Chapter 9: Three in One Day

July 3, 1989, McKinley, Ohio

"Everything OK at home?" Clarissa asked as we sat down with our lunches in the cafeteria at a table away from most other people.

"Why wouldn't it be?"

"Nobody is that mellow!" Clarissa protested.

"Not only is she that mellow, we have permission to conceive naturally, if you want."

"NO WAY!" Clarissa gasped. "SERIOUSLY?!"

"No," I chuckled. "Of course not!"

"That was mean, Petrovich! Even for you!" Clarissa exclaimed, but I could see in her eyes she wasn't upset.

"How often do I have a 'gotcha' with you?"

"Not very! So she's all good?"

"She is. And as open-minded as my cosmopolitan French wife is, she's not open-minded enough to allow what I teased about. But she's fine with our agreement, and she's not reluctant or concerned."

"She has no idea how badly you want to sleep with me, does she?" Clarissa asked.

"Except I don't, for obvious reasons."

"OK, before you married! Both marriages, too!"

"And yet, it wasn't about sex, which, by the way, is what would concern her, not the act, in and of itself."

"So casual sex is OK?"

"No, of course not, but it wouldn't be casual with you, which both you and I know."

She nodded and then asked, "How was your morning?"

"Fairly typical for the ED, though I did get to put in a chest tube."

"You wheedled it out of the on-call?"

"No. Doctor Taylor saw the red scrubs and the surgical 'S' on my badge and instructed me to do it because I was a surgical Intern and was being supervised by an Attending, which is the letter of the law. There's a low-intensity war between Cutter and Northrup, and I believe Doctor Northrup lost the battle but might win the war."

"How so?"

"Cutter was so insistent that I'm a surgical Intern that Northrup is taking him at his word. Obviously, I can't do anything I haven't been trained to do, but I can do chest tubes and emergency pericardiocenteses because I have been trained to do those. I'm sure that will lead to further internecine combat, but so long as I can stay out of the line of fire, they can fight all they want."

"Does he know about the tube?"

"I'm not sure if Doctor Pace will report it or if he'll see it on a chart review a week from now, but one way or the other, it will get back to him. Heck, Northrup might tell him just to tweak him."

"You're enjoying the politics?! What's next? Human sacrifice, dogs and cats living together ... mass hysteria?!"

"It's working to my advantage at the moment and to Ellie's disadvantage!"

"How so?"

"My locker is in the surgical locker room!"

Clarissa laughed, "Poor Ellie, she'll have to get her thrills some other way than seeing 'Big Mike'!"

"She's never seen Big Mike!" I countered.

"Tell me she hasn't seen you in your briefs."

"Fine, but she's never seen Big Mike ready for action, and she never will!"

"She'd redouble her efforts if she knew!"

"Twice nothing is still nothing," I replied. "How is your shift going?"

"A pair of interesting cases that have everyone stumped. I'm researching, but it would be so much easier if everything was computerized. Some stuff is, but not everything."

"I'll be happy with remote telemetry beds," I replied. "But your challenges are somewhat different from mine."

"I prefer the mental acuity tests to 'Can I make the right decision in a split second to save a life'. I could do it if I had to, but you get off on it."

"I don't think I'd go quite that far," I chuckled. "But I certainly prefer the adrenaline rush of the ED to the mostly intellectual exercise of Internal Medicine."

"Including the walk-ins?"

"I have to come down off the adrenaline high at least occasionally!"

"Everything is pretty much exactly as we had hoped."

"Minus Kitten not being here to see it," I said.

"You suffered quite a bit to make it here, Mike, and sacrificed so much. I'm positive she's proud of you and probably rolling her eyes at times."

"Of that, you can be sure!"

We finished our lunches without interruption, which was something I wouldn't be able to count on for years to come. I walked Clarissa to the elevators, then headed back to the ED, where Ellie asked me to catch some walk-ins. I found Len and Bob, then went to see Doctor Birch.

"Where are my toddlers?" I asked, referring to the Preceptorship students.

He laughed, "It does seem that way, doesn't it? They're in the lounge. Four students, all Second Years. No First years until August."

"That's something, I guess," I said with a wan smile.

Len, Bob, and I went to the lounge, and I introduced myself to the four students. I was tempted to call them by numbers — one, two, three, and four — but decided that was a bit too much hazing.

"Your task today is simply to observe," I said. "Take notes, ask questions between patents, and stand out of the way. Next week, there will be a quiz."

Three of the four groaned, and I wanted to laugh because, as Second Years, they should have been ready for something like that.

I led my small entourage to the admit desk and asked Alex what he had.

"Puking five-year-old; sixteen-year-old with a rash that appears to be poison ivy; twenty-three-year-old construction worker with nail gun injury."

"Nail gun injury?"

"Right through his foot."

"That's going to be surgical, so I'll take him."

"Mr. Logan," Alex said, handing me the chart. "He's in the wheelchair. Vitals normal, only complaint is the nail in his foot."

"Thanks. Len, you push the wheelchair."

"Low man on the totem pole," he chuckled. "Got it."

"Bob, history and physical. I'll confirm, then we'll discuss the plan of action outside the room."

I looked up at the board and saw that Exam 3 was open. Bob, Len, and I called for Mr. Logan, I introduced myself and my students, then Len and Bob took him to Exam 3 while I went to the desk and asked for a nurse to join us. The four Second Years followed us and stood clustered in the corner of the room, and Alice, who Ellie assigned, followed me into the treatment room. Bob did a good job on the H&P, and I confirmed his exam.

"Could I get something for the pain?" he asked.

Because there was potential for surgery, the most I could offer was ibuprofen or acetaminophen, as any opiates would create potential interactions with a general anesthetic, should one be necessary.

"Alice, 600mg ibuprofen PO, please," I requested. "Then irrigate and paint with Betadine."

"Right away, Doctor!" she said, making a note on the chart.

"Mr. Logan, I'll be right back," I said.

"Thanks, Doc."

We stepped out, and I asked Bob for his plan.

"Can you remove the nail?" he asked.

"Technically, I could, but I've never done it before, so I need either a senior surgical Resident or surgical Attending to supervise. What's your plan?"

"X-ray, then remove the nail, clean and irrigate, update tetanus, and a course of antibiotics. Ibuprofen or acetaminophen for pain."

"Any idea about the procedure to remove the nail?"

"No. I've never seen that done."

"OK. Len, call for a surgical consult, please."

Len went to the wall phone and made the call, and five minutes later, Doctor Rafiq arrived.

"Charles Logan, twenty-three, penetrating trauma to the left foot from a nail gun; irrigated and Betadyne applied; recommend X-ray, extraction, tetanus, and a course of antibiotics. If the X-ray shows significant bone involvement, then an ortho consult. I'd like to do the extraction."

"Have you done one?" Doctor Rafiq asked, sounding annoyed.

"No, but I know the technique — lidocaine times four, clip the exposed portion of the nail distal from the point of extraction, remove with constant pressure, address any bleeding, apply topical antibiotics. No sutures unless surgical repair is necessary due to arterial or veinous damage."

Doctor Rafiq glared at me but nodded his assent.

"Len, call for a portable X-ray, please," I said, and the four of us went back into the room.

"Mr. Logan, this is Doctor Rafiq, a surgeon. We're going to X-ray your foot to confirm it's safe to extract the nail without surgery. Just relax as best you can, and we'll get the nail out as soon as possible."

The X-ray tech arrived about five minutes later with the portable fluoroscope, which had a monitor that would give us a real-time image of Mr. Logan's foot. Doctor Rafiq and I examined the image.

"Soft tissue only," I observed. "The nail is in the dorsal interossei between the first and second left metatarsal with no bone involvement."

"I concur," Doctor Rafiq said.

"Lidocaine times four, clip the three centimeters that extend through the plantar, then extract dorsally."

"Proceed."

"Alice, lidocaine times four, please, and a procedure tray."

"Right away, Doctor!"

"Mr. Logan, I'm going to numb your foot with lidocaine. Have you had any problems with local anesthetics, including at the dentist?"

"No. I've had cavities filled and didn't have any trouble."

The procedure was straightforward — I numbed his foot with lidocaine injected near the nail on both sides, then used 5¼ inch podiatric nail nippers to cut through the part of the nail that was protruding from Mr. Logan's foot. Once that was completed, I grasped the upper end of the nail with 5½ Kellys and slowly and carefully extracted it.

"Minimal bleeding," I observed. "How are you feeling, Mr. Logan?"

"OK. My foot is throbbing, but otherwise, not bad."

"Great. Alice is going to irrigate and dress your wound and give you a tetanus shot. Do you have any allergies to antibiotics, or have you had a bad reaction?"

"No," he said, confirming what he'd told Bob during the H&P.

"OK. I'll be back in a few minutes with your discharge instructions."

"Thanks, Doc."

Doctor Rafiq left, and Bob, Len, the Second Years, and I went to the Attendings' office to see Doctor Taylor. I reviewed the injury and procedure and recommendation for 500mg amoxicillin three times a day for seven days.

"Approved," Doctor Birch said, making a note on the chart and signing it. "Good job, Mike."

"Thanks," I replied.

"You'll need to stay off your foot for at least a week," I said. "Then follow up with your regular physician. I'll fill out the necessary form for you to provide to your employer, and Patient Services will assist you with the Workman's Comp forms. Len, would you please call for an orderly with a wheelchair? Bob, get a set of crutches, please."

"Right away, Doctor!" Bob acknowledged.

"Will do," Len said.

"Mr. Logan, have you used crutches before?" I asked.

"Yeah, when I was sixteen, I broke my ankle."

I filled out a prescription form, the first one I'd personally written, and handed it to Mr. Logan.

"You can fill this at the hospital pharmacy or any other pharmacy of your choice. Make sure you take the antibiotics as prescribed and take them all, even if there are no signs of infection. For pain, you can use over-the-counter analgesics — Tylenol and Advil are good choices, and whichever one works better is fine."

"What about Anacin? That's my usual go-to for pain."

"If that works for you, and it doesn't cause you stomach problems, that's fine. We tend to recommend ibuprofen or acetaminophen, which are the ingredients in Advil and Tylenol, respectively, as they have fewer side effects."

"Never had trouble with aspirin, and it's all I've ever used."

"OK. Len will stay with you until the orderly arrives, then escort you to patient services. Do you need to call someone to pick you up?"

"My foreman brought me in. He'll take me home."

"OK. Keep your foot dry until you see your personal physician, but come back if you run a fever over 101°F or you see any discharge beyond a small amount of blood or clear fluid or a rash or redness that is spreading, come back right away."

"Thanks, Doc."

"You're welcome. Have a nice day."

"You, too."

I left the room, and a minute later, Bob returned with a set of crutches, which he took into the trauma room for Mr. Logan. He came back into the corridor a few seconds later.

"What was up with that surgeon?" he asked quietly. "He was giving you dirty looks the entire time."

"Doctor Rafiq is unhappy that I was allowed to do procedures as a Fourth Year that he wasn't allowed to do as a PGY1, and doesn't agree with Doctor Roth's training program for me. Fortunately, he's not my supervising Resident."

"Who would normally do the procedure you just did?"

"Historically, only a surgeon, but in the past year the policy changed such that after a surgical consult, an emergency medicine specialist can do it. If there had been any bone involvement, we'd have needed an orthopedic surgeon, and they'd have taken Mr. Logan up to the OR. Long term, a trauma surgeon would make the call, and then take the patient up, and consult with an orthopedic surgeon on the extraction and repair."

"What if an artery of vein had been compromised?"

"It depends on the volume of blood, but many times, it would require a surgical repair. That's not something I could even contemplate doing for four or five years, at least."

"How do you get your surgical training?"

"After two years in the ED, I'll handle all surgical consults during my shifts and assist with any emergency surgery. I'll have some scheduled procedures as well, as I have to be sufficiently versed in them to pass my surgical Boards. It works out to about eight or nine years, including a Fellowship. Let's catch another walk-in. Len can join us when he's finished with Mr. Logan."

We went to the triage desk, and someone had taken the puking five-year-old, and two others had arrived, but neither was sufficiently urgent to jump the queue ahead of the sixteen-year-old girl with suspected exposure to poison ivy.

"Miss Munroe?" I called out.

A tall, athletic blonde who was standing raised her hand.

"I'm Doctor Mike," I said. "I understand you believe you've come in contact with poison ivy?"

"Yeah, uhm, could I see a lady doctor? It's kind of in an embarrassing place."

"Let me see if someone is available," I said. "If not, do you want to wait?"

"Er, I guess it depends on how long."

"OK. Hang tight, and I'll see."

Bob and I went back into the ED, and I checked the board. Only Doctor Billings and Doctor Townshend were on shift, and they were in a trauma, so I walked over to Ellie to inquire.

"It's a bad one," she said. "Stabbing victim."

I contemplated offering to switch and take over for Doctor Townshend, a fellow PGY1, but Jill Munroe's situation wasn't serious enough to warrant interrupting a severe trauma. I began walking back to the waiting room.

"Patients are allowed to do that?" Joe, one of the Second Years, asked.

I nodded, "Yes. For any reason, too. We, as physicians, cannot choose our patients, but patients can determine who provides their medical care, and yes, that includes for racist or sexist reasons, though in this case, I'd say modesty."

"I didn't see the chart, obviously, so where is the rash?"

"Her buttocks and upper thighs. I suspect you can work out how that might have happened."

"I'd hate to be the guy and have it where I suspect he'd have come in contact with poison ivy!" Len declared.

"I might need to ask you to swap with Leslie to limit the number of guys in the room. It's not about you but about the patient. It's happened to me a few times."

"Understood."

"Let's see if our young woman will accept me as her doctor or wants to wait. We'll need a female nurse if Miss Munroe does agree, and we'll probably end up calling for an OB/GYN consult."

"Jill Munroe? Like Charlie's Angels?" Joe asked.

"Never watched it," I replied. "Which actress was that?"

"Farrah!" Ken, another of the Second Years, declared. "Seriously? You don't know that?"

I chuckled, "I know about Farrah, but I never watched the show. My best guy friend had the poster of her in his room."

"Who didn't?"

"Me," I chuckled. "It didn't fit with the icons."

"Icons?"

"I'm Russian Orthodox. Anyway, let's see what she has to say."

I went back into the waiting room with Bob and over to where Miss Munroe was standing in obvious discomfort.

"Doctors Townshend and Billings, the two females on shift, are both in a trauma, and it might be some time before they can see you. You're free to wait if you like. If you'd be more comfortable, I can also have a female medical student assist me instead of Bob."

"How long do you think?"

"I can't say, but the nurse said the trauma was bad."

"There are only two women doctors in the hospital?"

"Only two in trauma. I could call someone from OB/GYN, but you'd be in line behind any women in labor or needing prenatal care, and that might take even longer. You could see your own OB/GYN or GP, if either of those is an option."

She contemplated for a moment, "I'll wait."

"OK."

Bob and I returned to the triage desk, and I let Alex know.

"Want me to call OB and see if they have someone?" he asked.

"Probably a good idea, as we have no idea how long Doctor Billings and Doctor Townshend will be. I'll take the rule-out broken ankle."

He handed me the chart, and Bob and I went back to the waiting room. I first stopped to let Miss Munroe know that we'd called for an OB/GYN but couldn't give her an ETA, then went over to Miss Lucy Knight, age nineteen, and sitting in a wheelchair.

"Hi," I said. "I'm Doctor Mike and this is Bob, a medical student I'm training, and some other students who are observing. What happened?"

"I missed a step and landed badly. I twisted my ankle. My mom thinks it's broken, but I think it's just a bad sprain."

"We'll do an exam and an X-ray and see what's up. Is this your mom?"

"Yes."

"Mrs. Knight, we'll take good care of her and someone will come let you know when we've finished our exam."

"Can I come back with her?" she asked.

"That's up to Lucy," I said.

"Sure," Miss Knight agreed.

"Bob, if you'll do the honors," I said. "Exam 3 is open."

Bob pushed the wheelchair, and we went to Exam 3, where I conducted the H&P.

"I need to get an X-ray of your ankle," I said. "Is there any chance you're pregnant?"

"What kind of question is that?" Mrs. Knight asked, sounding offended.