Chapter 26: Let's Take a Walk

July 24, 1989, McKinley, Ohio

"That just seems so ... cold," Len observed after we had moved away. "I mean the way you told her."

I nodded, "That's the standard developed through years of experience. Our job in such cases is to clearly state that the patient has died. Emotional support, and everything else, comes from the chaplain, the social worker, or Doctor McKnight. I can't tell you why the patient died, and, generally speaking, doctors are not qualified grief counselors or spiritual counselors."

"You are, though, right?" Bob asked. "You were clergy."

I nodded, "I was a deacon, and I'm actually an appointed chaplain, though I can't do that here because it's literally not my job. That was one of the hardest lessons for me to learn during my clinical rotations, and I was reminded of that time and time again. Let's just say I had my nose whacked with the rolled-up newspaper sufficiently often to convince me to stop peeing on the carpet, as it were."

"Doesn't it bother you?" Bob asked.

"Of course it does, which is why it took so many applications of the rolled-up newspaper. But it doesn't bother me enough to go into private practice or pediatrics or internal medicine where there is more personal interaction and the lines are a bit fuzzier. Don't work in the ED if you can't handle that. Think about all the shorthand we use and how, at times, it's like an assembly line. We simply don't have the time to get involved.

"Going back to the monologue, that is something you need to memorize, and it's what you'll say each and every time a patient dies. You absolutely have to say 'he died' or 'she died' unequivocally, without euphemisms. And you don't give any diagnosis. It's almost always safe to say that the patient's heart stopped, and we could not revive them, as that is, from our perspective, the sign of death. No heart sounds, and nothing on the monitor is, for our purposes, definitive.

"With this patient, he was down for at least six minutes, and we don't know what his heart rhythm looked like before he went asystole in the EMS squad. Two doses of epi, chest compressions, and a vent, with his pupils fixed and dilated, were sufficient to stop trying. At that point, there was literally nothing left in our toolkit, as it were, so we called it. It's up to Doctor McKnight to say what the cause was, assuming Mrs. Breckenridge agrees to an autopsy."

"It's not automatic?" Len inquired.

"No. When a patient dies in the presence of a physician, the death certificate can be signed at that point, and it's up to the family to decide if they want an autopsy. When the patient dies outside the presence of the physician, the County Coroner holds an inquest, which almost always includes an autopsy. We also try to do them for patients who die unexpectedly, for our own purposes, but the family doesn't have to agree."

"Do you sign the death certificate?"

"No, because it needs to be signed by someone with a license. Attendings all have their licenses, but only some Residents do. Most get them during their second or third year of Residency, though surgeons sometimes wait, given it takes roughly eight years to be an Attending."

"How does that work for you?" Bob asked.

"I plan to take the licensing test late next year. I'll take my emergency medicine boards around the same time, and then in about six years, my surgical boards as a general surgeon. While I'll be fully qualified and be able to put FACS behind my MD, the vast majority of procedures I'll do will be chest tubes, pericardiocenteses, central lines, tracheotomies, and similar life-saving procedures. I will, at times, take a patient up to perform emergency surgery, but that won't be the main part of my job."

"Mike?" Nate called out. "EMS four minutes out with an electrocution. Use Trauma 3."

"Got it!" I replied, then turned to Len and Bob and said, "Let's go!"

We gowned, gloved, and went to the ambulance bay to meet the squad, which pulled up about four minutes later.

"Jerry Maclean, twenty-six; electrocution on a construction site. CPR performed by co-workers; tachy at 110; resps shallow at 16; BP 90/60; PO₂ 95% on five litres by mask; GCS 9; IV saline TKO; burns on both palms."

That indicated that the charge had gone across his chest.

"Voltage?"

"240."

"Trauma 3!" I ordered. "Bob, EKG and monitor; Len, CBC, Chem-20, ABG, and cardiac enzymes."

We began moving, and I called out to Ellie that I would need a nurse, and she sent Jenny with us.

"Jenny, switch the IV to Ringer's," I said. "Len, Foley, then draw the trauma and cardiac panels."

Everyone acknowledged my orders, and, with the help of the paramedics, we transferred Mr. Maclean from the gurney to the trauma table. I did a quick assessment and determined he was breathing OK and had a strong pulse, so immediate intervention wasn't needed. I began a more thorough workup while the others performed the tasks I'd assigned them.

"Foley is in!" Len declared. "Urine in the bag, and yellow."

He moved to draw the blood and let me know that he'd filled the tubes.

"Take the blood to the lab; trauma stat," I ordered.

"Right away, Doctor!"

"Arrhythmia," Bob announced.

"What do you see?"

"I'm not sure; I just know it doesn't look right!"

I looked up and nodded, "A-fib and irregular ST, both consistent with electrical shock. Put the unit in continuous print mode and call for a cardiology consult, please."

He did as I asked while I checked reflexes, all of which were nominal.

"What would you do next?" I asked Bob.

"Control the A-fib."

"Yes. Jenny, 0.5 meg digoxin IV push; 5000 of heparin in the IV bag."

"0.5 meg digoxin, IV push," she repeated. "And 5000 of heparin in the IV bag."

"Why those?" I asked Bob.

"Digoxin to control arrhythmia and warfarin to prevent thrombosis."

"Good. Now what?"

"Monitor; he'll need to have his INR checked daily to dose the warfarin."

"Correct. What about the burns?"

He moved to examine the patient's hands.

"Irrigate, debride, dress," he said.

"Yes. We'll wait for cardiology before we do anything else. What can you deduce from the burns?"

"He was holding wires?"

"Yes, but what stopped his heart? 240 will usually knock you on your ass but not stop your heart."

"I'm not sure."

"The charge went across his chest. Think about that."

"Ah," Bob said, the answer obviously dawning on him, "similar to defib, only in reverse."

"Yes. What will we look for in the blood tests?"

"Elevated cardiac enzymes, which indicate damage to the heart muscle."

I nodded, "Specifically, the MB component of creatine kinase and troponin."

"Javadi, Cardiology," Leila Javadi said as she entered with a Third Year.

"Hi, Leila," I said.

"Morning, Mike. What do you have?"

I ran through the patient's vitals, my exam results, and the treatment so far.

"I don't like the fact that he's still out," I concluded.

"Let me do an exam, but we may want a neuro consult as well. We can do that upstairs, though, because he needs continuous monitoring."

"The EKG is on continuous."

"Thanks," she said, beginning her exam.

She asked similar questions of her Third Year as I'd asked Bob and concluded by accepting Mr. Maclean on her service. In keeping with policy, she, Bob, and her student escorted the patient to Cardiology, and when I left the room, Nate indicated that there were walk-ins waiting.

"What do you have?" I asked at the triage desk, after Bob had returned.

"Take your pick — sprained ankle; abdominal pain, but without elevated temp; arm lac; alien infestation."

"Psych consult?"

"Either that or a Scientologist who failed to blow off his body Thetans with his e-meter!"

"Nice," I chuckled. "Who's been here the longest?"

"Psych consult."

"Let me take him and get him his psych consult, and I'll come back for another. Bob can take the arm lac."

"Sold!" he said, handing me two charts.

I handed the arm lac chart to Bob, instructed him to evaluate and come see me, then we each called out to our patients. I escorted Nelson Thomas, who had aluminum foil on his head, to Exam 6, asking Kellie to join us.

"What brings you here today?" I asked.

"Aliens inserted tracking probes into my brain!" he said.

"When did this happen?"

"Last night. I put the foil on to block the signals!"

"How did they insert the probes?" I asked.

"Up my nose!"

"I'm going to do an exam," I said. "I'll leave the foil in place, and once we've run our tests, we'll call our alien expert to check you out."

He looked at me strangely, "You believe me?"

"I need to take your report seriously to treat you," I said.

"The alien expert is secret, right? You guys are government, so you don't admit it like they don't admit the alien bodies and ship they have at the Air Force Base in Dayton, right?"

"Right," I agreed.

Hangar 18 in Area B of Wright-Patterson Air Force Base purportedly had the wreck of a crashed UFO from Roswell, New Mexico, along with the bodies of the crew.

"Jenny, let's draw CBC, Chem-20, glucose panel, and tox screen."

"I'm not on drugs!" Mr. Thomas protested.

"Are you sure the aliens didn't inject you with something?" I asked.

"Good thinking, Doc!" he said.

Once we'd completed the exam and the blood draws, I asked Mr. Thomas to lie down and wait. He complied without argument, and we left the room.

"You are strange!" Kellie declared.

"And what would have happened if I hadn't gone along with his delusion?"

"He'd have freaked out and wouldn't have coöperated, saying you were part of the conspiracy."

"Bingo. Now I just have to convince someone from Psych to play along with my charade long enough to get him upstairs."

"Why the blood tests?"

"Because it's possible his delusions are based on metabolic or other problems. You know Psych will only run those as a last resort in a case such as this one or if he develops other symptoms."

"So, wait for the results before we call Psych?"

"Yes."

"Unconventional, but likely effective."

"Thanks. I see Len coming; have him run the blood to the lab. I'll meet you in Exam 2 with the young woman with abdominal pain after I inform Doctor Gibbs. Bring her in, please."

She acknowledged my orders, and I went to see Doctor Gibbs, who was at the nurses' station.

"OK to present?" I asked.

"That goofy grin says you're up to something."

I laughed, "Busted, but I think you'll agree. I have a male patient, late twenties, who believes aliens inserted probes into his head last night. I humored him, ordered blood tests, and once they come back, I'll get a psych consult."

"Humored him?"

"I didn't make him remove his aluminum foil hat and said once we'd run the tests, I'd bring in our alien specialist to examine him."

She started laughing, as did Ellie.

"I also allowed that I knew about the alien spacecraft they have at Wright-Patterson."

"Psych is going to love you! And by 'love', I mean 'hate'!"

"The patient is calm, relaxed, and feels safe. Did I do any harm in accepting his delusions?"

"No."

"There you go. I did order complete blood work, including a tox screen, to rule out metabolic or other causes. I don't think he's on drugs, but there are things which manifest only as paranoid delusions or hallucinations. It's also the case that electrolyte imbalance, meningitis, and other ailments can cause mental confusion, including hallucinations and paranoia."

"And later, when he tells people we believe in UFOs?"

"He won't be wrong," I replied.

"Don't tell me YOU believe in UFOs?!"

"We all do," I chuckled. "There are absolutely, provably, Unidentified Flying Objects. There's no proof they're alien spacecraft or any such thing, but the UFOs are actually real!"

"Give me your chart to sign, you clown!" Doctor Gibbs said, rolling her eyes and shaking her head.

I handed it to her, and she scribbled a note and signed it. I winked, left, and put the chart in the holder outside Mr. Thomas' room, then went to Exam 2.

"Peggy Gibson, nineteen," Kellie said.

"Good morning. I'm Doctor Mike. What brings you here this morning?"

"My side hurts."

"More towards the front or the back?"

"The back."

"When did this begin?" I asked.

"Last night. I took two Tylenol, and that helped, but when I woke up this morning, it hurt worse, and Tylenol didn't do anything."

"Did you do anything in the last few days which might have strained a muscle?"

"Not that I can think of. I went to class, studied, then hung out in the dorm common area."

"Taft student?"

"Yes."

"Did you pick up anything heavy?"

"Nothing heavier than my chemistry book."

"Did you eat anything out of the ordinary?"

"No."

"Any nausea, vomiting, dizziness, or imbalance?"

"No."

"Blurred vision, ringing in your ears, or strange smells or tastes?"

"No."

"Are you taking any medication or using any drugs?"

"Just the Tylenol."

"OK. I'd like to perform a basic exam. Just unbutton one more button on your blouse and untuck it, please."

She complied while I washed my hands and put on gloves. I auscultated her heart and lungs and found nothing remarkable, then checked her eyes, ears, mouth, and nose with similar results and found nothing amiss with the glands in her neck.

"If you'd lie back, I'm going to examine your abdomen," I said.

She complied, and I palpated her abdomen and listened for bowel sounds, once again not finding anything remarkable.

I had her turn on her side and did a manual exam of her back, finding two spots where pressure caused her to wince but which didn't indicate any masses.

"Any trouble urinating or any burning sensation when you urinate?"

"No."

"You can sit up," I said. "There are a few possibilities, the most likely of which is an ovarian cyst. Is there any chance you're pregnant?"

"Not unless two girls can get each other pregnant."

"So, no relations of any kind with a guy?"

"Never. Not even a kiss."

"Then you aren't pregnant, which narrows down the possibilities. I'd like to do an ultrasound to confirm."

"What else could it be?"

"Kidney stones would be a possibility, but you're awfully young to have those unless you've been diagnosed with some kind of renal disease. Any kidney problems?"

"No. What's the treatment for a cyst?"

"It depends on the size," I replied. "Small ones usually resolve on their own. Larger ones need evaluation by an OB/GYN and could be surgical. But let's check it out first before we speculate. Kellie will give you a gown to put on. You can leave on your bra and jeans, but you'll need to take off your blouse.

"I'm not modest. I can just take off my blouse."

"OK. We'll step out to get the equipment we need. Just take off your blouse and then lie on your left side with your back towards this side."

She acknowledged me, and Kellie and I stepped out. I stood outside the door while Kellie retrieved the ultrasound. Bob came to me to report he'd irrigated the arm lac and felt it needed six sutures. I checked, confirmed that, then went back into the exam room with Miss Gibson. I performed the ultrasound and confirmed Peggy had a four-centimetre cyst on her right ovary.

"You have a cyst," I said. "It's small, so for now, take three Advil every six hours, which should help, along with warm compresses. Make an appointment with your OB/GYN for follow-up."

"That's it?"

"That's it. If the pain persists beyond three days or gets significantly worse, and you haven't seen your OB, come back, and we'll have an OB/GYN check you out and recommend treatment. Kellie will get you some Advil now, and I'll fill out the paperwork to discharge you."

"Thanks, Doctor."

"You can put on your blouse," I said. "We'll be right back."

Kellie and I left the room, and she touched my arm.

"You aren't going to ask for an OB/GYN consult or an Attending?"

"No. I've seen a number of these, and she has no symptoms which warrant anything more than 'wait and see'. Her OB/GYN is best suited to care for her. I've also done other gynecological procedures, so I know Doctor Gibbs will sign off without an exam."

We went to the Attendings' office, and I asked Doctor Gibbs if I could present. She nodded, so I ran through my exam and diagnosis.

"No blood work?" Doctor Gibbs asked.

"No. There's no need to run extra tests at this point. All her symptoms line up."

"You're positive she's not pregnant?"

"Lesbian," I replied. "And I did confirm that she'd never had relations with a guy."

"Let me have the chart, please."

She made her notations, then signed the chart and handed it back.

"Street her, as you proposed."

"Thanks."

I filled out the necessary discharge information, completed the chart, then returned to the exam room to discharge Miss Gibson. Once that was completed, I took the sprained ankle and finally received the results for Mr. Thompson's tests, all of which showed normal ranges, though with slight anemia, but that was insufficient to cause hallucinations or paranoid delusions. The tox screen was negative, though it didn't test for everything possible.

"The aliens are crafty!" Mr. Thomas said when I explained the nominal blood test results. "They don't use anything you can detect!"

I nodded, "That would make sense for an advanced species of aliens! Let me place a call and have someone who specializes in this come to see you."

"Thanks, Doc!"

I left the room, wondering which Psych Resident was on duty. I placed the call, and five minutes later, Leah Silver arrived with a Third Year in tow. I reviewed the patient's vitals, the exam results, and the blood test results.

"You seriously want me to pretend to be an alien expert?" she asked.

"My patient is calm and coöperative. I'd suggest maintaining the fiction until you get him upstairs. Otherwise, he's likely to fight you and have to be sedated."

"You know that's not protocol!"

"Hang the protocol!" I replied. "Our goal is to provide the best possible care, and if that means going along with his hallucination and delusion, at least in the short-term, so be it."

"Doctor Lawson will never agree to that."

I shrugged, "You have my advice, but you're the psychiatrist."

I handed her the chart.

"Oh, this is going to go over great," she said, shaking her head. "Your Attending signed off on this?"

"Again, we have a docile, coöperative patient who thinks we're going to help him, as opposed to one who thinks we're in league with his enemies."

She shook her head, "I have to follow protocol."

I almost said 'Of course you do', but bit my tongue.

"Kellie, prepare five of Haldol," I said. "We're going to need it."

"Right away, Doctor," Kellie agreed.

"Leah, can we at least just say you're a specialist and NOT say you're from Psych? Can't you see your way clear to maintain that tiny fiction?"