Chapter Twenty-Four Julian
CHAPTER TWENTY-FOUR
JULIAN
By the time my last appointment of the day rolls around, I’m tired, and in the good way.
At first, I resented all these small-issue appointments.
Physicals, sore throats, checkups—they felt like a huge waste of my time and knowledge.
But that was when I was looking at them as one-offs, thirty minutes with a person I’d never see again.
That’s how it is in a big-city ER. Most patients are not repeat visitors, and while before, thirty minutes with me might mean saving someone’s life, thirty minutes here meant me getting increasingly frustrated as I try to give a highly mobile, highly vocal three-year-old her vaccinations.
But now, I see this position clearly. These people with their broken fingers and flu swabs aren’t one-offs—they’re long-term subjects with case histories full of questions.
By the third visit with Mrs. Binardo for a recurrent UTI, we finally figured out she was suffering from kidney stones that were caused by insufficiently treated diabetes, trapping her in a vicious cycle of UTIs.
When a young couple brought in their colicky six-month-old in the middle of the night for a horrifying bloody diaper, I didn’t stop researching until we worked out the culprit—cow’s milk protein intolerance passing through the mother’s breastmilk.
And when Charlie received the first bottle of his Epidiolex prescription CBD oil through the special savings program I got him into, complete with a legal prescription he can take to school?
I felt like I won the Nobel Prize.
So, this morning when I saw Mr. Gutierrez booked the last appointment with me today, pride at how far I’ve come as a doctor surged through me.
I’m grateful Mr. Gutierrez trusts me with his care, and moreover, I’m excited to be his doctor.
Ever since Nomi assigned all that reading on Parkinson’s disease, I’ve continued to seek out more information about the condition.
I’ve always enjoyed the study of medicine, but having a real person looking to me to help them navigate their tricky disease adds so much urgency and meaning to the endeavor.
I want to help, and I feel good knowing I can.
When Mr. Gutierrez arrives for his appointment, I knock briskly on the exam room’s door, then step inside.
“Mr. Gutierrez, good to see you,” I say, finding I truly mean it. I hold out my hand.
He looks at it, then his own where it’s pinned tense at his side, his teeth gritted. He exhales in a burst of frustration. “I’m sorry, Dr. D’Angelo. I’m having a bad movement day.”
My face softens as I take in the rigid lock of his shoulder, the contorted posture of his spine, and his shallow, rapid breathing. “When did the inability to move start?”
Mr. Gutierrez closes his eyes briefly. His brow is beaded with sweat, despite the icy air-conditioning of the clinic. “Three days ago, maybe?”
“Any other change in symptoms?” I’m already drawing up his chart in the system, scanning the vital signs taken today and comparing them against the last visit. Both heart rate and blood pressure significantly elevated. A loss of five pounds. A fever.
“I’ve had a bad stomach virus this week. It’s mostly passed.”
I bite my lower lip in. A virus could explain the change in vital signs, but Mr. Gutierrez suffers primarily from dyskinesia—erratic and involuntary movement. This akinesia, or inability to move, is new. “Any change in medications or strains?”
Mr. Gutierrez tries to shake his head, then curses. “Just over-the-counter medication for my stomach.”
I take the names and his guessed dosages, then run a search in the medical database for drug interactions, but nothing. On a hunch, I fill a small paper cup with water and hand it to Mr. Gutierrez’s left hand, which is still able to move, albeit roughly and with effort.
“Please, drink this.” I watch closely as he brings the cup to his mouth, then struggles to swallow the sip of water, choking and spluttering. I stand up immediately, taking the water and patting his back until the coughing subsides.
Difficulty swallowing.
“Mr. Gutierrez, I believe you’re at the beginning of an akinetic crisis, likely brought on by failure to absorb your levodopa due to the ongoing diarrhea you’re experiencing. You need to go to the hospital right now.”
“The hospital?” Mr. Gutierrez cries. “Which hospital?”
“Your neurology team is out of Philly Gen, right?”
“Yes, but how am I supposed to get to Philadelphia?” Mr. Gutierrez tries to shake his head again and groans in frustration. “I had to call a car to get here!”
I buzz Khalil at the front desk for a wheelchair, then help him up to standing when it arrives.
“I’m taking you.” I wheel him in a quick jog toward the door. “I’m your doctor, after all.”
I send Nomi a flurry of texts since she’s Mr. Gutierrez’s emergency contact, but I can’t wait for a response before getting him to the hospital.
I just hope she reads them. I’ve been trying to give her the space she needs, but every day she’s felt more distant.
I keep telling myself that once we win the hearing, we’ll pick up where we left off, but can we?
Or is she making Wildwood a casual, one-off thing, after all?
The thought feels like a screwdriver grinding into my sternum, taking me apart.
The drive to Philly Gen passes in a blur of brake lights, toll plazas, and insane New Jersey drivers, seriously, what is wrong with my people?
As we cross the Ben Franklin bridge into Philadelphia, a sea of high-rises greets us.
Crossing this bridge used to feel like an escape hatch out of being a D’Angelo and the baggage that name holds in Sparrow Nook, the city’s skyline filling me with visceral relief.
But now, it’s just a skyline. A perspective that no longer fits. And as I glance at Mr. Gutierrez’s rigid body laid out in the front seat of my car, it’s a means to getting my patient the help he needs, urgently.
We roll up to the hospital’s valet, and I leap from the car, calling for a wheelchair as I throw my keys to the attendant. I push Mr. Gutierrez through the patient entrance to the ER. It’s chilling, being on this side of the equation.
I charge through the reception area, ready to use him like a wheel-bound battering ram to get to the back.
“Excuse me, sir? SIR.” The reception desk attendant stands and yells through the hole in the glass safety partition.
Shit. Cynthia. ER physicians have a somewhat fraught relationship with administrative staff, and for good reason. They think we’re dramatic entitled shitheads, and… well. We are.
Mr. Gutierrez whimpers as I abruptly freeze, then wheel him toward the desk. I take a deep breath as I approach, my left wrist tingling ominously like a dickhead portent.
Lower your fists, Julian, Nomi’s voice reminds me, the proverbial angel sitting on my shoulder. You don’t need to come out swinging.
“Dr. D’Angelo?” Cynthia’s stern voice turns baffled as I smile through the window. “What’re you doing here?”
“Hey, Cynthia.” I smile at the second attendant, too. “Hey, Dashonda. Listen, I need your help getting this patient admitted to the Neuro ICU immediately, skipping straight past the ER wait. What can you do for us?”
“Why are you wheeling random old people up to my desk, asking for things you know I can’t do?” Cynthia folds her arms. “We have a protocol, Dr. D’Angelo.”
I breathe deeply. “I wouldn’t ask you to break protocol unless I was certain that’s what this patient needs. And he needs help right now, Cynthia. He cannot afford to wait.”
Cynthia eyes me doubtfully.
“I’ll take whatever heat comes for breaking protocol, I swear. And don’t tell me you can’t get around the rules. You know this place inside and out.”
It’s true, I’m not saying this to suck up to her. Cynthia’s been here for twenty years and runs this whole floor.
Her eyebrows lift. “Something’s happened to you.” She gestures at the entirety of me with one finger. “This is weird.”
“Please, Cynthia? I won’t ask for anything else, ever again. And—and I’ll make you a coffee and bring it to you after I get him settled.” I clasp my hands together. “Heavy cream, light on the sugar, right? You want one, too, Dashonda?”
Dashonda looks alarmed. “Um, yes?”
Cynthia presses her eyes closed and sighs. “Fine, but if Dr. Riveras comes at me for this, I’m sending her your way.”
“Thank you, Cynthia!” I call out over my shoulder as she presses the button, and the doors to the back open.
“And no Splenda!” Cynthia yells after me. “Cane sugar, you hear me?”
After I get Mr. Gutierrez buzzed into the Neuro ICU and snatch my favorite neurologist for him, I head to the breakroom to fulfill my coffee promises. I brew a fresh pot, get them fixed up just right, and am about to head back to the reception area when a throat clears behind me.
“Dr. D’Angelo. What the hell are you doing here?”
I wince, then spin slowly, holding the coffees. “Dr. Riveras… great to see you.”
Her eyebrow’s arched as she blocks the way out.
I sigh. “Listen, I’ll explain, but can you walk with me while I do?
I need to deliver these before they get cold.
” Dr. Riveras’s frown deepens, but hot coffee is sacred at Philly Gen, so grudgingly, she follows me to reception while I tell her everything: Mr. Gutierrez’s ongoing issues, the akinesia, my suspicions for diagnosis, and because Cynthia’s already giving big narc energy as we approach, how I convinced the staff into letting me bypass the ER straight for the Neuro ICU.
Dr. Riveras grunts as I pass Cynthia’s and Dashonda’s coffees over the partition. “This is all very…”
I brace myself for the worst. Out of line. Irresponsible. Entitled.
“… weird.”
“Right?” Dashonda takes a big sip of her coffee and mmms to herself.
Dr. Riveras folds her arms. “It’s frankly bewildering to see you taking your primary care position so seriously, Julian. I must admit, I didn’t expect you to rise to the occasion.”