Chapter 13: A Long Night During a Long Shift

July 4, 1989, McKinley, Ohio

"I need to discharge Mr. Temple," I said to Doctor Mastriano.

"Do that, then come to my office."

"Yes, Doctor," I agreed.

Mr. Temple had not had a repeat of his syncopal event, nor had he experienced additional bouts of A-fib, so I wrote out the cardiology referral to keep Medicare happy, completed the discharge papers, directed him and his wife to Patient Services, then went to the Attendings' office where Doctor Gabriel was with Doctor Mastriano.

"Give us the room, please," Doctor Mastriano said to Doctor Gabriel.

"Morning, Mike," Doctor Gabriel said.

"Morning, Pete," I replied.

"Rough night?"

"Long, but I'm doing OK."

He left, closing the door behind him.

"If you EVER contradict me or undermine my authority again, I'll bounce you from this program so fast you won't know what happened."

I was tired, and I knew it, and that meant I had to be extra careful in what I said and how I said it, lest I allow fatigue to cause me to say or do something foolish.

"May I please suggest you take this up with Doctor Cutter and Doctor Northrup?" I requested. "My situation is different from all other emergency medicine Residents because of my special program."

"You aren't special. You're a PGY1, and you have neither the experience nor the skills to make the judgments you're making."

"Which is why you slept all night and insisted that I not bother you?" I asked snidely, instantly regretting it.

"This is not about me, Loucks. You directly disobeyed my instructions."

"I'm sorry I mentioned you sleeping all night," I said, intending to twist the knife despite my earlier resolve to be careful. "But, Doctor, I didn't disobey your instructions. You instructed me to call for a consult, which is performed by a surgical Resident. I'm a surgical Resident, and Doctor Roth confirmed that I was authorized to make the assessment."

"You know very well that I meant to have the on-call surgical Resident come down, not to play word games. And then you disappeared for forty minutes!"

"Doctor Blake directed me to scrub in to help with the surgery."

"You're a fucking Intern! You don't touch patients in an OR!"

"I performed a blind pericardiocentesis under Doctor Blake's instruction, with the goal that I'll be able to do those in the ED."

"Not in MY trauma rooms."

"I don't know what to say beyond that you should take it up with Doctor Cutter and Doctor Northrup, or Doctor Gibbs, once she comes back on Friday."

"This is going in your file, Loucks. And I won't stand for a repeat."

"Yes, Doctor," I said, knowing an argument would do me no good.

"You are to confirm every single procedure with me."

"If you insist, I'll be happy to wake you to ask about giving a patient a Tylenol."

"You know what I meant!"

"I heard you say 'every single procedure', Doctor. I'm going to err on the side of caution to ensure there are no misunderstandings or misinterpretations."

"Don't be a smart ass."

"It's not being a smart ass. It's a proper response to being reprimanded for interpreting your instructions in a way you consider incorrect or insubordinate but which benefitted the patient. May I be dismissed so I may speak with my mentor about this?"

"Doctor Casper is not here."

"No, but Doctor Taylor is."

"What does he have to do with anything? Casper is your mentor."

"Not Josh Taylor," I replied. "Vince Taylor."

"He's a surgeon, not an emergency medicine specialist!" Doctor Mastriano protested.

"Indeed, and the red scrubs and the 'S' on my badge indicate I'm on the surgical service. May I go?"

"Get out of here!" she growled.

I left and went to the nurses' station and called to see if Doctor Taylor was available. The nurse said he was just about to go into surgery, so I decided to go up and talk with him while he scrubbed.

"Hi, Mike! What's up?"

"Hi, Vince," I replied. "Doctor Mastriano basically put me on double secret probation because I followed the program set by Doctor Cutter."

"She's ... no, I can't say that to you. Let me handle it with Doctor Cutter. Can you give me the nutshell in two minutes?"

"Yes."

I explained the events of the previous twenty-four hours, including the contradictory things Doctor Mastriano had said.

"Her shift ends right about now, doesn't it?"

"Yes."

"When are you on with her again?"

"I'm not sure of her schedule, but certainly next week, Monday."

"OK. Who's the senior Attending today with Gibbs out?"

"Brent Williams."

"Explain briefly what happened, and have him clear you to perform the procedures everyone has signed off on. Keep your comments about Mastriano neutral, please."

I nodded, "I will."

"OK. I'll get in touch this afternoon after I speak with Doctor Cutter."

I thanked him, left, and returned to the ED.

"You OK?" Tom asked.

I nodded, "Just part of the turf war, I think. I need to go see Doctor Williams."

I saw him in the Attendings' office and decided to wait until Doctor Mastriano left before talking to him, so I went to the lounge where Mary was on the couch.

"How do I get off triage and get to work with you more?" she asked.

"There isn't much I can do about the policy," I replied. "Given EMTALA requires us to provide an exam and treat all emergent cases and active labors, we have to have someone trained in H&P handle walk-ins, where before it was done by the clerk, who now has other duties. There's a staffing problem with exclusively using nurses, and that's why more medical students are assigned to the ED now than in the past. Next week, for this shift, Doctor Varma's student will handle overnight, and you'll just have a two-hour shift during the day. Did that happen last month?"

Mary nodded, "Yes, but I also wasn't working with you. You're more willing to allow your students to do procedures than anyone else, and I want to learn."

"I'll do my best when you aren't on the triage desk, but I can't change that."

"It just sucks that Tom got to scrub in on the emergency surgery; no offense Tom."

"None taken," he replied. "But I also won't apologize!"

"Nor should you," I interjected. "Mary, I'll do my best to make sure you get procedures, and we should have plenty of opportunities today, if history means anything. If you'll excuse me, I need to see Doctor Williams. You two should get your breakfast now."

They left, and I found Doctor Williams in the corridor and asked to speak to him.

"I got an earful from Mastriano," he said.

"Vince Taylor in surgery suggested I speak to you about the restrictions Doctor Mastriano placed on me."

"Well, she's not here, and if you come to ask me about giving a patient Tylenol, you'll regret it!"

"Understood."

"Is it true she blew off a patient with a head injury?"

"She insisted, and wrote on the chart, that I was to wait for his EtOH level to drop before she'd consider any further actions beyond life support."

"He seized and herniated?"

"I didn't get a report from neuro, but that would be my impression based on what I know."

"That's going to be an ugly M & M if he's gorked."

"Yes, it will," I confirmed. "May I raise one other topic?"

"You never stop, do you?" he asked with a sly smile.

"No, which I suspect is part of Doctor Mastriano's problem with me. In any event, this isn't a request or even recommendation, but my Fourth Year asked about less time on the triage desk and more time doing procedures."

"Stop the presses! Breaking news! Medical Student wants more procedures! Film at 11!"

I chuckled, "You kind of mixed your metaphors there with print and broadcast media."

"You are a pain in the ass, Mike!" Doctor Williams declared with a grin. "A great young physician but a major pain in the ass!"

"All part of my master plan for world domination!" I chuckled.

"I'd actually be OK with you being Emperor of the World! You care too much about people to be an evil dictator!"

"I suggest you ask Rachel that question in about twelve years!"

Doctor Williams laughed, "I have an eleven-year-old daughter, and I'm positive she thinks I'm a cross between Genghis Khan, Attila the Hun, and Pat Robertson!"

"Two of those aren't so bad," I replied.

Doctor Williams laughed, "Let me guess, you think Robertson is the truly evil one in that trio?!"

"Let's just say that I have significant differences of opinion from the so-called Moral Majority."

"You and me both! And yet, I believe that's the main area of conflict with my daughter!"

"May I ask how old you are?"

"Thirty-three. We had Michelle as my graduation present from UofI. Not the best timing, but I'm very happy we have her. How is your daughter?"

"Asserting her newfound independence," I replied. "Her favorite word is 'no', followed closely by demanding to see her Aunt or her best friend."

"It doesn't get much better! Wait until she discovers boys!"

"Oh, she has, and has ZERO use for them!" I chuckled. "But that will change in about twelve years."

"Or sooner. My daughter decided they were interesting just before her eleventh birthday."

"Lord, have mercy!"

"You can say that again!" he replied, then immediately said, "STOP!"

"What? " I asked with a 'What, me worry?' look.

"You were going to actually say it again! I could tell by the look on your face!"

"My reputation precedes me. OK to get my breakfast?"

"Yes. Make sure your students eat."

"I sent them to have their meal when I came to speak with you."

"When are you with Mastriano again?"

"I honestly don't know. I only looked at my schedule."

He pulled open a drawer and pulled out a calendar.

"Saturday," he said. "I'll speak to Doctor Gibbs and Doctor Northrup and let them decide what to do."

"Thanks, Brent."

"You're welcome. Naveen has walk-ins, so you're on ambulance runs and monitoring as soon as you come back."

"OK."

I left the Attendings' office and hurried to the cafeteria where I got eggs, bacon, yogurt, toast, and coffee, then sat down with Mary and Tom, who were already eating.

"How much trouble are you in?" Mary asked.

"The usual amount," I replied. "It won't affect anything for the rest of this shift."

"Tom wasn't sure exactly what happened."

"Neither am I, in the sense that everything seemed more or less OK with Doctor Mastriano during my shift on Saturday."

"She slept all night?" Mary asked.

"I'd prefer we didn't discuss what Doctor Mastriano did last night," I said. "As I mentioned, there's something of a turf war between the ED and Surgery, and it's best if we all keep our heads down as best we can. I'm kind of stuck in the middle with a balancing act, and I need to let the Attendings and Chiefs fight this out and try not to be hit by friendly fire, so to speak."

"But the new specialty makes so much sense!" Mary protested.

"So did hand washing and the germ theory of disease," Tom interjected. "And I'm sure you remember that from Practice of Medicine."

"I just don't get it," Mary said, shaking her head. "Just because something is new doesn't mean it's bad."

"No, but what's the number one rule of thumb in medicine?" I asked. "Not what they taught you in Practice of Medicine, but in reality?"

"Go with what works," Mary replied.

"Exactly. So, if something works, the system is designed to stick with it until it's proved that there is a better way. Sometimes, that's easy, usually around pharmaceuticals. Sometimes, it's difficult, such as with new surgical techniques. Can you tell me why?"

She thought about it for a moment, then nodded.

"Because the system is designed to protect physicians who follow a specific standard of care, and looks askance on variations from that standard, even if they're successful."

"Why?"

"To prevent a 'Wild West' environment where anything goes and there are no standards."

"Yes, and think about what that means for emergency medicine. What's different there?"

"You don't have time to think in many cases."

"Right. What do you know about succinylcholine and etomidate?"

"They're used for intubation," Mary said.

"Why?"

"Adverse effects are exceedingly rare, they're short-lived, and have standard dosage for adults."

"And the value of that?" I prompted.

"You save precious seconds and don't have to worry about contraindications."

"Correct. So if someone came up with a new drug, how would that be received?"

"Skeptically because what we have works and is very, very low risk."

"So even something that is somehow better would be difficult to adopt. Why?"

"Because the new benefits are unlikely to be sufficient to take the risk."

"Yes. And what mentality does that engender?"

"Semmelweis," she replied.

"Here endeth the lesson," I said with a smile. "We need to finish eating and get back."

"Sean Connery in The Untouchables?" Tom asked.

"Yes," I replied.

We finished our breakfast and headed back to the ED where Doctor Fitzgerald and Doctor Lewis had come on shift alongside Naveen Varma and me, which was the normal daytime contingent of PGY1s, with Doctor Williams as the Attending and Doctor Gabriel as the senior Resident. The Attendings would work between twelve and eighteen hours, while senior Residents worked between eighteen and twenty-four, and the PGY1s as much as thirty-six hours. The only doctor with regular hours was Doctor Gibbs, who, as the Chief Attending, worked between ten and twelve hours Monday through Friday.

"Mike," Doctor Williams called out, seeing us walk into the ED.

"Yes?" I inquired.

"Hand lac in Exam 6 if your student wants a procedure."

"Nah," I replied. "What med student ever wants more procedures?"

He laughed, "OK, because, not if."

"Mary, do you feel comfortable doing the procedure with Tom, explaining what you're doing, and completing the discharge?"

"Yes!" she exclaimed.

"Then we'll all go in, and I'll stand in the corner and observe. Introduce yourself as a Sub-Intern, but don't explain what that is unless asked. If they ask, you say it's a 'trainee doctor'. Introduce me as your supervisor and Tom as a new student."

"Yes, Doctor!"

"Then let's go."

The three of us went to Exam 6, stopping at the door so Mary could review the chart, which was in the holder on the wall.

"Forty-two-year-old male," she said. "Bagel-slicing accident; five-centimetre lac on his palm with no tendon involvement and clean margins."

"Before we step in, what are you going to do?"

"Appreciate the wound; irrigate; inject lidocaine, probably times five; paint with Betadine; suture with 4-0 nylon; apply a clean dressing."

"Good," I confirmed. "Tom, what else?"

"Verify his tetanus. Mary should also ask about negative reactions to local anesthesia and allergies."

"Very good. I'll stand aside and only step in if I see something that concerns me."

We went into the room, and Mary introduced herself, Tom, and me as I'd instructed. She proceeded exactly along the lines she'd suggested and did an excellent job suturing. Tom administered a tetanus shot, and then Mary discharged the patient.

"How does it feel to be a doctor?" I asked Mary after we returned to the lounge.

"That's the first time I was ever allowed to do everything from start to finish."

"And you did an excellent job. Write it into your procedure book, and I'll sign it. Do one more like that, and I'll sign off for you to do them without observation. Tom, you'll get your chance before the end of the month as well."

"Thanks," he replied.

"Doctor Mike?" Nurse Ellie said from the door to the lounge. "EMS five minutes out with failure to fly."

"Thanks, Ellie. Which room?"

"Trauma 2. I'll send you Nancy."

"Thanks."

"Failure to fly?" Tom asked.

"Kid, usually between four and eight, almost always a boy who fell out of a bunk bed or something similar," I replied. "Let's go."

Five minutes later, the EMS squad arrived.

"Danny Baldwin, six; fell from his bunk bed; BP 110/70; pulse 90; PO₂ 98% on room air; contusion on forehead; no other obvious injuries; unconscious for about two minutes; GCS 11 on arrival, 14 now; cervical collar. His parents are right behind us."

"Trauma 2!" I ordered, and we began moving. "Hi, Danny. I'm Doctor Mike, and we're going to take good care of you."

"My head hurts!" he said.

"We'll do our best to fix that!" I said. "Mary, primary survey, please. Tom, pulse oximeter only."

"Trauma panel?" Nurse Nancy asked.

"I think we can dispense with that for the moment," I replied.

The four of us, plus the two paramedics, gently moved Danny to the trauma table.

"Danny, this is my friend Mary," I said. "She's going to check your eyes, ears, nose, and mouth and listen to your heart and lungs. My other friend Tom is going to put a clip on your finger to measure how fast your heart is beating."

"Will it hurt?" he asked.

"No."

Mary, who already had on gloves, picked up the otoscope, put on a fresh speculum, and began her exam, announcing her observations as she checked.

"No CSF in either ear; pupils reactive; nasal passage clear and free of fluids; throat clear."

"OK. Tom, Babinski, please. Danny, my friend Tom is going to rub the bottom of your feet."

Tom did the test and reported his findings.

"Normal flexor, both feet."

"Indicating?" I asked.

"No spinal damage, but it's not definitive."

"Correct. Danny, I need to check your neck," I said. "I'm going to ask my friend Mary to hold your head and you need to keep very still."

"OK," he said.

Mary stabilized Danny's head, and I carefully loosened the cervical collar and appreciated his spine and neck muscles.

"No indication of trauma," I said.

"Everything OK in here?" Doctor Williams asked from the door of the trauma room.

"Just completing the primary exam and about to remove the cervical collar."

"Proceed," he said. "Call me if you need me."

I removed the collar and asked Bobby to slowly turn his head from side to side.

"Does that hurt at all?" I asked.