Chapter 35: Do You Get Used To It?

August 7, 1989, McKinley, Ohio

"Fill out your procedure book," I said to Al as we walked back to the ED after an uneventful flight to and from OSU. "You now have one flight; you need four more, and either your MD or certification for Advanced Life Support and my signature, and you'll be certified as a flight surgeon."

"Whoa! Seriously?"

"Seriously. I qualified the week after I graduated from medical school. I was short of the required number of flights, but the paramedic ride-alongs that new trauma, medicine, and surgical Residents will do going forward count as well."

"But surgeons don't fly, do they?"

"Rarely. It's almost always a trauma doc or, more rarely, someone from Medicine."

"Your Residency is both trauma and surgery, right?"

"Yes, and there will be at least one trauma surgery slot here for your Match, but it's going to be highly competitive. That said, surgeons will be doing trauma rotations, and you could, after PGY5, apply for a trauma Attending role. Well, that's the plan; no guarantees."

"You're giving me reasons to Match here rather than in Virginia."

"That's home?"

"Arlington. My dad is a lobbyist, and my mom is a Congressional aide."

"That's convenient," I replied.

Al laughed, "You would think, but Dad is a defense lobbyist and a Republican, and Mom works for Nancy Pelosi, a first-term Democratic Congresswoman from San Francisco."

"I'm a Reagan Democrat, and my wife is a card-carrying socialist, so I can relate."

We arrived back in the ED and while Al updated his procedure book, I checked in with Ellie, then went to see Doctor Gibbs.

"All the way both ways in the helicopter this time?" she asked with a smile.

"Two good engines both ways! I didn't even think about what happened last time. I think it's the positive vibes from Kellie."

"You two seem to have a perfect working relationship."

I nodded, "She gives me good advice and seems to anticipate what I need and what needs to be done."

"The qualities of an excellent nurse. Going back to the patient you transported, how the heck did you pull calcium gluconate gel from thin air? I'd have had to look that up!"

"Honors chemistry," I replied. "I remembered hydrofluoric acid has an affinity for bonding with calcium, and I know the IV treatment for hypocalcemia. I then remembered reading an article in JEM about acid burns and gave the orders."

"You're a natural," Doctor Gibbs said. "There's a reason you're called the most promising young doctor in the hospital."

"Clarissa Saunders would disagree with you and point out she scored higher on Step 2 of the MLE!"

"By a point!" Doctor Gibbs declared. "Meaningless in the larger scheme of things."

"So you would think, but trust me, I'll hear about it after she and I retire in fifty years!"

"It's a good thing you come as a matched set, and we have both of you!"

"Changing topics, I'm sure you'll hear from Krista about me taking Al on the flight."

"And if Krista were my student, she'd be on scut for the entire month," Doctor Gibbs said.

"You know my take on that," I replied. "While I'll heed Leila Javadi's advice of watching her carefully, I won't relegate her to pure scut. I've already spoken to her twice and given her strong direction on how to improve. I have to give her a chance to do so."

"If you've had to have two separate conversations with a Fourth Year on the first day of a rotation, you have to know she doesn't belong here."

"I have twenty bucks in my pocket which say that you and Doctor Northrup assigned her to me for exactly that reason. She'll either be Felicity or Tim, and that has to be because of her, not because of me. We've had this discussion in the past, and I haven't changed my opinion."

"Remember, this morning I said I didn't know why her procedure book was light."

"And yet, I'm sure you read her previous evaluations, so you at least had a clue that she was a poor performer, and that's why she was assigned to me."

"What's your plan?" Doctor Gibbs asked.

"I assigned her several pieces of homework. First, to learn how to read an EKG, something she should have done during her cardiology Sub-I. She admitted she hadn't asked Leila Javadi or Barb Abbott to teach her. Second, to find out who Sir William Osler was. She didn't know, and neither did Al, and the medical school is partly to blame."

"How so?"

"His book is optional reading for Practice of Medicine. It ought to be required, even if it's subversive with regard to the way most medical schools handle First and Second Year students. McKinley has instituted Preceptorships precisely because of what Osler taught, yet they don't assign his seminal work as required reading material. And yes, I'll make that point to Nora Mertens when next I see her."

"What brought that on?"

"Krista was academically talented but is clinically deficient."

"So, like Felicity?"

"I know a fact about Felicity's past, which explains her initial animosity to me, which I cannot share, so I think the two situations are distinguishable. It's also the case that I was a fellow student, whereas now I'm an Intern."

"An Intern who is as good as any Attending here, present company included. If you weren't, we wouldn't have signed off on you basically operating on your own with minimal supervision."

"Speaking of that, was your offer to help earlier simply an offer to help or making sure I wasn't in over my head?"

"Yes," Doctor Gibbs replied with a smile. "You shouldn't be surprised at that."

"I'm not, nor am I bothered by you checking up on me. Despite all the accolades, I'm still a very junior physician."

"And you haven't let it go to your head. You make the right calls, but you also ask for help when you need it. Just remember — arrogance kills."

I nodded, "I'll remember."

"Conduct your students' training in the way you see fit, so long as you can defend it if necessary."

"I'm curious as to how you feel I should handle discussing Krista with the other Residents at shift turnover?"

"I'd say you tell him what you personally discovered — that her procedure book is light and that she'll need close supervision. I believe that fits within your desire not to poison the well, as it were."

"It does."

"Have you had a meal break?"

"No. I ate a granola bar when we took off from OSU for the return trip."

"And then fell asleep, right?"

"Yes."

"Take your meal break."

"I'll make it my dinner break, given it's nearly 4:00pm."

"OK."

I left her office and headed to the cafeteria, returning to the ED about twenty minutes later. Al and I handled four walk-ins before he and Krista went off shift at 6:00pm, with Serenity Cooper and Walt Foster relieving them.

As was my usual practice, I asked Serenity and Walt for their procedure books and thumbed through them. Both of them had what I considered to be a typical number of procedures, with Serenity having completed a Medicine Sub-I and Walt an OB/GYN Clerkship.

"Any thoughts on the Match?" I asked Serenity.

"Nuclear medicine," she replied. "My dad is a physicist who works for Fermi National Laboratory outside Chicago. I think what he does is cool, but I'm not interested in being a physicist."

"You're from that area?"

"Naperville."

"That's where my dad's family lives," I replied. "My mom's family is from Ohio. What about you, Walt? I know it's almost two years away for you."

"Surgery," he said. "I decided during my Preceptorship. You're wearing surgical colors; why?"

"I'm training to be a trauma surgeon," I replied. "I'm on the surgical staff but assigned to the Emergency Department. I'll end up with what amounts to a dual Residency in emergency medicine and general surgery and spend most of my time in the ED."

"That's cool!"

"Mike?" Josh, the evening clerk, called out. "Paramedics four minutes out with an MI. Use Trauma 3, and Penny is your nurse."

"Thanks," I replied. "Serenity, Walt, let's go."

The three of us went to the corridor, and I ensured they put on gowns and gloves, then we joined Penny in the ambulance bay, waiting for the EMS squad to arrive.

"Penny, CBC, Chem-20, ABG, and cardiac enzymes; Serenity, you'll hook up the EKG and pulse oximeter, cut away the shirt if necessary; Walt, switch the oxygen from the portable bottle to the hospital system. If the paramedics are performing CPR, I'll give new instructions."

About two minutes later, EMS Squad 4 arrived, which meant John and Roy. When it pulled to a stop, John jumped out.

"Charles Ramsey, fifty-eight; complained of chest pains and shortness of breath; tachy at 120; BP 90 palp; PO₂ 95% on five litres; IV saline TKO."

"Trauma 3!" I ordered. "Mr. Ramsey, I'm Doctor Mike. We'll take good care of you."

We quickly moved Mr. Ramsey into Trauma 3 and onto the treatment table, and everyone sprang into action. Both Serenity and Walt performed their assigned tasks with reasonable speed as I performed the primary exam. When I heard Serenity push the power switch on the EKG, I looked up.

"Inverted T wave," I said. "Mr. Ramsey, you're having a heart attack. Walt, call for a cardiology consult, please. Serenity, Foley catheter; I'll guide you. Mr. Ramsey, we're going to insert a catheter to drain urine, as you're very likely going to need a cardiac procedure."

I completed my exam and then talked Serenity through the Foley catheter insertion, though she had done several during Third Year.

"Lyon, Cardiology," Doctor Judson Lyon said, coming into the room with a student in tow. "What do we have, Mike?"

"Hi, Judson. Charles Ramsey, fifty-eight; complained of chest pains and shortness of breath; tachy at 120; BP 90 palp; PO₂ 96% on oxygen by mask; inverted T-wave, loud second heart sound, and possible increased jugular venous pressure, all indicative of pulmonary embolism. Patient is catheterized; full cardiac trauma panel ordered."

"Got it!" Judson replied. "Mr. Ramsey, I'm Doctor Lyon, a cardiologist. I'm going to do a quick exam, and then we'll take you upstairs."

He repeated my exam, then ordered heparin, which Penny administered.

"Cade," he said to his student, "call upstairs and tell them we're bringing up a suspected PE for an angio. Mike, we have this."

"Walt, get a gurney and assist in transport," I instructed. "Serenity, print a strip, then switch to the portable monitor; Penny, portable oxygen."

Three minutes later, Mr. Ramsey was on his way up to Cardiology.

"Serenity, bring that strip with you so we can examine it when Walt returns."

I'd decided that it was incumbent on me to teach all of my students to at least read a basic EKG and ensure they were able to at least call out the deviations from normal sinus rhythm, even if they couldn't propose a diagnosis.

"You could tell he has a pulmonary embolism simply based upon exam and EKG?" she asked.

"That's my suspicion," I replied. "You heard Doctor Lyon say 'suspected PE' after I said the symptoms were 'indicative' of a PE. Formal diagnosis requires imaging, either an angiogram or an ultrasound. There are a number of other heart ailments which have similar signs, but shortness of breath, chest pain, an inverted T-wave, and increased jugular venous pressure all point in that direction. Doctor Lyon was sure enough to order heparin, which is the primary treatment."

"If you knew, why not administer heparin right away? she asked.

"Let's wait for Walt to return so he can hear the conversation."

"OK."

Five minutes later, Walt returned, and we went to the lounge.

"Any trouble during transport?" I asked.

"No. We took him straight to the cath lab, and they sent me back."

"OK. Serenity, ask your question."

"If you knew the diagnosis, why not administer heparin?"

"It was a judgment call. The patient wasn't cyanotic, which gave us more time. Given that, I preferred to wait for the Cardiology Resident to decide what he wanted to do. The main reason for that is the minute the patient crosses the red line that spans the corridor, he belongs to the other service. Because of that, it's better, if possible, to let them make the decision. Had Mr. Ramsey been cyanotic, had LOC, or shown any signs of imminent death, I'd have intervened beyond ordering blood tests and the EKG and calling for a consult.

"Speaking of the EKG, neither of you has had a Sub-I in cardiology, but you're going to get a head start because every physician who works in the ED needs to be able to at least describe the arrhythmia even if they can't diagnose it, and know when calling a cardiology consult is necessary because many arrhythmias are not primary to heart disease. Serenity, let's look at that strip."

I explained the grid system and the PQRST system of evaluating the EKG and explained the phrase I'd used, 'inverted T-wave'. I also pointed out that Cardiology would switch from a five-lead to a twelve-lead EKG, which would provide further information and help narrow down the diagnosis, something we generally did not do in the ED.

"So," I concluded. "Get your cardiology textbook and read the two Chapters on EKG, assuming you understand the basic heart rhythm. If not, go back a Chapter and read about electrical impulses and normal heart rhythm. Walt, I didn't see any reference to EKGs in your procedure book."

"Only fetal monitors," he replied.

I took my trauma notebook from my pocket, flipped to the correct pages, and handed it to him.

"Copy these two diagrams and the lists of leads for five- and twelve-lead EKGs. You should memorize both, but for now, focus on five-leads as that's nearly always what we use here. Next week, I'll give you a chance to show me what you've learned in that regard. Serenity, as soon as we have a case that requires intubation, I'll have you do that, assuming we have a second doctor available to conduct the primary assessment while I teach you.

"The one downside of this rotation is that for the rest of August, Fourth Years are still manning the triage desk. As of September 1st, it'll be nurses. That means you'll have to sit at the triage desk from 6:00am to noon tomorrow. On the plus side, that means you should be able to catch a nap at some point overnight, and my advice to both of you is to sleep if and when you can."

"I heard they're reducing your hours," Walt observed.

"Yes. The goal is for Interns in the ED to not work more than eighty hours in a week, as opposed to between ninety and a hundred. And they're killing the thirty-six-hour shifts. You know why, right?"

"Some case from New York where Residents caused a patient death," he replied.

"Honestly, the system killed Libby Zion, not the unsupervised PGY1 and PGY2. There was no emergency medicine Attending on duty at the hospital, and her personal physician didn't communicate properly with the hospital physicians. Those two Residents were at the very end of a thirty-six-hour shift, had poor supervision, and didn't have all the information they needed. To put all the blame on them, as some have done, is simply wrong."

"You have those shifts now, right?"

"Yes, but the key difference is that policy at Moore Memorial has always required an Attending physician on-site for the ED. That's not true for other services, but I expect that to change over time. The same is true for Resident work hours on other services. The problem, of course, is that more Residents will be needed and that costs money, which is always in short supply."

"Mike?" Josh called out from the door. "Arm lac in Exam 4 with serious bleeding. Penny is with the patient."

"Thanks."

Serenity, Walt, and I left the lounge and went to Exam 4, where the patient was lying on the treatment table.

"This is Mr. Marsh," Penny said. "Severe laceration of his lower arm. Pulse 90; BP 90/60."

"Hi, Mr. Marsh," I said. "I'm Doctor Mike, and these are my students, Serenity and Walt. How did you cut your arm?"

"My girlfriend tried to stab me."

"Let's take a look, please."

I did and saw a very deep wound that appeared to involve tendons.

"Penny, let's put on a fresh pressure bandage, please. Walt, call the surgical scheduling nurse and let her know we have a severe laceration which will require sub-cu sutures and potential orthopedic repair due to tendon involvement. Mr. Marsh, I'd like to do a primary exam, which means listening to your heart and lungs."

"OK, Doc."

I performed the exam and noted nothing atypical, but the slightly low blood pressure indicated he needed volume. Given he was going up for surgery, the correct course of action was IV saline.

"Penny, IV saline, and type and cross match for surgery."

"Right away, Mike!"

"They'll be ready in twenty-five minutes," Walt announced.

"Mr. Marsh, when did you last eat?"

"About 5:30pm," he replied.

I noted that on the chart, as the anesthesiologist would want to know, despite the repair most likely being done under local rather than general anesthesia.

"Any allergies?"

"No."

"Any negative reactions to anesthesia, including at the dentist?"

"Nah, I've had cavities filled and never had a problem with those shots."

"Any difficulties swallowing or eating?"

"No."

"When was your last tetanus shot?"

"I don't recall having one."

"Then we'll make sure you get one once the surgeons repair your arm."

"You can't just stitch me up?"

"No, because I'm concerned about tendon damage, so we need an orthopedist to evaluate the arm, which he'll do upstairs. Also, the cut is deep, so you need more than just simple sutures."

"Serves that bitch right that she was arrested."

"How did you get here?"

"The McKinley PD brought me here."

"OK. We'll keep you here until they have the OR ready upstairs. Penny, pulse oximeter and the new automatic BP cuff. Call me if his pressure drops."

"Will do, Mike."

"Mr. Marsh, we're going to see other patients, but we'll be close by."

"Thanks, Doc."

Walt, Serenity, and I left the room, and I saw three charts in the rack.

"Serenity, take the first chart and tell me what you'd do."

She picked up the chart and scanned it.

"Migraine headache," she said. "H&P and trauma panel."

"Male or female?" I asked.

"Female, so ... pregnancy test if warranted."

"Criteria?"

"Any sexual activity since her most recent period."

"Do you know how to ask?"

"Yes. I ask, 'Is there any chance you might be pregnant?', and clarify if necessary."

"Then you and Walt bring the patient in, Walt should take vitals, and you proceed as you suggested. I'll observe, then we'll step out and assess."

"Can I ask a quick question?" Serenity inquired.

"Sure."

"Why did the nurse call you 'Mike' instead of 'Doctor'?"

"That's my preference," I replied. "You two need to use 'Doctor' because not doing so will unhinge some of the more traditional medical practitioners here."