The Warning Signs

By Terrence Loftus

Jack uses his connections with the robotics industry and an android named Caine to find the stalker and d the campaign of terror. Despite the attacks and numerous attempts on his life, Jack and his friends remain optimistic and confident with a shared sense of humor throughout the ordeal as they learn the truth about the stalker's motivation and intentions.

• Language: English
• Publisher: BookBaby
• Release date: Oct 14, 2019
• ISBN: 9781543989489

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Copyright © 2019

Terrence J. Loftus

ALL RIGHTS RESERVED

No portion of this publication may be reproduced, stored in any electronic system, or transmitted in any form or by any means, electronic, mechanical, photocopy, recording, or otherwise, without written permission from the author. Brief quotations may be used in literary reviews.

This book is a work of fiction. Any references to historical events, real people, real businesses, or real places are used fictitiously. Other names, characters, businesses, places, and events are the products of the author’s imagination and any resemblance to actual events, places, businesses or persons, living or dead, is entirely coincidental.

ISBN: 978-1-54398-947-2 (print)

ISBN: 978-1-54398-948-9 (eBook)

FOR INFORMATION CONTACT:

Terrence Loftus

LoftusHealth.com

This book is dedicated to my family:

Jennifer, Louie, Gabe, Ellie and Lila.

Contents

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EPILOGUE

1

My father was the first person to say to me, You’ve been warned. He didn’t say it often, but when he said it, I listened. It meant, pay attention. He never said it as a threat or with anger. When it came from him, it was a genuine warning designed to create situational awareness. The last time he said it to me was just before I left home for college. Little did I know at the time, but that simple phrase would follow me around for the rest of my life. It became a signal that something important was about to happen in my life. As I learned from my father, it was not a message to be feared. It was an opportunity. When you’ve been warned, he used to say, be wise, act boldly. It was advice I carried with me throughout my life.

My name is Jack Hyland, and this is my story. I spent most of my career as a surgeon. The most significant influence on my career choice was my father. His name is Dr. Morris Hyland, better known as Mo. He was also a surgeon who began his practice toward the end of the twentieth century. He received a medical degree at an excellent school, graduated in the top of his class, and trained as a General Surgeon. He began in solo private practice and eventually formed a group practice that worked out of a hospital in our hometown. He liked to think General Surgeons were the Swiss Army Knife of healthcare. They were versatile and capable of taking care of just about any problem.

Like many surgeons of his day, he specialized over time. He didn’t think of it as specializing so much as adding another skill set to his tool belt. His first big niche was laparoscopic surgery which was a minimally invasive approach to operating. Back in the day, surgeons operated through big incisions. Toward the latter half of the twentieth century, a few renegade surgeons challenged this approach and began performing operations through small incisions using a device called a laparoscope. The laparoscope was placed through a small incision, and a camera was used to project the image on a display. Instruments used to assist with the operation were placed through other small incisions. In time, this new approach prevailed. The older surgeons of the day told my father he was a damn fool for trying this risky approach. As time would tell; he was on the leading edge of a practice that would ultimately transform surgery forever. My father took great pride in participating in this transition, and he encouraged me to do the same.

He practiced at our local hospital and used to bring me to work with him whenever he could. The medical staff of the hospital elected him Chief of Staff, and he used his position to allow me to accompany him during his daily rounds on patients. My favorite activity was watching him operate. I was a teenager the first time I watched him perform an operation. I’m embarrassed to say, it was not easy the first few times I saw blood. It never bothered my father that his son was always on the verge of passing out at the sight of blood. One night on our way home, he confessed he use to do the same thing when he was in medical school. He said it just took some time to get used to seeing another human bleed. Getting anxious at the sight of blood is healthy, he would say. Why, one would have to be a psychopath to not get disturbed at the sight of blood, he would add. One time on our drive home from the hospital, I asked him when he finally got used to the sight of blood. He said he never got used to it; he just got better at controlling his reaction to it. When I asked him, when that happened, he smiled and said, when I learned how to stop the bleeding. Right then and there, I decided to become a surgeon, just like my father.

About the time I entered medical school, laparoscopic surgery was in full swing. There were now minimally invasive approaches to the chest, abdomen, spine, knee, hip, and brain. It was also when robotic-assisted surgery became popular. My father, the former laparoscopic renegade, was now a skeptic. I hadn’t performed my first operation yet, and I was a believer. Now who’s the damn fool?, I retorted during a debate with him over laparoscopic versus robotic surgery. He took it in stride, but I could tell the comment stung. He tried using the robot but didn’t see any benefit for him compared to just using the laparoscope without the assistance of a robot. It just wasn’t good enough, he would say. He was, by the measures of his day, an advanced laparoscopic surgeon. In his eyes, it wasn’t contributing anything to his skill set and just cost more. He also said the scientific literature didn’t support the robotic approach and that the outcomes were no better than that of an advanced laparoscopic surgeon, like himself. He had a point. The literature back then demonstrated mixed reviews. I once asked him, if it’s no better, then why are surgeons using it more and more every day? He knew this was true and could see the growth in robotic-assisted surgery. He told me, because it has the potential to one day be better. We had many more debates over the years, but this was the closest I heard him come to conceding the point.

We lived in a modest home with a large back deck that overlooked a lake. My father used to refer to it as the lakeside surgeon’s lounge. It wasn’t uncommon for my parents to invite a group of colleagues and friends over for drinks and appetizers. Most of them had some connection to healthcare, but my favorite group for entertainment was the surgeons. They were all characters in their own quirky way, and each of them had an opinion on every topic. My father loved the debates that would carry on late into the evening. My mother would serve up appetizers and drinks. I would help her, but mostly I was there for the entertainment. One summer evening the surgeons got into it over robotics, and there was no doubt how they felt about the subject.

Mo, what’s this I hear the hospital administration wants to buy a robot for the operating room? They’re always crying about how we must cut costs, and now they want to spend money on a machine that will never be used. I’ve never seen such a stupid idea. The hospital is screwed if this is the direction we’re going, said Ned Walker, a colleague, and good friend of my father.

The hospital is recruiting a Urologist, and they say none of the recent graduates will work in a hospital without a robot, my father said. Ever since the Boyd brothers moved their practice to the outpatient surgery center, we haven’t had any Urology coverage. It’s unlikely those guys will ever bring their business back to the hospital. Plus, it’s not like they did big cases even when they were there fulltime. These days the prostates and kidneys are being removed with the assistance of a robot. If we’re going recruit a Urologist and do those cases, then we’re going to need a robot. It’s just a tool, Ned. Why are you getting so worked up about it?

It’s not just a tool, Mo! It’s a Trojan horse, and it’s just like the Urologists to sneak it into the hospital. No self-respecting General Surgeon would be caught dead using a robot. It’s like training wheels for surgeons who don’t know how to operate. Even the Gynecologists are fawning over it. What better proof do you need? The worst part of all this is, it doesn’t make them better surgeons, it just makes them feel like better surgeons, Ned said, emphasizing the word feel.

That’s not true Ned, there’s research to support its use for prostate cancer, piped in Dave Richmond, an Anesthesiologist who worked with all the surgeons present. If I need my prostate taken out, then I’m looking for a Urologist that will take it out using a robot. The Boyd brothers never even considered learning how to use the robot, let alone laparoscopy. I say, good riddance to them. Let them do minor cases at the surgery center, and bring on the robot for someone who knows how to use it.

Oh, come on now Dave, the Boyd’s weren’t that bad, replied Ned.

That’s not the point, Ned. We need Urologists that will practice in our hospital. I’m not a big fan of the hospital administration, but I admit, I support recruiting another Urologist, and if that means getting a robot, then I’m for it, said Dave.

The debates would go back and forth like this for hours. I cherished these conversations. My parents socialized with a wide assortment of people, but it was the surgeon gatherings that got most of my attention. My father loved these discussions just as much, if not more than me. To an outsider, it might sound like an odd way for professionals to be making conversation. To an insider, it was just how old friends talked to one another.

Ned was usually the center of attention. He was the personification of what it meant to be a surgeon. Ned was confident, brash, and quick to decide. He commanded the operating room and the respect of his peers. In his busier days, he was the surgeon’s surgeon. The kind of doctor another doctor sent their patients, but also their friends and family. My father said Ned was as technically skilled as any you could find. If he or any of the other surgeons got into trouble, then they would call Ned. Ned would show up any time of the day, drunk or sober. Some said you would rather have Ned operating on you when he was drunk than most surgeons sober. My father didn’t buy into that thinking. He was the one who pulled him off the line when it got out of hand.

My mother told me the story of how that happened. The phone rang in the middle of the night, which was not an uncommon thing to happen in our house. My father answered it with a grunt, listened, hung up the phone, and softly swore. When he returned several hours later, he told my mother Ned was trying to help another surgeon on staff with a complicated case. The anesthesiologist asked the nurse in the room to call my father because Ned was so drunk he was falling asleep standing up against the operating room table. My father pulled him out of the room and left him on a couch in the physician’s lounge. He then helped the other surgeon finish the case. When he returned to the lounge, he found that Ned was still passed out and pissed in his pants. My father helped him change and drove him home. He met Ned’s wife, Suzanne, at the door and told her never again. A few days later, Ned entered an alcohol treatment center. He’s been sober ever since. No one talks about it. My mother said it was part of the code of silence of being a surgeon.

Complications and deaths were discussed at the monthly Morbidity and Mortality conference, also known as M&M. Surgeons would meet in a closed conference room and discuss their cases with one another. Each surgeon would present their complications and be questioned on just about anything related to it. Some things were never discussed. It was these types of things that not only had an impact on the patient’s care but also the health of the surgeon. Ned’s drinking was one of those things. Of the cases they did discuss, many of the more interesting ones were recounted on our back deck.

Why didn’t he just throw the patient down the elevator shaft? It’s a whole lot quicker, growled Ned. At least the poor devil would have had a chance of surviving.

Earlier that day, Ned was moderating the monthly M&M conference. As usual, Ned managed the meeting with his characteristic take-no-prisoners approach. As Chair of the Department of Surgery peer review, he also provided oversight for quality improvement for all matters related to surgery. Ned didn’t limit his observations to just surgeons and used M&M as a platform for critiquing all physicians, nurses, and hospital administrators.

On this day, Dr. Parker, a General Surgeon, was presenting a recent case of his. The patient was an elderly man who had part of his intestine removed for colon cancer. Within days of the operation, the patient spiked a fever that Dr. Parker attributed to a urinary tract infection. The patient was placed on antibiotics, however his condition worsened. The real source of the fever was an infection in his abdomen that was killing him. Dr. Parker eventually returned the patient to the operating room to address the infection. Sadly, it was too little, too late, and the patient died shortly after the surgery. Ned was not happy as he retold the story.

I told him he should have taken that patient back to the operating room as soon as he started getting sick. I asked him, can you help us understand why you would sit on such an obviously sick patient for so long? Ned said to the small group of physicians on the back deck.

Parker told us, the Internist on the case diagnosed a urinary tract infection. Parker thought it seemed reasonable to him at the time, and let the Internist manage the infection.

I said to him, ‘Dr. Parker, you operated on the man! You were that man’s surgeon. He trusted his life to you, not some Internist who knows nothing about how to manage post-op patients. Are you serious?

He said to me, ‘I wouldn’t describe it that way, Ned. He takes care of all my post-op patients and does a pretty good job. He just got it wrong this time’.

Ned went on to say, We’re not talking about an Internist’s care of a patient. We’re talking about your care of a patient. That patient was sick for days, and you did nothing. At the very least, you should have done a CT scan looking for the real source of his infection. To attribute this to a simple urinary tract infection is piss-poor management. This is a room full of surgeons Dr. Parker. You’re not fooling anyone. It’s time to take responsibility for this man’s death!

My father interjected at this point and said, Dr. Parker did own up to it Ned and admitted he should have ordered a CT scan. And he also said if he made the diagnosis earlier, he would have brought the patient back to the operating room.

That’s how it usually ends at M&M, which is when the surgeon admits their mistake and recognizes what should have been done to either prevent or mitigate the effects of their decisions. Surgeons are particularly fond of the confession. Most of the time, once you confess your sins, all is forgiven. If a surgeon repeatedly makes the same mistake, then the consequences are different. If you learn from your mistakes, then you can continue to practice. The harsh tone is standard at M&M meetings. It starts in the training of a surgeon and continues throughout a surgeon’s career. Most Departments of Surgery have at least one Ned. Sometimes the whole department is made up of people like Ned. Having a thick skin for criticism is a job requirement. The crazy part of all this is, the same people who will criticize, humiliate, and yell at each other during M&M, will turn around and go golfing with each other the following weekend. It’s just an accepted part of the culture. Each presentation ends with the same question. What would you do differently? Failure to respond appropriately to this question is the greatest sin of all among surgeons. A surgeon must acknowledge their mistakes and recognize there are always other options from which to choose.

2

Eve, an Emergency Medicine physician working at the Medical Center where my father worked, called one night. These calls usually meant a trip to the Emergency Department for my father to consult on a patient. If it wasn’t too late, then sometimes I tagged along, so I quickly finished my dinner.

Yea, I’m covering for Ned. He’s in Chicago at a conference. How can I help you?

He listened for a few minutes, with an occasional, uh-hah thrown in to acknowledge that he was listening. He told Eve he would come see the patient. Returning to the dining room, he looked over at me, shaking his head from side to side and said, What do you think Jack, you want to ride along with your old man and see what a slam-dunk lap-chole looks like?

Of course! I said. What’s that?

I’ll explain on the way to the ED.

The patient was a young woman who Ned operated on before leaving town for a conference. Ned and my father had their own surgical practice, but would cover for one another whenever they left town for vacation or meetings. Typically, before leaving town, they would limit their caseload to not burden the covering surgeon too much. Just before he left town, Ned called my father and said he had only one case to sign out. In Ned’s words, it was a slam-dunk lap chole. As my father said those words, he grimaced and said, Jack, remember this for the rest of your life, there is no such thing as a ‘slam-dunk anything.

A lap-chole is short for laparoscopic cholecystectomy and is an operation that uses a laparoscope to remove the gallbladder. In this case, the woman’s gallbladder was removed two days before she presented to the Emergency Department. Instead of feeling better, she developed worsening pain in her abdomen.

She says the pain never went away after surgery and got progressively worse ever since, said Eve. The patient looked uncomfortable on arrival, so I gave her some morphine. All her lab work is normal. She’s over in ultrasound right now checking for fluid in the abdomen like you requested.

Did you pull up a copy of her operative report? my father asked.

I couldn’t find one. I couldn’t even find a short note in the medical record. Aren’t surgeons supposed to write one of those after an operation? Eve asked.

Most of the time, my father responded. No worries, I’ve something better. I have Ned’s cell phone number. I hope he remembered to bring his phone with him.

We made our way over to the Ultrasound Department. Roy, the technologist, was just finishing up the exam as we knocked on the door. Roy recognized us and waved us into the room. My father introduced us to the young woman lying on the exam table and began looking at the ultrasound images.

Definitely looks like some fluid. It’s mostly up around the liver, Dr. Hyland.

Can you see the common bile duct? asked my father.

Yea, I can. It appears normal as best as I can determine with ultrasound.

The patient’s name was Emily, and she just had a baby boy about six weeks ago. She suffered recurrent attacks of pain from gallstones during the last part of her pregnancy. Once she delivered, Ned scheduled her for the operation to remove her gallbladder. In the last trimester of pregnancy, you want to avoid operating due to the size of the uterus. Following pregnancy, the abdominal wall is stretched out creating more space in the abdomen which provides better exposure in which to operate. Surgeons love better exposure. This is why Ned referred to this case as a slam-dunk operation. Or so he thought it would be.

Ned, do you have a minute to talk?, my father asked. I need to talk to you about the lap-chole you did a couple of days ago. She’s back in the ED with fluid in her abdomen.

That got Ned’s attention. They talked for a few minutes. Mostly my father was listening. The conversation appeared to be going well until my father suddenly said, Okay, I understand. No, I’m not going to open. There’s no reason for you to fly back. I’ve got it covered. Enjoy the rest of the conference. I’ll call if there are there’s anything new.

So what’s up? I asked.

It turns out the slam dunk lap-chole was a little more complicated than he thought it was, he said.

Didn’t Ned know that? I asked.

Of course, he did. my father answered. Ned’s a good surgeon Jack. In fact, he’s an excellent surgeon. Even excellent surgeons take chances. The patient didn’t want to wait until Ned returned from his trip, so he felt pressured to get the case done sooner. I’m sure he didn’t think this would become complicated. I probably would have done the same if I was in his situation. I wouldn’t have called it a slam dunk operation, and I would have alerted whoever was covering me if I left town. He also ran a full clinic the day he flew to the conference, so I think he was under some time pressure. It’s stuff like that which throws you out of your routine and increases the risk for problems. I was operating in the room right next to him the day he did this case. I would have helped him with the case if he asked. As good as Ned is, there are times when that man is too proud to ask for help.

So now what are you going to do?, I asked.

Fix the problem, he grumbled.

The patient ended up having a leak from where the gallbladder was removed. A drain was placed that night and she was scheduled to have the leak repaired the following morning. The patient was admitted to the hospital, and we were on our way home before I knew it.

What did Ned mean by opening her, I asked.

Well, that was the way it used to be done in the past. If a surgeon had a complication, the first thing you would usually do was to open the area where you operated with a big incision, determine what the problem was and fix it, he explained.

So how come you’re not opening her up?, I pressed.

Nowadays we don’t have to always do that. There once was a time when opening patients was the standard. We’ve learned that a more minimally invasive approach can often be safer and less traumatic to the patient. Don’t misunderstand Jack, the open approach is still a good choice when you really need to use it. It’s just that in this case, this can probably be fixed with a less invasive approach. Ned trained in a time when opening up the patient was the preferred option in these situations. If I know Ned, then he will be the first to remind me of this if a less invasive approach doesn’t work. We’re good friends, but he was the first to tell me I was a damn fool for training in advanced laparoscopic surgery when it first came out. He wasn’t the only one. Most of those guys were older and since then either retired or died. The ones still in practice, like Ned, eventually learned the new techniques. Ned’s comfort zone is with the more basic uses for laparoscopic surgery and the open approach so he’ll choose one of those approaches every time. My comfort zone is the advanced laparoscopic approach. We’ll know soon enough if this is the best approach with this patient.

The next week was Fall Break for school, and I asked my father if it was okay for me to hang out with him on rounds. He approved and the following morning we went to the hospital. I was curious to see what happened to Ned’s patient. We rounded on a couple of other patients; my father consulted on that weekend. One was a patient who had appendicitis. Another was a patient who had a bowel obstruction that was getting better without an operation. The next patient was Ned’s patient. She looked good, all things considered. My father had some charting to do and asked me to wait for him in the surgeon’s lounge.

The surgeon’s lounge was located right next to the operating room, or OR, as it’s more commonly called. It’s a place the OR staff and surgeons can go to relax in between cases. In it were a few tables with chairs, a couple of big couches, a refrigerator, and a microwave to warm up food. It wasn’t fancy, but it served its purpose. It was also prime territory for sales representatives from the various medical device and pharmaceutical companies. They typically had to be invited back to the lounge, but most of them, like me, knew the passcode to get into the room. It was here where I met my first crush.

Hello, handsome. You surgeons are getting younger-looking all the time, she said. What’s your name?

Jack, I said. Jack Hyland.

You must be the son of the famous Dr. Hyland. I can tell by your good looks, she said, shaking my hand. My name is Ashley Adams. So, would you like to learn about robots, Jack?

Careful Jack, Ashley is here on business, I heard Angie, one of the OR nurses, say as I stood there shaking Ashley’s hand. She has been waiting around all morning to catch your father.

"That’s only partially true Angie, I’ve been waiting around to talk with any of the surgeons. So, tell me Jack, do you plan on becoming a surgeon like your father?

I couldn’t take my eyes off Ashley. I must have looked quite smitten at the time. She was stunningly beautiful, and she made me feel like I was the center of the universe. I didn’t know what to say at first, and I certainly didn’t want to disappoint her.

Um, yes, I’m planning on becoming a surgeon, I blurted out after what seemed like an eternity.

That’s fantastic, Jack. If you ever want to learn anything about robotics and surgery, then you just ask me. By the way, is your father here with you?

Of course, he is, I thought. I just nodded yes and let Ashley lead the rest of the conversation. She sat down on one of the couches and motioned for me to sit next to her. As I did, she pulled out a laptop from her bag and opened it up.

Jack, you’ll be entering surgery at a fascinating time. Let me show you a glimpse of what can be your future.

Ashley could have been showing me pictures of garbage cans, and I still would have been mesmerized. Sitting next to someone so beautiful was like a dream. The smell of her perfume and the way she subtly touched my arm whenever she needed to point something out on the screen was just about more than this high school senior could take. It didn’t last long. The look on my old man’s face, as he entered the surgeon’s lounge, was priceless. He rolled his eyes and shook his head from side to side.

I have to admit Ashley, you are good, really good. It didn’t take you long before you got your talons on my boy.

Whatever do you mean Dr. Hyland? I’m here to educate the world about the benefits of robotic-assisted surgery, and Jack appears to be very interested in the future of surgery. You might be too if you would spend some time with me.

Oh, I can see he’s interested. I’m not so sure robotics is what has his attention. Come on, Jack. Time for you to go home and for me to get to the clinic.

Dr. Hyland you may be interested to hear, we just signed a contract with the hospital for a new robot. I can easily arrange for you to be trained.

Thanks, but no thanks, Ashley. That robot is for the Urologists and Gynecologists. I’m a General Surgeon and prefer the laparoscope for my cases. I still don’t see the value in the robot. The literature says the outcomes are no better, and it cost more. It might be helpful for certain cases, but not the type of cases I do. An experienced laparoscopic surgeon can still out operate any surgeon using a robot. There may come a day when that will change, but that day is not today or any in the foreseeable future. You may as well be trying to sell Dr. Ned Walker on it.

It’s funny you mentioned Dr. Walker, she said with a mischievous grin. I just received a text from a colleague at the meeting in Chicago. He said Dr. Walker is even considering signing up for robotic training. What do you think of that Dr. Hyland?

I think Ned must be drinking again, my father mumbled as he waved me toward the door. Have a nice day, Ashley.

And you as well Dr. Hyland. I’m sure we will be talking again very soon.

It took me a while to understand my father’s cautious approach to robotics. As Chief of the Medical Staff, he was consulted on the purchase of a robot by the administration. He listened to the debate on the pros and cons of robotics and, no doubt spent some time with Ashley. It took him a while to come around to accepting the idea of using a robot to operate. Not me, I was sold on robotics immediately. She had me at Hello handsome.

Little did I know, but that chance encounter in the surgeon’s lounge impacted the rest of my career and my life. I knew I wanted to be a doctor and specifically a surgeon. My idea of being a surgeon was to be one just like my father. That chance encounter was the first time I could recall any doubt in my plan. Sure, it was fueled by a teenage crush, but I didn’t care. I wanted to learn more about robotics and learn it from Ashley. Years later, I would be at a party or in a crowd at some event and smell a hint of her perfume, and it would take me back to this day. When people would ask me why I became interested in robotic-assisted surgery, I would spend hours describing my great interest in technology and all the good it can do for humanity. I would often describe it as my first love. It took me years to understand the connection.

Jack, when you get older, you’ll understand, my father said as we drove home.

Understand what Dad? I replied.

You’re probably wondering why your old man is not a big fan of robotics.

Are you not a big fan of robotics or are you just not a big fan of Ashley? I could tell you two don’t seem to get along very well. I said in her defense.

"We get along fine Jack. We just disagree. I’ve devoted my career to minimally invasive surgery. From my perspective, the robotic approach is another form of minimally invasive surgery, just like the laparoscopic approach. Right now, the evidence suggests that place is primarily in Urology. It’s proven its worth for taking out the prostate. I’ll go so far as to say there might even be some other areas where it is a preferred approach. There’s no evidence to say it is better for any of the types