Chapter 50: I Should Have Expected That Answer!

September 18, 1989, McKinley, Ohio

Band practice had gone well on Sunday, and I felt we were ready for the concert at Shaken Not Stirred. But that was Friday, and it was Monday, and I had to confront Krista about her lies to me. I'd decided on a plan and cleared it with Shelly, and now I was going to execute it. I received the patient handoff briefing from Kayla Billings, had a quick word with Kellie, then went to find Krista.

"I need a minute," I said to her when I saw her in the lounge.

I led Krista to the consultation room but left the door open.

"I have sufficient information and evidence to be reasonably certain you've lied to me," I said. "I'm not going to debate you or get into an argument about that. What I am going to do is say this once, and only once — if, from this point forward, you lie, obfuscate, dissemble, or dissimulate, I will fail you. Period. And I'll make it stick. That's all. You're dismissed.

"But..." she began.

"You're dismissed," I said firmly, cutting her off. "Go."

Krista frowned and left the consultation room while I went to speak to Kellie.

"You observed that the door was open the entire time, right?" I asked.

"Yes," Kellie confirmed.

I nodded, then reached into the pants pocket of my scrubs and pressed 'Stop' on the pocket tape recorder Shelly Lindsay had provided when I'd seen her in the locker room upon my arrival. I hadn't told Kellie about the recorder, but I'd started it right before I spoke to her before meeting with Krista to provide a timeline and a witness.

The tape would never see the light of day unless Krista forced my hand. I didn't like the subterfuge, but Shelly had insisted I record the conversation, and after thinking about it, I had decided she was correct. What happened next was completely in Krista's hands, but I was resolute in my plan to fail her if I caught her being less than completely honest at any point during her emergency medicine rotations.

I stopped at the Clerk's desk to make sure there were no immediate needs from walk-ins, had a brief conversation with Nicki, then went to check on the two patients Kayla had handed over — a concussion who was being monitored and would be released, and a rule-out MI who was waiting on blood work. The concussion patient was ready to be released, so I filled out the discharge form and allowed him to leave. The blood work was not back for the MI, so after reviewing the EKG, I left the exam room.

"My office, please," Doctor Gibbs said as she walked into the ED just as I was taking a chart from the rack.

I put the chart back and followed her to her office.

"Is this about a clinical matter?" I asked flatly.

"Shut the door, sit down, and drop the attitude!"

I shut the door but didn't sit, nor did I change my attitude. Rather, I said the Jesus Prayer forty times and kept my mouth shut.

"We have to find a way to work together," Doctor Gibbs said.

"I don't have a problem working with you," I replied.

"And the only way this can ever be solved is if I commit career suicide?"

I suppressed a strong urge to roll my eyes, took a few breaths, and silently said the Jesus Prayer before I responded.

"I don't believe saying something such as 'I agree with Doctor Loucks in principle, but I would have approached it differently' would be career suicide. Instead, you refused to lift a finger to back me up, then agreed to unjustly monitor me and be a «стукач», which is best translated in this case as 'rat fink' rather than 'snitch'." ("stukach")

"You are insufferable," Doctor Gibbs said, sounding exasperated. "And I don't think that's a fair characterization."

"You are, obviously, entitled to your opinion," I replied.

"Damn it, Mike! Will you just stop? You're trying to score points and to intentionally piss me off."

"Right, because I shouldn't be bothered by you refusing to back me in front of Doctor Northrup on a topic about which I know you agree with me. Then, to twist the knife, you wouldn't even admit, privately and off the record, that you agreed with me in the past. How should I have taken that betrayal? May I go treat patients, please?"

"Stop being an ass!"

"Grow a backbone."

"Get out of here," Doctor Gibbs growled.

I left her office and saw that Jake and Heather had arrived, so I asked them to get the first chart in the rack and let me know when he or she was ready to be seen. That was the first in a stream of fourteen patients we saw before lunch, a relatively busy morning, as Doctor Varma saw a similar number of patients.

There were a number of factors that had led to the increase in patients, and a major one was drugs. When I had been in High School, just ten years previous, pot and alcohol were the drugs of choice, and it was rare to see, or even hear about, anyone using anything harder. Now, we were seeing a spate of cases related to MDMA, methamphetamines, and other drugs.

And it wasn't just the drugs but the violence associated with the drug trade that had increased our patient load. I'd read that the police had discovered significant quantities of MDMA and methamphetamine in the room of the man who had shot Detective Townshend, along with several firearms and quite a bit of cash. What had started as a simple case of statutory rape had turned into a major drug bust, and it explained why the man's brother had come out shooting. Detective Townshend had been discharged from the hospital but would likely be on disability for several months before he could return to work.

At lunch, I chose to eat with the surgeons, as Clarissa couldn't take her break, which was, in a way, my fault, as I'd sent her three admissions between 10:30am and 11:45am. When we finished eating, I spoke briefly to Shelly Lindsay to let her know what had transpired with Krista. I also let her know about the conversation with Doctor Gibbs.

"I'd cut Loretta some slack," Shelly advised. "She really can't take a position where she supports the surgical team over Emergency Medicine."

"Except it wasn't about that," I replied. "It was about supporting me."

"May I be blunt?" she asked.

"Yes."

"You're being naïve, Mike. Or maybe you've decided you can live in some fantasy world where internal politics simply do not exist, and no consideration has to be made for them."

"At the expense of patient care and medical training?" I queried.

"Aren't you the one who has said, time and again, that students have to find a way to learn from doctors who are poor teachers or who treat them badly?"

"And I am doing that. I will engage with Doctor Gibbs on any clinical or medical concern."

"Do you know the psychological concept of 'splitting'?" Doctor Lindsay asked.

"Yes. It's a defense mechanism that people use where they divide the world into 'good' and 'bad', and everyone goes into one category or the other, and there are no grey areas."

"And Doctor Gibbs is now ... what's the name of the guy you joke about being slapped by Santa Claus for being a heretic?"

"Arius," I replied with a slight smile.

"Him. Or Judas Iscariot?"

"I don't believe that's what I've done," I countered. "I'm simply insisting that the relationship be purely professional."

"If you cut off every friend who ever, in your mind, does you wrong, you're going to be very lonely and become a bitter man. You admit you aren't perfect, Mike; don't demand others do what you insist you cannot do. You have a tendency to be like a dog with a bone on certain topics, and in many cases, that's a good thing. But finesse and subtlety are necessary to succeed.

"If you either cut off or piss off everyone, what possible good can come of it? Not only will you not achieve your goals, but you'll likely end your own career. I understand your righteous indignation, but when it becomes self-righteous, it goes too far. Take a cue from your heroes, and figure out a way to achieve your goal that doesn't involve burning down the hospital and your career with it. Neither of those things is in the best interest of your patients."

"All I can do right now is promise to consider what you've said," I replied.

"Be smart, Mike. Rome wasn't built in a day."

"And tolerating injustice only furthers injustice," I countered. "But I did hear everything you've said."

"Then find a balance that doesn't end with you losing everything. Going down in flames won't change anything and, in fact, will make it less likely anyone will step up. Check in with me tomorrow, please."

"I will," I replied.

Shelly and I parted, and she headed upstairs for her next surgery while I headed back to the ED, where I was immediately called for a consult on a potential surgical case.

"What do we have?" I asked Doctor Nielson when I went into Trauma 2.

"Grady Brown, eighteen, tackled hard during a pick-up football game. Ultrasound shows free fluid in the peritoneum. BP 90/60, pulse 100, PO₂ 95% on nasal cannula. Abdominal tenderness and visible contusion. Weak distal pulses in both ankles, slow cap refill."

"Sounds like a splenic rupture," I observed. "Given he's hemodynamically unstable, we'll send him up as soon as I verify the ultrasound findings."

"Grady, I'm Doctor Mike, a trauma surgeon. With your permission, I'll examine you and determine if you're going to need surgery."

"OK, Doc," he replied.

I performed a gross exam, finding the same symptoms Doctor Nielson had reported, then verified the free fluid in Grady's abdomen.

"Confirmed," I said. "Grady, you're going to need surgery. Janice, please call upstairs and book an OR."

Janice, Doctor Nielson's Fourth Year, went to the phone and made the call.

"They'll be ready in ten minutes," she reported when she hung up the phone. "The nurse said that Doctor Burke requested you and your Fourth Year scrub-in, as they're short-handed."

Which made sense, given Shelly had mentioned they had a full slate of scheduled surgeries for the afternoon.

"Perry, I'm going to call my students back from lunch, and we'll take the patient up."

"Thanks, Mike."

"Grady, in about ten minutes, we'll take you up to an OR."

"You're doing the surgery?"

"I'll assist," I replied. "I'm still training."

And I actually wouldn't get to do very much, as I'd be an extra pair of hands for Doctor Burke, but I wouldn't say that to Grady.

"How long does it take to become a trauma surgeon?"

"About twelve years, if you include four in medical school. And that's after an undergraduate degree."

"What about just working in the ER?"

"About seven years of training, including medical school," I replied. "But all of us will continue to learn for the rest of our careers because medicine is constantly changing."

"Thanks, Doc."

"See you in a few minutes," I said.

I left the room and asked Nate to page Jake and Heather with '99999' so they would come back right away. He did that, and about ninety seconds later, the two of them hurried into the ED.

"We have a surgical patient," I said. "Surgery is booked solid, so Jake and I will scrub in to assist Doctor Burke."

"Bummer," Heather groused. "Is there any way I can scrub in?"

"I can ask when we get upstairs," I said. "Did you guys actually get to eat any of your lunches?"

"I'd skip meals for a week to scrub in!" Heather declared.

"And pass out from low blood sugar in the OR," I replied. "But I understand the sentiment. If you didn't eat much, grab some peanut butter crackers or even a candy bar, we have about five minutes."

They both went to the supply room and got packages of peanut butter crackers, which would be enough to tide them over, and I let Doctor Gibbs know I was going up to surgery. Once my students had wolfed down their crackers, I had Heather get a gurney. Once she had done that, the three of us went into Trauma 2.

"Grady, these are my students, Jake and Heather. I need to go over the consent form, then they'll help you onto the gurney and we'll take you upstairs."

"OK, Doc."

I picked up the clipboard and began reading the consent statements, which were a list of potential negative outcomes, including death. Per policy, we had to read them and not try to couch or finesse them, though the document did say such instances were 'rare' and 'uncommon'.

"Do you have any questions?" I asked.

"How many lawyers did it take to create that list?" he inquired.

I chuckled, "Dozens, I'm sure. But, as the form says, significantly negative outcomes are possible, though they are rare. They do happen, which is why you'll need to sign the form."

He accepted the clipboard and signed the form, then Doctor Nielson and I both signed it as witnesses. I put the clipboard in the small rack on the gurney, then had Heather switch the nasal cannula to a portable oxygen bottle. She did that, then she, Jake, and I helped Grady scoot onto the gurney.

Five minutes later, we handed him off to a pair of masked medical students and a nurse, then went to the scrub room.

"Doctor Burke, would you permit my Third Year to observe?" I asked.

"She's your student, so that's up to you."

"Thank you. Heather, do you remember how to scrub from your Preceptorship?"

"Yes."

"OK. Let's put on fresh scrubs, then scrub in," I said.

Ten minutes later, the three of us were in the OR with Doctor Burke, three nurses, and an anesthesiologist.

"Mr. Grady, we're going to put you to sleep now," Doctor Burke said, then nodded to the anesthesiologist, who began the flow of drugs.

"He's out," Doctor Cromwell, the anesthesiologist, said.

"Thanks, Tom," Doctor Burke said. "Mike, you're officially second surgeon, but with limited time in the OR, I'll have you operate suction for me; Jake can hold the retractor. If everything goes well, I'll supervise you closing."

"OK," I acknowledged, then turned to my student, "Jake, step up to my left, please. Do exactly as you're told, no more, no less."

"Absolutely, Doctor Mike!"

I could tell he was extremely happy to be able to participate, which was a very rare thing and was only possible because of the full surgical schedule. The surgery was textbook; there were no complications, and as he'd promised, Doctor Burke walked me through closing the incision.

"Before you start, Mike, what's the difference between 'layered' closure and 'mass' closure?"

"Layered closure is the sequential closure of each fascial layer individually; mass closure is continuous fascial closure with a single suture. The two have relatively equal negative outcomes, so it's a choice by the surgeon. What's yours?"

"I prefer 'mass'," Doctor Burke said. "It provides even distribution of suture tension across the entire closure, and it's faster. 'Layered' closure provides better closure integrity in that a single suture breaking won't allow dehiscence or a hernia, but those risks are minimal, making it a free choice. We'll use the small-bite technique; do you know that?"

"Yes. It means keeping the distance between the suture and the wound edge to between 5 and 8 millimeters, and the distance from stitch to stitch of about 5 millimeters."

"Then proceed. I'll act as assistant."

I nodded, "Nurse, Kocher clamps to Doctor Burke, please."

She handed them to him, and he clamped the fascial layer midway through the incision and then applied tension.

"Zero PDS on a suture needle, please," I requested, saying a silent prayer of thanks that I had studied closure techniques regularly since my surgical Sub-I.

"I'll begin at the superior aspect of the incision," I said.

I passed the first suture through the vertex of the fascia, making a loop and passing the needle through the loop to lock the stitch, then ran a continuous suture, with each bite including tissue from the linea alba, the rectus sheath, and muscle itself, closing all fascia at once.

"Very nice technique, Mike," Doctor Burke observed. "How would you close the sub-cu layer?"

"A continuous suture," I replied. "With the same absorbable sutures."

"Then continue."

I completed that, then closed the skin with 3-0 nylon, which I preferred.

"Owen wasn't kidding when he said you were an ace at suturing," Doctor Burke observed. "An excellent job, Mike. Make sure you bring me your procedure book later. Tom, you can stop the sedation. Mike, if you and your students would escort Mr. Brown to recovery, I'll send someone to relieve you in a few minutes."

"We'll take care of it," I confirmed.

Heather, Jake, and I carefully moved Grady to a gurney, assisted by the nurses, and moved him to recovery. About five minutes later, two surgical students arrived to take over, so my students and I headed back to the ED.

"That was too cool for words!" Jake declared.

"Write it in your procedure book, and I'll sign it," I said. "That'll improve your chances of holding retractors or even handling suction during your Sub-I."

"I am SO glad I didn't switch schedules!" he declared. "I'd never have had this chance with anyone else."

"Same here," Heather replied. "Just watching was pretty cool, though participating would be better."

"We'll see what we can do next year during your emergency medicine Sub-I," I said. "I can't promise because this doesn't happen very often, but as with today, it does happen."

"Now I just need a helicopter flight to basically cover everything," he said. "You're a qualified flight surgeon, right?"

"Yes, though there will be fewer opportunities in the future because once we're certified at Level I, we'll have literally everything except a major burn unit. That said, if you Match for emergency medicine or internal medicine here at Moore Memorial, you'll do a week of paramedic ride-alongs."

"I heard Internal Medicine Interns are going to do rotations in the ED," Heather said.

"Yes, that starts next month. Paramedics are already doing their rotations to learn intubation, but they're being taught by Attendings."