Good Medicine - Residency II
Copyright© 2025 by Michael Loucks
Chapter 17: Tell Me About This Patient
April 19, 1990, McKinley, Ohio
"Doctor Roth needs to see you before you head downstairs," Kelly, the surgical charge nurse, said as I came out of the locker room on Thursday morning.
I checked my watch, and if the meeting lasted more than five minutes, I'd be late for my shift.
"Would you call downstairs and let Ellie know Doctor Roth requested a meeting, and I'll be there as soon as possible."
"Of course. It's not disciplinary, but knowing you, you'll wish it was!"
"Wonderful. Thanks."
I hurried to Doctor Roth's office and rapped on the open door.
"Come in, Mike. Shut the door and sit, please."
I did as he requested.
"What's up?" I asked.
"I know for a fact you're going to hate this, but you were specifically requested by Cutter and Nels Anderson, and I can't think of a good reason to say 'no'. They want you as one of the two Residents on the oversight committee for the construction of the new surgical wing."
"Is someone trying to drive me to drink?" I asked.
"Shelly wasn't happy, either. Nor were Bob Aniston or Penny Nichols. I figure if I have to do it, so should you four!"
"Misery loves company," I said, shaking my head. "What's involved?"
"Making sure that everything is completed to our satisfaction. Consider it similar to a building inspector. That's what your dad does, right?"
"He's the Director of the Property Division now, but yes."
"So, what do you say?"
"Nothing like being 'voluntold'," I chuckled.
Owen laughed, "That's awesome. Did you just make that up?"
"No. I heard it from Kellie Martin. In the Navy, officers would say, 'I need a volunteer!' then say, 'Martin! Thanks for volunteering!'. That meant she was being told to volunteer — 'voluntold'."
"Think she'll mind if I steal that?"
"Nope. Anything else? I do need to get to the ED."
"No. That's it. Thanks, Mike."
"You'll forgive me if I don't thank you for this assignment."
"I will, but you and I both know that you will make damn sure everything is done right and working properly before you sign off. Just as the others will."
"You can count on it."
I left his office and hurried to the ED, where Mary was waiting. She looked at her watch, raised her eyebrow, and tapped her foot.
"You need to put your hands on your hips to have any effect," Ghost said to her. "Russian women have it down pat!"
"Speaking of Russian women, my cousin by marriage seems to be in no rush to have whatever my wife's cousin's kid would be."
"I think first cousin, once removed," Mary suggested. "But only by marriage, so not sure it's a thing for you, and I guess technically not for Rachel because there are no common ancestors, except by adoption or marriage."
"Thank you for the genealogy lesson, Miss Anderson!" I said with a grin. "Perhaps you'll practice medicine now?"
Mary laughed, "I'll get a chart from the rack."
"Kris said Oksana thinks she's going to have to be induced," I said.
"Me, too," Ghost replied. "So does Candace. She already scheduled us for Monday."
"Sorry to cut this short, but I need to supervise my soon-to-be Intern."
Ghost rolled his eyes and shook his head, clearly agreeing with me that Mary was capable of working with oversight, rather than supervision.
I followed Mary, who was pushing a patient in a wheelchair into Exam 2. She helped the patient onto the treatment table, then moved the wheelchair out of the way.
"Jackie, I'm a Sub-Intern in training, and this is my supervisor, Doctor Mike. Doctor Mike, Jackie Barkhurst, seventeen, complaining of an ankle injury."
"Good morning," I said. "Mary, proceed."
"What caused you to come to the hospital today?" Mary asked the patient.
"As I told the nurse, I tripped last night when I was jogging. My ankle hurt, but I could walk on it. This morning, I couldn't put any weight on it, so I had my dad bring me in."
"Did you twist it or roll it?"
"I think I rolled it, if you mean my foot bent sideways, not rotated around my leg."
"Yes. Any previous injuries?"
"I had a pulled hamstring about six months ago."
"Did you see anyone about that?" Mary inquired.
"My regular doctor, but his office doesn't open until 9:00am, and I couldn't walk."
"Do you know what grade he or she assigned the injury?"
"Grade 2. I just had to ice it and rest, and wear an ace bandage. I was allowed to start walking longer distances after about a week and allowed to resume jogging after four weeks."
"Are you an athlete?"
"Volleyball, but it's a Fall sport."
"Any other complaints?"
"Besides my little brother?" Jackie asked.
Both Mary and I laughed.
"They haven't taught me a procedure to resolve that," Mary said with a smile.
"Me, either," I chuckled. "And I'm a trauma surgeon. In my case, it was a little sister."
"Any other injuries or sickness?" Mary inquired.
"No."
"Are you taking any medications, vitamins, or supplements?"
"I took Tylenol right after I hurt it last night, then again this morning. It helped last night, but not much this morning. Otherwise, just birth control pills."
"Is there any chance you might be pregnant?" Mary asked. "I need to know because we'll most likely need to X-ray your ankle."
"I just said I'm on the Pill!" Jackie protested.
"Yes, but even with perfect use, three women in a thousand will become pregnant over the course of using the Pill. Have you had intercourse since your last period?"
"That's the point of the Pill, right?" Jackie asked with a smirk.
"Usually," Mary replied. "I started taking them at fifteen for bad cramps. That was convenient about a year later when I needed them for their primary purpose! If you've had sex, we'll need to run a rapid pregnancy test before we X-ray you."
"Oh, that would simply make my day," Jackie said, shaking her head.
"I'd like to examine your ankle, please," Mary said.
"Sure."
Mary washed her hands, put on gloves, then pulled the stool over and carefully examined Jackie's ankle. I saw severe ecchymosis, and even from where I was standing, I could tell the ankle was swollen. Mary carefully examined the injured ankle, then the healthy one for comparison.
"Doctor Mike, I suspect an ankle fracture," Mary announced. "I recommend an ankle series."
"Please verify no high fibula fracture," I requested.
"I'm not sure how to do that," Mary said.
"Palpate the calf proximally and check for pain or movement of the bone."
"Both legs, right? For comparison?"
"Correct."
Mary examined both legs in a manner I was confident was sufficient.
"Grossly normal," Mary said. "Rapid pregnancy test, then ankle series. Once complete, orthopedics consult."
"Proceed," I said.
Mary wrote everything on the chart and handed it to me to sign.
"Jackie, can you give us a urine sample?" Mary asked. "That'll be quicker and easier than a blood test."
"If someone can help me," Jackie said.
"We'll send a nurse to help you. Once we see the results, we'll send you for your X-rays."
"OK."
Mary and I left the exam room, and she asked Ellie for a nurse to help Jackie with her urine sample. Ellie sent Becky and a student nurse to help, and six minutes later, Becky came out with the test container.
"Negative," she said.
"Thanks," Mary replied.
Mary called Radiology, and they could take Jackie right away, so Mary called for an orderly. Once the orderly arrived, Mary escorted Jackie to Radiology. Mary was back two minutes later and went to the waiting room to update Jackie's dad.
"They said about twenty-five minutes," she said when she returned to where I was waiting. "They'll send her back."
"OK. Good job on your assessment."
"I missed the high fibula check."
"No, you simply hadn't been taught it yet. I've seen enough ortho consults that I check right away so we don't have to send the patient back for further X-rays. Technically, it's an ortho thing, but it's simple enough to check that I prefer efficiency for the patient's sake. Nobody would have said a word if we hadn't done that, but it's better for the patient."
"Next chart?"
"Next chart."
Mary went to the triage desk, retrieved a chart, and went to the waiting room to call the next patient. We treated a toddler with an ear infection, and once he was discharged, Mary called to check on Jackie's X-rays.
"The radiologist says the wet read is a non-displaced fracture."
"Call Ortho for a consult. Non-displaced fractures almost always result in wrapping the ankle and referral to an orthopedic specialist for outpatient treatment."
That was the end result, and after showing Jackie how to use crutches, we discharged her. I could still do that on my own for the next two days, so I simply signed the chart and returned it to the nurses' station.
"Mike," Naveen said. "I need a consult, please."
Mary and I followed him to Trauma 1 and confirmed the patient needed a cholecystectomy for significant gallstones. Unfortunately, Mary and I didn't get to scrub in, as it wasn't emergency surgery and would be done after the day's scheduled surgeries were completed.
"You did a good job on the ultrasound," I said. "And before you object, I didn't find gallstones the first two times without guidance. It's easier with the CAT scanner, but if we can diagnose with ultrasound, we do that because there is no ionizing radiation. It's also less expensive. Next time, you'll be more likely to find them. But remember, sonography has limits that CAT scans do not. What I'd really like is a Magnetic Resonance Imaging scanner — MRI. They don't use ionizing radiation, so they're much safer."
"I've read about those; how long before we get one?"
"Ten years, I'd guess. First, we won't have room for one until the new surgical wing is built and the old building is remodeled. The surgical wing is scheduled for completion in 1993, and remodeling is expected to be completed around 1996. They'll leave space for an MRI scanner in the remodeled radiology area, but someone will have to come up with the money to actually purchase one."
"It always comes down to that, doesn't it?" Mary asked.
"Sadly. I've had this conversation with several doctors and friends. In the end, there are limited resources, and we have to figure out the best way to use them. My wife's solution is for all doctors to work for the government, for all hospitals to be government hospitals, and for all care to be no cost at the point of service, with everything paid for by taxes. But even then, there are limited resources, and you still have to ration care."
"Mike?" Ellie said. "Bounceback abdominal pain in Exam 3. He was seen by Paul last night around 10:00pm. Kellie is with him."
"Thanks, Ellie. Mary, how would you handle this?"
"Review the chart, then ask the patient questions."
"Reverse that."
"Why?"
"If you read Paul's notes, you'll have Paul's view and risk forming an opinion based on it, rather than your exam. Conduct a full H&P and perform an exam. The patient may well tell you what Paul said, and that's fine. But do your own exam. Think about how consults work."
"They always do their own exam, even though we've already done one. I've never seen a single bounceback done the way you just said."
"But does it make sense?"
"Absolutely."
"Then let's go see him. You take the lead."
We went to Exam 3, where Kellie was waiting with the patient.
"Doctor Mike, this is Ken Webber, thirty-six," Kellie said. "He was in last night and saw Doctor Lincoln. Pulse 72; BP 120/70; PO₂ 99%; temp 38.1°C."
"Good morning, Mr. Webber," I said. "This is Mary, a Sub-Intern whom I'm supervising."
"Hi, Mr. Webber," Mary said. "What brings you back to us?"
"The pain in my gut got worse. The doc last night said to come back if it did."
Mary conducted a thorough H&P, then examined Mr. Webber, finding guarding on palpation of his abdomen, increased pain when he was on his left side, and increased pain with coughing. She finished her exam, and only then did she look at the chart.
"CBC, Chem-20," Mary said. "Then ultrasound."
"Approved," I replied. "Also, type and cross-match, please."
Kellie drew the blood while Mary went to get a portable ultrasound machine. The sonogram revealed exactly what I had expected — a seriously inflamed appendix.
"7 points on the scale and obvious inflammation," Mary announced.
"Agreed," I replied.
"Mr. Webber," Mary said, "you're going to need immediate surgery to remove your appendix."
"Why did they send me home last night?" he asked.
"I'll have to speak to Doctor Lincoln," I interjected. "Right now, let's focus on treating you. Mary, call upstairs. Kellie, a gurney, please."
They both did as I'd directed.
"Twenty-five minutes," Mary said. "She needs to page Doctor Flynn. It's OK to bring the patient right up."
"Do you have someone with you, Mr. Webber?"
"My girlfriend brought me in."
I discussed the procedure with Mr. Webber and had him sign the consent forms. With his approval, I went to the waiting room and found his girlfriend.
"Hi, I'm Doctor Mike. Ken is going to need emergency surgery to remove his appendix. I'll have a medical student escort you up to the surgical waiting room."
"Can I see him?"
"We're transporting him right now, so no. Just wait here, please."
I went back into the ED and borrowed Naveen's Third Year, Katy, and asked her to escort Mr. Webber's girlfriend upstairs. Five minutes later, we wheeled the patient into OR 4, the smallest and oldest of the operating rooms at Moore Memorial, which was only used for emergency surgery. That was necessary as it was early in the morning, scheduled surgeries were in progress, and they couldn't be pushed.
"Doctor Roth said to scrub in," Nurse Julie said. "Both you and your student. Anesthesia will be here in five minutes, so you'll need to prep."
"OK. Blood type should be available in five minutes or so; remaining blood work in about fifteen minutes."
Mary and I quickly put on fresh scrubs, scrubbed in, gowned, and gloved. We quickly prepped the patient with help from two nurses, inserting a saline IV, affixing EKG pads, and administering IV antibiotics. The anesthesiologist, Doctor Ross Burnside, arrived as we finished prep.
"Doctor Roth instructed me to put him under," Doctor Burnside said.
"Doctor Flynn should be here in ten minutes. I'll intubate as soon as you do that. Mary, connect the EKG leads, please."
Doctor Burnside asked the patient a series of questions, then administered IV anesthetics. Once the patient was under, I quickly intubated and connected him to the ventilator.
"Temp is up to 39°C," Nurse Barb announced.
That did not bode well.
"You administered etomidate and ketamine, then propofol, right?" I asked Doctor Burnside.
"Yes," he confirmed. "You have him on vancomycin, right?"
"Yes," I said. "Barb, call the lab. I want to know his white count."
"Right away, Doctor!" she replied.
"Let's get ahead of this," I said. "Deb, chemical cooling packs for both underarms, please."
Nurse Debbie did as I asked, just as Doctor Flynn came into the OR.
"What do we have, Mike?" he asked.
"Ken Webber, thirty-six; bounceback abdominal pain from last night. Pulse 66; BP 110/70; PO₂ 99%; temp 39°C, up a degree after administration of vancomycin and anesthesia. Cooling packs in both underarm areas."
"I have the lab results," Barb announced. "Neutrophilia; everything else in range. A-positive."
"How high is that white count?" Doctor Flynn asked.
Barb spoke into the phone, then announced, "10.8."
"Mike, you're familiar with the procedures, right?"
"I've done two," I replied.
"As in assisted?" he asked.
"No, as in performed two. I recently assisted with one that ruptured, so I'm familiar with the lavage protocol."
"OK. Let's do this. Are you cleared to Bovie?"
"Yes."
"Who's your student?"
"Mary Anderson; she Matched here for trauma surgery."
"Miss Anderson, have you operated suction before?"
"Only once," she replied.
"I'll guide her, Josh," I said.
"Bobbie, I'll need you on retractors then," Doctor Flynn said to the most senior surgical nurse in the room. "Deb, hang a unit of A-positive in case we need it."
"Ready, Ross?" Doctor Flynn asked.
"Vitals are stable, he's under. We need to keep an eye on his temp."
"Then let's go," Doctor Flynn said.
We worked quickly with Doctor Flynn cutting, Mary suctioning, and me using the electrocautery.
"Rupture," I observed when the appendix came into view.
"Peritonitis protocol," Doctor Flynn announced. "Deb, hit him with another dose of antibiotics. Mike, let's get this out and clean him up."
"SVTs!" Doctor Burnside announced. "Run of six. Don't dawdle. Pressure and sats are still good."
"Deb, have adenosine ready, please," Doctor Flynn ordered.
He and I quickly removed the ruptured appendix, then I used three pitchers of saline for lavage, with Mary suctioning it away.
"PVCs!" Doctor Burnside announced. "Run of three. Get this done, Josh!"
We worked quickly to close, and Mr. Webber didn't have any further cardiac events.
"Cease anesthesia," Doctor Flynn ordered. "Mike, I want you to sit with him in recovery, please. Keep him on the EKG and call cardiology if you see anything. Usual antibiotic protocol."
Before I could respond, the monitor blared.
"V-fib!" I declared. "Paddles to me; charge to 150! Mary, pads!"
She quickly put the pads on Mr. Webber, and I positioned the paddles.
"CLEAR!" I commanded as soon as the machine chimed.
Everyone moved, Doctor Burnside disconnected the vent, and I pressed the buttons, causing Mr. Webber's body to spasm.
"No conversion!" Mary announced.
"Charge to 200!" I ordered, and as soon as the machine chimed, I called, "CLEAR!" and pressed the buttons.
"No conversion!" Mary announced.
"Begin compressions!" I ordered. "Charge to 250! Epi, IV push!"
Mary started chest compressions, Doctor Burnside re-connected the vent, and Deb injected the epinephrine.
"CLEAR!" I commanded
Everyone moved, and I shocked the patient again.
"Nothing," Doctor Burnside said as he re-connected the vent.
"Resume compressions," I said. "Charge to 250."
"CLEAR!" I commanded once the machine chimed.
"No conversion," Doctor Burnside announced.
"Deb, bicarb and epi!" Doctor Flynn ordered.
"Mary, continue compressions! Bobbie, atropine with a cardiac needle to me."
"Not usually indicated for V-fib, Mike," Doctor Flynn countered.
"Can it hurt?" I asked.
"No. Debbie, atropine to Mike."
I had Mary stop compressions and injected atropine directly into Mr. Webber's heart, but it had no effect on his arrhythmia.
We worked on Mr. Webber for ten minutes, to no avail.
"Asystole," Doctor Burnside announced. "No electrical activity."
"Six shocks, three doses of epi, one of atropine," I said. "I don't think we're getting him back."
Doctor Flynn checked the patient's eyes and auscultated his chest.
"Absent heart sounds; pupils fixed and dilated; time of death, 08:33am."
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