Chapter 14: A Long Shift Finally Ends

July 4, 1989, McKinley, Ohio

I had just enough time to finish my phone call and coffee before the X-ray results were back for Alicia Sanderson's ankle.

"I'd call this a Grade 2 sprain," I said, looking at the X-rays with Doctor Williams on the light panel in the Attendings' office. "That was the radiologist's assessment as well."

"Then it's unanimous," Doctor Williams said. "Treatment plan?"

"Wrap in an Ace bandage, crutches, rest with the ankle elevated, ice as necessary, Tylenol or Advil for pain, and a referral to a sports physiologist in the medical building next door for follow-up."

"Make it happen."

I took the X-rays from the viewer, then Tom, Mary, and I left the Attendings' office and went back to the exam room to discuss the results with Alicia and her mom. In the exam room, I put the X-rays on the light panel and turned it on, then explained what we'd found.

"Long-term, it should heal completely with no permanent impairment," I said. "I'm going to refer you to Doctor Jeong Kim, a sports physiologist. You should call his office today and make an appointment for Friday. Until then, rest, keep your ankle elevated, use ice to bring down the swelling, and take Tylenol or Advil for the pain. We'll give you crutches, and you can put no weight on your ankle at all until you're cleared by Doctor Kim to do so."

"When can I run?" she asked.

"Typically, about twelve weeks, but Doctor Kim will discuss that with you after he examines you, and he'll recommend a proper course of rehabilitation. It's very important you follow my instructions and his so you don't do any permanent damage to your ankle."

"That stupid dog!" Alicia growled.

"Tom, would you get me an Ace bandage, please?" I asked. "Then get a set of crutches. Alicia is tall, so she'll need the larger size."

He went to the supply cabinet and took out a package with an Ace bandage, opened it, and handed me the bandage, then left to get the crutches.

"OK to wrap your ankle?" I asked.

"Yes," she replied.

I wrapped the Ace bandage tightly around her ankle, using a clip to attach the loose end to the layer below it.

"Leave this on until you see Doctor Kim," I said. "I take it you haven't used crutches before?"

"No."

"Then let me explain. Mrs. Sanderson, you could go to Patient Services while we do this."

"OK," she agreed.

I gave her the discharge papers, and she left. I went through the proper usage of crutches, and when Tom returned, Mary and I helped Alicia practice until she had the hang of moving with them.

"You'll need to sit in the wheelchair," I said. "Policy again."

Alicia rolled her eyes, and Mary helped her from the table into the chair and set the crutches next to her.

"Tom will wheel you out," I said. "Good luck with your rehab."

"Thanks! You have a really soft touch!"

"Thank you," I said. "Tom?"

He wheeled her out and as soon as they were in Patient Services and out of earshot, Mary laughed.

"And just what exactly did she want you to touch?"

"Whatever it was, if I did that, it would result in me dying somewhere between climbing out of my Mustang in my driveway and the front porch of my house!"

"Mike?" Ellie called out. "Doctor Gabriel needs you in Trauma 1."

Tom, Mary, and I went to Trauma 1.

"You asked for me?"

"Probable surgical case. Rafiq is in Trauma 2. Can you do the consult?"

"Yes."

The ultrasound was set up, as he had used it for his assessment. I immediately saw fluid in Morison's and said so.

"Let me call upstairs," I said.

I called the scheduling nurse and let her know, then Mary and I took the patient up to the OR, but given how busy we were in the ED, there was no way we could scrub in.

"Bummer," Mary said as we returned to the elevator.

"You'll get your chance," I replied. "I felt the same way, by the way. Always ready for more."

"It's your fault! You let me manage two cases, and that made me want more!"

"It is addictive," I replied. "Or like Lay's chips — nobody can eat just one! Remember how concerned you were with missing the toddler with croup?"

"Yes, and obviously, you didn't hold it against me."

"You accepted correction and committed to not making the same mistake a second time. That's all we can ask. You weren't given a chance to do any procedures in June?"

"Sutures only," she replied. "I was mostly with Doctor Townshend and Doctor Lewis, and they did everything."

"When you do your evaluation, make sure you note that. There won't be any negatives, and it will help Doctor Gibbs know how to help them."

"I was warned not to say anything seriously negative on evaluations."

"I was never given that advice, and I certainly wouldn't have followed it! Simply be truthful and honest. I want feedback, and if I'm doing something that interferes with your training, I want to know about it, and Doctor Gibbs should absolutely know about it."

"At the risk of you making my life hell because I sound ungrateful, I'd say more procedures!"

"As Doctor Williams said to me earlier, it's not news that med students want more procedures! I'm totally with you on that, and I'll do my best, though the rules are pretty strict about when I can let you handle things. Other times, it's a judgment call."

"Cute teenage girls?"

I laughed, "I did notice, but that wasn't a consideration. It was that I hadn't seen any sprains or fractures in your procedure book, so I felt you should watch one before I ask you to do one or teach one."

"I had seen them but never had a chance to do anything."

"Next one, then," I said. "How are you on X-rays?"

"Other than the Preceptorship in Radiology and the plates we saw in class, I haven't had a chance."

"Then, next set of X-rays, I'll have you look at them before I say anything to see how much you can discern. You notice I took them to Doctor Gabriel before I spoke to the patient, right?"

"Yes. Is that required?"

"In the sense that we're supposed to go to our Attending with anything beyond our comfort level, yes. I haven't seen enough films to be confident in my diagnosis, though I could rely on the radiologist if I elected to do so. I'd rather confirm the finding with my Attending because every doctor makes mistakes or misses something, and that's as true of radiology as any other service."

We reached the ED, and Ellie directed me to triage again.

"Fifteen-year-old male; line drive to the chest during a Little League game; large contusion just over the right nipple; vitals normal."

I accepted the chart and asked Mary to find Tom and meet me in Exam 2, which I saw was open on the board. She walked back into the ED, and I went to the door of the waiting room.

"Nick Smith?" I called out.

"Me," a boy in a baseball uniform called out.

I went over to him and introduced myself.

"Is this your dad?"

"My coach," he said.

"Coach Nichols," he said. "I was concerned about the line drive, so I brought him in. I heard about an incident in Cincinnati last year where a kid died after a similar incident."

"You were wise to bring him in. There's a rare condition called comotio cordis that can occur with a blow to the chest at a specific point in the heart rhythm. Let's go back and I'll do an exam. Have you notified his parents?"

"They both work," Nick said.

"Then we'll call them once we check you out. Your coach can come back with you if you want."

"Yeah," he agreed.

The three of us went to the exam room, where Tom and Mary were waiting. I introduced them, then went to the sink to wash my hands.

"Tom, history, please."

He completed the history, and then I did the physical exam.

"Everything appears to be OK," I said. "The bruise is pretty nasty, but I don't believe there are any other injuries. I do want to get an EKG just to be sure. If you'd take your jersey off, Mary will attach the leads."

Five minutes later, with a perfectly clean EKG, I was confident Nick was fine.

"You're good to go," I said. "Ice and either Tylenol or Advil for pain."

"Can I play?"

"As long as you're comfortable," I said. "Let me speak to my supervisor, and we'll discharge you. Coach, you can use the phone there to call his parents."

Tom, Mary, and I went to find Doctor Williams, and I had Tom present the case.

"No X-rays?" Doctor Williams asked Tom.

"Uhm, Doctor Mike didn't think we needed them."

"And what do you think?"

"Well, he did a physical exam and ran an EKG and didn't find any signs of injury beyond the bruise."

"And what would we do for a broken rib?" Doctor Williams asked.

"Unless a lung or other organ was compromised, monitor and refer to his physician."

"And there were no signs of breathing trouble?"

"I didn't listen, but Doctor Mike said his lungs were clear."

"So, about the X-ray?"

"I don't think it's necessary because it basically wouldn't matter."

"Correct. Good report, Mr. Lawson. May I have the chart, please?"

Tom handed Doctor Williams the chart, and Doctor Williams returned it after making notes and signing it. We returned to the exam room and let Nick and his coach know they were OK to leave and to return if Nick had any breathing problems or an irregular heartbeat.

"I wasn't sure what to say to Doctor Williams," Tom said after Nick and his coach had left.

"Never be afraid to say that you don't know," I counseled. "I get asked those same questions, only I'm expected to have the complete answer, not need to have it drawn out by questions. But you're a Third Year in your first clinical rotation, so you did fine. Eighteen months from now, you'd be expected to give the same answer, just complete in response to the initial question."

"You had questions like that?"

"All the time. And there were times when I had to say that I didn't know. What I figured out early on is that you have to ask to be taught, and you need to be both curious and proactive. Every Resident is different, and you'll find good teachers and ones that aren't good teachers. Your job is to figure out how to learn in both cases."

"How? I mean, if the teacher is bad, how can the student learn?"

"By observing and generally making a nuisance of themselves with questions. If the Resident refuses to answer, you go to your Attending or your advisor at the medical school and let them handle it. But mostly, you should find a way. That's what I did when I had suboptimal teachers. They were good doctors, mind you, just poor teachers. Sometimes you have to go to someone else, and generally nobody will complain about you doing that."

"Is there any way to choose our Residents?" Tom asked.

"Not really," I replied. "And if you truly don't get along with your Resident, it's incumbent on you to find a way to get through the rotation. After all, you can't expect to like every doctor, and no doctor is liked by everyone."

"Even you?" Mary asked, with a twinkle in her eye.

"Especially me! I am, as a number of Attendings and Residents will attest, a pain in the ass."

"But you graduated first in your class!" Tom protested.

"Which has nothing to do with not being a pain in the ass! Part of it is what I said before - make a nuisance of yourself, if necessary, to learn. I sure did. Most of the time, it showed the Resident or Attending how serious I was; other times, it simply pissed them off. I've had Residents do things which might be considered retaliatory or punitive and my response was to grin and bear it."

"Like what, if you can say?" Mary asked.

"A Resident who decided he didn't like me and assigned me shifts that knowingly conflicted with church attendance and assigned me every single bit of scut available."

"That's not right."

"No, it's not, but I won the battle by not letting it faze me or affect my attitude. In fact, it actually ensured I was the cheeriest I'd been on any Third Year rotation!"

"An interesting way to get revenge," Tom said.

"Indeed. That Resident was more perturbed that I wasn't upset than I was perturbed by the hazing. That is how you deal with the BS."

"Mike?" Ellie called out. "Doctor Williams would like to see you."

The three of us went to his office.

"Your neuro consult gorked," Doctor Williams said. "Expect to be called in front of the M & M a week from Friday."

"Thanks for letting me know," I said.

We left his office and went to the lounge, got a bottle of water, then I basically collapsed onto the couch. I'd been on for twenty-nine hours and had no sleep, and I could feel it. I wondered how I'd get through the concert, let alone the two or three hours afterwards.

"What happens now?" Tom asked.

"You mean the M & M? Have you been to one?"

"No."

"You should attend as many as possible, even coming in if you aren't on shift. If you are, ask for permission to go. It'll usually be granted. You, too, Mary."

"I've been to a couple," she replied.

"Good. The answer to your question, Tom, is that it's a question-and-answer period about interesting or difficult, or, in this case, cases with bad outcomes. What will happen is I'll present the case, then answer questions from other doctors about the management of the case. They'll critique my handling of it, give advice, and try to find the root cause of the problem."

"Why don't you seem nervous?" he asked.

"First, it's not adversarial, but second, think about what I did."

He was quiet and shook his head.

"I insisted Doctor Mastriano write her order on the chart," I said.

"Whoa! That was self-defense?"

"Very much so. In my opinion, she was wrong, so I made her put it in writing. She'll be roasted at the M & M, even though it's not adversarial."

"Roasted how?" Tom asked.

"For sleeping," Mary interjected. "She was more interested in not being disturbed than spending five minutes examining the patient."

"That about sums it up," I said.

"Mike?" Ellie said from the door to the lounge, "Doctor Williams needs you. EMS is three minutes out with a young drowning victim."

"Lord have mercy," I said aloud. "Be right there, Ellie."

"Survival rate?" Tom asked as I got up.

"During the Summer? Near zero if not revived at the scene. During Winter, one in four due to the effects of hypothermia."

We hurried to the ambulance bay, grabbing gowns and gloves on the way.

"EMS is performing CPR en route," Doctor Williams said, conveying that anything we did was likely going to be futile.

"Intubation and EKG?" I asked.

"Yes. Is your student ready for that?"

That question reinforced what I'd surmised.

"Mary is capable," I replied. "I'll guide her."

"Good," Doctor Williams said. "Tom, EKG and monitor."

"Yes, Doctor."

"Mary, tell me the steps for intubation, please," I said.

She took a deep breath, let it out, then said, "Select the correct endotracheal tube based on the patient's physiology, then gently open the patient's mouth, insert the laryngoscope blade, and slide down the right side of mouth until the tonsils are visible. Move the blade to push the tongue centrally until the uvula is visible. Next, advance over the base of the tongue until the epiglottis is seen.

"At that point, advance steadily until the tip of the blade is at the vallecula and the epiglottis is visible below it. Lift gently forward and upward to raise the epiglottis and reveal the arytenoid cartilages and vocal cords. Once the cords are visible, insert the tube in the groove of the laryngoscope so that the cuff passes the vocal cords. Once the tip of the tube is at the glottis, remove the stylet and gently advance until the cuff is past the vocal cords. Inflate the cuff to protect the airway from secretions and form a seal around the tube. Then confirm placement."

"Textbook answer, almost word for word," I said. "How do you confirm placement?"

"With a ventilator or bag at one breath every five or six seconds, checking for chest movement and bilateral breath sounds."

"Correct. And if you don't hear them?"

"Reposition the tube, usually withdrawing slightly, unless no sounds are heard, in which case you remove the tube and begin again.

"Good. Do exactly that. Remember, slow and smooth is the fastest way, even though it sounds contradictory."

"Because it's more important to get it right than to be fast and get it wrong."

"Exactly. Thirty seconds sounds like a short amount of time, but it's really a long time in the scheme of things. Again, I know that sounds contradictory, but it's true. If the patient is conscious, what drugs?"

"How old?" she asked.

"Around ten," Doctor Williams said as the Fire Department EMS squad pulled into the driveway.

"For adults, it's weight-based," she said. "For a ten-year-old, there's a set dose in my book."

"Look it up now," I said.

She did as the squad came to a stop.

"Ten-year-old male found floating in a pool; unresponsive and not breathing; no vitals; CPR performed after recovery."

I was positive the boy was dead, but that didn't mean we wouldn't try.

"Trauma 1!" Doctor Williams ordered. "How long down?"

"At least twenty minutes," the paramedic said as we rushed the gurney with a firefighter performing CPR while the other paramedic bagged him.

In the room, the six of us quickly moved him to the treatment table, and Nurse Amelia took over bagging while I relieved the fireman who was performing chest compressions.

"Intubation kit to Mary!" Doctor Williams ordered. "Mike, stop compressions."

I did as Nurse Jenny brought the kit to Mary, who picked up the laryngoscope and the pediatric endotracheal tube.

"No heart sounds," Doctor Williams announced. "Mike, resume compressions. Jenny, stat pH!"

Tom worked around me to get the EKG leads attached, Amelia got an IV into the boy's arm, and Jenny drew blood for the pH test. As they did that, I watched as Mary used the correct technique to get the tube inserted.

"I'm in!" she said.

"Connect the vent and set it to ten per minute," I said. "Once it's on, I'll stop compressions so Doctor Williams can listen."

"Asystole," Doctor Williams declared. "An amp of epi down the tube, please."