Good Medicine - Residency II
Copyright© 2025 by Michael Loucks
Chapter 19: Shit Happens
April 27, 1990, McKinley, Ohio
"Good afternoon," Doctor Cutter said promptly at 3:00pm. "Our first case today is Mr. Ken Webber, who coded immediately following emergency surgery for a ruptured appendix. Doctor Paul Lincoln was the initial receiving physician. Doctor Lincoln?"
Paul got up and moved to the lectern.
"Good afternoon," he said. "Mr. Ken Webber, a Caucasian male aged thirty-six, presented at the triage desk at 21:49 on April 19, complaining of abdominal pain. Triage vitals were normal. My students and I brought the patient to Exam 3 thirteen minutes later at 22:02. A complete H&P was performed, and vitals were all within the normal range for a healthy thirty-six-year-old male.
"No nausea or vomiting was reported. Patient had last eaten just after 18:00. Gross exam revealed tenderness in the umbilical region but no other signs. Given he was afebrile and his Alvarado score was 1, I concluded that the best course of action was to send the patient home, asking him to return if he became febrile, felt nauseated, or the pain increased. I conferred with Doctor Boyd, who signed the chart, and the patient was discharged. I went off shift at 0600 the following morning."
"Were any blood tests run?" Doctor Collins from Medicine asked.
"No. Our protocol for afebrile, non-specific gastric pain is to wait unless a bowel obstruction is indicated. Palpation did not reveal any of the signs, and auscultation revealed normal bowel sounds."
"And you didn't think to run an ultrasound or call for a surgical consult?" Doctor Collins asked.
"I did, but again, neither of those is indicated where there are no symptoms or signs except for a generalized complaint about peri-umbilical pain."
"Thank you, Doctor Lincoln," Doctor Cutter said. "Doctor Boyd, do you have anything to add?"
"No. Paul relayed all of that to me, and it is reflected on the chart."
"Thank you. Doctor Mike?"
I touched Mary's arm, and she came with me, and we stood together at the lectern.
"Go ahead," I said quietly.
"Good afternoon," Mary said.
"Excuse me," Bill Lawson from Psych said, standing up. "Why is your student presenting?"
"She performed the intake H&P under my direct supervision. With Doctor Cutter's permission, I'd like to use this as a teaching exercise for her."
"Proceed," Doctor Cutter said.
Doctor Lawson glared at me and sat down.
"Thank you," Mary said. "Mr. Webber returned to the triage desk the following morning at 06:08 and was seen four minutes later at 06:12 by Doctor Mike and me. Vitals were taken by both the triage nurse and Nurse Kellie Martin and showed a BP of 120/70, pulse of 72, temp of 38.1°C, and PO₂ of 99% on room air. Mr. Webber complained of a significant increase in abdominal pain, now in the lower-right quadrant.
"Doctor Mike instructed me to take a complete history and physical under his direct observation. Gross exam revealed Dunphy's sign and Sitkovskiy's sign. Alvarado score was 7, indicating acute appendicitis. I proposed CBC, Chem-20, and ultrasound, and Doctor Mike confirmed. Nurse Martin drew blood, and Doctor Mike added a request to type and cross-match."
"Mike?" Clarissa prompted. "Why?"
"Because bounceback abdominal pain is nearly always surgical, and with that Alvarado score, it was obvious to me we were dealing with acute appendicitis, as Miss Anderson indicated. Mary?"
"I performed an ultrasound under Doctor Mike's direct supervision and confirmed an inflamed appendix. Given the obvious condition, Doctor Mike made the decision to send Mr. Webber up for immediate surgery."
"Before the labs came back?" Doctor Baker asked.
Mary looked to me.
"Yes," I said. "Time was of the essence, and we could prep the patient and have him in the OR when the labs came back."
"No tox screen?" he inquired.
"The patient denied any use of illicit drugs and admitted use of Tylenol to Miss Anderson. I did not feel he was being deceptive. His eyes were clear, his nose did not show any signs of inhaled stimulants, there were no lesions in his mouth, and there were no track marks. He was well-groomed, his clothes were clean, he had good hygiene, and his speech was clear."
"Continue, Miss Anderson," Doctor Cutter directed.
"Doctor Mike reviewed the consent form with the patient, who signed it. We transported the patient to OR 4, turned him over to the nursing team, and then went to scrub. Doctor Mike?"
"Doctor Roth had instructed Mary and me to scrub in, which we did, and then, with the assistance of the surgical nursing team, inserted a saline IV, administered standard prophylactic vancomycin, and sterilized the patient's abdomen. The patient was stable, and his vitals were consistent with those taken by triage and in the exam room. At that point, Doctor Burnside arrived. Doctor Cutter, do you wish me to continue, or do you wish to hear this part from Doctor Burnside?"
"Continue, please."
"Doctor Burnside entered and stated that Doctor Roth had instructed him to put the patient under, as Doctor Flynn had not yet arrived after being called in. Doctor Burnside administered etomidate and ketamine, followed by propofol, and I intubated the patient and connected the ventilator. The patient's temperature rose almost immediately from 38.1°C to 39°C. His other vitals were consistent with anesthesia limits. I asked the circulating nurse to call for the lab results, and I ordered chemical cold packs under his arms."
"Why was that?" Shelly Lindsay asked.
"I was concerned about a sudden spike in temperature, which occurred within two minutes of the administration of anesthesia and five minutes after vancomycin."
"Did you observe any hives or respiratory problems?"
"None. At that point, Doctor Flynn came into the OR."
"Thank you, Mike," Doctor Cutter inquired. "Anything to add, Ross?"
"No," Doctor Burnside said as Mary and I returned to our seats. "As Mike said, other than the one-degree temp spike, vitals were stable and well within safe ranges for an adult male under anesthesia."
"Thank you. Doctor Flynn?"
Doctor Flynn moved to the lectern.
"I was the on-call surgeon and was completing my morning exercise routine at home when my pager went off. I called the scheduling nurse, who informed me of the patient's condition. I immediately left home and arrived at the hospital twelve minutes later. Because I had been sweating, I took a quick shower, put on clean scrubs, and entered the scrub room at 06:58, sixteen minutes after I was paged.
"When I entered the OR, the patient had been prepped and anesthetized, and Mike gave me the bullet. Immediately after he finished, Barb Sutton, the circulating nurse, reported that the patient's white count was 10.8, indicating neutrophilia. She also reported the patient's blood type as A-positive.
"Following protocols for emergency surgery, Mike acted as second surgeon and operated the electrocautery, while Miss Anderson handled suction. Nurse Debbie Schmidt handled the retractors. The surgery went according to plan, and when the organ was exposed, Doctor Mike immediately stated that it had ruptured, and I confirmed.
"At that moment, Ross announced a run of six SVTs but confirmed the patient's blood pressure and sats were still in range. We quickly removed the inflamed organ, then began the peritonitis protocol of triple gastric lavage plus additional vancomycin. We had just completed the lavage when Ross announced a run of ten PVCs and advised finishing as quickly as possible.
"I completed the closure without further incident and instructed Ross to cease anesthesia, which he did. I then instructed Mike and his student to escort the patient to Recovery and stay with the patient. I ordered a cardiology consult and directed Mike to keep the patient on EKG.
"At that point, Mike called out V-fib and requested the paddles. He administered shocks of 150, 200, and 250, with CPR between shocks, along with epinephrine, IV push. With no conversion, I ordered an amp of bicarb and an amp of epi while compressions continued. Mike ordered atropine on a cardiac needle. I questioned him about it and, after a brief back-and-forth, concurred with his assessment that it was worth trying.
"We continued CPR for another five minutes, interspersed with three more attempts to convert his V-fib, at which point the patient had been down for ten minutes. When the monitor showed asystole and no electrical activity, Mike stated his opinion that after six shocks, three doses of epi, and one of atropine, we weren't going to get him back.
"I examined the patient and appreciated no corneal response and heard no heart sounds. I called time of death at 08:33. I asked Mike to review the case with me from the start, which he did, and then we notified the patient's girlfriend that he had expired on the table. I filled out the appropriate forms, which were turned in to Doctor Roth. As per protocol, the patient was delivered to Pathology, along with all surgical materials and the diseased organ."
"How long did you sleep?" Doctor Forth from Psych asked.
I hadn't detected any fatigue in Doctor Flynn, but I knew that was an important question to ask, even if it did come from Psych.
"I had just come off shift, but I had slept a total of six hours overnight on the couch in the Attending's office. My next shift didn't start until Sunday evening."
"And you, Mike?" Doctor Forth asked.
"About six hours," I replied. "My shift began at 05:00."
"Ross?"
"About eight hours. I had been assisting Doctor Roth with a scheduled surgery, but it was routine, so I called a Resident to complete that surgery and attended the emergency appendectomy."
"Thank you, Doctor Flynn. Paul?"
Doctor McKnight rose and moved to the lectern.
"I'll cut to the chase, he said. 'Shit happens'. Now, let me give you my findings."
That was something Loretta had said to me near the beginning of my Preceptorship, and I'd seen it several times before. I had come to that conclusion myself — that the patient's death was unpredictable and not something that could likely have been prevented. Doctor McKnight continued.
"The deceased was sent to Pathology at 08:48, and per our protocol, I set aside other autopsies to investigate this unexpected death immediately. Post-mortem labs were drawn, a complete autopsy was conducted, and all surgical materials and drugs were examined.
"Other than generalized inflammation of the peritoneum consistent with a ruptured appendix, the gross exam was negative. The same was true for the sections, and I discovered no lesions or tumors. Post-mortem lab test results were consistent with pre-surgical labs.
"The tox screen showed only metabolites of self-admitted Tylenol usage and drugs recorded on the patient's chart, and was negative for all other substances for which we can test. All of the vials of drugs administered were correct, matched the serial numbers of vials that had been in our inventory, and were uncontaminated.
"As is the norm in cases such as this one, I interviewed the patient's parents, brother, and live-in girlfriend, none of whom could shed any light on the case, nor did any family member report any significant medical conditions or any family history of conditions which might have caused the negative outcome. A review of the patient's medical records held by his primary care physician, John Smith, showed no indications of any condition that might lead to arrhythmia.
"Given the symptoms reported by the physicians who attended the case, I conclude that the most likely cause of death was an adverse reaction to anesthesia. Given no physical signs and no respiratory anomalies, I do not believe it was a reaction to vancomycin. No blood was given, so a hemolytic reaction was also ruled out. In my opinion, the delay from the previous night had no bearing on the results of this case, though I cannot prove that."
"Thanks, Paul," Doctor Cutter said. "Comments? Conclusions? Lessons?"
Doctor Wernher rose.
"While I would prefer less earthy language, I believe that, per Doctor McKnight's analysis, as well as my own investigation, all protocols and procedures were properly followed. One can certainly quibble about lab tests on first presentation, but a surgical consult would not have changed anything. That said, an ultrasound might have detected the condition sooner, and as such, I intend to require an ultrasound for all cases of abdominal pain where we cannot trace a cause. That said, as Doctor McKnight succinctly stated, earlier diagnosis would very likely not have prevented the adverse outcome."
"I concur," Doctor Roth said, standing up. "A surgical consult during his first visit was not warranted, except in hindsight, and it is unlikely any of my Residents would have ordered an ultrasound when the patient was afebrile, had not vomited, and complained of peri-umbilical pain."
"What do you think, Mike?" Doctor Strong asked.
I chuckled, "I do have the reputation of being freer with the use of lab tests and imaging, but in this case, I'd have done exactly what Doctor Roth said, and would, with the same information, have discharged the patient just as Doctor Lincoln did."
"Doctor Wernher," Doctor Baker asked. "What about lab tests showing an infection?"
"Let me turn it around — if I called one of your Residents for a consult with the specific report that Doctor Lincoln provided, what would the result have been? I'd like one of your Residents to answer, if you don't mind."
"Doctor Saunders?" Doctor Baker inquired.
Clarissa stood up.
"Very likely, we'd have asked the ED to monitor and run repeat lab tests after two hours, waiting to see if any new symptoms emerged. Past protocol would, in most cases, have been immediate antibiotics, but MRSA has changed that protocol. Had a Medicine consult been requested, the surgery might have occurred an hour earlier, but as Doctor McKnight opined, the results would very likely have been the same."
"Thank you, Doctor Saunders," Doctor Baker said. "I concur with my Resident."
"Then," Doctor Cutter said, "unless someone wishes to present a plausible alternate theory or point out something we've missed, this one is closed as unexplained post-surgical arrhythmia resulting in death."
That was the only case for the day, so everyone filed out of the auditorium.
"Malpractice suit?" Clarissa asked.
"Always possible," I replied, "but at every step of the way, we did the right thing. I'm sure some hotshot attorney could make hay out of sending him home, which looks bad but really didn't have anything to do with it. Wernher's response really shows that — requiring an ultrasound for all non-specific abdominal pain. But you know why that's not a panacea."
"It's entirely possible it wouldn't have shown on an ultrasound the night before. A CAT scan might have shown it, but we can't go around giving people huge doses of X-rays on the off chance it'll find something. Not to mention, we only have one machine. Mary, you did a great job!"
"Thanks, Doctor Saunders!" Mary exclaimed. "I have a great teacher!"
"Don't feed his ego, please!" Clarissa declared.
"Go push pills, Lissa! We surgeons have REAL work to do!"
"«Иди в жопу» (idi v zhopu)!»" Clarissa declared. ("Kiss my ass!")
"Love you, too, Lissa!"
We hugged, and she headed to Medicine while Mary and I headed to the ED.
"What did she say?" Mary inquired.
"'Kiss my ass'," I chuckled. "She's taken up my old behavior where I would only swear in Russian."
"I don't think I've heard you speak Russian."
"I mostly stopped about two years ago, and really, I hadn't used it regularly since around age eight. It was always my second language, and given how highly inflected it is, I make a complete mess of it at times."
"My grandmother taught me some Swedish when I was little, and it's actually very simple. The verbs don't change for person or number, and there are only two genders with regular rules for forming plurals and for articles. Unlike English, it's spoken exactly as it's written."
"English spelling is a nightmare," I stated. "One teacher in High School pointed out that English is basically the only language where a Spelling Bee makes any sense and is any kind of serious challenge. He also mentioned that the first national spelling bee was held in Cleveland in 1908. Where did you grow up?"
"Minnesota, of course, along with the rest of the Viking maidens!"
"You do not want to know the vision that just put in my head!"
Mary laughed, "Hammered metal breastplates that are form-fitting? Ahistorical!"
"Which has zero to do with the image popping into my head! How did you land here?"
"Dad took a job in Toledo, and we moved when I was twelve."
"What's he do?"
"He's a mechanical engineer at the Jeep Toledo Assembly Complex. My mom is a private duty nurse."
"My dad is a civil engineer and is the Director of the Harding County Property Division. My mom is a secretary/paralegal for an attorney. They're divorced, and they each remarried. My stepdad is an attorney, though not the one for whom my mom works. My dad's wife is a homemaker."
"Stepdad but not stepmom?"
"She's four years younger than I am."
"Wow!" Mary observed, raising an eyebrow.
"Yeah."
We reached the ED, and I instructed Mary to get a chart so we could begin seeing patients. There was a backlog as several ED docs had been in the M & M, and that kept us busy until 7:00pm, when I was fortunate to be able to have dinner with Clarissa.
"I figured someone would try to throw you under the bus," Clarissa observed once we had our food.
"There was no opportunity to do so once McKnight made his findings. And even without them, it would have been Paul Lincoln, Chuck Boyd, Ross Burnside, or Josh Flynn. I was the one who identified the ailment and rushed him to surgery. Lawson and Forth had nothing."
"I was surprised you threw Mary to the lions!"
"What better case for her to present? I mean, I read McKnight's report, and I was positive I could let her get her feet wet without suffering withering fire from Friday Afternoon Quarterbacks! Now that she's done an easy one, the difficult ones will be easier."
"And gave you a chance to tweak Attendings and Residents about hands-on training with active participation."
"Because it's the better way," I replied. "It's not new or innovative unless you count doing what the first doctor to start a Residency program did as 'new' or 'innovative' because we stopped doing it! What I'm doing was proposed a hundred years ago by THE most influential teacher in modern history. The other members of the Big Four at Johns Hopkins were important, too — William Stewart Halsted, a surgeon; Howard Atwood Kelly, a gynecologist; and William Henry Welch, a pathologist."
"Osler was an internist!" Clarissa declared.
"Every famous person has some weakness," I smirked. "That was his!"
"Seriously? The guy who you revere the same way you revere your icons was weak because he specialized in internal medicine?"
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