21. Buster

TWENTY-ONE

Buster

4:06 pm

Five hours. This was supposed to be a straightforward cholecystectomy, in and out in a couple of hours at most. But nothing about this case went as planned.

I glance at the clock, exhaustion tugging at my muscles. The OR is eerily quiet except for the steady beep of the monitors. My team is tired but focused, their faces masked in concentration as we wrap up the procedure.

"Alright, we're almost there," I say, my voice steady despite the fatigue. "Let's close her up."

The patient, a middle-aged woman named Mrs. Thompson, came in with acute cholecystitis. Simple enough, or so we thought. But once we got inside, it was clear this wasn't just a routine inflammation. Her gallbladder was severely necrotic, and there was extensive scarring from previous undiagnosed episodes.

"Scalpel," I say, holding out my hand. The instrument is placed in my palm with practiced efficiency. As I carefully cut through the remaining tissue, I think back to the start of the surgery.

An hour in, we encountered unexpected adhesions, likely from past infections. Every time we thought we had a clear path, we found more scar tissue. At one point, her blood pressure dropped dangerously low, and we had to stabilize her before continuing. The necrosis made the gallbladder incredibly fragile, and removing it without causing further damage was a delicate, time-consuming process.

"Suction," I instruct, my eyes never leaving the surgical field. The assistant moves quickly, clearing the blood and fluids to give me a clear view. The worst part was when we discovered a small perforation in the duodenum. A complication like this can turn a routine procedure into a nightmare. We had to repair the perforation meticulously to avoid any leaks that could lead to sepsis.

"Clamp," I say, taking a moment to wipe the sweat from my brow. The repair went well, but it added hours to the surgery. As I place the final sutures, I can feel the collective relief in the room. Mrs. Thompson is stable, and her vitals are strong. We managed to navigate the complications, but it was a close call.

"Let's start closing," I announce, my voice filled with exhaustion and satisfaction. The team moves with practiced efficiency, closing the incision layer by layer. I inspect each step, making sure everything is perfect. This has been a tricky surgery, but seeing her vitals stabilize is worth every minute.

"Good job, everyone," I finally say, stepping back. "Let's get her to recovery."

As we wheel Mrs. Thompson out of the OR, I finally let myself breathe. Five hours in surgery is grueling, but knowing she's going to be okay makes it all worth it.

I head to the scrub room, the adrenaline slowly wearing off. I need to brief the family and explain what happened and why it took so long. But first, I take a moment to gather myself, washing away the stress and sweat.

Just as I leave the scrub room, I check my phone. A dozen missed calls and messages light up the screen. My stomach drops as I see Cole's name among them, along with several from unknown numbers.

Something's wrong.

I quickly open the most recent message from Cole.

My heart skips a beat, and the exhaustion from the surgery is replaced with a surge of panic. I grab my things and head towards the ER, dialing Cole as I move.

"Please go update Mrs. Thompson's family," I bark to the PA as I put the phone to my ear. Normally, I would go out to speak with them after surgery, but I need to find out what is going on with Maddie STAT.

My heart races as I sprint through the sterile corridors of the hospital, the urgency of Cole's message propelling me forward. I quickly dial her number, my fingers trembling slightly. She answers on the second ring, her voice thick with tears.

"Buster," she sobs, barely able to get the words out.

"Cole, I'm on my way. I'll be there any second," I say, trying to keep my voice steady despite the rising panic. "Don't worry, okay? I'll be right there."

I can hear the fear and desperation in her voice, and it takes everything in me not to press for details. But I know asking her to explain over the phone will only upset her more. I need to be there to see for myself, to understand what's happening with Maddie, and to speak with her attending.

"I'm almost there," I say again, more to reassure myself than anything else. "Just hang on."

I hang up and push through the doors to the ER, my eyes scanning the chaotic room for any sign of Cole. I spot her near the nurses' station, her face streaked with tears, clutching her phone like a lifeline. The sight of her like this sends a fresh wave of fear through me, but I force myself to stay focused.

"Cole!" I call out, rushing over to her.

She turns, her eyes wide with relief and panic. "Buster, my sweet Maddie," she chokes out, fresh tears spilling over. "She was unresponsive at school. They don't know what's wrong."

I pull her into a tight hug, feeling her trembling against me. "I'm here now. We'll figure this out," I whisper, hoping to offer some comfort. "Where is she?"

Cole points towards a room at the end of the hall. "They're running tests. They won't know anything until the results come back."

I take a deep breath, trying to steady my own racing heart. "Let's go see her."

We walk together to Maddie's room, my mind racing with possibilities and worst-case scenarios. But I push those thoughts aside. Right now, all that matters is being there for Maddie and Cole and doing everything I can to help.

As we reach the room, I brace myself for whatever comes next. Maddie needs me, and I won't let her down.

We step into Maddie's room, and my heart breaks at the sight of her lying so still on the hospital bed. Her small chest rises and falls with the help of an oxygen mask, her face pale and serene in a way that's utterly wrong.

Right now, I feel less like a doctor and more invested than I ever have. I've never been in this position, seeing someone I genuinely care about like this. I want to put all I know and all I've learned to work to fix this.

Well, I'm aware that I cannot just fix it. But I can damn sure make certain we do everything and anything to get to the bottom of this and then get her the proper and best care available.

I pull out my stethoscope and gently place it on her chest, listening to her heart rate and breathing. Her heart is steady, but her breaths are shallow. I move the stethoscope to different points, making sure I'm not missing anything.

"Her heart sounds strong," I say to Cole, trying to offer some reassurance. "But her breathing is shallow. Let's see what else we can find out."

I grab the nurse's computer and quickly log in, pulling up Maddie's chart. I scan through her vitals and the notes the doctors have made so far. Her blood pressure is stable, and her oxygen saturation is within normal limits, but there are still too many unknowns.

"They're running a lot of tests to figure out what's going on," I explain to Cole, who's watching me with wide, fearful eyes. "They've already done a CT scan to check for any brain issues, blood tests to look for infections or metabolic imbalances, and a lumbar puncture to rule out meningitis or other infections in her cerebrospinal fluid."

Cole nods, but I can see she's barely holding it together. "What does all that mean? Do they have any idea what's wrong?"

I shake my head, frustration gnawing at me. "Not yet. The tests take time, and they need to rule out a lot of possibilities. Right now, they're monitoring her closely to keep her stable while they wait for results. It could be any number of things, honestly. But these tests should be able to narrow it down significantly."

Cole's shoulders slump, and I place a reassuring hand on her arm. "We'll get to the bottom of this, I promise. Maddie's in good hands. I won't stop until we have answers."

I take a deep breath, knowing we need more help. "I'm going to call Dr. Bellinger personally," I tell Cole. "He's a general surgeon but also did a fellowship in pediatric metabolic conditions. It's fortunate he was here today when you brought her in. If anyone can help figure this out, it's him."

Cole nods again, a glimmer of hope in her eyes. "Thank you, Buster."

I leave the room, pulling out my phone to call Jonah. As I wait for him to pick up, I glance back at Maddie and Cole, determination hardening my resolve. We'll get through this. We have to.

Just after the first ring, I spot him walking down the hall, his white coat flapping slightly with each determined step. I quickly end the call and put the phone away. Relief washes over me, and I hurry towards him, pocketing my phone.

"Jonah!" I call out, my voice seems a little too loud in the quiet corridor. He turns, surprise flickering across his face before he sees the urgency in mine.

"Buster, what's going on?" he asks, concern immediately replacing the surprise.

I catch up to him, slightly out of breath. "It's Maddie Johnson," I say, my heart tightening even further at the prospect of talking to him about this little girl I've come to care about. "Her mother is my friend."

Friend? We're so much more than friends, but right now, that's just semantics.

"Can you take a look at her chart? She was found unresponsive at school. They've done a CT scan, blood tests, a lumbar puncture... but we still don't know what's wrong."

Jonah's eyes narrow, all professional now. "They've ruled out sepsis?"

"Yes," I confirm, swallowing hard. "But we need to get to the bottom of this. Do you have any thoughts about what could be going on? Can you take the lead on this?"

Jonah nods, his expression grim. "I have a hunch it could be Acute Myeloid Leukemia, AML. Her symptoms fit, but I need to see a few more things before I can say definitively."

My stomach drops. "AML," I repeat, the weight of the words pressing down on me. "What do we need to do?"

"We need to confirm it with a bone marrow biopsy," Jonah explains, his tone steady but urgent. "If it is AML, we'll need to start treatment immediately. It's aggressive, but catching it early gives us a better chance."

I nod, my mind racing. "Whatever it takes."

Jonah places a reassuring hand on my shoulder. "We will, Buster. Let's go back to her room. I'll check her vitals and order the necessary tests. We'll get through this."

As we head back to Maddie's room together, I feel a surge of determination. Maddie's life is in balance, and I won't let her down. With Jonah's expertise and our combined efforts, we'll find a way to pull her through.

As we walk back to Maddie's room, my mind races, trying to gather everything I know about AML from med school and residency. It's been years since I've encountered it, and the details feel frustratingly elusive.

AML… It's a type of cancer that starts in the bone marrow but quickly moves into the blood. I remember it being aggressive and requiring immediate intervention. Symptoms include fatigue, frequent infections, and easy bruising or bleeding, all because the bone marrow fails to produce normal blood cells.

"Jonah," I say, my voice tense, "I'm trying to remember everything about AML. It's been a while since I dealt with it. Can you fill in the gaps?"

Jonah nods, his expression focused. "AML is a rapidly progressing cancer of the blood and bone marrow. The bone marrow produces abnormal white blood cells that crowd out the healthy cells, leading to a variety of symptoms. In Maddie's case, her unresponsiveness could be due to severe anemia or an infection her body couldn't fight off."

I nod, recalling the basics. "Right, and the treatment typically involves chemotherapy, right?"

"Yes," Jonah confirms. "The first phase is called induction therapy. The goal is to kill the leukemia cells in the blood and bone marrow, putting the disease into remission. This is followed by consolidation therapy to eliminate any remaining leukemia cells and prevent a relapse. The entire process is intense and can take several months."

"What's her prognosis if it is AML?" I ask, needing to know what we're up against.

Jonah's face softens with empathy. "It varies depending on a number of factors—her overall health, how well she responds to treatment, and the specific genetic mutations of the leukemia cells. Children generally have a better prognosis than adults, but it's still a tough road. Early diagnosis and aggressive treatment are key."

We reach Maddie's room, and I take a deep breath, trying to steady my nerves. "So, what's our next step?"

"We need to confirm the diagnosis with a bone marrow biopsy," Jonah says. "If it's AML, we'll start treatment immediately. She'll need to stay in the hospital for the initial phase of chemotherapy, and we'll monitor her closely for any complications."

I nod, feeling a mixture of fear and determination. "Let's do it. Whatever it takes."

We step into Maddie's room, and Cole looks up, her eyes red and filled with hope. I give her a reassuring nod, and Jonah steps forward to explain the plan.

"Cole, we need to perform a bone marrow biopsy to confirm the diagnosis," Jonah says gently. "It's a small procedure where we take a sample of the bone marrow from her hip bone. If it is AML, we'll start treatment right away."

Cole nods, her voice trembling. "Okay. Just… please help her."

"We will," I say, squeezing her hand. "We'll do everything we can."

As Jonah prepares for the biopsy, I stand by Maddie's side, feeling the weight of the situation. This is a battle we have to win—for Maddie, Cole, and all of us. And with Jonah's expertise and our determination, I know we have a fighting chance.