SCENE 24

Scene 24 opens with Richard at a nurse's station on the phone, on hold once again. Hold Richard, sick of being on hold, for a few moments.

Radiology (OS)

Radiology.

Richard is startled.

Richard

Hey, I need a CT of the abdomen for my patient.

radiology (OS)

We'll be the judge of what you need and what you don't need.

Pause. Richard stares blankly, he has no idea how to respond to this.

radiology (OS)

assertive

Who is this?

Richard

This is Richard with Medicine 3A.

Radiology (OS)

Are you a doctor, Richard?

Richard

I'm a medical student.

Radiology (OS)

Is that right. Well Richard, why don't you call us back when you get a degree.

<click> Radiology hangs up.

After 3 months Richard is not surprised by this. He hangs up the phone and walks out of the nursing station into the hall without any emotion. Carolyn happens to be walking by. They are very familiar to each other - it is obvious that they have been spending time together over the intervening months. They start walking down the hall together, and stop in front of a patient's room.

Carolyn

Hey Richard!

Richard

with a warm but weary smile

Hey Carolyn, what's going on.

Carolyn

Can you believe it's the last day of our first rotation?

Richard

Can I believe it? I've lived six lifetimes in the past three months.

Carolyn

You're done with internal medicine!!

A male patient in a room near where Richard and Carolyn are standing starts his incantation: "Nurse...Nurse...NNNNNUUUUUUUURRRRRRRSSSSSSSEEEEEEEE." He is obviously shouting at Carolyn. Richard and Carolyn try to ignore him, but continues his chant until they address it.

Richard

Well I still have to make it through today. You must be excited to finish surgery.

Carolyn

Yeah, it's been a lot of work. But it's been fun.

Richard

I can't believe I have surgery last. It's going to kill me.

Carolyn

upbeat

You know, you'd be amazed at what you can get used to. After a few weeks you don't even notice you're not sleeping.

Richard

Carolyn I've really had enough of your positive attitude.

Carolyn

laughing, gives Richard an affectionate push

A little caffeine goes a long way.

Richard

chuckling

Yeah.

Richard and Carolyn stand there a few seconds, semi-laughing, trying to ignore the patient, but his cries are becoming unbearable.

Richard

I think he's calling you.

Carolyn glares at Richard.

Carolyn

How do you know he's not calling you?

Pause. Richard gives a Carolyn an "I don't know" look.

Richard

Just a hunch.

Carolyn

Well don't assume.

Richard speaks to the patient.

Richard

What can I do for you, sir?

texan

thick accent

Oh I'm sorry doctor, I was trying to get the attention of that cute little thing standing next to you.

Carolyn, whose back had been to the patient, wheels around and screams at him, very uncharacteristically.

Carolyn

shouts

I am not a nurse!!!

texan

Oh I'm sorry honey. Hey listen it looks like I've shit all over myself again, could you get your boss over here to clean me up, sweetheart?

Carolyn growls and pulls Richard down the hall. They talk as they walk.

Carolyn

So did you ever convince Dr. Toto to like you?

Richard

Not at all. I feel like when he writes his evaluation, he'll be thinking of his most recent encounters with me, so I'm counting on leaving him with a good impression this afternoon.

Cut to patient's room, Richard performing a physical exam. The patient is watching TV and eating, totally ignoring Richard, who finishes auscultating the heart and starts mashing down on his belly with exaggerated force; the patient doesn't even notice. While Richard mashes, he asks some questions.

Richard

So you have some belly pain?

Patient continues to watch TV and eat as he nods in response to Richard's question.

Richard

Do you have any medical problems? Diabetes? Hypertension? Asthma? Seizures? Heart problems? Anything? Ever been hospitalized?

Patient barely acknowledges the questions, as he is engrossed in the show he's watching. He shakes his head weakly.

Richard

How long have you had belly pain?

acute abdomen

About a month.

Richard

Where is it? What does it feel like?

Mr. Abdomen motions around his naval. He's still watching TV and eating McDonalds.

acute abdomen

Kinda burning-like.

Richard

Okay. Is your pain relieved by eating?

acute abdomen

Yeah, I have to eat all the time.

Richard

Great. I'll be back with my boss in a couple hours. We'll get you better and you'll probably go home tomorrow.

Acute abdomen

Cool.

Richard walks out of the room, and as he turns out of the door, he slams into Dr. Toto, causing Dr. Toto to spill coffee all over himself. That's for you Billy.

Richard

Oh hi Dr. Toto.

Dr. toto

glaring at Richard for causing him to make a mess

Richard, is this your patient?

Richard

Yes, but I just-

dr. toto

So you've performed an exhaustive history and physical examination, yes?

Richard nods weakly.

Dr. toto

And you've formed your assessment, including differential diagnosis and plan?

Richard

Um, yeah.

They both stand there staring at each other for a few moments. Dr. Toto is waiting, Richard is oblivious.

Dr. toto

Well are you going to present this patient, or are you waiting for me to do a little dance first?

Richard

Yes, but-

Dr. toto

Excellent. Go ahead then.

Richard takes a deep breath.

Richard

This is a 32 year old male without any past medical history who presents with one month of abdominal pain. The pain is described as burning and localized to the epigastric region. He reports that the pain is relieved by food. Physical exam is unremark-

dr. toto

Vitals!!

Richard

Oh yes, um, vital signs are stable.

dr. toto

glaring at Richard

Oh are they?

Richard

Yes. Physical exam is unremarkable. Abdomen is completely benign. My assessment is that this man has an ulcer, and I would like to start him on a proton pump inhibitor and discharge him tomorrow morning.

Richard has finished, but Dr. Toto is waiting for more.

Dr. toto

Anything else?

Richard

Nope.

dr. toto

It's always nice to work with a medical student who casts a wide diagnostic net, who refuses to be lured by the siren song of common symptoms and signs and leaves no stone unturned in the formulation of his differential diagnosis.

Dr. Toto walks into the room, drum-heavy music starts up.

Mr. Abdomen is now in obvious distress, sweating profusely, motionless and rigid as a board, breathing rapid shallow breaths. Dr. Toto calmly walks up to the bed and for a few moments sizes up this patient, who looks like he's about to become a statistic. He turns his head to Richard, who somehow is not surprised by this turn of events.

dr. toto

Good afternoon, sir. I'm Dr. Toto. Where is your pain?

Mr. Abdomen is too sick to answer, but glances down at his naval.

dr. toto

Is it your belly?

Mr. Abdomen nods quickly. Dr. Toto attempts to palpate the belly, but as soon as he touches the patient Mr. Abdomen lets out the yell of his life. Cut to black, audience hears yell continuing for a few seconds with black screen.