Good Medicine - Residency II
Copyright© 2025 by Michael Loucks
Chapter 29: Aye, Aye, Sir!
June 12, 1990, McKinley, Ohio
Late on Tuesday morning, which had been quiet, Nate let me know I had a phone call. I walked over to the wall phone, picked up the handset, and pressed line 3.
"Doctor Mike Loucks," I said.
"Mike, it's Gale Turner."
"Hi, Gale. How are things?"
"I start at my friend's practice next Monday. We're just finishing packing, and the movers will be here later today."
"I'm glad things worked out OK for you," I said. "It just sucks for the community."
"Things might be looking up. I had a call from someone at Planned Parenthood who asked about the clinic and the assets."
"That helps with family planning, but doesn't replace the other services," I said. "And I can't be involved with them."
"I understand. You were always principled in your opposition to abortion. Perhaps, if they do take over the clinic assets, someone will be able to find a benefactor to support low-cost medical services that don't involve the lightning rod that abortion has become."
"I'm completely behind that idea, and I'll volunteer time as I'm able."
"If anyone contacts me about that, I'll put them in touch with you. Once we're settled, I'd like to have you, Kris, and your girls over for dinner."
"We'd love to. Where are you going to live?"
"Terrace Park. The practice is in Mariemont. I'll have a ten-minute commute."
"I'll give you a call, probably in August, given Kris is due in about a week."
"That sounds great! I'll speak to you then."
We said 'goodbye' and I hung up. I was just about to go to the lounge when Ellie let me know that EMS was four minutes out with a GSW and that Perry Nielson had requested my help. Gunshot wounds were rare, and I made a wager with myself that it was someone who had been shot by law enforcement. I called Al and Molly, and the three of us put on gowns, gloves, and goggles, and headed to the ambulance bay.
"Hi, Mike. No details, but an obvious surgical case."
"Hi, Perry. Flashbacks to Cook County?"
He laughed, "Only if this was the fifth or sixth in the past twenty-four hours!"
He gave instructions to the medical students and nurse, and two minutes later, the squad turned into the driveway, followed by two Sheriff's cruisers, indicating I was likely correct in my suspicion. The squad rolled to a stop in front of us, and Roy jumped out.
"Male, early twenties; through-and-through GSW right shoulder; BP 90/70; tachy at 110; PO₂ 99% on five litres by mask; 2mg morphine; GCS 15 before morphine; unit of plasma running in."
"Trauma 3!" Perry ordered.
"He's under arrest!" Deputy Kenseth called out, getting out of his cruiser.
"Your doing?" I asked as he joined us moving towards Trauma 3.
"Traffic stop. He came out with a pistol."
"Molly, call upstairs and tell them we have a through-and-through GSW to the shoulder; patient is stable."
"Right away, Doctor Mike!" Molly replied.
Perry and I completed our exams, and because there was a surgical team available, neither Mary nor I were called up to assist. We sent the patient upstairs with Deputy Kenseth and Deputy Turner guarding him, and my students and I returned to the lounge.
"Do you know why Ellie asked you to take that run instead of me?" Mary asked.
"Perry Nielson requested me," I said. "You didn't miss anything, though. Patient with a through and through 9mm GSW to the right shoulder. Stable and sent up for surgery. My entire exam was looking at the shoulder and saying 'yep, he was shot'. I will mention to Perry he should simply ask for a surgical consult, and I'll make sure Ellie and Julie know to assign them to you."
"Thanks. I don't mean to seem like a whiner, but you are going to be out for a full week, and I really don't want to have to call someone down."
"I hear you, and we'll do our best to get you enough procedures."
"Doctor Mike?" Molly inquired, "OK to get a chart?"
"Yes."
We handled six walk-ins while Mary caught two EMS transports, but neither needed a surgical procedure. I had lunch with some of the surgical staff, and when I returned from lunch, we had a construction accident with a collapsed lung, and I guided Mary through the procedure. The afternoon was routine until just before 4:00pm.
"Mass casualty event!" Nate announced over the PA.
"What do we do?" Mary asked.
"Assemble by the Nurses' Station and wait for Doctor Wernher to give us details and assignments."
Mary and I, along with our students, went out to the Nurses' Station.
"A Greyhound bus overturned on Route 50 just east of town," Ellie announced. "No word on number being transported. Doctor Wernher ordered a Level I Disaster Protocol. First victims should arrive within ten minutes."
I went over to the wall phone and dialed home to let Kris know I'd likely be late, and just as I hung up, Clarissa came into the ED as part of the response team. Others filtered in over the next two minutes, and Doctor Wernher came out of his office.
"Let's clear the trauma and treatment rooms as quickly as we can. Doctor Vega, please have the rule-out concussion in Exam 2 moved to your ward; Doctor Shore, please have the rule-out MI in Exam 1 moved to your ward."
Both of them, along with their students, went to the respective exam rooms to have those patients moved.
"Fourth Years Baker, Lawson, Campanelli, and Schroeder, you're on triage for anyone not brought in by ambulance. Third Years Strickland and Jones, you are lab runners. Third Years Sexton and Miller, you're blood bank runners. All others, stay with your Residents. Doctors Atkins, Gómez, and Saunders, you'll treat triage patients. Doctor Mary Anderson, surgical assessments; Doctor Mike Loucks, surgical procedures. I'll assign EMS transported victims as they come in."
"At least fifty being transported!" Ellie called out.
"I wonder if this was a replacement driver," Ghost said. "They were on strike until a month ago and hired replacement drivers."
"It was an ugly strike, too," Perry Nielson said. "Reminiscent of the old days — union thugs and company thugs battling it out, including someone killed by a strikebreaker driving a bus."
"Remind me to stay off Greyhound," Mary said.
The next two hours were chaotic, but all of the injuries were minor, except for two passengers with broken arms, and three with concussions significant enough that they were admitted and kept overnight. I performed no procedures, and Mary admitted no patients to surgery.
"That could have been a lot worse," Mary observed when we finally were allowed to leave at 7:15pm.
"Once the first Deputies explained it wasn't actually a rollover, just the bus running off the road into a ditch and leaning sideways, it was obvious we weren't going to see any critical injuries. Pure chaos, examining sixty-two passengers plus the driver, but all that did is delay us going home."
"Go figure, not a single procedure or admission for us. Which sounds as if I was hoping there were."
"I said something similar — we only have procedures when someone is badly injured, so hoping for procedures seems as if we're hoping for injuries. The thing is, those injuries will occur whether we're here or not, and it's better to be here."
"You said that to me!" Mary exclaimed. "At least twice!"
"Some things bear repeating! That's why you study your flashcards during downtime in the lounge and outside the hospital, too. And some things are going to be repeated over and over for the next eight years. I'm sure you agree with me that's actually a good thing."
"I do. Repetition leads to expertise. I just hope I'm given the same early opportunities in the OR you've had."
"In many ways, it was circumstance, and a circumstance I'd actually give up for Deputy Sommers to be alive and for Loretta not to suffer from a spinal injury."
We finished changing into our street clothes, left the locker room, and headed to our respective homes.
June 15, 1990, McKinley, Ohio
On Friday afternoon, rather than have a Morbidity and Mortality Conference, the Resident Review Board met to examine the actions of Doctor Paul Lincoln. He'd chosen Leila Javadi as his advocate, which I felt was a wise choice. She was well respected and wasn't on either the surgical or emergency medicine services.
Doctor Anderson called the Board to order and introduced the members — Shelly Lindsay, Resident in Surgery; Carl Strong, Resident in Cardiology; William Collins, Attending in Internal Medicine; Roger Moore, Attending in OB/GYN; and Lucy Vanderberg, Attending in Neurology. I felt the members were a good mix, and I trusted all of them to render a fair verdict. My only concern was no member was from Emergency Medicine, but I suspected that was intentional.
The first order of business was to review the report from the Morbidity and Mortality Conference, which, to me, was definitive. All members of the Review Board had reviewed it in advance, so they agreed not to read it verbatim, and Doctor Cutter simply provided a summary of the findings. To me, there wasn't anything else to add, and Paul Lincoln had acted properly in both bounceback cases; he'd simply been unlucky.
Doctor Anderson had appointed Tim Baker as the Investigator, which amounted to, in effect, acting as prosecutor. He rose once the M & M Conference had been summarized, and began by questioning Paul, who gave answers congruent with what he had said during the M & M, and what I had observed from Paul Webber's chart. Doctor Baker homed in on what, in my mind, was the only thing that might possibly weigh against Paul — the failure to call a consult for either patient.
Paul reiterated the facts, including the standard practice to not call for a surgical consult for patients who had generalized abdominal pain with Alvarado scores below 5, unless there was some other indicator that the case was surgical. In Mr. Webber's case, he hadn't performed an ultrasound, but he had in the second case and had seen no obvious signs of inflammation.
When Doctor Baker finished questioning Paul, I felt Paul was in very good shape, and nothing had changed to make him guilty of anything other than, in effect, being in the wrong place at the wrong time, and having a patient who coded on the table through no fault of his. I wasn't surprised when I was called by Doctor Baker to come forward to the table where those giving their evidence sat.
"Doctor Mike, would you tell us what you observed with the first bounceback — Mr. Ken Webber?"
"From all indications, including the chart, a textbook case of early-stage appendicitis. According to the chart, his Alvarado score was 1 when he was sent home. When I saw him, it was 7, and I confirmed an inflamed appendix by ultrasound. I ordered Mr. Webber to surgery immediately."
"In your professional opinion, should Doctor Lincoln have asked for a surgical consult?"
"It wouldn't have mattered if he had, because it would have been refused based on the salient facts — the patient did not meet the criteria set by Surgery for a consult."
"I'm curious — what would you have done?"
"Hindsight is 20/20, Doctor Baker," I said. "I'm not comfortable playing Monday-morning quarterback on a case where the doctor followed the standard of care prescribed by the hospital."
"I've reviewed every case where you evaluated abdominal pain, and you have, on several occasions, provided a consult in the ED on cases similar to Mr. Webber's. How do you reconcile that with your statement about the refusal of a consult?"
"Because I am a surgeon assigned to the ED, and I am acting as a member of the ED team. As such, I can be asked for help by any other member of the team. That is not an official consult."
"Aren't you splitting hairs?" Doctor Baker asked.
"As Doctor Saunders will tell you, smirking while she says it, I'm special that way."
Everyone in the auditorium laughed, including Doctor Baker.
"Being serious now, my role is very different from that of any other doctor in the hospital, or was until about two weeks ago, when Doctor Mary Anderson began her Residency in trauma surgery. The point I'm making is that a doctor in the ED asking for my opinion is no different from, say, Doctor Saunders asking Doctor Gómez for assistance."
"Again, isn't that splitting hairs? It's still a consult, isn't it?"
"Actually, it's not. While I am a surgical Resident, I am assigned to the ED and work for Doctor Wernher. I follow his guidance and instructions, and one of the clear pieces of guidance in the ED is that we assist one another informally, on request. When Paul saw Ken Webber, and the second bounceback, there was no trauma surgeon on duty in the ED, which would have necessitated a formal consult, which, as I said, would have been refused."
"You're blaming the system?" Doctor Baker asked.
"In the sense that the standard of care, in effect, resulted in a bounceback, yes. That said, it is my opinion, corroborated by Doctor McKnight, that the patient would have coded whether he was sent home or not."
"Isn't that speculation? We don't know what would have happened."
"It's my considered professional opinion backed up by the M & M Conference and the autopsy results. To go back to your earlier question, in the same circumstance, I would have done the same thing Doctor Lincoln did. I'll note that in the second instance, he performed an ultrasound and documented it as inconclusive on the chart. At that point, only an ex-lap might have shown inflammation. We don't, as a rule, perform ex-laps on abdominal pain with no other symptoms."
"Where do you fix the blame for Mr. Webber's death?"
"Genetics," I replied. "Something about his physiology was incompatible with anesthesia. Generally speaking, there is no way to determine that in advance. You know the statistics as well as I do, Doctor Baker. This is, to put it politely, one of those things that happens from time to time, and medicine has no answer, any more than it did for my wife's sudden death due to an undetected and inoperable intraparenchymal bleed. The system did not fail her any more than it failed Ken Webber. Their bodies failed them. Period. There are, in fact, cases where there is literally nothing we can do to prevent a patient's death."
There were murmurs from the assembled doctors, nurses, and medical students, and Doctor Getty stood up.
"Doctor Anderson, with all due respect, I'd say that's definitive. Can we end this charade?"
"Charade?" Doctor Anderson asked.
"Charade," Doctor Getty said firmly. "This is all about the lawsuit, but nothing we do or say here is going to make one bit of difference, except perhaps to ruin the career of a promising young doctor for no good reason. McKnight was right in his conclusion, even if he was earthy. End this, please."
Doctor Vandenberg and Doctor Moore had a quick, quiet conversation, then turned to Doctors Strong and Collins to speak, and Doctor Collins spoke to Doctor Lindsay.
"We unanimously find Paul Lincoln not to be at fault," Doctor Collins said. "There is no point in continuing."
"That's not the procedure," Doctor Anderson said.
"Maybe not," Doctor Collins replied, "but we're wasting the time of around sixty doctors, nurses, and medical students for no good reason."
Doctor Zenker, head of OB/GYN, stood up.
"Nels, they're right. We can't convene Review Boards against doctors who follow the standard of care and hospital policy. If you want to review the policy, by all means, do so. That said, I think we have the solution in progress — trauma surgeons. If I understand correctly, we'll have coverage except for about thirty-six hours on Saturday and Sunday, once Doctor Mary Anderson is trained in the necessary procedures. It's a simple matter, then, for Dutch to simply require one of the trauma surgeons to sign off on the discharge of cases such as non-specific abdominal pain."
"I concur," Doctor Roth said, standing up. "With the expansion of the number of Resident slots that will result from the expansion of the ED and the conversion to a Level I center, I believe we should bring on two Residents in trauma surgery each of the next two years, which will give us complete, round-the-clock coverage, including vacation times. Dutch has already implemented an ultrasound requirement, and, as Mike noted, it was inconclusive in the second case. The Review Board expressed its views, Nels. Accept them, and let's all get back to work."
"I'll enter a finding of no responsibility," Doctor Anderson said. "You are all dismissed."
I stood up, and Doctor Baker quickly stepped over to me.
"That wasn't personal, Mike," he said. "I had a role to play."
I nodded, "I know, and I suspect you were fully aware of what I was going to say."
"I was, though you buried the inquiry by linking it to your wife's death."
"That wasn't planned," I replied. "It just came to me while I was speaking."
"I have, indeed, heard Clarissa say you are 'special'."
I chuckled, "She's known me since Freshman year at Taft, and her usual comment is she can't leave me alone for more than about two minutes without me finding some way to get into some kind of drama."
Doctor Baker laughed, "The best physicians are often like that. You're one of the best."
"Thanks."
We shook hands, and Paul Lincoln came over to me and shook my hand, thanking me effusively.
"I was worried," he said.
"Me, too," I replied. "But, in the end, it all worked out."
"Not the malpractice suit; that's going to stick despite what you said."
"Sadly," I replied. "There are just enough facts to piece together a theory that a jury of laypeople will believe. You saw the response of the medical community, and that was not the 'white coat' problem."
"I just wish Ken Webber's family would accept the settlement offer with no admission of liability."
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