-books.

Without limiting the exclusive rights of any author, contributor or the publisher of this publication, any unauthorized use of this publication to train generative artificial intelligence (AI) technologies is expressly prohibited. HarperCollins also exercise their rights under Article 4(3) of the Digital Single Market Directive 2019/790 and expressly reserve this publication from the text and data mining exception.

FIRST EDITION

Cover design by Paul Miele-Herndon

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Title page illustration © Iryna/stock.adobe.com

Digital Edition JUNE 2025 ISBN: 978-0-06-341289-7

Version 04102025

Print ISBN: 978-0-06-341287-3

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