Chapter 6: Johanna Rajah, M.D.
"Gowns and gloves are stocked up over here" Teddy said pointing to the bins attached to the wall holding yellow gowns and boxes of different sized gloves. Teddy handed her a gown and a pair of medium gloves. She took them and followed her as she headed towards the double sliding emergency room doors to the ambulance bay. A couple of people were already outside, putting on their gowns and gloves. "And we wait here for the ambulances" she said stating the obvious. Joey secured her gown and snapped on her gloves. "This is Dr. Schmidt and Dr. Helm" she said pointing to them respectively, "two of our fourth year surgical residents. Schmidt, Helm meet Dr. Rajah, our new trauma surgery attending".
"Hi" Helm said enthusiastically.
"Hi" Schmidt said with a timid wave. "Nice to meet you". The sliding doors opened behind them and another doctor came out to meet the ambulances with them.
"Dr. Rajah, this is Dr. Casey Parker" Owen said making another of many introductions she'd have to go through today. "Parker is our front runner for chief resident. Parker, this is Dr. Johanna Rajah. She's our new trauma surgery attending. It's her first day so make sure all the residents meet her and make her feel welcome".
"Ma'am" he said respectfully. "Nice to meet you" he said with a nod and a smile.
"Nice to meet you too".
"Parker is prior service as well. Air Force" Owen said.
"I guess it doesn't wear off" she said referring to his courteousness.
"Not for some of us anyway". Two ambulances came pulling in, lights and sirens going. Owen and Teddy stepped forward.
"Helm, you're with me" Altman said heading for the first ambulance.
"Schmidt with me" Hunt said heading for the second. "You take the next one" he said pointing to Joey. She nodded.
"So, where you coming from ma'am?" Parker asked as they waited for the next ambulance. They moved off to the side as Teddy and Owen came by with their residents and the EMTs, wheeling their patients inside.
"Uh, Germany" she said simply.
"Germany, wow" he said. "Didn't pick up the accent?" he joked.
"Oh, no" she said with a laugh. "I'm not susceptible, I guess".
"Did you work with Dr. Altman?"
"No, I didn't".
"Ah. I thought maybe with her having worked over there…" he explained. "Anyway, welcome to Grey Sloan".
"Thanks" she said as the next ambulance came pulling in. "I guess you're with me" she said slightly asking. He looked around.
"I guess so". They met the ambulance as it came to a stop. The doors opened and EMTs emerged and immediately started shouting out the stats as they unloaded the patient. They spoke louder as two more ambulances pulled in with the sirens going. More doctors came out to meet them and receive the new patients as they headed inside. They passed the first and second trauma rooms which were already occupied by Altman and Hunt. "Trauma three is over there" Parker pointed. She nodded and directed their patient's gurney that way.
"Ok. Transfer on three". She gave the count and they transferred the patient from the ambulance gurney to one of their own. The EMTs took their gear and cleared out. "Let's get him on the monitor and get some fresh vitals, please". They got to work getting his clothes off and hooking him up to the monitors. She could see now from introductions and what different people were doing in the trauma room what the scrub colors meant. Light blue was for surgical residents. Dark blue for attendings. Nurses wore green. "I need a standard trauma panel, type and cross, and hang a liter LR" she said ordering her labs. She noticed the bruising across his chest resulting from the slab of ceiling that fell on him during the collapse. "Let's get a portable chest as well, please" she added. "Hi, Alan" she said remembering his name from the paramedics. "I'm Dr. Rajah" she said with a caring smile, "I know you're in some pain but I want you to just try and relax, ok? We're gonna take good care of you" she said giving his shoulder a soothing rub. He gave a nod and closed his eyes, taking deep breaths of oxygen being pumped into his mouth and nose by the mask on his face. "How are we doing with those vitals?" she asked, looking for an update as she listened to his heart and lungs. He had good breath sounds but she detected a slight murmur. Joey removed the buds of her stethoscope from her ears and hung it around her neck.
"B/P is holding at one hundred and two over seventy-eight. Heart rate's at one fifteen. Pulse ox is ninety two" the nurse announced as she changed the bag on his IV.
"Alan, have you ever been told that you have a heart murmur?" she asked looking down at him. He shook his head no. She deduced that he probably sustained a contusion from the trauma. Something to keep an eye on. In addition to the obvious bruising and lacerations to his chest, he had a wound on his head that had soaked through the dressings the paramedics had applied. She lifted it to reveal the gash underneath. She examined the cut "Can I get some fresh dressings for this head lac, please?" she asked the nurse as she continued with her physical examination. Then she stopped. "Dr. Parker" she said getting his attention. "This is a teaching hospital right?"
"Yes, it is" he said with a nod.
"So why don't you take over the physical exam. Talk me through your findings, make your diagnosis and tell me your treatment plan" she said taking her hands off the patient.
"Uh, okay". He took over where she let off with his head lac. "Head lac is pretty deep. It'll need suturing" he said examining the gash. "No step off" he said palpating the area around the injury with his fingers. He took out his pen light and looked in the patient's eyes, "pupils are round" he said flashing the light in his eyes, "equal and reactive. I think he should get a full neuro exam just to be safe" he said confidently. He turned to the nurse and asked for a page to the neurosurgeon on call. The technician came in with the portable x-ray machine. Drs. Rajah and Parker put on aprons and the others stepped out while the films were taken. The technician cleared out and the other staff filed back in to continue caring for their patient. Parker moved on to an abdominal exam and noted that there was guarding and rebound which indicated some internal injuries and possible need for exploratory surgery.
"You're doing fine but you're missing something" she said. "You're taking care of a conscious patient" she reminded him. "Talk to him".
"Oh, right. Of course" he said with a nervous laugh. He wasn't usually like this but being evaluated by a new attending was making him uneasy. It definitely didn't help that he found her incredibly attractive. The last thing he wanted to do was embarrass himself in front a beautiful and obviously very capable new attending. "How are you doing Mr. Houser?" he asked addressing the patient for the first time. "Can you tell me where you're having any pain or discomfort?" Alan reached up and pulled the mask down from his face.
"Chest hurts. It's get… getting harder…. to breath" he informed him.
"Ok, let's take another listen here" he said as he took his stethoscope from around his neck to continue his exam. Joey kept her eyes on the monitor, watching Alan's vitals as he did his exam. They were just starting to trend down but were not yet alarming. She was reserving action to continue assessing what her resident was capable of. The door to the exam room slid open and a short brunette woman in dark blue scrubs entered.
"Neuro's here" she announced energetically. "Parker, what have we got?"
"Uh, Alan Houser, ceiling collapse victim. Deep head lac. No step off. Pupils were equal and reactive on exam but I thought he needed a full neuro exam just to be safe".
"Your patient is taking a turn Dr. Parker. Talk and work at the same time please", Joey said bringing him back from his update. "And faster. Let's try to stay ahead of his vitals, okay" she said in hushed voice. "Hang in there Alan" she said louder, calming the patient. Amelia proceeded with her neuro check and Parker got back to his exam.
"Short respirations" he said listening to his lungs. He moved the diaphragm over his chest to listen to his heart, "and muffled heart sounds".
"So, what are you gonna do?"
"Can I get the portable ultrasound please?" he asked looking to the nurse. He nodded and moved to get it for him. He pushed the ultrasound over, retrieved the wand and handed it to him. Parker turned it on as the nurse put a small amount of ultrasound gel on Alan's chest, then placed the probe on his chest and moved it around to obtain a good visual of his injuries.
"Neuro exam seems clear but I wanna scan him" Amelia said as she stepped away from the patient. "His pupils are getting a little sluggish and I can't be sure that it's not from his head injury. Can you add it to his orders, Dr?" she said leaving it open for an answer.
"Oh Rajah" she answered realizing she was talking to her. "Johanna Rajah, new trauma surgeon. Nice to meet you".
"Amelia Sheppard, neuro. Nice to meet you too" she said nicely. "So, you'll add the head CT to his orders?"
"Yeah, you got it" she said with a nod. Amelia nodded and gave an appreciative smile as she made her exit. "Ok, Parker tell me what you see" she said looking at the monitor from her side of the bed.
"There's fluid in the pericardium" he said studying the scan.
"Diagnosis?"
"Pericardial effusion" he said confidently. "Should we page cardio?" he asked looking to his attending.
"Should we?" she asked with a shrug.
"It's, uh, it's kinda protocol for a patient presenting with cardiac symptoms".
"Ok. Let's page cardio. What's next?"
"Pericardiocentesis to evacuate the fluid and relieve pressure on the heart".
"No" she said simply.
"Uh… it's not?" he asked confused.
"Your patient's still conscious. Next you explain to him what's happening". She could tell he was well trained but it seemed his nerves were getting in the way.
"Mr. Houser, the trauma from the slab falling on your chest has caused some fluid to build up in the sac around your heart. It's what's causing your chest pain and shortness of breath" he explained as Joey lowered the head of his bed. "I'm going to use a needle to extract the fluid and allow your heart to beat properly".
"I don't want you to worry, Alan" she said seeing the look of worry on his face at the thought of having a needle put into his heart. "You're in excellent hands" she reassured him.
"Do you have any drug allergies that you know of?" Parker asked. He shook his head no. "Ok". He ordered lidocaine and asked for an eighteen-gauge needle. "You're just gonna feel a little pinch and some burning with the local now" he said as he administered the local anesthetic. Joey adjusted the ultrasound monitor and positioned the wand on his chest for him to see. He inserted the needle and began to withdraw the fluid. He only got a small amount of fluid in the syringe before he couldn't withdraw anymore. She moved the wand to get a view from another angle and saw that he now had collapse of the right ventricle and a clot had formed.
"Dammit" she said under her breath. "He's tamponading". She told him to withdraw the needle. They'd have to use a different approach. She asked about their cardio consult that hadn't arrived yet. They paged again just as their patient lost consciousness.
"B/P is bottoming out, heart rate's up to one twenty-seven. Pulse ox down to eighty four on one hundred percent O2" the nurse announced as his vitals began to nosedive.
"Ok. Intubation tray, fifty of etomidate, one hundred of succinylcholine and set up for subxiphoid pericardial window please" she said deciding to take over. His blood pressure was now dangerously low and she wanted to make every effort to prevent cardiac arrest. "Hang a unit of O neg and another liter of LR. I'm assuming you know how to intubate" she said looking to Parker. He nodded and moved quickly around to the head of the bed to place the tube.
"I'm in" he said announcing the placement of the tube. The nurse attached the ambu bag and began ventilation. He returned to the side of the bed and listened to his chest to check proper placement of the tube then watched as she did the pericardial window. She performed the procedure with grace and ease, as if she had done it countless times before. Muscle memory. Blood rushed out of the open incision she made in the pericardium, causing only a slight improvement in his blood pressure. "Systolic is up to fifty-seven" Parker informed her. "Holding there". She couldn't get to the clot through the incision she'd made. She asked Parker for more retraction on the clamp, giving her more room to maneuver. Still, she couldn't get to the clot. She had wanted to avoid opening his chest but she had no choice now.
"Dammit" she said making one last effort. "I can't get to the clot. I'm gonna have to open his chest. Thoracotomy tray, please". They cleared out one tray and replaced it with another. Parker smiled slightly. He noticed how she always managed to say please. He couldn't think of another doctor who took the time for that courtesy. She made her incision and opened his chest to get better exposure and visualization to evacuate the clot. Just as she finished opening his chest, his heart arrested. "Starting cardiac massage" she said as she gently but firmly squeezed his heart, attempting to restore its rhythm. The trauma room doors opened and Maggie entered.
"I've got your portable chest scans" she said looking down at the tablet in her hands. "They look clear. No aortic injuries". She looked up to see an unfamiliar doctor doing cardiac massage. "What the…" she rushed over. "What are you doing?" she asked as if it weren't obvious. "Who are you?" She ignored the new incredibly rude and unhelpful doctor who'd just entered the room and focused on her patient. She continued massaging his heart until, a few seconds later, it restarted.
"We've got a heartbeat" Parker confirmed upon seeing a rhythm on the monitor. Joey widened her incision on the pericardium so she could visualize and remove the clot. Maggie was still trying to figure out who she was.
"Excuse me, I can take over from here" she said trying to insert herself.
"I've got it, thanks" Joey said without looking at her.
"Who are you?" Maggie asked again, still not understanding where this person came from. She wasn't wearing any scrubs and she had never seen her before. "Who gave you privileges here?" She continued to ignore her and successfully removed the clot. Without any further blockage, she could see his heart starting to beat stronger through the window in his pericardium.
"Blood pressure's up, one thirty-two over ninety. Normal sinus rhythm" the nurse announced with some delight in her voice.
"Nice job, Dr. Rajah" Parker said impressed.
"Thank you" said as she stepped back and removed her gloves and gown. "Can we get some adhesive drapes on his chest, please?" she politely asked to the nurse next to her. "Dr. Parker, can you get him up to CT?" she asked.
"Head and abdomen?" She nodded. "I'm on it". Once his chest was covered with the adhesive dressing, they wheeled Mr. Houser out of the trauma room and up to get his pre-op scans. Without acknowledging Maggie, Joey followed them back out into the ER. She looked around to see if her help was needed anywhere else. It seemed everyone had their patients under control. She made her way back over to the admitting desk. She grabbed her shirt and pulled it back on then grabbed her bag, shoved her jacket inside and put it on her shoulder.
"Hi". She turned around to see a very pretty red head in dark blue scrubs standing there with a smile. "I'm April Kepner" she said gesturing to herself. "And you must be Dr. Rajah".
"Yeah, that's me" she said with a soft smile.
"Teddy, uh, Dr. Altman had to take her patient straight up to the OR so she wanted me to give you the tour". One thing Joey was noticing was that this hospital had quite a few upbeat and enthusiastic doctors. "It's settling down in here so I thought we could do that now before we get another wave" she suggested. "If you have time" she added.
"Umm…. I just sent my patient up to CT so…"
"Oh perfect" she exclaimed. "I'll show you all the important places, like the lab and the cafeteria…" she thought for a moment, "forget the cafeteria" she said waving off the idea. "We don't have to go by there but it's on two if you get hungry. Also the auditorium where we have lectures is on two. The lectures are always posted so you can decide in advance which you wanna go to". She started walking. Joey followed. They came to a stop in front of the elevators and April pushed the up button. "The lab and radiology on this floor are down this hall and around the corner. There's two more of each in the hospital on three and five. The outpatient surgery clinic is on three. The attendings take turns being assigned there. We can just swing by for now. Then we can go up to the fourth floor nurses station, that's where the OR board is and it's usually where we gather for big surgical staff meetings and announcements. Then we can swing by the media room and the skills lab. There's quite a few throughout the hospital but you'll probably use the rooms on four the most" she said pushing the button impatiently. The elevator dinged and the doors finally opened. They let people exit before they entered for their ride up to the third floor. "Oh, I'll show you the dispensary too so you can get some scrubs" she said noticing she was still in her street clothes. "Then I'll show you the attending's lounge. You can change in there and put your bag away. From there we can swing by CT and check on your patient's scans and get you to the OR with plenty of time to scrub in for your surgery".
"Sounds good" she said with a polite smile.
"So, Teddy says you're in the Army".
"Yeah" she nodded. "Reserves".
"I spent some time in Jordan volunteering with an awesome group of soldiers" she said happily. "It was amazing work. Have you ever been?" she asked. "To Jordan?"
"Uh, no" she shook her head. They exited the elevator on their floor. She followed April's lead through the halls.
"There's the lab" she pointed. There was a long line of people in different colored scrubs waiting to get their results. "I'm sure you've noticed the different colored scrubs everyone wears".
"Yeah, I noticed. Surgery is blue, right? And nursing is green". April nodded.
"Yep. ER wears brown, OB wears pink, psychiatry wears orange and I think dermatology is light purple" she said with a chuckle. "I always wonder who decided the colors" she said as they kept walking through the halls. "Thank god we got blue, right?"
"Right" she said slightly distracted by trying to notice and remember the rooms she was passing by.
"Right. Ok" April said with a sigh. Joey was definitely not as upbeat as she was. It made for a very awkward dynamic. They stopped in the outpatient surgery clinic for a minute where she introduced her to Dr. DeLuca who was assigned to cover the clinic that day. From there they went to another elevator and April, again, pushed the up arrow. "So, how'd you chose Seattle?" she asked trying to make conversation.
"Um, I had a few options for my next post and this is closest to my parents and my sister" she explained. "They're in California".
"Oh, that's nice" she said genuinely. "So, did you work with Teddy when you were in Germany?" The elevator arrived and they got on.
"No" she said simply. "I- I'd heard of her, of course, being a woman and chief of MEDCOM but I'd never met her personally. I was stationed at Landstuhl". The elevator stopped and the doors opened for them to exit, this time on the fourth floor. April took her by the dispensary for a pair of scrubs, as promised, then showed her to the OR board. They found out she'd be in OR four for her patient's exploratory laparotomy. Parker found them there. Their patient was done in CT and up in pre-op being prepped for surgery.
"Oh, where can I review his scans" she asked.
"Oh, here" he said handing her his tablet. She hesitantly took it from him.
"We get tablets?" she asked intrigued.
"Well, we don't get our own personal tablets. We share" April said with a shrug. "But yeah. There are charging ports at all of the nurse's stations. You can just take one and use your code to access patient files and scans" she explained as Joey looked over the scans. "We'll also have to get you a pager so people can find you" she said showing her the pager around her neck. She noticed Parker had one as well. "We can do that later though, when you're done with surgery".
"Ok. Dr. Sheppard cleared his head CT?" she asked Parker, handing his tablet back to him. He nodded.
"Yes ma'am, we're good to go".
"Ok. I'll see you up there". He started to walk off towards the elevator. "Oh and Parker" she called after him. He stopped and turned to see what she wanted. "You don't have to call me ma'am". He nodded.
"Habit" he sighed. She gave an understanding nod as he turned to continue on his way. They started to walk to the lounge but they were stopped again.
"Dr. Rajah" they heard from behind them. They both turned to see Dr. Bailey approaching them. "I was hoping to catch you".
"Chief Bailey" she greeted her politely.
"Kepner" Bailey said acknowledging April.
"Chief".
"So, first day. How's it going so far?"
"Good. Really good" she said happily. "I'm actually gonna be scrubbing in on my first surgery in a bit so…"
"Oh, hitting the ground running" Bailey said pleased with her initiative. "I heard about the ceiling collapse. You got one of the victims?" Joey nodded. "Good. Go. Save lives. Don't screw up".
"Yes ma'am". Joey and April turned to go on their way again.
"You called her ma'am" April pointed out.
"Habit" Joey said repeating Parker's excuse. Finally, they made it to the attending's lounge.
"Hey, guys" April said as she entered the lounge. "This is Dr. Johanna Rajah" she said pointing to the doctor trailing behind her. "She's our new trauma surgery attending and it's her first day".
"Yeah, we've met" Amelia said as she reached into her bag of chips. "Hi again" she said before pushing two chips in her mouth.
"Hi" Joey said with a smile.
"This is Meredith Grey and Alex Karev, our chiefs of general and pediatric surgery" she said pointing to each of them. They exchanged hellos. "And Jackson Avery, chief of plastics and ENT".
"Hey, nice to meet you" he said politely.
"Nice to meet you too".
"Uh, you can put your bag in that closet and the bathroom is right over there" April said pointing things out for her. "When you're ready I can show you up to OR four".
"Ok, thanks". She went over and set her bag down on the floor and pulled out her tennis shoes before shoving the bag onto the closet floor and going into the bathroom to change.
"You were assigned to the new doc, huh?" Jackson asked as he took a seat on the couch.
"Yeah, Teddy's in surgery so she wanted me to show her around" she said with a shrug. "She seems great so far. She jumped right in to help with the ceiling collapse victims. She's scrubbing in on her first surgery in a few minutes".
"Yeah, I cleared her guy's head CT" Amelia said over a mouthful of chips. "Maggie doesn't like her though". Alex scoffed.
"Already?"
"What? Why?" April asked in disbelief. "She seems really nice".
"They had some kind of clash in the trauma room" she said with a shrug. She started to laugh, "Maggie was fuming. You know how she is when she gets going".
"Doctors clash over trauma patients all the time" Alex said. "She'll get over it". Joey emerged from the bathroom in her new scrubs. She put her clothes and shoes in her bag then returned it to the closet.
"Ok. I'm ready" she said walking over to April. "Except" she felt her hair, "I don't have a hair tie".
"Oh, here" April said offering her the one on her wrist. "You can use this one".
"Are you sure?"
"Yeah, I have extra".
"April was a girl scout" Meredith joked. Everyone laughed.
"Ok, since when is being prepared an insult" she asked defensively.
"I don't think it is" Joey said graciously accepting the hair tie.
"Thank you" April said appreciatively.
"You don't have to suck up to her" Alex said while reading over his patient's charts. "She doesn't have any juice". They all laughed. Just then Maggie walked into the lounge.
"What's so funny?" she asked interestedly. Joey turned and saw the doctor who'd made a rude entrance to the trauma room earlier.
"Oh nothing" April said as the laughter died down. "Alex is just making fun of me, as usual".
"You make it so easy" he quipped.
"Ok, I'll take you up now" April said, hoping to make a quick exit to avoid any conflict now that Maggie was present.
"Oh, I'll tag along" Maggie said inviting herself. "We weren't properly introduced earlier" she said addressing Joey directly. "I'm Maggie Pierce, head of cardiothoracic surgery".
"Hi" Joey said simply. She pulled her hair back and put it into the bun with ease.
"I'll be placing the drain for the pericardial window you did this morning" she said with some disdain in her voice.
"Great" Joey said with a hint of sarcasm.
"Just for future reference, you really should let us cardio surgeons handle the cardio surgery. I mean, my patient now needs…."
"Mine" Joey said interrupting her. "He's my patient" she corrected. Everyone perked up at her correction. Alex looked up from his charts to tune in. "And I handled the cardio surgery just fine". Jackson shifted his position on the couch, as if to brace himself for whatever was about to transpire between the two doctors. "I didn't really need your help" she said honestly.
"Then why'd you page for a cardio consult?"
"Oh, I was told that it's protocol here" she shrugged.
"Well, you opened his chest which really wasn't necessary" Maggie said annoyed.
"How would know what was necessary?" Joey asked. "You weren't even there".
"Well, if you had waited for me I would've been there".
"I did paged you twice. You didn't show. If I'd have waited the patient would be dead" she said unapologetically.
"I'm just saying, I walked into the trauma room and saw you doing cardiac massage on a patient I'd been called to consult on" she said with tensed shoulders. "I'm the cardio surgeon and if something had gone wrong it's on me. I don't know you and…."
"I don't know you either" Joey said interrupting her again. Amelia's eyes widened and Meredith shifted in her chair. They didn't know whether to take offense to her tone with their sister or be impressed with how she was standing her ground despite being new here. "And he was my patient so anything that would've gone wrong would've been on me" she said correcting her on another point. "And I resent your assumption that I'm incompetent just because you don't know me".
"You're new here. Just…. some respect for the doctors who work here, particularly for the doctor whose job you were doing, would be nice" she said condescendingly.
"Is that what you had for me? Respect?" she asked rhetorically. "You walked into that trauma room, assumed I didn't belong there and then tried to insert yourself between me and my patient while I was working to save his life" she said recounting the events, making it very clear who was lacking respect. "I didn't do any procedure that wasn't necessary. I did my job. I took care of my patient. And I would have been perfectly happy to leave the cardio surgery to the cardio surgeon had you been there". She was cordial with everyone and always respectful to those who respected her but she wasn't going to be walked over just because she was the new guy. "But you're right about one thing, we weren't properly introduced. I'm the new trauma surgery attending, Johanna Rajah. Joey, if you'd like. I'll see you in the OR". Before Maggie could get another word in, she walked away to head up to the OR. April followed closely behind her.
"Well, that was… really something" Amelia said breaking the awkward silence.
"I like her" Alex said before returning his attention to the charts he was reviewing.
"Did she just say Joey?"