Good Medicine - Residency II
Copyright© 2025 by Michael Loucks
Chapter 27: Another Deposition
June 4, 1990, McKinley, Ohio
Thankfully, the emergency surgery on the patient with the GSW went smoothly, with nary a blip on the monitors, and no problem removing the spent .38 round from his chest. Because I was assigned to the ED, Doctor Flynn handled getting the patient to recovery, and I returned to my duty station.
"How'd it go?" Mary asked.
"Smooth as silk. No trouble at all removing the round, minimal bleeding, and your pericardiocentesis with valve held until we could resolve the chest trauma."
"That was totally cool! Everything I read was about doing it with a fluoroscope, except in rare instances."
"There's almost never time for the fluoroscope in the ED. The risks are minimal, so long as you use the EKG lead method. I'll sign your procedure book, but you need to do four more under supervision before you can fly solo. You'll need to do five chest tubes and five crikes before I sign off on those. The crikes are rarer, so that might take some time."
"You didn't do five."
"No, but those are the instructions I was given by Owen Roth, and we'll follow his plan. Wernher is a by-the-book Chief, which means we need to stick to the plan set by Owen to prevent conflict over medical procedures."
"I was notified about my paramedic ride-alongs. They'll be August 5th to August 11th."
"OK," I said.
I pulled my daybook from my pocket and made a note on the appropriate pages that Mary would be out of the ED. As I slipped it back into my pocket, I saw someone I'd hoped never to see again, but knew it was inevitable — Jack Strickland. While it was true that I believed he was redeemable, I had heard through the Residents' grapevine that he was still prone to off-color jokes, though he stayed just inside the lines, so to speak.
That said, I had to give him a chance and treat him properly. He was on his first Clerkship, and he wasn't assigned to me, so I'd have minimal interaction with him. If he followed my advice and also managed to keep his mouth shut, he might succeed, though I had serious doubts, given what I'd heard. In the end, though, it wasn't up to me.
"Doctor Mike?" Nate called out. "I have a message for you."
I walked over to him, and he handed me a message form. What was on it surprised me. The consultation room was empty, so I let my students know and went to the consultation room to have privacy for the call. I dialed the number on the message form, and the phone was answered on the third ring.
"ARH Harlan, how may I direct your call?"
"Internal Medicine, please."
There were clicks, and the phone rang twice.
"Internal Medicine; Nurse Williams."
"Nurse Williams, my name is Doctor Mike Loucks, and I'm calling from Moore Memorial Hospital in McKinley, Ohio. I'm returning a call to Doctor Melissa Bush."
"One moment, Doctor."
I was on hold for about two minutes, then the call was picked up.
"Doctor Bush."
"Doctor Mike. I was surprised to hear you had called! How are you?"
"The hospital keeps me busy, and I'm no longer drunk and disorderly on Fridays."
"Met a guy?"
"A US Marshal, believe it or not. His name is Tim. How are you?"
"I'm glad to hear about Tim," I replied. "I just started my PGY2 year, and I'm training Moore Memorial's second trauma surgeon. Rachel is almost three and growing fast, and baby number two, another girl, is due in about two weeks. What can I do for you?"
"Would you be willing to train a visiting emergency medicine doctor in thoracotomies, cricothyrotomies, and pericardiocenteses?"
"You? Or a colleague?"
"Me. You know we're a Level IV trauma center, right?"
"I remember. And that means no surgical Attendings at the hospital overnight, and possibly not even a surgical Resident, with Medicine covering the pre-op and post-op care."
"Exactly. We have our own helicopter, in addition to the county and the state helicopters, and we transfer at least one patient a day. Because I split time, there are no opportunities, really, and a reluctance on the part of surgeons to teach us anything."
"What did you have in mind?"
"Our Chief of Internal Medicine would call your Chief and make the request. Medicine owns the ER, so to speak. And it's damned close to the old definition of ER."
"Typical for rural coal country," I replied. "I assume you want my support as well?"
"I do. I know coming to Hayes will likely cause some people ulcers, but it really is the best option. You know me, so I hope you'll support the request."
"Gutsy," I replied.
"I'll just say it straight — I'm taking advantage of your belief in redemption."
"This is only going to be possible, if it is, because Loretta is on leave recovering from her gunshot wound."
"If that were to happen around here, a nurse carrying concealed would have plugged him the second she saw his gun."
"Guns? In the hospital?"
"If you thought Harding County was rural, you should see Harlan County! Even I have a gun, but I don't bring it to work."
"How was your PGY1 review?"
"No deficiencies," she replied. "That's the best you can score. For a hospital like this, that's like a gold star."
"OK. Have your Chief call Owen Roth, who's Chief Surgeon. Give me a day or two to speak to him. I suspect your chief will also need to speak to Dutch Wernher, the Chief of Emergency Medicine. In theory, I should be able to convince them, but in the end, it'll be John Cutter, the Medical Chief, who'll have to sign off. I'm sure Risk Management will weigh in as well."
"OK. Why don't you call when you've spoken to them? I'm noon to midnight Monday through Saturday for June."
"That has to play havoc with your social life."
"It beats the heck out of those thirty-six-hour shifts I had until the end of May."
"No doubt. I'll talk to you in a few days."
"Thanks, Mike."
"You're welcome."
We hung up, and I left the consultation room just in time to catch an incoming EMS run for an MVA. The patient had broken bones and lacerations, but wasn't a surgical case. I met Clarissa for dinner, and once we sat down, I let her know about the phone call.
"Are you insane?!" Clarissa growled. "Seriously? You'd bring her into OUR hospital? As a doctor?"
"Take a breath, Lissa," I said.
"Seriously, Petrovich? Take a breath?"
"Do the people of Harlan County deserve good medical care?"
"Don't start that crap with me! She falsely accused you of demanding sex for helping her!"
"She did. I believe she's a changed person."
"There is no way Loretta Gibbs will agree," Clarissa observed.
"It's not up to Loretta; it's up to Owen Roth and Dutch Wernher.
"You know they'll ask her."
"Is it your position that patients in Harlan County should die because their hospital is a Level IV trauma center and the ED is mostly staffed by doctors from Medicine?"
"No, but it's not your responsibility!" Clarissa exclaimed.
"And if any other Doctor there asked for help because they knew a friend of mine, you wouldn't have such a negative reaction."
"You're right, but Melissa Bush is not any other doctor!"
"While that's true," I said, "she is a doctor, Matched to a hospital in an underserved area, and received a positive evaluation."
"You said it, Petrovich — a hospital that had to scrape the bottom of the barrel to find someone!"
"And, as I said to Loretta when Melissa Matched, if she served a year in what is literally a fourth-rate hospital and showed she could be a good doctor, that would demonstrate repentance. I once made an unfavorable comparison between her and Jack Strickland, but I think I have to reverse that."
"Uh-oh. Now what?"
"The Residents' grapevine says he's still telling off-color jokes, but staying just on the proper side of the line. That tells me he hasn't changed; Melissa's year in the literal wilderness, where there are no surgeons on duty after 6:00pm, tells me she has."
"Wait! Not even a Resident?"
"Not even a Resident. Medicine handles pre-op and post-op care, and basically runs what passes for their ED. Calling it an Emergency Room is truer than you think."
"I'd say that's crazy," Clarissa observed, "but I've heard about the small regional hospitals in rural areas. They're barely more than advanced clinics."
"ARH Harlan has their own helicopter, and they transport an average of one patient a day because they can't properly care for them. Seriously, teaching Melissa how to perform basic procedures will save lives. And you know there's no guarantee it'll be approved, even if I think it should be. Owen Roth will remember her, and Dutch Wernher will look up her records. I'll make my argument, but unless her Chief has some serious pull, it's going to be an uphill battle. That said, I will lend my support because it will improve patient care in a rural area, and that is literally my number one priority."
"I still think it's crazy, but it's Petrovich crazy, which means it's consistent with your thinking even though it looks completely insane to the rest of the world."
"I can only be true to myself, and that means following my faith wherever it leads me."
"Which includes Frank and Melissa Bush," Clarissa observed.
"As Jesus said, 'I have not come to call the righteous, but to call sinners to repentance'. Melissa is a step ahead of her dad in that regard."
"You know if someone asks me, I'm going to say we should refuse."
"I know, and I understand. I love you, Lissa."
"I love you, too, Petrovich."
June 5, 1990, McKinley, Ohio
"Whatever I think," Owen Roth said, "I don't think Risk Management will sign off, given her poor reviews while she was here and her failure to Match."
"What do you think?"
"I think it's a good idea in principle, but the person in question is, well, questionable."
"What if I went there, instead?"
"Leaving us short a surgeon for a few weeks?"
"I'll use vacation, if I need to."
"Why would you do that for her, given everything that happened?"
"While she would be the recipient of training, the beneficiaries would be the people of that rural county. Fifteen years ago, that was Moore Memorial, though without the helicopter to transport patients, which ARH Harlan does on a daily basis. A patient who comes into their ER, and I say that intentionally, after 6:00pm is likely to wait thirty minutes for a chest tube or pericardiocentesis, and forget about a crike, as the patient would be dead before a surgeon could arrive."
"Let me discuss it with John Cutter. Hold off on saying anything to anyone, including Dutch Wernher, because you know Loretta will do anything she can to torpedo this."
"I know."
"Give me a few days and I'll let you know what we think. I won't offer to send you there until we give her request due consideration. I'm also not endorsing your request to go there at this time, but I promise to give it proper consideration."
"That's all I can ask. Thanks."
"How is Mary doing?" Doctor Roth asked. "I heard she took a loss on her first day pretty hard."
"She did, but we talked it through. Losing kids still gets to me, and I know that's true for most everyone in the ED."
"What's your private opinion of Paul Lincoln?"
"He's a good doctor," I replied. "But the second bounceback is going to cost him dearly in the Webber case. Fortunately, the second one was textbook surgery and recovery."
"And that jackass Braun is refusing to settle because he wants a high-profile trial."
"He's going to get one," I observed. "At this point, I'm positive he knows he can't lose, and he has no incentive to settle. We can't offer him a number big enough to make going to trial risky without him turning around and using that to get a jury to give an even higher award."
"This is going to cost us millions, if not tens of millions," Doctor Roth said, shaking his head.
"Worse, he's going to massage the facts to prove we ignored malignant hyperthermia."
"And find some jackass with an MD to be his 'expert'."
"My bigger concern is actually Doctor Burnside."
"We found zero evidence, and I mean zero, that he has ever come to the hospital inebriated or even under the influence. He voluntarily had a hepatic panel, and it showed no indication of alcoholism, though it's not conclusive. His piss test was clean, though it was obviously long after the surgery. There's talk about mandatory drug and alcohol testing."
"You'll have a revolt bigger than the one by the nurses that's in the offing!" Doctor Roth observed.
"That's why I said it's talk, but you know that at some point, risk management is going to demand it, and if not them, our insurance carrier. There are already random tests for law enforcement and firefighters."
"I wouldn't mention that to the nurses' union before a new contract is signed. That said, I don't see how we avoid a strike, given the County Board has no extra money AND they're going to have to allocate at least $10 million in reserve for the Webber case."
"Sadly, I agree with you. I'm not sure how this ends well."
"Me, either."
"Ross Burnside won't need you as a character witness. He's reinstated as of tomorrow morning."
"Good."
June 7, 1990, McKinley, Ohio
On Thursday afternoon, I had to leave the ED for my second deposition with Amanda Temple and Arthur Braun. It was limited to forty-five minutes, but if Leland Crowe asked questions, the time he took, and the time my answers took, did not count against those forty-five minutes. I had conferred with Leland and we'd come up with a strategy.
I arrived in the conference room about five minutes early. I sat down, placing an electronic chess clock on the table, with one side set to forty-five minutes, and the other to ninety, so that Leland's flag wouldn't fall before Amanda Temple's. I fully expected the two Volstead & Braun attorneys to object, but they would need some kind of accurate time keeping, and a chess clock was perfect for that purpose.
Leland came in a minute later with the stenographer and videographer. We greeted each other, and about two minutes later, Leland's secretary ushered in Amanda Temple and Arthur Braun. We all greeted each other.
"Judge Tannenbaum's order allows forty-five minutes with no possible extensions," Leland said. "In order to ensure accurate time keeping, Doctor Mike has an electronic chess clock. As soon as you ask your first question, he'll start the timer. It will run until either we agree to go off the record for some reason or I ask a question. It will resume when you ask the next question."
"We'll keep our own time," Arthur Braun said.
"As you're welcome to do, but we're going by our time, and it's definitive. If you're ready to begin, we can go on the record."
"We're ready," Amanda Temple declared.
"Then, proceed."
As soon as Amanda Temple opened her mouth, I pressed my side of the chess clock, starting their timer counting down.
AT: We are on the record with Doctor Michael Loucks. Doctor, in your previous testimony, you admitted that you had dantrolene available in the operating room. Is that still your testimony?
ML: Yes, because it's true.
AT: In addition, you testified that Mr. Webber had an increase in body temperature and suffered from arrhythmia. Is that still your testimony?
ML: Yes, again, because it's true.
AT: Doctor, what are the symptoms of malignant hyperthermia?
ML: Increased body temperature, respiratory acidosis, muscle rigidity, increased heart rate, and arrhythmia.
AT: Calling your attention to the morning of April 19th. You testified that you diagnosed Mr. Webber with acute appendicitis necessitating emergency surgery.
ML: I did.
AT: And you testified you were the assistant surgeon on the procedure.
ML: That is correct.
AT: What is your responsibility as assistant surgeon?
ML: To follow the directions of the primary surgeon and complete whatever tasks he assigns, as well as call out any relevant observations.
AT: Could you give an example?
ML: Anything relevant to the surgery, including observed changes in vital signs, bleeding, and any surgical observations, such as announcing the appendix had ruptured.
AT: In this surgery, what were you assigned to do?
ML: I was instructed to operate the Bovie, an electrocautery device.
AT: Who else was involved in the surgery?
ML: Doctor Ross Burnside, a team of nurses, and my student, Mary Anderson, who at that time was a Fourth Year.
AT: And what was her assignment?
ML: To operate suction under my direct observation and guidance.
AT: And the nurses?
ML: The only ones who touched the patient were Nurse Bobby Garrett and Nurse Deb Michelson, who helped us prep the patient. Nurse Garrett also handled retractors.
AT: Is it typical that a nurse handles retractors?
ML: In emergency surgery, yes. The same is true for a medical student operating suction, though that is also done during training on a surgical rotation.
AT: Is it typical for a first-year Resident to act as assistant surgeon?
ML: My Residency program is different from the normal surgical Residency or emergency medicine Residency, and was only recently created, so there is no 'typical' by which to judge.
AT: Let me rephrase — is it typical for a surgeon with so little experience to act as assistant surgeon?
ML: A surgeon with very little experience does not typically act as assistant surgeon; I have sufficient experience to act in that role.
AT: Who has to sign off on that?
ML: Doctor Owen Roth, the Chief Surgeon, and Doctor John Cutter, the Medical Director.
AT: Do you know what criteria they use to make that determination?
ML: Procedures recorded and signed off in the surgeon's procedure book, as well as personal observation and judgment of maturity and skill of the surgeon.
AB: Leland, we would like to examine Doctor Loucks ... sorry, Doctor Mike's procedure book, as well as those of other surgeons.
LC: Please file a motion for discovery, and we'll discuss it in front of the judge.
AB: We'll do that today. Continue, Amanda.
AT: Doctor, you testified you observed Mr. Webber had an increase in temperature after administration of anesthesia. Is that still your testimony, and what was the change in temperature?
ML: That is still my testimony, and Mr. Webber's temperature increased from 38.1°C to 39°C.
AT: Would you express those in the typical units?
ML: Those are the typical units in medicine. If you are asking for Fahrenheit, it would be from 100.6°F to 102.2°F.
AT: So a two-degree spike, correct?
ML: No. 0.9°C or 1.6°F.
AT: Did you consider that significant?
ML: I did, which is why I ordered the cooling packs to be applied.
AT: What was your concern?
ML: Malignant hyperthermia.
AT: Does a temperature of 102.2°F signify that condition?
ML: It could, but without a reference temperature, it's impossible to say.
AT: A reference temperature?
ML: Mr. Webber's typical temperature at that time of day.
AT: When would it always signify the condition?
ML: Not every case of increased temperature is related to the condition; there are other causes, including infection, sepsis, and other possible complications of acute appendicitis. At that point, I did not consider his temperature to be dangerously high, but rather something to be monitored.
AT: At what point would you have considered it dangerously high?
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