Chapter 21: A Hot Appy

July 15, 1989, McKinley, Ohio

On Saturday morning, I'd actually gone to band practice, and afterwards, Kris, Rachel, and I had done our weekly grocery shopping, and then I'd headed to the hospital for my Saturday shift.

"Mastriano is gunning for you," Doctor Billings said when we met for the turnover. "Watch your back, or you might end up with a scalpel in it."

"Wonderful. What do you have?"

"Rule-out MI, which turned out to be gastrointestinal, going up to Medicine as we speak. OD from last night waiting on a psych consult for rehab referral."

"Drug of choice?"

"Speedball."

"Because mixing a stimulant and a depressant is a wonderful idea," I replied, shaking my head. "Not that using IV drugs is a great idea to start with. Condition?"

"Coming down. Tachy, diaphoretic, and irritable."

"Male or female?"

"Male in Trauma 1. Callie and Gabby are up to speed."

"Perfect, thanks."

Doctor Billings left, and I went to find my medical students, who I discovered were in the lounge.

"The M & M was interesting," Callie observed. "Can I ask you about it?"

"Yes, though I probably don't have much more to add than I said."

"I was more interested in what 'internal matter' means."

"It's when the facts don't show a violation of the standard of care but do indicate bad judgment, poor reasoning, improper behavior, or policy violations."

"So what will happen?"

"That's up to the Chief," I replied. "And not something about which we should concern ourselves."

"I'm actually curious about what could happen."

"Anything from counseling to a disciplinary letter to suspension to dismissal. That's up to the Chief and depends on the totality of the circumstances."

"Is following the standard of care a 'Get Out of Jail Free' card?" Callie asked.

"There is no such thing. Following the standard of care will protect your rotation evaluation and medical license, assuming there aren't extenuating factors. It won't prevent malpractice claims, nor prevent the malpractice claims being paid, because it's up to the insurance carrier, and they almost always pay because it's more cost-effective."

"But then you'd have a claim against you!" Gabby protested.

"In most of the settlements, the hospital doesn't admit liability. The other thing to remember is that medical students and Residents are working on the license of their Attending, who is ultimately responsible. For you as students and me as a Resident, so long as we follow the instructions of our Attending, and those instructions conform to the standard of care, we're mostly safe. It's the Attending who is left holding the bag, so to speak. Anyway, let's go see the OD in Trauma 1."

We made our way to Trauma 1, and I handed the chart to Gabby.

"Present, please."

"William Bisch, twenty-six. Transported by EMS after being found unconscious by his girlfriend. Naloxone administered prophylactically upon arrival. Tox screen showed high levels of cocaine and heroin. This morning, patient admitted injecting himself with a 'speedball' last night. Tachy at 110, with no arrhythmia. All other vitals normal. Waiting on rehab consult."

I nodded to acknowledge her.

"Mr. Bisch, I'm Doctor Mike. How are you feeling?"

"OK," he replied.

"Hi, Mike," Doctor Silver said, coming into the room with a Third Year medical student.

"Hi, Leah. Gabby, please present to Doctor Silver.

Gabby repeated the details, and once Doctor Silver had introduced herself, Callie, Gabby, and I left the room.

"Good job on the presentation," I said to Gabby. "I know most doctors accept 'normal' for vitals, but I prefer the actual numbers."

"Yes, Doctor. Sorry."

"No need to apologize; I do some things differently. Remember, you can't spell 'details' without dotting the i's and crossing the t's."

"Got it!"

"Mike?" Doctor Varma said, coming up to us. "Can I get a surgical consult? The on-call Resident just took up a traumatic amputation."

"What do you have, Naveen?"

"Suspected hot appy; bounceback abdominal pain discharged last night. Exam 3."

"I'll take a look. Gabby, get the ultrasound, please. Callie, what are we looking for?"

"Male or female patient?" she asked.

"Female, twenty-five," Doctor Varma replied. "Negative pregnancy test last night."

"Then we're looking for pain in the lower right quadrant on palpation. Lack of appetite is indicative, as is nausea. Doctor Varma, did the CBC show elevated white count?"

"No."

"Temperature?"

"38.8°C."

"Also indicative, but not definitive," Callie observed.

Gabby brought the ultrasound, and the four of us went into the exam room where Doctor Varma's medical students were waiting.

"Ms. Brundle, this is Doctor Mike Loucks, a surgical Intern."

"Good afternoon, Ms. Brundle," I said. "May I examine you?"

"Yes."

"Cough, please," I requested as I palpated her abdomen.

She did and winced in pain, exhibiting Dunphy's sign.

"Have you eaten anything since last night?" I inquired.

"No. I haven't been hungry."

"Have you felt nauseated?"

"Yes."

"I'd like to do an ultrasound," I said. "Gabby?"

She wheeled the cart over, turned it on, and handed me the transducer. She squirted gel on Ms. Brundle's abdomen, and I placed the transducer at the approximate location of the appendix. I moved it around to locate her appendix and quickly found it.

"No obvious enlargement," I said. "But there is free fluid in the right iliac fossa. Callie?"

"Not determinative, but the combined signs suggest it's an appy."

"I agree. Call upstairs and let them know we have a hot appy. Ms. Brundle, it appears you have acute appendicitis, and you'll need to have your appendix removed immediately."

"I knew that last night, but they sent me home!"

"Appendicitis can be difficult to diagnose, especially in the early stages," I said.

"Mike," Callie called out three minutes later. "The nurse wants to speak to you."

I excused myself and went to the phone.

"Mike Loucks."

"Doctor Mike, Doctor Aniston is taking the other case that just arrived with Doctor Rafiq and Doctor Burke, and we're shorthanded today. He said to bring up the patient and scrub in. You'll assist Doctor Blake with the appendectomy. Bring your students. He said you should ask Doctor Mastriano to call in someone from Medicine to cover for an hour."

That meant all the Attendings were either tied up or unavailable because it was rare that a Resident, even a PGY6 such as Doctor Blake, took the lead on a surgery without an Attending in the OR to supervise.

"We'll bring her up right away," I said.

I hung up, asked Gabby to call for an orderly, excused myself, and went to speak to Doctor Mastriano.

"What?" she asked.

"Doctor Aniston instructed me to bring up a hot appy and scrub in."

"You can't leave us short-handed!" Doctor Mastriano protested.

"Doctor Aniston suggested following the protocol to call someone down from Medicine."

"This experiment gets worse every day," she groused. "Just go."

I left the office and went back to the exam room.

"You two get to scrub in," I said. "Naveen, the OD in Trauma 1 is having a rehab consult with Psych. You'll need to take him."

"Got it," he replied.

The orderly arrived, and we helped Ms. Brundle move to the gurney, then, we accompanied her up to the surgical ward.

"OR 2," Nurse Penny said.

"Follow me," I said to Callie and Gabby.

"Callie, you had your surgical rotation, so start scrubbing in. Gabby, do you recall the scrub procedure from your Preceptorships?"

"No," she replied.

"OK. Step up to the sink, and I'll talk you through it."

I began scrubbing and explained each step along the way. The scrub nurse, Jean, came in about halfway through and assisted us with masks, hats, gowns, and gloves. Once we were scrubbed, we went into the OR, where Doctor Blake, two nurses, and an anesthesiologist were preparing Ms. Brundle for surgery.

"First solo, Bill?" I asked.

"Second. First was an appy as well."

"Open procedure?"

"Yes. I'm not certified for laparoscopy yet."

"Under and stable," Doctor Peter Larson, the anesthesiologist, announced. "You may cut when ready."

"Mike," Doctor Blake said, "take the assisting surgeon's position, please. Who are your students standing in the corner?"

"Callie Newsom and Gabriella Martin."

"Step up, ladies, but ensure you leave room for Mike to move his arms."

They moved to stand just behind me on my right and left.

"OK, here we go!" Bill said. "Mike, I'll cut, you retract, Annie will suction."

He began with a transverse incision parallel to McBurney's point, incising the epidermis and dermis. I retracted, and he used a Bovie to dissect down to the external oblique aponeurosis. Following that, he opened the aponeurosis, exposing the internal oblique muscle, and I added a second retractor. After dividing the muscle, he divided the transverse abdominal muscle, and I shifted the retractors. He then grasped the peritoneum with forceps and made an incision, then located the appendix.

"There's that little bugger," He said. "Babcocks, please."

Nurse Felicity handed him the forceps, and he grasped the taeniae coli and advanced until the appendix was externalized.

"Good call, Mike," he said. "Inflamed and enlarged."

He dissected the mesoappendix, then applied two clamps to the appendiceal vessels, divided them, and ligated with silk sutures. Finally, the appendiceal stump was inverted into the cecum.

"And that's it," he said. "No rupture, no involvement of any surrounding tissue. Nice and clear. Mike, Doctor Aniston said you could close if I felt comfortable. What would you do?"

"Begin with an antiseptic lavage, then each of the three muscle layers is closed separately with running absorbable sutures. With no rupture, no drain is necessary, so close the dermis with 3-0 subcuticular absorbable sutures, then close the epidermis with basic mattress sutures.

"Correct. Felicity, surgical closure tray to Doctor Mike."

"Bill, could you see your way clear to allow Callie to close the epidermis? She's signed off for unsupervised laceration sutures, and this is an extremely simple procedure."

"Are you sure?"

"Positive," I said firmly.

"If you complete everything else with no complications, then, yes."

I could tell from her body language that Callie was about to burst, but she didn't say anything, which was the appropriate response. I worked slowly and methodically, ensuring I made no mistakes, and when I had closed the dermis, Doctor Blake gave Callie permission to close the epidermis, which she did flawlessly.

"Good work, Ms. Newsom. Mike, you may now resume your regularly scheduled duties!" he said. "Peter, you can bring her out from under."

"What happened that you're shorthanded?" I asked.

Doctor Blake laughed, "Department golf outing. Didn't you get the memo?"

"No. When was it sent out?"

"End of June. Ah, before you started. But it's on the bulletin board, which you should check on a daily basis."

"Will do."

"Scrub out, and we'll get her to recovery. Stop by on break, and I'll sign your procedure book. I'm here until midnight."

"Thanks, Bill," I said.

We left the room and scrubbed out, and the three of us went to the locker room to change scrubs.

"Holy shit!" Callie gasped when the three of us were alone in the locker room.

"You may be the first Fourth Year to ever suture in surgery," I said. "May I suggest you put it in your book but keep it to yourself?"

"Mastriano?" she asked.

"Let's just say you don't want to put a target on your back. With two weeks to go on this rotation, there's no point in riling her up. Let me take all the flak from her."

Five minutes later, dressed in fresh scrubs — red for me and blue for my students — we returned to the ED where, unsurprisingly, I found Clarissa covering for me.

"One patient," she said. "Finger fracture. Splinted and discharged. Meet for dinner?"

"I'll call you when I take my meal break."

She left, and I went to Doctor Mastriano's office to let her know I was back.

"Let me guess, you performed the appendectomy," she said disgustedly.

"Of course not," I replied. "I've only seen a few, and I've never used a scalpel on a live patient except for chest tubes. Doctor Cutter may be changing the norms a bit, but I can't imagine anyone would allow a PGY1 to perform even something as simple as an appendectomy."

"Walk-ins."

"Yes, Doctor," I replied.

I left her office, and after the 'high' of surgery, we now had the 'low' of walk-ins with complaints that mostly should have been handled in a physician's office or at the Free Clinic. The afternoon was entirely routine, and I managed to meet Clarissa for dinner at 6:15pm.

"I take it from the lack of details earlier, you stood and watched?"

"I closed," I replied with a grin. "Well, everything but the epidermis. I asked, and Callie was allowed to put in the final sutures."

"Holy shit, Petrovich! You're an Intern! She's a Fourth Year!"

"Surgery was short-handed," I replied. "Today was the departmental golf tournament."

"You're joking!"

"You know how serious they are about golf! The problem really was a traumatic amputation, which required three surgeons, leaving Doctor Blake to take a bounceback hot appy. Protocol is they call in a surgeon, but neither case could wait, and Bill Blake had done a solo appy before. I held retractors, then closed."

"What did Mastriano say? She must have totally lost her shit!"

"She asked if they let me do the appy, and I said I couldn't imagine Doctor Cutter would ever allow an Intern to perform surgery, even something as simple as an appendectomy. That's only the third or fourth one I've seen, and despite knowing the procedure, I've never used the Bovie electrocautery before nor made any incisions in living tissue except for chest tubes."

"You didn't tell her you closed?"

"Why create more animosity?"

"She's going to find out."

"Probably. I did tell Callie to simply write it in her procedure book and not talk about it."

"Riiiigggghhht! Because a Fourth Year who sutured in the OR isn't going to tell every single person she knows? I don't know a single female med student who wouldn't offer to have your baby for the chance to do that!"

"You know my take on that, Lissa."

"And you know I was exaggerating for effect! Besides, you'd prefer the seventeen-year-old who offered!"

"I prefer my wife," I replied. "Period."

Clarissa smiled, "With one exception."

"Yes, but you know that will never happen, no matter how much we might prefer to conceive that way."

"Speaking of that, how are things at home?"

"I sleep. Rachel is very unhappy. I'm gone for long stretches, then eat and sleep when I get home. Kris is handling it OK, and we're on track for trying for our first starting in September. You?"

"I feel as if I never see Tessa, but she seems to be handling it OK."

"The lot of Interns everywhere," I replied. "And even if changes are made, they couldn't be implemented before we're PGY2s because the ED would need five more Residents to have the same coverage; more if hours are reduced across the board."

"Think it'll happen?"

"I suspect, eventually, the pressure will be so great that the Accreditation Council will make changes to fend off legislation in other states. For the entire medical industry, the nightmare scenario is states having different, incompatible standards. That plays havoc with licensing and the ability of doctors to move from one state to another. It's the same with medical school, though adding Preceptorships doesn't create the same problem, though it does disadvantage students who don't have them."

"I can't imagine you closing an appendectomy without having had that extra experience."

"Me, either. I think, importantly, it also allows students to form important relationships early on. That was certainly a major plus for me."

"Playing golf?"

"Yes, but the relationships were far more important than the golf. Another important thing to consider with regard to hours is whether there are actually enough qualified Residents and enough slots in medical schools to train them. I'm not sure there are, given that Residency slots go unfilled every year."

We finished eating and, after a quick hug, returned to our services.

"I was just about to page you," Becky said. "Doctor Gabriel said you should handle the incoming EMS run."

"What do we have?"

"Sexual assault," she said. "They're two minutes out. Trauma 2 is open."

"I'll need an OB/GYN and a nurse trained on rape kits, please."

"I'm trained, so I'll assist. Let me call for the consult. Female, right?"

"Preferably, in case the victim refuses a male doctor. Get a kit once you've done that, please."

She acknowledged my orders, and I went to the lounge to get Callie and Gabby.

"Sorry, I can't let you have your dinner now. We have a sexual assault victim two minutes out."

"Oh, God," Gabby moaned. "I hate these."

"I understand, and if you can't stay in the room without exhibiting emotion, you can swap with Kim, Doctor Varma's student. These can be tough."

"No, I can handle it," she said.

"Then let's go."

We hurried out of the lounge, put on gowns and gloves, and went to the ambulance bay, stepping outside just as the EMS squad turned into the driveway. It pulled up, stopped, and Mark Klein, a new paramedic, jumped out of the cab.

"Hi, Doc. We got a bad one. Julie Rafferty, nineteen; beaten and sexually assaulted. GCS 7; pulse thready at 120; BP 80/50; PO₂ 96% on five litres; facial and abdominal contusions; blood around the vagina."

"Oh, God," Gabby gasped again.

"Keep it together, Miss Martin!" I said firmly. "Trauma 2!"

The three of us and the two paramedics rushed Ms. Rafferty to Trauma 2, where Becky and Kellie were waiting for us. The seven of us quickly moved Ms. Rafferty to the trauma table. She was so badly injured that the rape kit took a back seat to stabilizing her.

"Callie, EKG and monitor; Kellie, CBC, Chem-20, pregnancy test, ABG. Becky, IV Ringer's. Gabby, ultrasound."

"What about the kit?" Callie asked.

"Cut away her T-shirt and bra and put them in the bags. The protocol is different for a badly injured victim. She'll need a Foley, but that can wait. Becky, modesty cloth, please."

"Mike?" Nurse Angie said, coming into the room. "Detective Kleist is here."

"She can come in," I said.

I began a careful primary exam as the others sprang into action, following my orders.

"Are you preserving evidence?" Detective Kleist asked.

"As best we can with an unstable, unconscious patient. I'll forego the Foley until OB performs an exam."

"What do we have, Mike?" Doctor Alice Carmichael asked, coming into the trauma room with her student.

"Apparent sexual assault. Primary exam not yet complete; patient is unstable. Would you perform the pelvic exam and kit, please?"

"Right away. Jacqui, assist me, please."

She and her medical student began the pelvic exam while I completed my exam, calling out my findings.

"Belly is rigid," I announced. "Possible surgical case. Gabby, I need the ultrasound. Becky, type and crossmatch; Kellie, hang a unit of plasma."

"Blood around the vagina and anus," Doctor Carmichael announced. "Suspect internal injuries; collecting swab samples before the internal exam."