Chapter 34: As Frosty as the South Pole in July

July 2, 1990, McKinley, Ohio

"The nurses are pissed," Mary said quietly when I walked into the ED just before 5:00am on Monday morning.

"I see what appears to be the usual complement of nurses," I observed.

"Eight OR nurses called in sick this morning," Mary said. "Rumor has it that nurses in other departments are doing the same."

"Wonderful. Why not the ED?"

"Strategy, I'd guess. The ED continues to function, but only emergency surgeries can be performed."

I nodded, "That way, reporters wouldn't be able to make a strong case for 'putting lives at risk'."

"That's my take. Doctor Roth canceled all surgeries for today last night."

"No surprise."

"Doctor Wernher is here, and he said he expects to keep the emergency protocols in place for the rest of the week while we see how this plays out."

"Bobby Murphy suggested they could walk off the job, but that they'd risk being fired if they did. I think that's something of an empty threat because we've had trouble filling open nursing slots."

Mary smirked, "Not from what I hear!"

"Miss Anderson!" I said, trying to reprimand her, but I struggled to keep a straight face.

"Sorry," she said with a wink. "Anyway, two on the board, waiting for admit to Medicine. Otherwise, all's quiet."

"Let me go check in."

I walked over to the nurses' station to speak with Ellie.

"Hi, Ellie," I said.

"Please address me as Nurse Green, Doctor," she said flatly.

I almost asked if she was joking, but I knew that I was likely to incur her wrath, as she was obviously extremely unhappy.

"Good morning, Nurse Green," I said. "I'm reporting for my shift."

"Put your name on the board, Doctor; that is not my job."

And so it began. I walked around the nurses' station and wrote my name on the board, then went back to Mary.

"You could have warned me," I said quietly.

"What part of 'pissed' didn't you understand?" Mary asked.

"Wonderful."

"I bet I know how you could get Ellie to lighten up!" Mary smirked.

"Resulting in ME needing the ED, if not Doctor McKnight!" I chuckled. "Where are our toddlers?"

"In the lounge, hiding from the nurses. There are a pair of Second Years on duty to chase labs and X-rays, as well as re-stock treatment rooms. Guess what's not in the nurses' contract?"

"Wonderful."

"That's the word of the day?"

"It's better than any other word I could use under Dutch Wernher's guidelines for appropriate language in the ED!"

"What would you say in Russian?"

"Given the circumstances, one of the earthier ones I rarely used when I regularly swore in Russian — «блядь» (blyad). That means," I lowered my voice, "something like 'fuck', but not as in the act."

"That about sums it up. There are other things they won't do as well, but I don't know the full list."

"Anything not expressly written into their contract."

"Boy, won't THIS be fun," Mary said sarcastically.

"Doctor," Nurse Lisa said, "there's a patient in the waiting room."

"Chart?" Mary asked.

"That's not our job," Lisa said.

Which explained why Doctor Wernher had not modified the schedule.

"Mary, have Al and Tom man the triage desk, please. You supervise, I'll respond to any EMS transports or surgical consults with Molly and Nelson."

"«блядь» (blyad)," Mary replied, pronouncing it very close to correctly. ("Fuck")

"Yeah," I agreed. "You weren't aware?"

"No. The nurses ran triage last night."

"I'd guess someone reviewed the contract and found that triage wasn't in it, as it was written before we started triage by medical staff, rather than just have the clerk put names on a list except for obvious heart attacks and severe blood loss."

"Am I allowed to treat patients?"

"Yes. Use Nelson and one of the Second Years. I know it's not protocol, but they can observe, make phone calls, and do anything that doesn't involve touching the patient. That said, they could assist in moving a patient from a gurney to a trauma table because that's not 'treatment', and orderlies can assist with that."

"OK."

Mary and I went to the lounge and informed our students. Al and Tom left with her, and I walked over to the two obvious Second Years who looked like deer caught in headlights.

"I'm Doctor Mike," I said.

"Nora Jones," the female student replied.

"Stan Peters," the male student replied.

"Did anyone give you instructions?"

"Doctor Mary said we're going to be chasing labs and stocking treatment rooms," Nora replied.

"Correct. In addition, you'll likely be called to help in other areas. Make the maximum use of this extra time in the hospital. I know it's scut, but if you watch, listen, and ask questions, you'll learn for next year when you're actually permitted to touch patients."

"If the nurses are here, why are we missing class for this?" Stan asked.

"I have a two-part answer," I replied. "The first part, and the official one, is that the nurses are doing exactly as their contract specifies, no more and no less. In addition, a number of nurses have coördinated calling in sick, leaving services short-staffed, especially Surgery.

"The second part, and this is personal opinion — you are FAR better off here than in class, now that you've completed anatomy. There is an optional book for your Practice of Medicine course — The Principles and Practice of Medicine by Sir William Osler, co-founder of Johns Hopkins Hospital. Did either of you read it?"

"No," they both said.

"You should, even though some of the material is dated. Doctor Osler, who worked at Johns Hopkins, is responsible for creating the first Residency program. He said something very important that unfortunately hasn't been widely implemented — 'Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words in the lecture room or read from the book. See, and then reason and compare and control. But see first'.

"That's the entire point of Preceptorships, which are not typical at teaching hospitals, though they are becoming more common. I'm not saying you should neglect your books, nor your studies, but real learning occurs in the hospital with real patients with real ailments who need care from trained physicians. Most of what I do every day was learned from other physicians while treating patients.

"With regard to studies, if you aren't already doing it, you should create sets of flashcards and study them whenever you have a chance, whether it's sitting in the lounge, standing in line at the BMV, or riding in a car. Those flashcards should cover all the material you're expected to know, and will be fleshed out as you receive hands-on training. I have a deck here."

I pulled out my flashcards and showed them.

"This deck," I continued, "Has two hundred random cards from my collection of around 3500, assembled over the past five years."

"You still study as a doctor?" Nora asked.

"Residents are students," I replied. "The MD that will be conferred in just less than three years does not give you the right to practice medicine; that requires a medical license, which only comes after completing your Residency. You're allowed to practice medicine, but only under the supervision of a fully licensed physician — an Attending, in hospital parlance."

"Residents teach," Stan observed. "How does that work?"

I wondered why he didn't know, then remembered they had just begun their Second Year, and if the Residents they had shadowed during their Preceptorships hadn't made it clear, they wouldn't have had any other way to know, short of investigating it on their own.

"Even when they're teaching, they're learning from more senior physicians," I replied. "A perfect example is Doctor Mary, whom you met. She's a PGY1, and I, a PGY2, am training her on basic surgical procedures performed in the Emergency Department, while I'm being trained on more complex procedures by Senior Residents or Attendings. You'll first see that in action during Third Year when Fourth Years will show you the ropes."

"Doctor Mike?" Ellie said from the door to the lounge.

"Yes, Nurse?" I replied, despite my severe distaste for the formality.

"EMS is five minutes out with a single victim from a rollover MVA."

"Thank you, Nurse. Please ask Doctor Casper and a nurse to join me."

"Right away, Doctor. Use Trauma 1."

"Molly, Nelson, let's go. Nora, you come with us; Stan, you'll get your turn next. Someone will call you if they need you."

We left the lounge and put on gowns, gloves, and goggles.

"Can I ask a question?" Nora inquired.

"Always."

"Why don't you wear masks?"

"You haven't had your ED Preceptorship, have you?"

"No."

"Masks are optional except in the case of dangerous communicable diseases. If you feel more comfortable wearing a mask, by all means, put one on. Nobody will look askance if you do."

"Another question — why are you wearing red scrubs? I thought red was reserved for surgeons."

"I am a surgeon," I replied. "Just as Doctor Mary is. We're both Residents in trauma surgery, which is a relatively new discipline. Emergency medicine, as a specialty, only came into existence about fifteen years ago. Over time, more and more procedures are performed in the Emergency Department, including basic surgical procedures such as pericardiocenteses, thoracostomies, cricothyrotomies, escharotomies, and central lines. Do you know all those procedures?"