Chapter 41: You're Still a Pain in the Ass, Loucks!

August 24, 1989, McKinley, Ohio

"Julie Perez, twenty-six," I said. "Presents with a complaint of numbness and tingling in her left foot, with onset early this morning. Pulse 76; BP 110/70; temp 36.7°C. No other complaints. Nothing remarkable upon exam; nothing remarkable in the blood work. No motor or reflex impairment; neuropathy test showed lack of sensation for five touches on her lower leg, three on her big toe, and two on the ball of her foot. Moderately active with no family history of neuropathic disease."

"Hi, Julie, I'm Doctor Lucy Vanderberg from neurology. I'm going to examine you and very likely ask some of the same questions Doctor Mike asked."

It had actually been Al, but there was no point in correcting that, as I'd listened to the entire exchange, and Al had done a very good job.

"OK," Julie agreed.

Lucy performed her exam, including a neuropathy test, confirming my findings.

"Mike," Doctor Vanderberg said, "let's get a complete set of X-rays from the knee down on both legs. I'll review those before we decide next steps."

"What do you think is wrong?" Julie asked.

"The most likely cause of the symptoms you're exhibiting is compression neuropathy, that is, something pressing on a nerve in your leg. The X-rays are to rule out a cyst or other condition that might cause it. If the X-rays are negative, we'll try soft-tissue treatment, which, in layman's terms, is massage therapy, as muscle tension or tightness can cause the symptoms you're experiencing. I'll come back and see you once we have the X-rays."

"Thanks."

"Mike, call me when you have the films."

"Will do," I replied. "Thanks, Lucy. Julie, I'll make the arrangements and be right back."

I followed Doctor Vandenberg from the treatment room, electing to make the call from the Clerk's desk as otherwise I'd have been alone with Julie. I called Radiology and arranged for the X-rays, then called for an orderly. I asked Kellie to join me, then went back into the treatment room to let Julie know that an orderly would take her to Radiology in a wheelchair.

I left the room and returned to check on Mr. Nylander. His labs were back and showed no elevated cardiac enzymes, which strongly suggested he hadn't had a heart attack. When combined with the EKG, they indicated either unstable angina or atherosclerosis. That meant a toss-up of a cardiac consult or referring him to his personal physician and advising him to see a cardiologist.

I had a very strong feeling that I could safely street him, but the last thing I wanted was a bounceback MI caused because his arteries were seriously occluded. The counterargument was that he wasn't having an MI and could reasonably safely schedule a non-emergency stress test and cardiac echo.

"I don't see any signs of a heart attack," I said to him. "Your cardiac enzymes are normal, as is your EKG. Give me ten minutes to confer with a colleague, and I'll let you know the next steps."

"Mind telling me what you think?"

"Not at all. The two most likely diagnoses are unstable angina or atherosclerosis, and those aren't mutually exclusive. Both are treatable, and neither of them are immediately life-threatening. The options are admitting you for further testing or releasing you with instructions to see your personal physician and a cardiologist. My inclination is for the latter because you'll be far more comfortable sleeping at home than here at the hospital.

"But, as we discussed earlier, I'm an Intern, so I need to discuss this with my mentor to confirm my findings. That said, if you prefer, I can call a cardiologist who'll examine you and decide between those two options. Generally speaking, with your symptoms, cardiology would give the same opinion I just provided. But before you decide, I want to at least discuss this with my mentor."

"Thanks for the total honesty," he said. "So far, you seem to have done everything right."

"Thanks. Al, you can come with me to present to Doctor Gibbs. I don't believe Mr. Nylander is at any immediate risk."

Kellie moved to check Mr. Nylander's IV while Al and I headed to the Attending's office to see Doctor Gibbs. I presented the case and my recommendation.

"I think you're right," she said. "Will the patient accept being streeted with a referral?"

"Yes. I discussed the two options before I came to present. I did state that I would call a cardiologist if he insisted, but he didn't seem inclined to do that. Al watched the monitor for a good twenty minutes and saw nary a blip. All symptoms resolved with nitro and ASA, as I mentioned. I'll street him and tell him to take a daily low-dose aspirin until he sees his personal physician."

"Approved."

I handed her the chart, she made some notations, signed it, and handed it back.

"Al," Doctor Gibbs said, "run me through how you'd deliver this information to the patient."

"Well, given Doctor Mike already suggested the course of action, I think simply saying that we confirmed our diagnosis with you, and we don't believe he's in danger of an immediate heart attack. As such, he should follow up with his personal physician as soon as possible and see a cardiologist. I'd advise him to take a daily low-dose aspirin tablet until told otherwise by his doctor or a cardiologist, and if he experiences further symptoms, he should call 9-1-1. And lay off the Taco Bell."

"Good job. Mike, you deliver the diagnosis and treatment plan."

"Will do," I replied.

Al and I left and returned to the treatment room to advise Mr. Nylander, and he, as I had been positive he would, accepted the plan of seeing his doctor and a cardiologist. While I filled out the discharge paperwork, Al disconnected the EKG and pulse oximeter, then removed the IV. I went over the discharge instructions with Mr. Nylander, referred him to the cardiology practice in the nearby medical building, then directed him to Patient Services.

"Thanks, Doc," he said. "I appreciate you explaining everything."

"You're welcome."

After Mr. Nylander put on his shirt, Al escorted him to Patient Services, and I checked with Nate, who said that the orderly had taken Julie for her X-rays. Al and I went to the lounge to get coffee, and I saw Krista on the couch reading a textbook.

"Let me know when you're ready for your quiz," I said to her as I poured myself a mug of coffee.

"High-speed, head-on MVA coming in," Ellie said from the door to the lounge. "Ghost asked for you to join him. Three minutes out."

"Be right there," I replied. "Krista, your choice if you want to keep studying or join us. Al, let's go."

I didn't wait for Krista's decision, as I didn't have time to debate or discuss it, and only she could save herself at this point. Al and I quickly left the lounge, put on disposable trauma gowns and gloves, and headed for the ambulance bay where Ghost, Angela, and Matt, a Fourth Year, were waiting.

"Where's your other student?" Ghost asked.

"Studying the procedure for RSI, as directed," I replied.

"Let's chat after this trauma."

"OK."

"Matt, intubate; Al, EKG and monitor, then Foley. Angela, full trauma panel; Mike, evaluate lower extremities and be ready for a pneumothorax or hemothorax."

Everyone acknowledged his orders, and a minute later, the EMS squad rolled to a stop in front of us. Bobby hopped out and moved towards the back while giving the bullet.

"Male, nineteen; high-speed, head-on MVA; belted; tachy at 120; BP 80/50; PO₂ 93% on ten litres; severe crush injuries to both legs; severe hematoma left temple; facial and left arm lacs; GCS 7; 5mg morphine; IV saline TKO."

"Trauma 1!" Ghost ordered.

With that blood pressure, he was most likely bleeding internally, though it could also be an effect of the morphine they'd given him.

"Single car?" I asked as we hurried into the trauma room.

"Two," Bobby replied. "Other driver exsanguinated on site."

In the trauma room, we moved the patient to the trauma table, and everyone got to work.

"Tube is in!" Matt announced.

"Good breath sounds right and left," Ghost announced.

"V-tach!" Al announced. "Pulse 140, BP 70 over unmeasurable, PO₂ 93%."

"Compound fracture right tibia," I called out. "Crush injury left tibia. Need an ortho consult."

"Foley is in," Al announced. "Blood in the bag."

"Belly is rigid," Ghost said. "He'll need an ex-lap before ortho. Al, get the ultrasound for Mike."

Five minutes later, having confirmed free fluid in the patient's abdomen, we were on our way up to the OR. I wasn't invited to scrub in, so Al and I returned to the ED. I poured out the cold cup of coffee and refilled it. Krista said she was ready to explain the procedure for Rapid Sequence Intubation, so I walked over to her.

She went through the procedure sufficiently well that I felt I could try to talk her through an intubation. I drank my coffee, then went to check Julie's X-rays. I saw a cyst just below her knee that was most likely the cause of her problem, which made resolving it simple, and the only possible complication would be if the cyst were malignant. I called Lucy Vandenberg, and she came down to review the films.

"I agree," she said. "That cyst is absolutely the cause of her symptoms. It's outpatient surgery, and a general surgeon can do it because it's pressing on the nerve, not involving it. Street her with a referral to the outpatient clinic."

"Will do. Thanks, Lucy."

"Good job reading the X-ray."

"Thanks," I replied.

"If you ever want to do REALLY challenging work, come see me when you pass your general surgery boards."

"I like adrenaline far too much to do neuro! And I have to feed my caffeine addiction. That doesn't bode well for rooting around someone's brain with surgical instruments!"

Lucy laughed, "That is the one thing I miss, but you're right."

She left, and Krista, Al, and I went to see Julie.

"You have a cyst," I said. "Let me put the X-rays up on the light panel, and I'll show you."

I went over to the panel and showed her the small cyst just behind the lower portion of her knee.

"That's it?"

"Yes. You'll need surgery to remove it, but it's an outpatient procedure. I'll write you discharge orders, and you can go down the corridor, through the main lobby, and about thirty feet down the next corridor. That's where the outpatient center is. The nurse there will schedule an appointment for you."

"What do I tell her?"

"I'll give you a referral sheet that has the details. Give it to the nurse and she'll explain everything to you and get you onto the schedule."

"Thanks very much," Julie said. "Can you tell me what caused the cyst?"

"The surgeon and the pathologist who'll examine it after it's removed are best suited to answer that question. The X-ray really doesn't tell us more than that it's there and how big it is."

I sat down and wrote out the referral form for Julie's outpatient procedure, then filled out the discharge form. I handed her both, advised her she could take Tylenol or Advil for any discomfort, and then directed her to the outpatient clinic. Once she was on her way, I suggested to Krista and Al that they take their meal break, and I went to find Ghost. We went to the temporary Residents' office, and he shut the door.

"What happened with Krista?" he asked.

"Right before you came into the first MVA, I was going to talk Krista through an intubation and she didn't know what the 'sniffing position' was."

"Oh, for Pete's sake!" Ghost exclaimed. "She's a Fourth Year halfway through her trauma Sub-I!"

"I realize. I partly blame myself because I should have asked as soon as I saw how light her procedure book was. After she observed the surgery on that MVA, I instructed her to take a break, get her textbook, and memorize the steps for Rapid Sequence Intubation. When Ellie let me know about the most recent MVA, I gave Krista the option of studying or joining the trauma. She chose to study, and when I asked after the trauma, she could repeat the steps sufficiently to be guided through them."

"You may not want to hear this," Ghost said, "but not everyone who wants to be a physician is cut out to be one. Krista is not. I know you think she's a reclamation project, but I honestly don't believe she can be reclaimed. You spoke with Leila Javadi, and you saw Krista's procedure book. You've also heard about her previous reviews. Do you feel she's qualified to be a doctor?"

"I think the correct answer is I'm not ready to say she's not."

"How would you rate her?"

"Ask me in about five weeks."

"She's had three weeks, Mike. I don't believe she's going to turn it around. I know you're predisposed to see the good in everyone, and that's admirable, but our evaluations are not about finding the good or giving someone the benefit of the doubt. I've heard the same things about Krista from Doctor Baxter and Doctor Billings, as well as Doctor Gibbs. You've heard it from Doctor Gibbs and Doctor Javadi, and you've seen Krista's procedure book. Is it, as she says, that everyone is out to get her, or is she just not cut out to be a physician?"

"I believe that too often, opinions are formed and become self-fulfilling prophecies. For every Tim Burg, there are three or four Felicity Howards, and the ratio might even be greater."

"So all of us are wrong, and Mike Loucks is right?"

"As you pointed out, I'm predisposed to see the good and to believe everyone can be saved. That translates into believing people can be successful in their endeavors with proper support and encouragement."

"Let me know when the Reds put you into a game as a reliever instead of John Franco or the Bengals bench Boomer Esiason, so you can start. Or, given your predilection for hockey, when Mario Lemieux steps aside so you can play. Or, to switch professions, when President Bush asks you to take command of the USS Nimitz."

"Interesting analogies, but there's a major flaw. Were I a AAA minor leaguer, a college Senior starting for Ohio State, or the XO on a carrier, then the analogy would actually work because I'd be basically qualified for those roles, similar to having an undergrad degree in biology, having scored well enough on the MCAT to get into medical school, and having passed step 1 of the MLE. Neither you nor I could walk onto a ball field and make a team any more than a High School Senior could walk into the hospital and be a Sub-Intern."

"Then assume you are in one of those roles — playing AAA ball for the Nashville Sounds, the Reds farm team. Does that guarantee you'll ever make it to the Majors? And if you do, that you'll ever be a starter? Or, in Franco's case, a closer? Would winning the Heisman Trophy twice guarantee you being a great NFL player? Or would being XO on a carrier guarantee you a command?"

"Archie Griffin?" I asked.

"Decent rookie year, but then four years without a touchdown and only mediocre stats."

"But he did make the NFL!" I countered.

"And yet, by all evidence, didn't belong there, despite being one of the greatest college football players of all time and the only one to ever win the Heisman Trophy twice. That is, in fact, an excellent parallel — great undergrad performance, good MCAT, good classroom work, and passing step 1 of the MLE, but then flaming out.

"Allowing for the differences between sports and medicine, that is exactly what is happening here. We're the equivalent of scouts, evaluating players and determining which ones we want to draft, hoping to get the best possible prospects onto our team. The difference is we don't have minor-league teams to which we can assign our draft picks. They have to be starters from the moment they're drafted.

"And let's compare to a specific known quantity. Think back a year to your first trauma Sub-I. You were trusted to do things usually reserved for Interns. And that was true of every member of your study group. I'm going to ask a question, and I want a completely honest answer from you, without any qualifications — would you have accepted Krista to your study group?"

"Yes," I replied. "Unequivocally. The problem with her is NOT academics or book knowledge, but clinical skills."

Ghost smiled wanly, "I walked right into that one."

"You did," I agreed.

"Then forget I even asked that question! But the point remains — she is not ready to call up to the majors. Of your six students, across all your shifts, where would she rank?"

"Last," I replied.

"And if you had to decide between Al and Krista for a procedure, which one would you trust to do it?"

"Al," I replied.

"Think about that, Mike. He's a Third Year in his second rotation. Krista is a Fourth Year in her eighth rotation. I understand you rooting for the underdog and believing in the innate goodness of every individual, but in the end, that's not what we're about. We're about saving lives. Can Krista save a life? You certainly could as a Fourth Year, as could Clarissa, Maryam, Fran, Peter, and Nadine. Krista probably belongs in research, if she wants to stay in the medical field."

"Is it Doctor Gibbs' intention to give her a failing grade?" I asked.

"I think that is the only way to send a clear message that she should consider her alternatives."

"She believes she's being treated unfairly."

"Do you think that's the case? Have you treated her unfairly?"

"I'm dissatisfied with how the Emergency Department has handled this," I replied.

"But was it unfair, or was it a reflection of her skills and abilities, or lack thereof? And it's not just the ED, Mike. YOU immediately noticed her procedure book was seriously deficient and took it upon yourself to speak to Leila Javadi to get another opinion."

"Krista still has five weeks to improve," I countered.

"That's true, but do you really believe she can do that?"

"It doesn't matter if I believe it; it matters if she believes it and acts on that belief."

"And yet, in the end, what she thinks is of only passing interest. It's the judgment of Attendings and Residents that matters. If she can't convince us, she has no future in clinical medicine. You and I discussed that early on — now it's her turn to ask for admission to the guild. You made the point, time and again, you had to satisfy us to be invited in, and you made damned sure you did, as did your friends. Hold her to the same standard as you hold yourself, which is, as you and Father Nicholas have pointed out, the entire point behind the 'do not judge' command Jesus gave."