Chapter 20: Popcorn?

July 14, 1989, McKinley, Ohio

By Friday afternoon, I was once again the walking dead, though it wasn't quite as bad as the previous week. Just before 3:00pm, Doctor Gibbs, Mary, Tom, and I left the ED to attend the M & M conference. Because of the timing, that meant several ED docs couldn't attend, as someone had to cover the ED, and it was possible that Doctor Gibbs might be paged, though that would only occur if a disaster protocol was activated.

When we reached the hallway outside the auditorium, I saw Clarissa waiting for us and started laughing.

"Seriously, Lissa?" I asked.

She smirked and asked with faux innocence, "What?"

"Popcorn?"

"It seemed appropriate! Other people bring snacks."

"Mike," Doctor Gibbs said. "One piece of advice — keep it completely clinical."

I nodded, "That was my plan. And while I didn't bring popcorn, I'll sit back and watch once Doctor Mastriano is in the dock."

We went into the auditorium, and while everyone else sat towards the back, I sat down in the front row, as I'd be presenting. I opened the chart and skimmed it, doing one last check that I had the sequence of events correct in my mind.

"Good Afternoon," Doctor Jerry Rhodes said. "Our first case will be presented by Mike Loucks, surgical Intern. Doctor Loucks?"

I rose and went to the podium, took a deep breath, let it out, then began.

"Good afternoon. Just after midnight on July 4th, an African American patient was brought to the Emergency Department in private transportation and left in the waiting room. Upon exam, his breath smelled of alcohol, and it was obvious he had been in a fight. The triage team reported he was semi-coherent upon arrival but then appeared to have fallen asleep. At intake, his vitals were typical of an individual under the influence of alcohol.

"The patient was transported to Exam 2, and my Third Year, a nurse, and I evaluated him. A banana bag was hung immediately. The primary exam was unremarkable save obvious contusions and lacerations to the patient's face, and his vitals were stable and consistent with inebriation. Blood was drawn for a trauma panel, as well as EtOH levels. The nurse recommended soft restraints, but I did not feel they were necessary.

"About ten minutes after the blood was drawn, which was about twenty minutes after intake, the lab reported EtOH at 0.19, confirming that the patient was, indeed, inebriated. At that point, a Sheriff's Deputy arrived, gave us the patient's name, and confirmed that he had been severely beaten by other patrons of a bar. The patient's injuries were all consistent with the reported beating. The Deputy asked if he could question the patient, but I reported that the patient was incoherent.

"While I was discussing the situation with the Deputy, I heard a crash from the exam room and went in to find the patient on the floor, with his IV out and a small amount of blood leaking from the IV site. The nurse reported that the patient had come to, pulled out his IV, and tried to get out of the exam bed but fell and lapsed back into his unconscious state.

"The patient was moved from the exam room to a trauma room. Soft restraints were applied, and the IV was reestablished. On exam, the patient had minor bleeding from his nose, though it's unclear if he broke it during the fall or if it had been broken during the fight. I instructed the nurse to pack the patient's right nostril with gauze to control the minor bleeding. I also apologized to the nurse for not listening to her recommendation of soft restraints.

"At that point, I determined that the patient needed at least a skull series and noted that on the chart, along with the need to rule out a concussion, though the patient's inebriation would interfere with that determination. The nurse and I both conferred with the Deputy, who took brief statements about the injuries from us, then left.

"About that time, the patient came to again but was incoherent. I was concerned about that, as well as his lapsing in and out of consciousness, as his EtOH levels were not high enough to cause unconsciousness nor induce complete incoherence. The standard practice in such cases is to wait for EtOH levels to drop below 0.1, but given the blows the patient had taken to the face and his fall, I felt an immediate neuro consult and CAT scan were indicated and noted those on the chart.

"After consulting with the nurse, I went to present the case to my Attending, Doctor Mastriano, with my recommendations. I found her in the Attending's office and asked to present the case. I did so and made my recommendations. Doctor Mastriano countermanded my written plan based on the patient's EtOH levels. I repeated my concern that the patient would suffer neural deficits and possibly herniate. Doctor Mastriano stated clearly and firmly that I was to monitor until the patient's EtOH levels were below 0.05, so I asked her to write her order on the chart, which she did.

"I returned to the room and performed another set of neuro checks, finding no appreciable signs that were inconsistent with inebriation. Because of my concerns, I ordered oxygen by cannula, as well as a glucose stick test, which showed 96. I instructed the nurse to perform another stick test, an ABG, and obtain EtOH levels every thirty minutes and wrote that order on the chart.

"At that point, I was called for another patient who'd been brought in by his wife for a syncopal episode. While I was examining that patient, a nurse reported that the initial patient was seizing, so I ordered my medical student to wake Doctor Mastriano and hurried to the trauma room where the nurse who I'd left with him had inserted a bite guard. I ordered 4 megs of lorazepam IV push, which resolved the seizures.

"Postictal exam showed a blown left pupil and a sluggish right pupil. I ordered an immediate neuro consult. At that point, Doctor Mastriano entered the trauma room and asked what had happened. I presented, then ordered my medical student to hook up an EKG and monitor. Doctor Mastriano examined the patient and observed the same condition. She instructed me to call her after the neuro consult, but I asked her to stay as I was at the limits of my skills and abilities. She refused and left the room.

"I ordered new blood work, then went to check on my other patient. I returned when the neuro Resident arrived and presented the case. The most recent EtOH level at that point was 0.15. She performed an exam, including a Babinski, which showed normal flexor response. She proposed a diagnosis of a subdural hematoma and suggested a CAT scan, and I concurred.

"In order to take the patient with EtOH levels above the standard, she called and spoke to her Attending, who approved both the CAT scan and the admission. At that point, the patient was transferred to her care, and I went to handle an EMS transport of a car versus bicycle accident."

"Thank you, Doctor," Doctor Rhodes said. "Questions?"

"Mike," Doctor Strong said, standing up. "Why did you not want soft restraints?"

"Lack of experience," I replied. "The nurse was more than happy to point out that I should have listened to her, and I've learned my lesson."

There was laughter from quite a few attendees.

Doctor Javadi stood up and asked, "What made you think the patient had neurological problems?"

"He had been subject to a severe beating, and I was concerned about broken facial bones, though I didn't appreciate any. The autopsy report showed a non-displaced orbital fracture, which Doctor McKnight ruled was from a blow by a fist, not from contact with the floor. The contradiction, of course, was the high EtOH levels, but, as I noted, not high enough to cause unconsciousness in a typical adult male in their twenties."

She sat down, and Doctor Roth stood.

"Why not just call neuro?" he inquired.

"Because absent some kind of significant neurological sign, they won't consult on a patient with EtOH levels above 0.1 unless the ED Attending on duty certifies the need and places the call to her counterpart. I had no signs or indications other than my gut feeling, so all I could do was recommend to Doctor Mastriano that the call be made."

He sat down, and Doctor Taylor, the surgeon, stood up.

"Is it true that Doctor Mastriano was sleeping each time you approached her?"

"Yes."

"Is it also true she had given orders not to be disturbed?"

"Yes."

"How did she respond when you approached her about this patient?"

"She was annoyed."

He sat down, and nobody else stood.

"Thank you, Doctor Loucks," Doctor Rhodes said. "Doctor Cohen?"

I returned to my seat, and Doctor Cohen went to the lectern. She repeated her version of our interactions, which basically matched mine.

"Once he was transferred to our service, we took him immediately for a CAT scan, but he seized during the procedure. Neuro exam showed signs of significant brain injury, and despite administering mannitol, the brain swelling could not be controlled, and the patient expired. I have very little more to say, as we didn't complete the CAT scan."

Nobody had any questions for her, as she really did have very little more to add.

"Thank you, Doctor Cohen. Doctor McKnight?"

He replaced Doctor Cohen at the lectern and began his presentation.

"An African American male, age twenty-three, presented with facial injuries consistent with being struck repeatedly with fists. Upon autopsy, I appreciated a non-displaced fracture of his left orbital socket, as well as a hairline fracture of his left parietal bone, both consistent with being struck with a fist.

"In addition, he had a fracture of his nasal bone, consistent with either being struck with a fist or impact with the floor. It's my opinion that the injury was initially from a fist but exacerbated by striking his face on the floor. He had no remarkable injuries to any part of his body other than his face, though there were some defensive bruises on his forearms.

"Upon examination of his cranium, I found three large subdural hematomas, and the patient's brain had herniated. A thorough examination led to the conclusion that the injuries sustained from the fists were sufficient to cause significant bleeding in the brain, which led to herniation, resulting in the patient's death. I filed that report with law enforcement. Questions?"

"Would an immediate CAT scan have resulted in a different outcome?" Doctor Subramani asked, standing up.

"I'd have to be clairvoyant to answer that question," Doctor McKnight replied. "That said, the CAT scan would certainly have detected the hematomas."

Doctor Subramani sat down, and Doctor Rosenbaum stood up.

"Did the fall in the ED contribute to his death?"

"I don't believe so," Doctor McKnight said. "The fall certainly didn't do him any good, but there was no indication of injuries except to his nose. As I said, it's my opinion that injury was initially sustained when he was beaten."

"But the fall could have contributed to the outcome, right?"

"You know as well as I do," Doctor McKnight said, "that a minor bump on the head can cause a severe hematoma under the right circumstances. That said, there is zero indication that the fall had any significant impact on the patient's condition. In any event, such a fall could not cause hematomas in the regions where I found them. The laws of physics and what we know about the brain show that all three were the result of direct blows with fists."

Doctor Rosenbaum sat down, and Doctor Gómez stood up.

"Did you confer with law enforcement?" he asked.

"Yes. The Sheriff's Department confirmed that four men had set upon the patient and had beaten him up. Everything I saw was consistent with that, as was everything reported on the charts. I am absolutely certain the cause of death was the beating."

There were no further questions, and Doctor Rhodes called Doctor Mastriano to the lectern.

"Doctor, please explain your decision not to permit a neuro consult," Doctor Rhodes instructed.

"The standard of care," Doctor Mastriano said, "is that inebriated patients with no appreciable neurological signs, who are not in cardiac or respiratory distress, and who show no signs of internal injuries, are to receive IV fluids until their EtOH levels drop below 0.1, and if there are no indications of distress at that point, no further treatment until levels are below 0.05."

"Your Resident felt there was sufficient cause to discuss it with you and recommend a neuro consult and CAT scan."

"Interns don't have the experience to make those decisions, and I followed the standard of care."

"Does that include sleeping and demanding not to be woken up?" Doctor Taylor asked, standing up.

"On twenty-four-hour shifts, doctors are permitted to sleep," she countered.

"But isn't it true you gave express orders to both your Residents and the nurses to not wake you unless a patient was dying?"

"That's an exaggeration," she countered. "I left orders not to be disturbed unless necessary."

"How did you respond to Doctor Loucks' request to present?"

"I listened to what he had to say and made a medical judgment based on the standard of care."

"Mike," Doctor Taylor said, "would you tell us exactly what transpired?"

I stood up and relayed exactly how Doctor Mastriano had responded each time I'd tried to speak to her.

"One more question, Mike," he said. "Did Doctor Mastriano attempt to put a formal reprimand in your file because she disagreed with the standing orders from Doctor Cutter and Doctor Northrup for your training?"

"I cannot speak to her motives, only her actions. She did state she was going to place a letter in my file because I obtained permission from Doctor Roth to do a surgical consult against her wishes and then because I was asked to scrub in on an emergency surgery and didn't obtain permission from her."

"Thanks. Doctor Mastriano, who determines the training protocol for Interns and Residents?"

"The departmental Chiefs," she said.

"Do you believe you can substitute your judgment for theirs?"

"Doctor Taylor!" Doctor Rhodes said sharply. "Focus on facts, please."

"Sorry, Doctor. Doctor Mastriano, did you place a reprimand in Doctor Loucks' file?"

"Yes."

"And what happened?"

"It was removed and overturned by Doctor Cutter."

He sat down, and Doctor Subramani stood up.

"In hindsight, do you agree that the neuro consult should have been ordered for this patient?"

"That's not the standard of care," Doctor Mastriano replied.

"With all due respect, Doctor, that wasn't my question. Your Resident felt the standard of care was insufficient in this case, and reported that to you, and wrote it on the chart."

"CAT scans are expensive, and I saw no indication that one should be ordered. I couldn't justify it based on the standard of care."

"Then why not allow your Resident to call for a neuro consult?"

"Because with an EtOH of 0.19, they wouldn't have accepted him on their service."

"But that doesn't preclude a consult."

"Which would have shown nothing and achieved the same result."

"Mike, why did you think a consult and CAT scan were appropriate?" Doctor Subramani asked.

"The patient's neurological state did not conform to his EtOH levels."

"Thank you. Doctor Mastriano, isn't that a sign?"

"Everyone has a different response to alcohol, and a few hundredths of a percent difference is within the normal deviation."

Doctor Subramani sat down, and Doctor Rafiq stood up.

"Doesn't it make sense to bring in someone experienced when there is a disagreement?"

"He's an Intern, and it was his first week in the ED. He doesn't have the experience to make that judgment call."

"Which is why he came to you, but you appeared to be more interested in sleeping."

"Doctor Rafiq!" Doctor Rhodes said sharply.

"I apologize," Doctor Rafiq said, sitting down.

Doctor Cutter stood up.

"Doctor Mastriano, did you tell a surgical Intern that they had neither the experience nor skills to make the judgments they were making?"

"Yes, of course, because it's true."

"Doctor Northrup and I obviously disagree because we cleared Doctor Loucks for the procedures he's performing and set his training program. Are we wrong?"

"He's a PGY1 and has no business doing what he's doing."

"That's your judgment, Doctor. Are you perfect? Because if not, I find it odd that you do not care to listen to the opinions and judgments of others, whether they are junior to you or senior to you."

I was a bit surprised that Doctor Rhodes didn't intervene, but Doctor Cutter was the Chief of Surgery and the most senior doctor in the hospital besides Doctor Rhodes, which I suspected gave him more leeway.

"That is not true," Doctor Mastriano protested.

"Did you tell Doctor Loucks that he was to obtain your direct approval before performing any procedures, including ones I personally approved for him to do?"

"That's the prerogative of the Attending who is supervising the Intern."

"And your comment to him that he was not allowed to touch a patient in the OR?"

"That's the norm."

"And your judgment overrides mine?" Doctor Cutter asked.

"As I said, decisions about what procedures an Intern is permitted to do are the prerogative of the Attending who is supervising him or her."

"No, Doctor, they are not," Doctor Northrup said, standing up. "Jerry, I'll handle this internally. I believe we've established that we failed this patient."

"Then this case is closed," Doctor Rhodes said. "Our next case will be presented by Doctor Bielski."

I listened to the case of an angioplasty gone wrong due to a severely weakened aorta, where the conclusion was that there was no negligence and that not only had the standard of care been followed, but there had also been no indications of the problem prior to the insertion of the balloon catheter. The patient, under just about any imaginable circumstances, would have died with or without the attempted procedure, and the main lesson was that our imaging technology was not yet good enough to detect the problem encountered. A request was made for an MRI machine, and, as was nearly always the case with those kinds of requests, it was 'taken under advisement'.

There were no further cases, so the meeting was adjourned, and I walked over to Doctor Subramani.