Chapter 66: You're a Difficult Case

December 5, 1989, McKinley, Ohio

Doctor Evgeni arrived and, after conferring with me and Perry Nielson, checked Mr. Gianis and found nothing remarkable. Mr. Gianis' labs were clean as well, so after ninety minutes, we discharged him, and Doctor Evgeni took him home.

"What happens now?" Kelly asked.

"Doctor Evgeni will coördinate Mr. Gianis' care. That's actually the best way to handle things that don't require hospital admission. Do you remember the term 'continuity of care' from your Practice of Medicine class? A GP is best situated to manage an individual's care. One of the most important things we do when we discharge someone directly from the ED is to refer them to their personal physician. Our role in the ED is, as we pithily put it, to treat 'em and street 'em, and if you can't street 'em, admit 'em."

"That seems awfully harsh," Kelly observed.

I nodded, "We have limited resources, and our job is to stabilize patients and hand them off to other services or their personal physician. The biggest struggle I had initially was spending more time talking to patients than resources permitted. I push those boundaries further than most, but even I have to give in to the reality of patient volume. The one thing I was consistently called out for as a medical student was spending too much time with patients. Figuring out the correct balance was the challenge."

"Mike?" Paul Lincoln said, coming into the lounge. "I need a surgical consult."

"We'll be right there," I said.

He left, and my students and I followed him to Exam 2.

"Ms. Atkins, this is Doctor Mike, a surgical Resident. Mike, this is Jennifer Atkins, forty-eight, presents with durative colic in left upper abdomen for four days; deep tenderness in her left epigastrium without rebound pain; signs of peritonitis; CBC shows elevated white count; all other labs are normal. Dunphy's sign was absent. No other complaints, no history of abdominal pain or digestive problems."

"Hi, Ms. Atkins," I said. "I'd like to examine you, please."

"Of course!"

I performed an exam and confirmed Paul's findings.

"Kelly, I need an ultrasound cart, please."

"Right away, Doctor Mike!" she exclaimed.

"Ms. Atkins, we need to perform an ultrasound exam to see if we can determine what's causing your pain. We're a teaching hospital, so I'd like to have my student perform the exam. Would that be OK with you?"

"Sure."

Kelly returned with the ultrasound cart and I explained to both Kelly and Jenny how to set up the machine, then asked Jenny to perform the exam. I guided her through it and saw a strange shadow on the display.

"Stop there," I said. "Rotate the transducer about forty-five degrees and hold. Good!"

I pressed the button to freeze the image, then pressed 'PRINT' to get a physical copy.

"Do you see this, Jenny?" I pointed to a suspicious artifact on the display. "Any ideas?"

She shook her head, "That doesn't conform to any anatomy I know."

"No, it doesn't. It appears to penetrate the descending colon and points toward the tail of the pancreas. You can also appreciate fluid accumulation in that area. Ms. Atkins, you're going to need immediate surgery to determine what that is."

"Surgery?!"

"Yes. I can't say for sure what it is because the ultrasound can't show me sufficient detail. We'll take you upstairs for what's called a laparotomy. The surgeon who'll perform the procedure will explain in detail. OK?"

"What happens if I don't have the surgery?"

"The pain will continue, what appears to be peritonitis, that is, an infection, will worsen, and eventually you'll die from sepsis."

"I think I'll have the surgery," she said.

"Good choice!" I replied with a smile. "Kelly, call upstairs, please. We need a surgical team for an emergency exploratory laparotomy."

Kelly made the call, and after explaining what I'd requested, she hung up.

"About twenty minutes," she said. "They're prepping an OR."

I reviewed the consent form with Ms. Atkins, and she signed it.

"Doctor Lincoln will arrange for you to be taken up to surgery," I said. "Do you have any questions for me?"

"No, I don't. Thanks."

"Then I'll leave you in Doctor Lincoln's capable hands. Kelly, please return the ultrasound unit to the alcove and wipe down the transducer with alcohol."

"Will do!" she exclaimed.

The three of us left the room with Kelly pushing the ultrasound cart. She did as I asked while Jenny and I went to the lounge. About four minutes later, Kelly came into the lounge, and Nate let me know that Nelson Burke needed to speak to me. I picked up the phone and pressed the only flashing button.

"Nelson, it's Mike."

"Any idea about that laparotomy?"

"I'd say foreign body," I replied. "Given the length and shape, my bet is an ingested toothpick. There are signs of peritonitis, including an elevated white count, so you'll likely need a lavage as well."

"OK. We'll be ready."

"Thanks, Nelson."

I hung up and sat down on the couch.

"Ingested toothpick?" Jenny asked.

I nodded, "It happens. I haven't seen one before, but I read an article in a medical journal about foreign body ingestion. The most common are kids swallowing something, especially coins. The most dangerous things are actually strong magnets, which can cause severe trauma if they pull different parts of the bowel together. Coins usually pass, but sometimes they're lodged in a way that they need to be surgically removed."

"You don't get to assist with the surgery?"

"Sometimes. In this case, I couldn't, even if it was offered, because I'm designated primary on trauma. It works out to about twice, sometimes three times a month. Depending on the circumstances, you and Kelly might be able to scrub in as well."

"But you just observe, right?"

"I've actually been allowed to close, most recently on a splenic rupture."

"As a PGY1?!" Kelly asked, surprised.

"Yes. It's all part of developing the trauma surgery Residency. There's resistance to it for various reasons, but Doctor Cutter believes that having a surgeon in the ED at all times will lead to far better outcomes, which so far has been borne out. I've advocated for quicker hands-on training, and I've had some success in making that happen because I have the doctor who invented the concept of Residency on my side!"

"But that's only your program, right?" Jenny asked.

"Yes, so far, but I'm doing the same thing with my students, so you two are doing more than typical medical students. My advice is to push hard in every rotation for the opportunity to do advanced procedures. There will be resistance, but don't let that stop you unless you're told in no uncertain terms to stop."

"But isn't that risky?" Kelly asked. "I mean, pissing off a Resident could really cause problems."

"It's a judgment call," I replied. "You need to be assertive and aggressive, but not to the point of pissing them off. I've misjudged that line a few times, but apologies go a long way to solve that."

"Mike?" Nate said from the door to the lounge. "EMS four minutes out with two victims from an MVA."

"Did they say how bad?"

"No."

"Let Doctor Nielson know, please."

"Will do," Nate replied.

Jenny, Kelly, and I left the lounge and headed for the ambulance bay, joined by Jamie. A few seconds later, Doctor Nielson came out with Bill Weathers, his Fourth Year, and Nurse Julie.

"I'll take the first one," I said to Perry.

"You are primary today, so your call."

It turned out that neither of the victims was critically injured, and neither required surgery, though the driver was admitted to Medicine for overnight observation due to severe cervical acceleration-deceleration, colloquially known as 'whiplash'.

The rest of the morning was relatively quiet, and my students and I handled a few walk-ins before noon, which was when John relieved Jenny. The afternoon was busier, with two MIs, two MVAs, and a broken leg. The MIs were both admitted, the MVAs were treated and released, and the broken leg was admitted to Ortho.

"Are you doing OK, Mike?" Carl Strong asked when I joined him at dinner after he'd admitted the second MI to his service.

"Who spoke to you?"

"You know the hospital is worse than any TV soap!" he chuckled. "Does it matter?"

"I suppose not," I replied.

"One of the jobs of senior Residents and Attendings is to help the young doctors cope with the reality of our jobs. Ghost said you sought spiritual counseling."

I nodded, "I did speak to my «старец» (staretz). And Perry Nielson has ensured I climbed back on the horse." ("Elder")

"I'm sure you understand why that's necessary when there is absolutely no culpability and sometimes even when there might be."

"I do."

"No depression?"

"Sub-clinical, but the conversations have helped, and the work has helped even more, which is, of course, why Perry did what he did."

"We all have those moments when you do exactly the right thing, and there's an adverse outcome. I assume you know there will be an M & M?"

"I was sure that would be the case. After thinking about it, I'm not sure it will be helpful."

"From what I know about the case, there won't be a medical finding, but that's not the only point of an M & M."

"Dealing psychologically with adverse outcomes?"

"Yes, of course, but the more important thing is not to hesitate when inaction guarantees a bad result. That's true even if you know what you're about to do is risky and might not change the outcome. Think about the implications of following your initial objection."

I nodded, "It had a chance of success, even if the probability was low, whereas the probability of death asymptotically approached 100% if nothing had been done."

Carl laughed, "Only Mike Loucks would answer that way! Wouldn't you say her death was certain?"

"Given the strange things I've seen in about thirty months of clinical rotations, nothing is certain. My primary example is the patient who codes in the OR due to a bad reaction to anesthesia, which nobody could predict in advance. I know that the random occurrences nearly always work against the patient, but then you have the tumor that shrinks or disappears for no known medical reason."

"Leaving aside your pedantic nature, would she have died if you hadn't performed the thoracotomy? Just 'yes' or 'no', please."

"I want to say 'in all likelihood', but you won't let me get away with that because the answer you want is 'yes'."

"I won't argue with you that miracles and unexpected outcomes occur, but what I'm asking you is what the expected outcome would be?"

"That the patient would die due to a combination of trauma, hypovolemia, cardiac tamponade, and lack of oxygen circulating to the brain and other organs."

"So, in the face of that expected outcome, a doctor needs to act, taking any reasonable action to attempt to preserve life, even if the chances of success are small."

"I agree, obviously."

"And that's the message that will come out of the M & M. The case will be discussed, and some jackass will claim that some different course of action might have had a better chance of success, but in the end, he wasn't there, faced with the dilemma that Ghost solved by instructing you to continue. Your options were to refuse, in which case she likely dies waiting for a surgeon who would perform the procedure, or to do the procedure, hoping that it buys enough time to save her."

"Logically sound, but my heart isn't logical."

"No, it's not," Carl agreed, "It's in the right place, but what you can't do is let your heart override your intellect and training. And, as rough as this sounds, you suck it up, deal with it, and move on. Or, get back on the horse, as the saying goes."

"I get it," I replied.

"I'm positive you do," Carl replied. "I just want you to be prepared for some jackass from Urology or OB to try to second guess you. There's always one. It won't be a surgeon or cardiologist. It'll be someone who pushes pills for a living."

I chuckled, "Because it takes steel to heal. Or, in your case, angioplasty. Though you guys do recommend daily aspirin."

"A wonder drug! But you know our primary recommendations!"

"Stop smoking, limit drinking, eat a high-fiber diet, limit red meat, and exercise."

"Bingo. The drugs are mostly for people who haven't done that and show up in the ED or walk into a cardiologist's office. I believe you have an opinion on that."

I nodded, "If people would eat right, exercise, stop smoking, not drink to excess, wear seatbelts in cars, wear helmets on motorcycles, and have annual physicals, we wouldn't have a resource problem at the hospital! And we wouldn't need all the so-called 'wonder drugs' that mostly only compensate for poor lifestyle choices."

"Back to your patient," Carl said. "Do you know any more about what happened?"

"No. The only thing I know beyond her injuries is that they have her boyfriend in custody. Well, and McKnight discovered she was about four weeks pregnant."

"I think I know the answer, but what's your take on the death penalty?"

"I believe it serves no legitimate purpose. It's immoral, is ineffective as a deterrent, is fiscally unsound, and most importantly, denies the individual the opportunity for repentance."

"Charles Manson?" he asked.

"The poster child for the death penalty," I replied. "But I maintain that killing him in the name of 'justice' is contradictory, like ... screwing to preserve virginity!"

Carl laughed hard, "I love that! Mind if I use it?"

"Sure. It's not original with me. I heard it at Taft."

"Either way, it makes the point about contradictory ideas in an effective way. Back to you — have you felt hesitant in any way today?"

"No more than my usual mental review that I'm doing the right thing."

"OK. If you do feel hesitant or feel unsure of yourself, talk to Shelly, me, or Ghost, please."

"I will. I appreciate the concern."

"You're a difficult case..."

"For MANY reasons," I chuckled, interrupting him.

"True! But in this case, it's your usual stoicism, so it's not always clear to others when you're struggling. Just out of curiosity, is Doctor Saunders able to read you?"

"Like an open book," I chuckled. "Better than either Elizaveta or Kris, though with Kris, it's mostly due to the short time we've been together compared to Clarissa and me."

"Do you talk to her? Doctor Saunders, I mean?"

"Yes, though with our schedules and my family commitments, not as much as we have in the past. I actually spend more time talking with Shelly Lindsay."

"We're all here for you."

"Thanks," I replied.

I finished my meal, went to visit Nancy briefly, then headed back to the ED, where almost immediately, EMS arrived with a shooting victim.

"Three 9mm rounds to the chest," Roy announced before beginning the recitation of vitals, which indicated a patient in hypovolemic shock. I gave orders to Jack, Kelly, and Nurse Becky, and we rushed the patient to Trauma 1. I called out to Amy at the nurses' station that I needed another doctor, and once in the room, we quickly moved the patient to the trauma table.

"Becky, two units on the rapid infuser!" I ordered. "Kelly, get Doctor Mastriano, please! Jack, central line kit, then chest tube tray!"

The patient had lost so much blood that I thought it was hopeless, but I wasn't going to give up while he still had a pulse, as thready and weak as it was. First, I inserted the central line and hooked up the rapid infuser.

"What do you need, Mike?" Isabella asked, coming into the trauma room.

"Help me keep this guy alive long enough to get upstairs to surgery. He needs intubation, and I'm about to do a thoracotomy. Three 9mm rounds to the chest. A unit of plasma by the paramedics, two more on the rapid infuser, and whole blood on the way."

While I set about inserting the chest tube, Isabella intubated the patient and hooked up the ventilator. That would help, but the extra ventilation in his chest was not going to make it easy for him to breathe, even with mechanical assistance.

"300ccs on the floor," I announced as I made the incision.

I inserted the tube, hooked up the ThoraSeal, and saw blood.

"Blood in the ThoraSeal," I declared.

"Erratic heartbeat," John announced.

"Tamponade?" Isabella suggested.

"A good bet," I replied. "Becky, cardiac needle with a lead and an alligator clip, please."

"PVCs!" John announced. "Run of six!"

"Kelly, call upstairs; emergency surgery for three 9mm rounds to the chest, with no exits! Tell them we're still stabilizing the patient."

She moved to the phone while Becky brought me what I needed for the pericardiocentesis.

"Sats dropping, PO₂ down to 88%," John announced.

I performed the required blind pericardiocentesis and aspirated fluid from the pericardial sac, which relieved the pressure on the patient's heart.

"They'll be ready in ten minutes," Kelly announced as a technician from the blood bank brought in two units of whole blood.

"Becky," I said, "let's get a unit of whole blood in and hang the second before we take him up. Isabella?"

"I agree," she replied.

"Kelly," I directed, "get a gurney, please. We'll take him up. He's too unstable for normal transpo."

Ten minutes later, Kelly, John, and I rolled the gurney from the trauma room and made our way to the surgical floor.

"What do you have, Mike?" Bob Anniston asked.

"Thomas Kincaid, twenty-four, three 9mm rounds to the chest. Intubated; chest tube with a loss of 300ccs; 150ccs from a pericardiocentesis; three units of plasma, one of whole blood, second running in now. BP 90/50; pulse 115 and thready; PO₂ 89%."

"You didn't bring me an easy one!"

I certainly hadn't, but we had no time to waste, and unless the damage was repaired, his vitals weren't going to come up further. He went into the scrub room, and my students and I returned to the ED.