“James! Thanks for coming.” The ENT resident motioned to the bearded man in the examination chair. “This gentleman comes to us with a one-month history of a rapidly growing mass in his left neck. Night sweats and low-grade fevers, no recent travel history.”

“Got it.” James nodded as he prepared his aspiration setup. “I will take a sample for cultures, including tuberculosis.”

It was October, his fourth month of residency. James was on the cytopathology service. The pathologists were called by various departments in the hospital to perform a fine needle aspiration (FNA). Today, the call came from the ENT clinic for an FNA of a neck mass. James was flying solo, with no senior resident overseeing his performance. As the ENT resident emerged from behind the drawn curtain of the examination room, James positioned a small cart carrying a microscope, slides, and bottles of stains.

The patient reclined in the examination chair which resembled a dentist’s chair. His grey beard was scruffy and unevenly trimmed. His face was long and furrowed, with deeply ingrained wrinkles encircling his eyes, nose, and mouth. His receding hairline accentuated the length of his face.

“Hello Mr. Krause…” James simultaneously looked at the patient and his chart which he held. “I am Dr. Deetan from pathology. Did Dr. Samuelson explain to you what we are going to do today?” The patient stared at James, carefully following his every move. No response. “Well then, today, we will be doing a fine needle aspiration biopsy. I will be placing a small needle into the lump that you have in your neck, remove some cells, and smear them on these slides. I will stain the slides and look under the microscope to make sure we have enough material to make a diagnosis. I will also be taking a small amount for cultures to see if you have an infection. I understand you have been sweating at night and have some fevers?”

The stare answered. “Ok…I need to tell you about some of the risks. There is a small chance of bleeding but we use a needle that is smaller than the one we use to draw your blood. Also, there is a small chance of infection but we perform the aspiration with a sterile technique, minimizing the risk. Do you have any questions?” Another stare. “Ok…I will take that as a no.” James grabbed the consent form and placed it on the clipboard, positioning it in front of the patient. “Mr. Krause, I need you to sign and date this consent form authorizing me to perform this procedure and that all the risks and benefits have been explained to you.” No movement. James was losing patience. “Mr Krause…”

“What kind of name is that? Japanese?”

Startled by his voice, James blurted, “It’s Chinese.”

“You don’t look Chinese.”

“Well, I am. Could you please sign this consent?”

Signing the consent, he momentarily removed his stare. “I was at Pearl Harbor when the Japs attacked. I could see the pilots in their cockpits. You don’t look Chinese.”

“I assure you sir, I am Chinese. My family is from the Philippines and we fought alongside the Filipinos against the Japanese.”

“I was in Saipan and had to fight them bastards face to face,” the patient continued, ignoring James’ efforts to defuse the patient’s diatribe.

“I need to examine you. Please lean your head back…it’s on the left side, correct?”

“You don’t look Chinese…”

“Yes, we’ve established that fact. I’m going to be gently pressing your neck, tell me if any of this hurts.” James palpated the firm nodule below the skin just below the angle of the left jaw. “Feels like a lymph node. Let me clean the area up with some alcohol and we will be ready to go.” A few wipes of the alcohol pad, a drape of a surgical cloth on the patient’s shoulders, and James was ready to enter the nodule with his needle. The needle and syringe were held in a device that allowed the plunger of the syringe to be withdrawn while holding the needle in place. As James inserted the needle into the soft tissue of the neck, the syringe was pulled back creating a negative pressure, sucking the cells into the needle hub. After a few movements of re-positioning the needle within the tumor, the negative pressure was released, and the needle was retracted.

James quickly removed the syringe and needle and carefully positioned the needle over a clean slide. With a gentle motion, he forced air into the needle which produced a small drop of blood onto the slide. Picking up another slide and placing it on the blood drop, he smeared the two slides together, placing one in an alcohol fixative and the other left to dry in the air, to be stained by a rapid Diff-Quik stain. So intent on performing his task, James failed to notice the growing anger of the patient. “Don’t you stick that in me again!” He yelled. “You didn’t tell me you were going to stab me!”

“Sir, I explained the procedure to you. I didn’t stab you; I used a very small needle to take a sample of the tumor for my tests.”

“HE’S STABBING ME!”

The ENT resident bolted over from the next room. “Mr. Krause, everything is okay.” He quickly grabbed the patient’s hand and motioned to several orderlies.

“HE’S NOT CHINESE!”

“James, are you finished?”

James shook his head as he reviewed the Diff-Quik stained slide. “It looks like a reactive lymph node, probably infectious. I need to stick him one more time to get cultures.”

The ENT resident intervened. “All right, let me help you. Mr. Krause, we need to do this one more time. We are not stabbing you, it is just a simple blood test. No one is going to hurt you, understand?”

“I don’t trust him. I don’t trust JAPS!”

“Mr. Krause, please hold still, this will only take a few seconds.”

In his haste to prepare the new needle and syringe, James forgot to remove the safety cap on the needle. Positioning himself close to the patient, Mr. Krause lunged forward causing James to push the syringe forward. The positive pressure in the syringe forced the needle to shoot off the syringe, propelling it like a missile past the patient’s face, and implanting it into the cork bulletin board next to him. The orderlies and the ENT resident stared at the embedded needle and then at James.

“Oops.”

“WHAT THE HELL ARE YOU DOING?”

“Mr. Krause…settle down. Let me take a quick blood test to make sure you don’t have an infection.”

“WHAT THE HELL ARE YOU DOING?”

The ENT resident motioned to James to confer behind the curtain. “Bad needle day, huh? Look, let’s let things cool down a few minutes then I’ll stick him for the cultures. You obviously remind him of some nasty war experience.”

James nodded his head. Anything to get out of there. After a few minutes, a muffled laugh emerged from behind the curtains, and within a few minutes, the resident produced a syringe with the tell-tale drops of blood. “Got it, you can use this for the cultures.”

“Thanks.”

“You know, funny thing, the guy’s wife is Chinese. So I guess he really did know what a Chinese person looked like.”

James rolled his eyes. Gathering the microscope and slides, James drew the curtain aside and peered in.

“GET OUT OF HERE!”

Just another day in St. Louis. James trundled back to cytology where Franklin was preparing the specimen receiving area for the next case.

“Dr. Deetan, let me help you.”

“Thanks, Franklin.”

Franklin paused before he reached for the flat of stained slides. “I know that look, seen it lots of times. Doesn’t matter if I’m in Boston or St. Louis. Feeling overwhelmed?”

“Bad needle day.” James repeated the ENT resident’s sardonic comment.

“Have you figured it out yet?”

“What do you mean?”

“Every new place, it takes time to figure everything out. Who are the decision-makers? Which egos to stroke?” Franklin paused. “And there is always the scheming. The things I’ve seen. One time there was this resident who missed a diagnosis on a frozen section and…”

James shook his head, interrupting Franklin. “I know. Back home, I always felt like I was in control. Here, it’s one step forward and two steps backward. Everything I do, is never good enough, especially for Dr. Haas.”

“Yes. Dr. Haas. She will take some time. It took me a year before she made small talk with me. I had to be patient. Lots of smart people here. That’s what happens as you keep advancing in your training. Your circle becomes smaller and more competitive. More intense. You are working with the cream of the crop.” Franklin looked over James from head to toe. “You may not be able to be the smartest but you can make it seem that way. You set up intellectual barriers to entry. You find your niche. That’s what I did. No one does autopsies as well as me. No one cuts a frozen section as quickly as I do.”

James nodded. “You are good at what you do, Franklin.”

“Thanks. I’ve worked hard to get here. I’ve seen many residents come and go. The ones that succeed are the ones that look around, find a need, and fulfill it.”

“Like what? How do they do that?”

“Take Dr. Berkowitz. She’s so good at languages—Portuguese, Spanish, French. I think she even speaks some Chinese. When she was a first-year resident, she recognized the need for the hospital staff to have a quick reference guide to explain pathology results to their patients in their respective languages. So that’s what she did.” James had used these guides, conveniently placed at nurse’s stations. Deanna. James didn’t think he could be even more impressed with her.

Franklin watched him drift. “Yeah, she’s special, isn’t she? But watch your step, Doc. Special can be dangerous too.”

James forced a laugh, but when Franklin left, his thoughts lingered. Deanna inspired him to rise above Haas’ criticism. Wilma, meanwhile, was a different challenge: her eyes, her playful brush of his hand, haunted him even here, in the fluorescent-lit cytology suite. One grounded him, the other tested him.

“I’ve seen you work. You can do this, Dr. Deetan. You have that drive, something I see in everyone who succeeds.” Franklin sighed. “Just be careful, watch your back. Someone is always sacrificed in this department.”

“I will.” It was the second time he heard this warning. “Thanks for helping me out.”

Next Chapter: Chapter 15-Face Of The Enemy