The Plumber

Chapter One

Debris and waste littered the narrow alleyway. The smell of refuse overwhelmed the rainy pothole-covered corridor. As the car made the corner, its lights illuminated a discarded heap of trash soaked by a rusty drainpipe along the colorless clapboard building. The tires crashed into a deep rut with a wash of foul water spraying alive a discarded man in the middle of the mound.

A rough bearded man startled awake in pain. He shoved the debris away violently, trying to stand. Falling face down into the pile, a horde of rats scampered over his naked body. With his second attempt, he gained a footing, holding on to the drainpipe for support. One hand explored his back for the source of his pain, where he grimaced nearly falling again. Fresh red blood stained the palm of his hand covering a bare surgical incision carved sharply upon his right flank.

#

The patient appeared in the emergency room entry, naked and screaming about his flank. A fresh bloody incision appeared on it. The hospital staff rushed him to a room seeing the blood and hoping to silence the belligerent man.

"Expletive…it hurts. I am getting the shakes," the man yelled at all who would listen. Missing teeth, unshaven and dirty, he was an outcast sort of man, drug addicted, and wanting a fix. He gave a garbled history of an attack lifting him from his back street wreck of a room while in and out of consciousness. His next memory was the filthy alley accompanied by a painful and bloody incision.

Them cut me doc, the man said desperately Why did they do that? He spat, as he frantically questioned no one.

The wound was definitely urologic, an up-and-down slit centered over the right flank, in the back over the kidney. Accessing the location on his wound the triage nurse phoned the urologist on call.

Thompson Smith was the newly crowned urology chief resident at the University of Texas Medical Branch in Galveston, Texas. The phone call awakened him around three AM. It was an odd message, and one he couldn’t sort out. Unfortunately sleep escaped him. The emergency room intern had seen a man, but was confused, he must be. Galveston was an island medically dominated by the University. If someone were post-op with an incision like that, he would know about it. He decided sadly that he must arise and see the man himself. He dressed quickly in a green surgical scrub suit, threw on a paper tied cap and worn wrinkled brown cowboy boots.

The fluorescent light cast a worried silhouette across the tired unshaven face of Thompson. Snapping the radiograph onto the view box, he shook his head in a questioning manner as he viewed and thought about the curious image.

What appeared before him was the beginning of a so-called intravenous pyelogram (IVP). Here was an x-ray of the abdomen after the injection of contrast dye. The normal left kidney had picked up that dye, and excreted it into the funnel shaped collecting structure outlining its normal shape. The right kidney was outlined, but did not excrete contrast, a sure sign of severe obstruction of the kidney. In addition, there was an odd finding. A metallic flag-shaped object pointed to the right kidney. It was obvious and could not be explained.

#

The child sat on the edge of his bed, staring at the wooden framed mirror. In the dark reflection, a movement scared him and he began to cry. There again was the woman dressed in white. At the door, she motioned for him to follow.

He made his way across the room reaching up for the doorknob. While sliding silently down the hall he knew he forgot something. The woman looked at him and mentioned Ben. Silly boy you forgot your bear, she said slowly. Soon with the stuffed animal in his hand, he felt relieved.

The car ride was always the same, his fear building as they escaped the house with vicious yelling in the background. Down the street at a frightening speed, the impact was sudden and violent as the truck crushed into the driver’s door with a fierce and fitful sound. Glass exploded, the mother tossed like a ragdoll to land with a twisted dash and awkward violent ferocity. Her head lay at a perverse angle, dark convicting eyes staring silently asking for help from the abandoned boy.

Sobriety did not help; the dreams now more vivid and frequent. The story of his Mother’s death at the hands of his drunken Father played at least once per week. For Lee W. Hickok, they were always the same but always different. He would start drinking again if he only knew that this violent visual trailer would end.

The ceiling fan was off balance, flip flop, flip flop chasing the air when humidity was the problem. He turned to his bedside clock, 3:08 AM again, and no sleep in sight. Quietly he rolled off the waterbed. Sitting on the frame, he turned and smiled at his wife, who was asleep deeply and snoring as she was prone to do.

The coffee brewed as he stood in the Victorian kitchen in a continuing state of remodeling, waives of steeped aroma refreshing to the tired physician. He was a tall man with brown hair tinged gray at the temples, and a crop of similar growth on his bare chest. Dressed only in bare feet and boxer shorts, the cool of the night was refreshing after the summer’s brutal heat and dripping humidity.

He took the pot of coffee with him to the master bath and plugged it into the sole outlet hanging from an ancient light fixture. The peach colored porcelain tiles glistened, now only weeks since their finish. He had completed this two-sink modification of the original, but each drain functioned poorly. Lee W. figured he could get something done before surgery at 8:00 AM at the University. Dropping to his knees, he looked into the vanity, and began to take down the trap when the phone rang.

After several rings she was there standing like an angel in a frilly pink bathrobe and matching slippers. Her hair was even curlier this time of night, and she quietly said: Lee W. answer the f***in phone! It’s UTMB. Don’t they know we have a child trying to sleep? Amber Divine Hickok never minced her words, something that Lee W. often admired. She referred to their daughter Kellie, thirteen years old sleeping downstairs.

Lee W. wiped his hands on an old towel, kissed his wife on the cheek, grabbed the Mr. Coffee, and walked down the flight of stairs to the kitchen, grabbing the wall-mounted phone.

Lee W., sorry to bother you yaw-all. It’s Thompson at the hospital.

Lee W. thought for a moment. He scratched his groin through his white boxer shorts. Still quite fuzzy that morning he answered. What are you doing in the hospital? He knew Thompson Smith was the urology chief resident. When he got a call from the man there was a problem, usually involving a surgical case.

Lee W., sorry, but there is a guy here that I wanted to talk to you about.

Lee W. stood and moved to the Mr. Coffee. Drinking from its spout, he swallowed the remainder of the pot, old cold coffee, in two big swallows.

Yaw-all there?

Ya, Lee W. said quietly. He reached into a cabinet and shook himself out two aspirin, swallowing them dry.

There is a guy here that the intern called me about. His name is Rawley Spentwood, and he gives a sketchy history of finding himself half-nude in an alleyway. The thing is he has a flank wound that is fresh, still with bleeding skin edges. The wound is up and down over his right flank. Begins at the tip of the twelfth rib and goes down parallel to the spine to the iliac crest. Sound familiar to you, Lee W? It’s a dorsal-lumbotomy incision!

Ya, who did it?

That’s the point, yaw-all, no one. He wasn’t in the OR. No record here at UTMB, no record at St. Mary’s. The guy just says he woke up in an alley with this incision! And you know what? It’s closed with a nylon sutured horizontal mattress. Here Thompson referred to the wounds closing suture. Closed with a nylon suture horizontal mattress, the closure was somewhat unusual in the day of skin staples.

Weird.

Ya, now I wanted to check out that kidney so I gave him 50 cc of hypaque IV. The left kidney is normal. There is a delayed right nephrogram, no pyelogram and guess what? There is a foreign body right at the UPJ, looks like a flag, a thin metal paper like piece of metal with the medial edge pointed, pointing right where the UPJ is.

Thompson gave dye intravenously, performing an intravenous pyelogram (IVP) and taking a series of x-rays. The normal left kidney picked up and excreted the dye. On the right, a dense image of the meat of the kidney only was seen, no excretion of dye to identify the collecting system of that kidney. This was consistent with obstruction of the kidney. In addition, there was a paper like metallic foreign body shaped like an arrow pointing at the ureteropelvic junction or UPJ, the junction of the renal pelvis or funnel of the kidney and the right ureter.

What do you think is going on, Thompson?

I think someone tied his ureter off! He’s having flank pain and it radiates to his right groin as if that kidney is obstructed. Then there is that wound and it’s like a flag pointing at the UPJ. Very strange!

Lee W. knew he would not be able to sleep. He thought about the case, and realized that the guy would wind up in the OR.

Thompson, I am going to come in. I want to look at those x-rays and talk to this guy.

You sure Boss?

Ya, see you in a half hour.

#

The guy was hysterical when he first got to the ER. Talking about rooms and visions, not making much sense. Thompson led Lee W. into the ER room. He was a middle height man with a curl of brown hair and brown eyes. Upon entering there was an overwhelming foul smell. Both stopped at the door and looked at each other. Laying on a gurney, prone in front of them was their patient. To the left was a huge, morbidly obese woman. She was dressed in black stretch pants, pink hairy slippers, a red and orange apron, and a blue scarf covering greasy red hair. From the door they could tell that the smell was coming from this roommate, a female in a room with their male patient, contrary to hospital protocol.

They’re full to the rafters tonight, Thompson said looking at Lee W. He motioned with his head to the woman, and grimaced again at the smell. He was hysterical when he came in, the resident said now motioning to their patient. He’s a junky, at least we think. Some tracks on his legs and arms. We gave him some diazepam and that calmed him down. He was sleeping when I left. Look the guy hadn’t voided yet when I left He picked up the plastic urinal hanging on the bedside rail. A thousand cc’s of pink urine was present.

What is that smell, Lee W. said quietly as a nurse arrived on the scene?

Hi Donna, Lee W. said to the nurse who followed the two into the room. She was an attractive woman with a big brown hairstyle held together with plenty of hairspray, and a huge set of breasts. He’s asleep now, what is that incision on his back Thompson?

Lee W. pulled the curtain around their patient. He quietly asked the nurse about the smell.

Smell of unknown origin, she said laughing quietly and signaling in the direction of the woman. Despite the growing smell, the three turned their attention to Mr. Spentwood.

Before them on the gurney, lay a disheveled man, snoring despite the horrible bouquet from his roommate. He was on his belly in the prone position, with torn boxer shorts and one paper slipper. He opened an eye when the doctors approached, closing it, and drifting back asleep. Lee W. put on a disposable glove. He traced the incision gently. On the man’s back was a six-inch long, fresh looking incision that was closed in a horizontal mattress fashion. It was parallel to the spine, beginning at the tip of the twelfth rib and ending at the edge of the iliac crest.

This was a dorsal-lumbotomy incision used only by urologists to gain access to the kidney. It was an old approach, used only rarely in the modern urology world of 1981. It produced a less painful wound than say anterior approaches to the kidney through the belly and was nice in that it was in the back for cosmetic purposes. Its problem however, was exposure and only those with a lot of experience with the incision could use it to expose the entire kidney.

Lee W. thought of one of his mentors, J. Palmer Chasteen, an elderly urologist now retired. He taught Lee W. the incision during his training at UTMB. Lee W. continued to use that incision performing, weeks before, a ureteral-pelvic junction obstruction repairing a stricture at the junction of the ureter and renal pelvis in a teenage girl. As far as he knew he was the only person in Galveston actively using that incision, until now that is.

Lee W. dropped his glove in the trashcan. He uncovered the curtain. To his left was a female physician talking to the female patient. After this, she headed over to the group asking the nurse Donna to chaperon her for a pelvic exam. She pulled the bed curtain around the patient.

The two urologists left the room to talk. We need to know the status of that kidney. What did this guy do? Somebody obviously operated on him. Maybe he did nothing, but I doubt it.

Thompson pulled Lee W. to an x-ray box and put up the IVP that he had done.

Wo…wo…what are you doing, the woman patient yelled from inside the room. That hurts you bitch!

Lee W. smiled at Thompson. They both grimaced wondering what was going on.

That hurts…that hurts. Bitch, what’s that smell?

Ms. Anderson just relax. I found the source of your smell! But you have to put your legs back up in the stirrups. The resident whispered to the nurse: get me a large trash bag! And you better get some linens. And a bag of warmed saline.

Donna came running by the two urologists. She was hurrying, holding her nose, looking like she had just seen a ghost. She returned with a large sheet, IV bag and several plastic bags. Two other nurses followed into the room after her.

Now put your legs back up Ms. Anderson, Donna was heard to say. That’s good.

Oh, Oh, Oh. You fucking bitch that hurts. What are you doing?

The same smell was building up in the hallway. It was foul and thick. Lee W. thought he was going to vomit. Thompson moved to the doorway. Katy, do you need any help? He said to the resident.

Ah…you know….Thompson, we could use your hands.

Thompson looked at Lee W. astonished and moved into the room.

Screaming continued the smell building. A long loud shriek from the room echoed through the ER. Thompson appeared, grabbed a trashcan, and vomited into it. Lee W. came to his side. A sandwich, we found a sandwich under her panniculus. It’s so gross, Lee W. It took two of us to lift the panniculus and then the sandwich had essentially grown into her fat-fold. It’s an Italian sandwich, must be rotten cheese and the bread is black and bubbly. That woman must weigh 800 pounds. Her sandwich… she lost it two months ago!

Donna and Katy both exited the room with foul blackened sheets and a several foot in diameter mass held in the garbage bags. The looks on their faces said it all, foul, course, and filthy the scene would live for years. Hopefully the smell would dissipate sooner.

The nurses brought stand-up fans for the hallway and room. The smell entered the ER proper and several came over to assess the situation.

What the Hell is in there? One ER doctor said loudly.

It’s Ms. Anderson, Donna said quietly. Evidently didn’t finish her lunch!

The two urologists returned to the x-ray viewing box. Both were holding their noses and trying to concentrate on their patient. On the plan film, prior to dye appeared a normal KUB or Kidney, Ureter, and Bladder view. Over the area of the right kidney one could see a foil like metallic foreign body with a sharp tip pointing to the area of the UPJ. After injection of dye, the left kidney visualized and on later films promptly excreted the dye into the collecting system. Even on the one-hour post injection film only a dense picture of the meat of the right kidney could be seen, no excretion of dye into the collecting system, implying obstruction.

Sure looks like that metallic foreign body is pointing at the UPJ.

It is Lee W.

The stench was beginning to clear courtesy of the fans. It would take weeks for the odor to clear from the ER. Donna passed the two helping a limping Ms. Anderson to vacate the ER as quick as possible. The patient was grumbling as they disappeared down the hall. Donna turned her head and looked at the two, shaking her head and laughing quietly.

Let’s talk to this guy, Thompson.

Lee W. and Thompson walked into the room. Two huge fans that might be used by commercial painters were on full blast over by the woman’s prior gurney. Mr. Spentwood was still lying prone, in and out of sleep. Lee W. asked: how did yaw-all get this incision?

Spentwood turned and felt the wound. He shrugged his shoulders. Don’t know Doc. I remember being downtown and then being in the alleyway like trash and splashed with water by a car. It hurts doc!"

We’ll get you pain meds.

The man slowly turned onto his back. He looked at the two white coated men. But if I don’t get it soon I’ll get the shakes bad, yaw-all know what I mean?

Who is the intern, Thompson?

She’s Kory Michaels, she is not on tonight. Karen Briar is on call.

Well where the hell is she?

When she heard you and I were taking care of the case I think she went to the call room.

Well get her out of there. I want her to titrate this guy’s morphine, give just enough to prevent withdrawals. Tell her I insisted. That Girl just doesn’t care. Lee W. looked at Thompson and they both acknowledged a lack of caring in this particular housestaff.

Look, Mr. Spentwood, someone operated on your right kidney. It is obstructed and we’re going to have to fix it. Lee W. said to the man.

"Just keep