Chapter 10: Call on Line 3

July 3, 1989, McKinley, Ohio

"Hi!" I said to Kris when she and Rachel came to the Emergency Department just before 5:30pm. "How are my girls?"

"She seems a lot happier than she was this morning," Kris said. "Marcie said she had fun playing with her friends."

"Want to come to Papa?" I asked Rachel.

"NO!"

"What have you done now, Doctor Mike?" Nurse Wendy asked, laughing.

"I am sure the list of my failures as a dad is long and growing," I chuckled. "And once Rachel is able to articulate them, I'm positive I'll be given detailed instructions for improvement!"

Wendy laughed, "That sounds just like my fourteen-year-old son, who never misses a chance to explain just how clueless and out of touch I am!"

"Mike, do you have time for dinner?" Kris asked.

"Let me check with Doctor Taylor," I said.

I quickly checked with him and was cleared for my thirty-minute dinner break, with the caveat that, as always was the case in the ED, I could be paged if I was needed. I signed out, let Kristy know I'd be on break, let Len and Bob know, then accompanied my wife and daughter to the cafeteria.

"How has your day been so far?" she asked as we got in line to get our food.

"Busy and mostly good. We did lose one patient, but in all honesty, he was lucky to be alive when the paramedics got him to us. He fell off scaffolding onto reinforcing bars. Those are the green metal rods they use to make poured concrete stronger. The Fire Department had to cut him from them, and he had three of them lodged in his body when they got him to the ED. His internal injuries were too severe to survive."

"Wow! Does that happen often?"

"Usually, construction injuries are things like stepping on a nail, cuts, or broken limbs. This was a first for me."

"What else?"

"A broken ankle, an injury from a nail gun, a broken wrist, and two rule-out MIs, that is heart attacks. I did miss treating the sixteen-year-old female with poison ivy on her buttocks, upper thighs, and inner thighs."

"Not careful enough making love in the woods?"

"That's my guess," I said. "She requested a female doctor, which I totally understand. Doctor Carmichael came down from OB to treat her. I just wonder about her paramour!"

Kris laughed softly, "I bet that's even MORE uncomfortable!"

"Imagine explaining that to your parents as a teenager!"

Kris laughed again, "Even more uncomfortable!"

"My mom would have laughed," I said. "And would have had no sympathy for the discomfort caused by sinful behavior!"

"God works in mysterious ways?" Kris asked lightly.

"Could be," I chuckled.

I paid for our meals, though mine was subsidized, and we found an empty table. I put down the trays and retrieved a wooden high chair for Rachel, and Kris put her in it. I said the blessing, and we began to eat with Rachel, happily munching on a dinner roll.

"Do you think you'll be able to get any sleep tonight?"

"I'll try, but there are only three of us on overnight, so if it's at all busy, Naveen and I will be up all night and only Doctor Mastriano will get any sleep."

"Is that doctor Italian?"

"Yes, though she went to medical school and served her Residency in the US. How was your day today?"

"Good. My one and only math class, but it should be easy. When I arrived home, there was a message on the machine from the attorney who's helping Angie, Tom Kirkland. He'd like you to call him when you have a chance. He left both his work and home numbers."

"I'll see if I can find time tomorrow morning; otherwise, it will have to be Wednesday."

"What time do you want me to have your music and instruments at the lake tomorrow?"

"I'll leave here around noon," I said. "So around then would be good. Just bring them to the band shell."

"My parents and Lyudmila will come with me."

"Great!"

"«Tante»!" Rachel exclaimed. ("Auntie")

"My daughter is being corrupted by French women!" I groused good-naturedly.

"It could be worse," Kris replied.

"I'm not sure how," I chuckled. "She's three-quarters Russian and a quarter Dutch! That's a dangerous mix!"

"You're half and half!"

"As I said!" I chuckled.

We finished our meal, and I had time to walk Rachel and Kris to the car. I got Rachel settled in her car seat, then kissed her forehead.

"Papa home?" she asked.

"No, Papa can't come home," I replied. "Papa has to help sick people. I'll see you tomorrow."

Rachel pouted, but there wasn't much I could do about it. I hugged Kris, we exchanged a quick kiss, and she got into the car. Once she'd driven off, I headed back to the ED. Bob and Len had gone off their shift, and Mary Anderson and Tom Lawson had replaced them.

"Doctor Loucks?" a short blonde with long, braided hair asked as I walked into the lounge.

Next to her was a lanky guy about my height with short brown hair.

"Doctor Mike, please. You must be Mary and Tom. May I see your procedure books, please?"

They handed them over, and I quickly flipped through them. Tom, being a Third Year on his first rotation, didn't have many procedures in his book, but Mary had the usual number for a Fourth Year. Both had EKG diagrams at the end of their notebooks, and I wondered if word had been passed somehow.

"We're catching walk-ins overnight," I said. "So, Mary, you'll be at the triage desk with a nurse. Tom, you'll stay with me and help with histories and physicals."

"Should I go now?" Mary asked.

"Yes. You relieve Alex, who goes off shift in about five minutes. Make sure you go over everyone who's waiting. We'll take a patient in a few minutes."

She left the lounge, and I used the restroom, then Tom and I went to the triage desk.

"What have you got for me?" I asked Mary, who was sitting with Nurse Margie, a brand new nurse who had graduated from nursing school at the end of May.

"Dad versus carving knife, carving knife wins; toddler with croup; and the ever popular 'back pain and I lost my pills'."

"FF?" I asked.

"Three visits in six months; prescribed drugs each time."

"Assessment?"

"I don't have one; Alex did the exam. There is no red dot on the most recent chart."

"I'll take the kitchen injury," I said. "Tom needs suturing practice. I'll come back for the toddler. The drug seeker gets to wait."

"OK," she said, handing me a chart.

"Al Crowe; forty-two; vitals normal; bleeding from injury to left index finger; missing about 2mm of the distal tip."

"Oops," I said.

"Yeah. His kids are a bit freaked out by the blood."

"The family of four over there?" I asked.

"Yes."

I accepted the chart, went to the door, and called out, "Mr. Crowe?"

"That's me," he said, standing up.

"I'm Doctor Mike. If you'll come with me, we'll get you fixed up."

He kissed his wife and left her with two boys, I guessed were around ten and twelve, and Tom and I escorted him to Exam 1.

"Tom is a medical student doing his clinical rotations," I said. "He's going to perform the exam under my direct supervision, if that's OK with you."

"A student?" Mr. Crowe asked.

"We're a teaching hospital, and that's how we train doctors. He's had six years of classroom work and is now being trained by doctors. I'll be right here the whole time."

"OK."

"H&P, Tom, please."

"What brings you to the hospital today?" Tom asked Mr. Crowe.

"I thought that was pretty obvious!" Mr. Crowe said, holding up his left hand.

"Yes, Sir, but we always ask," Tom said. "What happened?"

"I was slicing a roast and not being careful. I sliced off the tip of my index finger."

"Did you save the fingertip?" Tom asked.

"Didn't even think of that," Mr. Crowe said. "Is that a problem?"

"Most likely not," I interjected. "We generally can't reattach a small piece of tissue. Go ahead, Tom."

He did a competent job of taking the patient's history, including asking about a tetanus shot, which the patient hadn't had in five years. After washing his hands and putting on gloves, Tom performed the auscultation, reporting what he heard, with everything being normal.

"How do you want to proceed?" I asked Tom.

"Irrigate the wound, sterile dressing, elevate, ibuprofen for pain, update his tetanus."

"Proceed," I said to Tom.

"Mr. Crowe," Tom said, "I'm going to examine your finger, rinse it with sterile saline, then apply a gauze dressing. We'll have you keep your hand elevated and wait for the bleeding to stop. Once it does, we'll give you a tetanus booster and get you on your way. You can take Advil or Tylenol for any pain. Is it OK to examine your finger?"

"That's why I'm here!" he said.

"We always ask permission before touching a patient if they're conscious," I said.

Tom irrigated the wound with saline, then examined it. I looked over his shoulder, and as I had suspected, there would have been no way to reattach the missing tissue, and the wound would heal with only minimal scarring. Tom applied a sterile dressing, then had Mr. Crowe put his hand on the opposite shoulder to elevate it above his heart.

"Mr. Crowe, I need to get the tetanus booster," I said. "I'll be right back."

"Don't nurses do that kind of thing?" he asked.

I nodded, "They do, but it seems silly to bother a nurse who is busy when I have keys to the drug room."

I left the room, went to the drug room, used my key to get in, then went to the refrigerator to get the tetanus booster. I recorded that I'd taken it on the clipboard on the fridge, then returned to Exam 1. I handed Tom the pre-filled syringe, he shook it, opened the package, and after cleaning Mr. Crowe's arm with the included alcohol wipe, administered the injection.

"We're done," I said to Mr. Crowe. "I would like you to stay for twenty minutes so we can ensure the bleeding has stopped. Just keep your hand on your shoulder, and we'll come back in about fifteen to twenty minutes to check on you."

"Thanks, Doc! Your student seems to know his stuff."

"Thank you," I said.

Tom and I left the room and walked towards the Attendings' office.

"Not to be impertinent, but aren't you supposed to clear all procedures with the Attending?"

"Every Resident has a set of guidelines as to what they can do without expressly asking, and what we just did falls completely within my list of authorized procedures."

"So the rumors are true that you receive special treatment?"

"I receive treatment commensurate with my demonstrated abilities and skills. That will happen with you, too. Once I'm satisfied you are able to suture, you'll do minor repairs without me standing over your shoulder. Yes, I'll check your work when you finish, but you'll do it without direct supervision. Have you decided on a specialty?"

"No. I want to wait to complete my Clerkships before I decide."

"You'll need to do that a bit sooner than that," I replied. "You'll need to set your Sub-Internship schedule in the Spring. But you still have time to think about it."

"Any advice?"

"Figure out what motivates you and do that," I replied. "It's what will get you through the thirty-six-hour shifts, among other things."

"You're on one of those now, right?"

"Yes. Just over a third of the way through, and there's little chance I'll get to sleep much before 7:00pm tomorrow. I will be ducking out for about four hours to play a gig at Milton Lake, and Kylie Baxter will cover for me."

"She's on until midnight, though, right?"

"Yes. But we have an arrangement that started when we were medical students."

We reached the Attendings' office, and I had Tom report to Doctor Mastriano and have her sign the chart.

"Come see me when you have a chance," Doctor Mastriano said.

"Tom, I'll catch up with you in a few minutes at the triage desk."

"OK," he said and left.

"What's up?" I asked.

"Overnight, do not wake me unless a patient is dying. You can handle anything that comes in either yourself or with a consult."

"I'm not signed off on every procedure," I said.

"Use your best judgment," she said. "I need to get some sleep. I'll sign your charts in the morning before I go off shift at 0700."

"OK," I agreed, deciding I wouldn't win an argument and knowing that I could never get in serious trouble for waking her up, no matter what she might have said.

I left her office and went to the triage desk.

"Anything new?" I asked Mary.

"Eighteen-year-old female reporting that 'it burns when I pee'. Vitals normal but with a slight fever at 38.1°C. Twenty-two-year-old with a forehead lac from, you'll love this, trying to crush a beer can on his forehead. Vitals normal, but has a headache, as you can imagine."

"An interesting variation on 'hold my beer and watch this'," I chuckled. "Let me take the bawling toddler and give the others a break."

Mary handed me the chart, and Tom and I went to the door of the waiting room.

"I'll do this one," I said.

"Your reputation as 'Kid Whisperer' precedes you," Tom said.

"Yes, but also, Mom looks harried, so I don't want to do anything to make her stress worse. No reflection on you, just on the circumstances."

"Got it."

I opened the door and called out, "Ms. Travis and Benny?"

The woman, who appeared to be about twenty, stood up and carried her crying two-year-old over to us.

"Hi," I said. "I'm Doctor Mike, and this is my student Tom, who'll observe as part of his training."

"OK," she said.

We went to Exam 2, and I went to the sink to wash my hands.

"What seems to be Benny's problem?" I asked as I rinsed the soap from my hands.

"He won't stop crying, and I'm basically at my wit's end," she said.

That was an indication we might need a social worker, as a mom in that condition was considered a risk. It was a judgment call and one I'd make once I'd completed the exam and learned more about the situation.

"Has anything changed with his health recently? Or at home?"

"Not that I can think of," Ms. Travis said.

I dried my hands, put on gloves, and went over to the exam table where Benny was lying down, still crying.

"Hi, Benny," I said. "I'm Mike. Does anything hurt?"

He didn't answer or stop crying, which meant I'd have to detect any potential pain via exam, which was an inexact science.

"OK to examine Benny?" I asked.

"Yes, of course," Ms. Travis said.

I did my best to listen to his heart and lungs, though the crying made that difficult. I didn't hear any crackles in his lungs, but I couldn't tell much about his heart. I draped my stethoscope around my neck, removed the otoscope from the holder, put on a fresh speculum, and looked into Benny's right ear, seeing a red, bulging tympanic membrane. I changed the speculum, then checked his left year, finding the same thing.

Next, I examined his nose and throat, noting inflamed tonsils. I set the otoscope aside and palpated Benny's neck, finding swollen cervical lymph nodes, with Benny crying harder when I touched them. My final check was his temperature, which was 39°C. I decided to re-examine his tonsils, noting significant exudates, and concluded the most likely diagnosis was streptococcal pharyngitis.

I reviewed the Centor criteria, and Benny scored 5 out of 5 — no cough; swollen and tender cervical lymph nodes; a fever over 38°C; tonsillar exudates; under age fifteen.

"I believe Benny has strep throat," I said, using the layman's term for my diagnosis. "Has he had diarrhea, been coughing, or had a runny nose?"

"No to the first two, but he's had a runny nose."

"Before or after he began crying?"

"After," she replied.

That meant, most likely, the red eyes and runny nose were related to crying and didn't provide contraindication for strep.

"I'm going to take a throat culture, but that will take twenty-four hours. Given the symptoms and signs, I'd say the odds are strong that it will be positive. I'm going to prescribe antibiotics. Is he allergic to anything?"

"No. He's normally really healthy and active."

"And he's had all his regular vaccinations?"

"Yes. He saw his pediatrician about a month ago, and everything was fine."

"OK. Right now, I'll give him some liquid ibuprofen with an eye dropper for the pain, and we'll get you on your way. The lab will call you tomorrow with the results. Benny needs to take the antibiotics as prescribed for ten days, even if he feels better. If you stop, the infection could come back and possibly be worse. It's vital you don't stop before ten days."

"Pills or liquid?" Ms. Travis asked.

"At his age, we'll go with liquid," I said. "I'm going to prescribe penicillin V, and you'll give him 125mg every six to eight hours, depending on his sleep schedule. I'll give you a discharge sheet that will have all the details. You can fill the prescription at the Walgreens down the street, which has a twenty-four-hour pharmacy. You should also pick up some liquid ibuprofen — that's the active ingredient in Advil — for his discomfort."

"OK."

"You should also follow up with Benny's pediatrician in seventy-two-hours, but if Benny spikes a fever higher than 102°F, bring him back, or if he develops a rash, has trouble breathing, or becomes listless. A nurse will call you with the test results."

"OK," Ms. Travis agreed.

"Let me get the ibuprofen now, and then I'll finish the paperwork so you can be on your way."

"Thanks, Doctor."

Tom and I left, and we went to the drug room, where I prepared a dropper of liquid ibuprofen, then returned to the Exam room to administer it to Benny. I was happy he accepted it without fighting, then Tom and I went to see Doctor Mastriano. I presented, and she signed off on the chart with no comments.

On our way back to see Benny, we stopped in to check on Mr. Crowe. The gauze had soaked through, so I had Tom add an additional layer, and we promised to come back and check in ten minutes. We left his room, I went to the nurses' station and got the appropriate antibiotic discharge instructions, filled in the blanks, then wrote out the prescription. We returned to Exam 2, I went over everything with Ms. Travis, then directed her to Patient Services.

"Doctor Mastriano didn't say a word," Tom observed when we left the room.

"You'll find that every Attending is different, as is every Resident. Some want detailed reports; some just want the salient points. Doctor Mastriano appears to trust her Residents."

Or she was lazy, which was a bigger concern, but I didn't have enough experience with her to know one way or the other. At some point, Naveen and I would compare notes, but he was working with Doctor Williams and handling incoming ambulance patients, though it had been relatively quiet for the past few hours, which meant he was mostly monitoring patients waiting on admission or discharge.

"Tom, I need to speak to Mary, so sit at the desk and take your cues from Margie."

"She's brand new, too!"

"And has two full years of clinical experience compared to your five weeks!"

We went to the triage desk, and I asked Mary to join me in the consultation room, as we Residents did not have an office to use and wouldn't until the construction of the new ED was completed.