Chapter 54: I Know the True Source of Your Problem

October 2, 1989, McKinley, Ohio

"What's your proposed treatment?" I asked Sophia when we received Crystal's lab results later on Monday morning.

"I'm not sure," Sophia replied. "Other than low calcium, I don't see anything on the lab report."

"What can cause that?" I asked.

"Liver disease, kidney failure, some medications, laxatives, and a number of rare conditions."

"Did you see signs of any of those things?"

"No."

"And you're confident she was telling the truth about other symptoms she's experienced?"

"Yes. I didn't detect any evasion or inconsistencies when I asked the same question in different ways."

"Good. Any other thoughts about her condition?"

"No, but I think you know."

"Think back to biochem — what affects uptake of calcium?"

Sophia thought for a moment, "Vitamin D. If she's deficient, that could cause the problem, but we aren't seeing any other signs of vitamin D deficiency."

"So, what would you do?"

"Get a 'D' level, then call for an endocrinology consult, as she doesn't show signs of IBS or other obvious conditions that would cause malabsorption."

"Nicole, what else would indicate that she might have a low vitamin D level?"

Nicole thought for a second, then smiled, "Her skin is really, really light, and she's flaxen-haired. She's wearing long sleeves despite it being warm outside. She also has a hat with her. She's a student as well, so I bet she doesn't spend any time in the sun. If she doesn't drink vitamin D fortified milk or eat the right kind of fish, her levels could be low enough to impair calcium uptake, but not low enough to show other signs."

"Very good. Obviously, there are other possible causes, but we have an initial path to go down before we call for the consult. Let's go see her. Sophia, inquire about sun exposure and diet please."

She acknowledged me, and we went back to Exam 3.

"Crystal, I have a few more questions," Sophia said. "Do you get much sun?"

"No. I'd burn to a crisp! A few minutes, and I look like a lobster. It's been like that since I was little."

"Do you drink milk?"

"Can't stand the stuff! I stopped drinking it when I was little."

"What about salmon or herring?"

"No. I'm a meat and potatoes girl from Ohio! And nobody in their right mind eats fish from Lake Erie or the Cuyahoga River!"

She had a very good point on that.

"We need to run one more test," Sophia said. "Unfortunately, we'll need to draw more blood."

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

Sophia looked to me, and I nodded.

"Low vitamin D could explain all your symptoms," Sophia said. "If that's the case, then we'll call an endocrinologist to review your case and advise you on what you should do."

"Can I just take vitamins or supplements?"

"Maybe," I interjected. "The reason we want to have an endocrinologist review the case is that there might be some other underlying problem. I don't think so, but it's possible. Remember, I'm a trauma surgeon, so I have basic diagnostic skills in this area, but an endocrinologist is much better suited to figure out the root cause. Now, if you were injured in an auto accident or having an actual heart attack, I'm your guy!"

"Why did they have you examine me, then?"

"You presented in the Emergency Department, so you'll be evaluated by an emergency medicine specialist. That's because the doctors who work in what you probably call the ER are all emergency medicine specialists. We call other doctors when we need an assist. Believe it or not, your GP is better at this than I am because it's his job. My main job is to save lives in an emergency, so that's where I've had my specialist training."

"My doctor is in Cleveland, so the nurse at Taft suggested I come here."

"She gave you very good advice," I replied. "Let's get the blood test, then we'll call the specialist."

"Thanks, Doctor!"

"You're welcome. Nicole will draw the blood, and we'll come check on you in a bit."

Nicole drew the blood, the three of us left the room, and Nicole put the tube and order in the rack at the Clerk's desk.

"I feel I should have known that," Sophia said.

"You're on your first day of a rotation where you're going to encounter almost anything under the sun," I replied. "You did fine. I had similar feelings when I was in OB. I bet you know far more about that than I do! And that's the point I was making to Crystal. Measure yourself by OB/GYNs and surgeons, not by generalists in Medicine or Emergency Medicine. I know you've done well because I saw your evaluations and I've seen your procedure book!"

"Hi, Petrovich!" Clarissa exclaimed, walking over to us.

"Morning, Lissa."

"Hi, Sophia; Hi Nicole," Clarissa said.

They both returned the greeting.

"Doctor Gibbs assigned me to walk-ins," she said.

"Me, too! I usually only get called when there is a surgical consult or multiple transports. Who are your students today?"

"Erik Hubbard and Ernie Snyder; Erik is the Fourth Year."

"I see five charts in the rack! Why are you just standing here?"

Clarissa laughed, rolled her eyes, and went to find her students.

"Do you have to do a Medicine rotation?" Nicole asked.

"No. I'm on the surgical staff. It's Medicine and Pediatrics who are doing ED rotations for now, and that might expand to other services. Emergency medicine specialists all have to do paramedic ride-alongs, and paramedics are rotating through the ED. We could really use a pediatric specialist in the ED, so I hope it expands to include them."

"I thought pediatrics was your specialty!" Sophia declared. "'Kid Whisperer'!"

"Clarissa would tell you I relate to toddlers because I am one!"

"She might have a point!" Sophia declared mirthfully. "Robby has his moments, too!"

"All men do," Nicole declared. "They're all toddlers, just with more body mass and money!"

"Yeah, yeah," I chuckled. "Go get a chart. This time, you do the H&P with Sophia supervising."

They went to the Clerk's desk, and I went to the lounge to get some water. As was my practice, I sat down with the glass of ice water and my flashcards, with today's topic being infectious diseases. Other doctors came in and out but didn't stay, and about ten minutes later, Sophia came to the door to let me know they were ready. I put my flashcards away and headed to Exam 2.

"Mr. Wheeler, this is Doctor Mike," Nicole said. "Doctor Mike, John Wheeler, forty-seven. Reports constant chest pain but no other symptoms; onset was five days ago; BP 140/90; Pulse 100; PO₂ 99%. No history of cardiac problems. No recent illnesses. No medication except Tylenol for discomfort."

"Good morning, Mr. Wheeler," I said. "Do you smoke?"

"No."

"Crap," Nicole said, barely audibly.

"It's OK, Nicole," I said. "Just remember next time. Mr. Wheeler, what do you do for a living?"

"I'm an attorney at a title company."

"Can you describe the pain? Is it dull? Shooting? Sharp?"

"Dull, like an ache."

"Does exertion or exercise change the level of pain?"

"Not really, but it does make it hard to breathe."

"OK. Nicole, what's our plan of action?"

"EKG and chest X-ray," she replied. "Nothing indicates a need for blood tests at this point."

"I agree. Proceed."

"Five-lead, right?"

"Yes."

She had Mr. Wheeler remove his polo shirt and connected the EKG leads. A minute later, I saw a perfect sinus rhythm.

"That looks normal to me," she said.

"I concur. Textbook sinus rhythm. Call for a chest series, then take Mr. Wheeler to Radiology. Mr. Wheeler, your heart appears to be in good condition. Your blood pressure and pulse are a bit high, but that could be the result of the pain."

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

"At this point, it would be wild speculation. The X-ray will give us a better idea. If it's inconclusive, then we'll discuss our next steps."

"Thanks, Doc."

Sophia and I left the room, and Nate signaled that he had labs for us. Sophia retrieved them and looked them over.

"Crystal's D level is 21 ng/ml," she said. "According to the printed reference ranges, that indicates insufficiency, not deficiency."

"And?" I prompted.

"That's consistent with our conclusion. Endocrinology consult?"

"Yes. They'll most likely refer her to a nutritionist, who'll most likely recommend vitamin D supplements, but let's simply tell Crystal what the report says and that we're calling for a consult."

We went to Exam 3, and Sophia explained what we'd found, then placed a call to Endocrinology.

"About ten minutes," Sophia reported when she hung up.

"OK. Stay with Crystal and report to the Resident. I'm going to check on Nicole."

"OK," Sophia agreed.

"Thanks again, Doctor," Crystal said.

"You're welcome."

I left the room and went to the other exam room to confirm that Radiology could take Mr. Wheeler, which they could, and Nicole had already called for an orderly with a wheelchair. I waited with them until the orderly arrived, then sent Nicole with Mr. Wheeler while I returned to Exam 2 just as Matt Keller arrived.

"Hi, Mike, what do we have?"

"My student will present," I said as we went into the room.

"Crystal, this is Doctor Matt Keller from Endocrinology," I said. "Sophia, please present."

She provided an excellent case report and answered questions from Matt Keller, who reviewed the charts, lab results, and EKG, then examined Crystal. He asked her a number of questions, then asked Sophia and me to step out.

"I don't think you need to bother anyone else," he said. "Vitamin D and calcium supplements and refer her to her GP."

"She's from Cleveland, and that's where her GP is. We'll refer her to the Free Clinic, and I'll give Gale Turner a call and fill him in."

"That'll work. She should have repeat labs in ten days to confirm the supplements have increased her D and calcium levels."

"I'll let Gale know."

He left, and Sophia and I had a brief conversation about the correct dosage of each supplement, then went back into the room and Sophia informed Crystal of our findings. I provided her with a brochure from the free clinic, along with written discharge instructions, then had Sophia escort her to Patient Services. I went to the lounge and poured a cup of coffee.

"She wanted to know if you were married," Sophia said with a twinkle in her eye when she returned to the lounge. "She was disappointed."

"I believe I already have my quota of pretty blondes," I chuckled. "Anyway, you did an excellent job with that patient despite your misgivings."

"I'm sure you know that's the first time I've been given what amounts to full responsibility for a patient."

"And I'm sure you know we throw Fourth Years into the deep end to ensure they can swim! You swam just fine. How did Nicole do during her H&P?"

"A bit tentative, but I didn't need to prompt her. The only thing she missed was the question about smoking. She asked the other questions you did, but I think nerves got in the way of giving a full, accurate report."

"I throw Third Years in the deep end as well," I replied. "You know my thoughts on that."

"Sir William Osler, right?"

"Exactly. You learn by doing. Watch one, do one, teach one. She watched one, now she's done one. She'll do dozens more in the next two months so that next year, she can do what you just did."

"You are so different from every other Resident!"

"That's good and bad," I said with a wry smile. "Clarissa likes to say she can't leave me unsupervised for thirty seconds without me finding some way to get into trouble!"

"So, like most guys, then!" Sophia teased. "Or toddlers!"

"Well, you're trouble, and I got into you!" I replied with a grin.

Sophia laughed, "I'm married now! No more wild Greek girl! And besides, you know my preference in that regard!"

"I do."

"What do you think the X-ray will show?" Sophia asked.

"If I had to guess, most likely a torn pectoral muscle or a fractured rib. If not those, then a tumor. If the X-rays are inconclusive, then we'll get a CAT scan, but I need an Attending to sign off on that."

"I was surprised you don't have an Attending sign off on all your cases."

"They will, after the fact. Doctor Gibbs signed off on me handling simple cases with obvious treatments without presenting them. She'll review the charts, of course, but in a busy ED, there just isn't enough time to present a vitamin D insufficiency with no underlying cause other than diet and lack of exposure to sun, especially with a consult from an endocrinologist."

"Do any other PGY1s have that privilege?"

"No. Doctor Gibbs did during her PGY1 year, though, as did Ghost."

"Will Clarissa have to present all her cases?"

"At least at the start. Once she shows she can handle basic cases, she'll receive sign-off as well. That's the key for when you start your Residency. Show your Attending that you know your stuff but also that you know your limits, and they'll allow you to do more things. Fundamentally, everything before Fourth Year is prep work for actually being a doctor, which is what Fourth Year is about. You'll be handed your MD, and at that point, you're a Resident and will be expected to be a Resident."

"Did that idea just blow you away?"

"Clarissa and I talked about it. One day, you're a med student; the next day, you're the doctor and expected to BE the doctor. Despite it being the culmination of twenty years of formal education, it's still mind-boggling."

"Mike?" Ellie said from the door to the lounge. "EMS three minutes out with a head-on MVA. Two victims. Doctor Gibbs wants you in the ambulance bay!"

"Be right there! Sophia, game time! This is where we earn our pay."

"I'm still an indentured servant!" Sophia objected.

We left the lounge, put on gowns, gloves, and the newly mandated plastic goggles, and headed to the ambulance bay where Doctor Gibbs, Doctor Foulks, Jamie, Mary, Kellie, and Vickie Cartwright, a Fourth Year, were waiting.

"Bad one," Doctor Gibbs said. "Both patients intubated in the field. One with massive crush injuries; the other a severe head injury; Neuro was paged. Mike, you and Nick take the crush injury, as it's certainly going to be surgical. Kellie, you're with them."

"Sophia," I said. "Get a chest tube tray and an ultrasound ready in..."

I looked to Doctor Gibbs.

"Trauma 2," she responded.

"Trauma 2," I confirmed. "Also, ensure there are at least three units of plasma in the fridge. As soon as we get the patient in, type and cross-match."

"Right away, Mi ... Doctor!" Sophia exclaimed, heading back into the building.

"Who's running this?" Nick asked.

"You. I'll do the surgical assessment and any surgical procedures at your direction."

"Vickie," Nick said, "monitor, but wait for the assessment before you put on the EKG. Kellie, trauma panel."

The first EMS squad turned into the drive, and I saw the second close behind it. They both pulled up in front of us a few seconds later. Bobby jumped out of the first squad.

"Roughly thirty-year-old male; high-speed, head-on MVA; crush injuries to chest and both legs; pulse 120; BP 70/20; no spontaneous breathing; intubated; difficult to bag; PO₂ 88% on Ambu bag; plasma and IV Ringer's."

"Trauma 2!" Nick declared as they moved the gurney from the squad. "Vickie, vent before monitor."

"He's in cardiogenic shock!" I announced, stating the obvious as we'd been trained to do.

Bobby, Sam, Fireman Schmidt, who was bagging, Doctor Foulks, Kellie, Vickie, and I quickly escorted the patient to Trauma 2, where Sophia was waiting. I noted the ultrasound was powered on, which was good thinking on her part, and I also saw the defibrillator was powered on but not charged. The assembled team moved the patient to the trauma table and the paramedics and firefighter left the room as we sprang into action.

A quick assessment showed signs of bleeding in his chest, which had been crushed, as well as his abdomen.

"He's hypovolemic," I announced. "Sophia, central line kit. We need to be able to get blood into him quickly. Nick, I suspect he's going to lose significant volume when I make the incision for the chest tube, but if I don't try, he's going to de-sat."

"Agreed!" Nick replied. "Do it! Kellie, set up the rapid infuser. Vickie, call the blood bank and get whole blood, stat! Sophia, what is his type?"

"O+," she replied.

Sophia assisted me in inserting the central line as Nick performed a complete trauma workup. The only positive note was that there was no indication of neurological damage.

"Hang the plasma on the rapid infuser," I instructed Kellie. "Start it as soon as I make the incision."

I waited for her to hang the unit, then began the procedure. As I'd feared, a gush of blood came from the incision as soon as I had dissected the subcutaneous tissue muscle.

"No BP! No pulse!" Vickie announced as the monitor blared.

"Severe hypovolemia with at least 750ccs of blood on the floor," I announced, working quickly to insert the chest tube and connect the Thora-seal. "Hang a second unit, please. And then the whole blood as soon as it arrives.

"BP 60/20," Vickie announced. "Pulse 120. PO₂ 90%."

"Sophia," I said, "call upstairs; we need a thoracic surgeon immediately. Nick, we need him on a table as soon as we get the first unit of whole blood into him. If we wait to try to stabilize him, we'll lose him for sure."

"Agreed! Vickie, get a Foley in, now!"

The whole blood arrived, and we rapidly infused a litre of O+, then Sophia, Vickie, and I transported the patient to surgery.

"Think he'll make it?" Sophia asked after we'd turned the patient over to Doctor Aniston and his team.

"He's lucky to have made it this far," I said. "I'd say a 10% chance, but that's 10% more than if the paramedics weren't as good as they are. Field intubation is huge because, without a clear airway, he would have been DOA with those injuries."

"Why 10%?" Vickie asked.

"Because he's unstable and hypovolemic, with low oxygen sat. Those are all negative indicators for expected outcome. He might code before they even start. But, in the end, he'd die if they don't, so even 10% is an infinitely better chance than he'd have without the surgery. Fundamentally, losing 750ccs means fifty-fifty at best, and I suspect the total blood loss was close to a litre, at which point survival is between ten and twenty percent for crush injuries to the chest. If he lives, his legs are going to need surgical repair. And those shattered bones induce additional risk. What is it?"