Chapter 65: Get Back On The Horse

December 4, 1989, McKinley, Ohio

"Mike," Mallory said just after 8:30pm, "I have the phone call you were expecting. Line 3."

"I'll take it in the consult room."

I went to the consultation room, closed the door, picked up the handset, and pressed the button for line 3.

"Mike Loucks," I said.

"Hi, Mike. It's Father Roman."

"Father, bless!"

"The blessing of the Lord be upon you. What's on your heart?"

"Two things, one of which is easier than the other. With your blessing, I'll take the easier one first."

"Go ahead."

"The easy one is that recently, I've struggled with communicating with one of my mentors. I quickly get my back up and push back hard on things which, ultimately, are beyond our control."

"Is this the same one with whom you had difficulties because she wouldn't speak up in your defense?"

"Yes. I thought we had moved past that, but events conspired to have her ask questions, and I reacted badly."

"And, of course, you used the prayer techniques as I instructed you, right?"

His tone of voice indicated he believed the opposite to be true, and he was correct.

"Of course not, or we wouldn't be having this conversation."

"The answer is within you, Mike," Father Roman observed.

"I know. I felt I needed to confess, and I won't see you until after Nativity. I promise to keep working on it."

"Good. What was the second thing?"

"A patient died from something I did," I said.

"An error?" Father Roman asked.

"A choice," I replied. "Doctor Casper, the Attending on the case, is convinced she would have died either way. Intellectually, I know he's right; I'm struggling with it."

"Are you able to explain in layman's terms?"

"Yes. A young woman who was stabbed multiple times in the chest and stomach was brought in by paramedics. She was given blood by the paramedics, who had also applied pressure bandages. When we received her, I put a large-bore IV directly into her jugular so we could give her blood quickly. In addition, a breathing tube was inserted, and she was connected to a ventilator because the amount of oxygen in her blood was low and dropping.

"There are a number of settings on the ventilator to control how much oxygen is provided, but there are limits to how high those settings can safely be set. The blood accumulating in her chest was putting enough pressure on her lungs that the ventilator was not working effectively, and the pressure could not be increased to overcome it. That meant she needed a chest tube to relieve the pressure.

"I knew right away that could cause a problem, in that the same blood that was making it hard for her to breathe, even with the ventilator, was compressing blood vessels and limiting bleeding. I reminded Doctor Casper of that fact, and he instructed me to insert the chest tube. I followed his instructions, and as soon as I made the incision in her side, a large volume of blood flowed out, causing her blood pressure to drop to nothing and her heart to stop almost immediately.

"I completed the procedure, we gave her blood as quickly as possible, including using a system that pumps it in and performed CPR. It was ineffective, and after a brief conversation between Doctor Casper and me, we agreed we should cease treatment, as there was no hope she could ever recover due to blood loss. Doctor Casper announced the decision and declared the patient was dead. Both he and the nurse noticed I was struggling emotionally, and he suggested I call you."

"He's Orthodox?"

"Married in," I replied. "He married Kris' cousin Oksana. He hasn't been chrismated yet but will be on Holy Saturday."

"I'm sorry to divert the conversation, but did they have a wedding in the temple?"

"Yes. And the answer to your next question is that he is the person I mentioned when we discussed my dispute with Father Nicholas about the necessity of chrismation before marriage."

"What else happened?"

"I did leave out that I prayed for the patient and for the medical team before, during, and after. I should have mentioned that, but I was, in effect, giving a layman's version of the treatment, and I cannot include 'prayed for patient and staff' on a chart."

Father Roman laughed softly, "No, I suppose you can't, even if it is completely relevant. What alternatives did you have?"

"None, really. I also left out what I had said to Doctor Casper just before the ambulance arrived — that we needed a fully trained surgeon for a patient with such severe injuries, and what I was able to do was limited."

"No fully trained surgeon was in the hospital?"

"No. Once the surgeries for the day are done, there are only Residents at the hospital. The Attending physician on call only needs to be able to arrive at the hospital within fifteen minutes of being paged. Generally speaking, that's sufficient given the time it takes to stabilize a patient for surgery."

"Were there things you could have done if you'd had more training?"

"More than likely no, but I won't know until we have our Morbidity and Mortality Conference, referred to as M & M Conference. That's a weekly review of interesting or difficult cases where a large group of doctors from every service discuss how to improve medical care and identify errors or weaknesses in the procedures or actions of a member of the medical staff."

"I'm quite surprised that there isn't a surgeon on duty at all times."

"There is, but surgeons who are in the hospital, including me, are only qualified to perform certain emergency procedures, including chest tubes, central lines, and tracheostomies. The central line is what I described earlier as a large-bore IV inserted into the jugular vein. A tracheostomy is inserting a breathing tube through the neck rather than through the mouth. There are a few other procedures, but those are the most important ones.

"Things will change in less than two years when our new Emergency Department opens, at which point we'll begin the process to be certified as a Level I trauma center. That certification requires fully trained surgeons to be in the hospital at all times, not simply to be on call. But, as I said, in this case, I don't believe it would have helped."

"What are you struggling with?"

"That a patient died as a result of a direct action on my part. Intellectually, I know I did the right thing, but my heart is heavy."

"You've had patients die in your presence before, right?"

"Yes, but this was the first one from something I did."

"I'd be concerned if your heart wasn't heavy, Mike. Being involved in someone's death ought to weigh on you. If I recall correctly, you had similar feelings the first time a patient died in your presence."

"Yes, I did."

"And you're certain that you did the right thing?"

"I don't see how I could have done anything else," I replied. "Doctor Casper agrees."

"The only advice I can give you is to pray, as the true danger lies on the other side — when you feel nothing at all. You've said the heaviness in your heart about patients who have died is minimal but still there, and it's impossible for death not to affect you if you are spiritually healthy. We can discuss this further if you feel it necessary when you visit after Nativity, but what you are feeling is a good thing, Mike. Your goal is not to allow it to overwhelm you."

"Thanks, Father."

"Make sure you speak to your mentors, especially the doctor who is a catechumen. They'll all have experienced what you have and can help you with it. Now, I need to pray and go to bed. I'll see you at the end of the month."

We said 'goodbye', I hung up and went to find Ghost to let him know I'd spoken to Father Roman.

"I'm sure Father Roman gave you good advice," Doctor Casper observed, "but I want to add something important — don't allow this to make you hesitant or doubt your skills as a physician. Patients die, as you well know, and some of them simply cannot survive their injuries or ailments. The key for a successful physician is to understand and accept that even if he or she does everything correctly, some patients will die. What we can't allow or accept is having that cause us to behave in such a way that a patient dies who we should have saved."

"Hi, Mike," Doctor Varma said, coming up to us. "Ready for the handover?"

"We'll talk tomorrow, Mike," Ghost said. "Do the handover and go home and get some sleep."

"Will do. Thanks, Ghost."

He walked away, and I turned to Doctor Varma.

"Problems?" Naveen asked.

"No. Just discussing a stabbing victim who bled out before we could stabilize her. There are two on the board — concussion being observed and showing no symptoms, who can be released at 9:30pm, and a kidney stone waiting on a nephrology consult in Exam 3."

"OK. I have it. Have a good evening."

"Thanks."

I left the ED and headed upstairs to the surgical locker room, where I showered and dressed before leaving the hospital to head home.

At home, I read to Rachel, then we said our evening prayers together as a family and put Rachel to bed.

"Who is that extra person you added to our prayer list?" Kris asked when we sat down together in the great room to relax before bed.

"A patient who died while I was working on her. She had been stabbed at least eleven times and died while I was working with Ghost to try to save her life."

"You don't normally add patients who died to our prayer list."

"This one was different," I replied. "We had only bad options, decided on the only one that had even a remote chance of success, and she died from the procedure. She would certainly have died otherwise, but it felt as if I had killed her. I hadn't, of course, but it felt like that because it was literally what I did that caused her to die. I called and spoke with Father Roman."

"That's good. How are you feeling now?"

"It's fading, and it's not all that dissimilar to the first time a patient died in front of me as a medical student, though it is somewhat stronger because I was directly involved. Father Roman basically said to keep doing what I'm doing, that is, praying, and Ghost spoke to me about not allowing what happened to interfere with treating patients."

"He was afraid you would be tentative?"

"Yes. In the end, Father Roman's larger concern was that I might become too emotionless and not feel something when a patient died."

"Which is a real possibility given your personality," Kris observed.

"Yes. I also spoke to him about my dust-up with Loretta the other day."

"Dust-up?"

"Kerfuffle? Set to?" I teased.

Kris slapped me softly on the arm, "You can't explain by using other slang words I don't know!"

"Sure I can, if my goal is to tease you!"

"Michael Peter Loucks!" she said with a smirk.

I laughed, "I wondered when I'd get the full 'three name' treatment!"

"If you take me upstairs, we can kiss and make up!" Kris offered.

There was no possible way I could refuse that offer, so I scooped up my squealing, squirming wife and carried her to the bedroom, where I ravished her before we fell asleep cuddled together.

December 5, 1989, McKinley, Ohio

"Are you OK?" Shelly Lindsay asked when I saw her in the locker room on Tuesday morning.

"Yes. Who talked to you?"

"Ghost called me. It was bound to happen, eventually. I remember the first time it happened to me. I was a PGY3, and I had just resected a portion of necrotic small bowel when the patient coded from an unrelated thrombosis."

"So now we're exchanging 'first time' stories?" I asked with a smirk.

Shelly laughed, "Three days before I turned eighteen, at Senior Prom."

"The Summer after I graduated from High School; I was eighteen-and-a-half."

"If you can tease, you're OK," Shelly observed. "According to Ghost, she had no chance."

"I counted eleven distinct abdominal stab wounds, and there may have been more. Not to mention lacerations on her hands and arms, which I'd suggest were defensive."

"That she didn't bleed out before she arrived here is a minor miracle in and of itself. Any idea what happened?"

"The cops arrested the boyfriend," I replied. "That's all I know. I was going to stop in and see McKnight later this morning to ask about the autopsy."

"According to Ghost, your technique was textbook."

"I was more curious about whether or not she was pregnant. The cops asked that question."

"You're thinking she refused to get an abortion, and the boyfriend objected?"

"Stabbing her repeatedly is more than 'objected'," I countered.

"Obviously," Shelly acknowledged, "but you know what I meant."

We finished changing into our scrubs and left the locker room together.

"I'm here to talk anytime you need me."

"Thanks, Shelly," I said, then walked to the stairs so I could go down to the ED.

"Morning, Jody," I said to Doctor Billings. "What do you have for me?"

"An empty board and an empty waiting room! I just discharged a rule-out MI. I'm heading home to get some sleep!"

She left, and I went into the lounge, poured myself a cup of coffee, then went to the Attending's office.

"Morning, Perry," I said. "Anything I need to know?"

"It was a relatively quiet night, so nothing at the moment."

"The waiting room is empty as well, so I'll be in the lounge."

I left the Attending's office and went to the lounge, where I sat on the sofa and began reading the McKinley Times. The lead article was about the stabbing and didn't have much information beyond what I already knew. The one extra piece of information was that the victim's sister had called 9-1-1. Jenny and Kelly came in a moment later.

"Morning," I said. "Any charts in the rack?"

"It's a ghost town out there!" Jenny said.

"Nah, he went off shift at midnight," I replied with a smile.

"BOO!" Jenny intoned.

"Mike?" Ellie called out from the door to the lounge. "EMS four minutes out with an MI. Perry wants you to handle it."

"OK. I need a nurse."

"I'm all yours!" she declared.

"Jenny, Kelly, let's go!" I said.

The three of us got up and followed Ellie to the ambulance bay, donning gowns, gloves, and goggles.

"Jenny, EKG and monitor. Ellie, O₂ hookup, then draw for ABG, Chem-20, CBC, and cardiac enzymes. Kelly, IV saline TKO, then I'll talk you through a Foley if one is necessary. Otherwise, watch Jenny hook up the EKG and monitor, and you'll do the next one."

All three of them acknowledged my orders, and about ninety seconds later, the EMS squad pulled into the ambulance bay. Ken hopped out of the cab and called out the patient's condition as he made his way to the rear doors of the squad.

"John Baxter, forty-six; non-responsive; complained of chest pains while eating breakfast, then collapsed. BP 160/100; pulse thready at 110; PO₂ 93% on ten litres by mask."

"Trauma 1!" I declared.

Ken, Larry, Ellie, my students, and I quickly moved to Trauma 1, where I gave the count to move the patient from the gurney to the trauma table. Ellie quickly switched the O₂ from the portable bottle to the hospital system while Jenny cut Mr. Baxter's shirt so she could attach the EKG pads.

"IV is in!" Kelly declared.

"Get a 16 French Foley," I said. "It has an orange sleeve on the distal end and is in drawer A. The packet is marked with large numerals and says 'Male'."

I quickly listened to Mr. Baxter's heart and lungs, working around Jenny as she attached EKG leads.

"ST elevations on the monitor," Jenny announced. "PO₂ 91%; pulse 110; BP 160/100."

"Call Cardiology! Ellie, 250mg ASA IV push! Kelly, use surgical scissors to cut away Mr. Baxter's pants, please."

"How?" Kelly asked.

"Cut from cuff to waist on the outside of each leg. Quickly! No prizes for neatness! Then cut away his underwear in a similar way."

She did as I instructed, and I realized we needed a larger catheter.

"Forget the 16," I said. "He's larger than average; get an 18. It has a red sleeve."

She retrieved the larger Foley as Ellie injected the ASA. I walked Kelly through the procedure, and she did a competent job for a first time.

"Now, check the collection bag and announce status," I said. "It's either 'urine in the bag' or 'no urine in the bag'. If there is urine present, note if it's cloudy or has a pinkish tinge. If so, you'll be asked to dip it for blood."

She examined the bag and announced, "Urine in the bag. It looks clear to me."

I confirmed her report.

"Pace, Cardiology!" Doctor Alana Pace announced, coming into the room with her student. "What do we have, Mike?"

"Jenny?" I prompted

She gave the vital information, and Alana performed her exam.

"Cath lab, stat!" Alana declared. "Ted, call upstairs and tell them we're coming!"

"Kelly, get a gurney," I ordered. "Jenny, portable monitor and EKG, and you escort the patient with Doctor Pace; Ellie, portable oxygen."

Everyone sprang into action, and two minutes later, Mr. Baxter was on his way to the cath lab.

"He looked pretty healthy," Kelly observed after we left the trauma room. "I mean, except for the obvious heart attack."

"Tell me the likely causes for a coronary event in a male in his forties."

"Coronary occlusion due to high cholesterol would be the primary one. It could also be genetic."

"And what else could cause thrombosis?"

"I haven't done my cardiology rotation," she replied. "I'm not sure."

"There are close to three dozen possible causes, though we can eliminate some of them because he's male. You should remember at least some of them from physiology."

"Birth control pills, but as you said, not in a male. Hyperthyroidism. Low blood pressure. Well, that last one isn't the case because his blood pressure was high."

"Which is also a risk factor for a STEMI — ST Elevation Myocardial Infarction. There's a big one you're missing."

She thought for a moment, then said, "Undetected diabetes mellitus."