“Andrea,” I said, “I need you to listen carefully. Twenty-two-year-old male. Five-hour history of progressive right lower quadrant pain, nausea, vomiting, fever. No diagnostic workup completed. Symptoms consistent with acute appendicitis, likely ruptured or on the verge. The attending on duty is Leonard Vance, and he has been treating the patient as a drug seeker.”
There was a beat of silence, then a muttered curse. “I’m twenty minutes away,” she said. “I’m calling in Raymond Kowalski from general surgery right now to assess him. And Garrison…” She exhaled. “I’m sorry. Vance has been a problem for a while. We haven’t had enough documented incidents to force action. This may be the case that finally does it.”
Raymond Kowalski arrived in fifteen minutes, still zipping his jacket as he walked into the bay. He was young, maybe early thirties, with the kind of focused intensity I recognized immediately as the mark of a surgeon who took every patient personally. He introduced himself to Ethan directly—not to me, not to the chart, but to the patient first—then explained exactly what he was going to do before he touched him. Even in that small detail, the contrast with Vance was infuriating. Proper care is often not dramatic. It is simply attentive, systematic, humane. Kowalski examined Ethan thoroughly, and as he worked, his expression hardened.
“Significant rebound tenderness,” he said. “Guarding. Rigidity. McBurney’s point is exquisitely tender.” He looked at me. “Given the five-hour progression and the fever, I’m very concerned about perforation.”
“What do you want?” I asked.
“CBC, CMP, inflammatory markers, blood cultures if his temp climbs any higher. CT abdomen and pelvis with contrast, stat.” Then, after one glance back at Ethan, “Honestly, based on presentation, this is appendicitis until proven otherwise. The delay is the issue now.”