Good Medicine - Residency II
Copyright© 2025 by Michael Loucks
Chapter 35: Are We Having Fun Yet?
July 2, 1990, McKinley, Ohio
"Doctor, you had a phone call," Ellie said when I walked into the ED. "I am not your appointment secretary."
I so wanted to roll my eyes, but I knew that would make things worse.
"I assume you didn't take a message, so may I suggest you allow Nate, or whichever clerk is on duty, to answer the phone if you aren't going to take a message?"
"You don't decide the procedures, Doctor."
"I'm going to say just one thing. When all of this is over, you will still have to work with us. Consider how your behavior towards us is going to affect that when we don't have a darn thing to do with the dispute."
"Is there anything else, Doctor?" Ellie asked.
"No."
I updated the board to show I had returned from my break, then went to the lounge and asked Molly to come with me to the triage desk. Because Mary had gone home, I would only handle walk-ins and surgical consults until Mary returned at 7:00pm.
"Al, take your lunch, please," I said. "Molly will cover for you."
He acknowledged me and got up. Molly sat down.
"Tom, when Al comes back, you take your lunch. You don't need to ask, just go. Molly, when they both finish their breaks, you take yours."
They both acknowledged me, and I went to Nate's desk to have a quiet conversation with him.
"What's the standard procedure for taking outside calls?"
"There isn't one. Why?"
"Ellie said I had a call, but didn't take a message, and said it's not her job. When I suggested she allow you or the other clerks to answer the phone, she said I didn't have the authority to decide the procedures."
"It's always been casual because the same lines are used for both medical and non-medical calls."
"Wonderful. Out of curiosity, is the call volume so high that the clerks couldn't take all calls?"
"Probably not, no. Nobody calls with an emergency the way they did when I started in 1978, and we dispatched ambulances from here. There were always two clerks on at any time in those days, but that ended when the Fire Department started the paramedic program."
"OK. Thanks."
I left his desk and checked the board to see if Doctor Wernher was with a patient, which he was, so I went to the lounge and asked Nelson to get a chart so we could see a walk-in patient. We saw two before I was able to speak to Doctor Wernher.
"May I make a suggestion?" I inquired.
"Certainly, Doctor."
"It appears the nurses are no longer taking messages for outside calls, and I wonder if you might direct that all calls be answered by the clerks. I checked with Nate on the volume of calls, and he seemed to think the call volume was low enough that the clerks could handle it."
"Did something specific happen?"
"Nurse Green said I had a call, but that she was not my appointment secretary, and didn't take a message."
"A personal call?"
"I have no idea, actually. I've met enough physicians, medical students, and prospective medical students who do not have my home number and would, naturally, call here to reach me that I can't say for sure."
"Did you say anything to Nurse Green?"
"Only that when all of this is over, we're going to have to work together, and she should consider that in how she handles her job."
"That is true. Your suggestion is reasonable, though I'll need to discuss it with Nels Anderson, as the clerks are part of the administrative staff, not the medical staff."
"Thank you, Doctor."
I left his office and saw someone I'd been waiting to see — Leticia Jefferson, Clark's cousin. She'd finished her HR paperwork and was now beginning her hospital orientation. She'd have her first regular shift on July 8th.
"Hi," I said. "Welcome!"
"Thanks! I'd stay to chat, but I have to be at pre-school in Internal Medicine!"
I chuckled, "Enjoy!"
The rest of the afternoon was routine, though busy, with walk-in patients and two surgical consults. Given the circumstances, I didn't even bother to ask to scrub in, as there were no elective surgeries and most surgical teams were upstairs twiddling their thumbs. I had dinner with Lucy Vanderberg and Carl Strong, then had a relatively routine evening. Mary returned at 7:00pm, and two hours later, my shift over, I headed up to the ICU to check on Sara.
What I had failed to account for was that the nurses would not be accommodating in any way, and as my name wasn't on Sara's chart, I was refused entry into the ICU. I considered appealing to the Resident, but decided I'd deal with it in the morning by speaking directly to Rebekah Cohen. I walked to the surgical locker room, changed into my street clothes, then headed home.
July 3, 1990, McKinley, Ohio
I returned to the hospital just over seven hours after I'd left. With only eight hours between shifts, that meant about six hours of sleep, and a few minutes with Kris, Rachel, and Charlotte each day. I wasn't happy about that, but, in the end, caring for patients had to be my top priority. We needed a resolution to the labor dispute, but I wasn't holding out much hope.
I met Shelly in the locker room, as usual, and we chatted while we changed into scrubs. When we were both dressed, she headed to her office while I made my way to the ED. The first thing I noticed was Nurse Sally, one of the youngest nurses, manning the nurses' station. That was not typical, and I wondered if the 'sickout' had spread to the ED. I put my name on the board and went to triage to see Mary.
"How bad?" I asked.
"Half the ED nurses called in sick today, and the nurses from Medicine who are qualified refused assignment to the ED."
"Of course they did," I replied. "What's the plan?"
"No change, though obviously it will slow down seeing walk-ins because we have to prioritize patients brought in by EMS. I was speaking to Perry Nielson earlier, and he said when this happened in Chicago, they closed to trauma. They could do that because there were at least four other hospitals that could take EMS transports. They also turned away walk-ins, which we can't do because of EMTALA."
"Something very bad is going to happen, and it's going to make the Ken Webber case look like a discount matinée of a two-year-old movie. The liability will be limitless."
"Isabella said basically the same thing. The only option would be to completely close the ED to all patients."
"I don't think that would necessarily save us from an EMTALA violation," I said. "The definition the law uses is 'a specially equipped and staffed area of the hospital used a significant portion of the time for initial evaluation and treatment of outpatients for emergency medical conditions'. The ED will still exist, and depending on the time frame, a claim that it was used for those purposes continuously for fifteen years, might overcome declaring it 'closed'."
"I'm not sure you're right, but I'd hate to take the chance."
"Which is my point, actually. I have no clue how that would be interpreted, and I bet Leland Crowe doesn't, either. I also object on ethical grounds, so I'm not sure what options we have, if any."
"Doctor?" Nurse Karla, another very young nurse, said, coming up to me.
"Yes, Nurse Pearson?"
"EMS four minutes out with an MVA; two victims."
"What nurses are available?"
"None, Doctor."
"OK. What doctors are free?"
"You'll have to look at the board, Doctor."
I wanted to smack my head on the wall, but I didn't say anything as she walked away.
"What the fuck?" Mary asked quietly.
"Yeah, I know. But we have a job to do. Leave Al here; take Tom. I'll take Molly and Nelson; who are the Second Years today?"
"Joy Fox and Olivia Delgado; both have had ED Preceptorships."
"Thank Heaven for small favors. We'll each take one, though there isn't much they can do. Let's go see if anyone is free to help."
I checked the board, then went to the lounge and asked Isabella to join us, assigned Joy to assist Mary, and assigned Olivia to assist Isabella. The entire cohort made our way to the ambulance bay, grabbing gowns, goggles, and gloves on the way.
"Are we having fun yet?" Isabella asked.
"I'm all for labor unions," I said, "and I fix the blame for this on the County Board. That said, people who work in healthcare have an ethical and moral duty to society to do our jobs, even under the worst of conditions."
"Who does what, Mike?" Mary asked.
"You take the first patient, Isabella will take the second, and I'll assist whoever needs me. Molly, Nelson, you'll be our stand-in nurses — O₂ hookups, blood draws, retrieving instruments, and administering drugs. Olivia and Joy, you'll make phone calls or run blood to the lab. Molly and Nelson, please follow Doctor Mastriano's instructions. Tom, you know what to do."
EMS squads 1 and 2 arrived about two minutes later, and Bobby hopped from his cab first.
"Karen Mueller, fifty; T-bone MVA; tachy at 120; BP 80/50; PO₂ 90% on ten litres; crush injuries to the left extremities, and left ribs; significant impact injury left side of the head; unresponsive to stimuli; plasma IV; cervical collar and backboard."
"Trauma 1!" Mary commanded, and they were off.
Jesse Adelman jumped out of Squad 1's cab.
"Denise Mueller, twenty-three; six months pregnant; tachy at 100; BP 120/60; PO₂ 98% on three litres; multiple contusions; laceration on the right cheek."
"Trauma 2!" Isabella commanded.
"Olivia, call immediately for an OB consult!" I ordered. "GO! Isabella, I'll help Mary."
I quickly moved inside, following Olivia, and headed for Trauma 1.
"What do you need, Mary?" I asked.
"Check distal pulses and Babinski!"
I did as she requested and reported my findings.
"No pulse left ankle; no pulse left knee; thready pulse right ankle consistent with tachycardia and low BP; indifferent Babinski."
"Ortho before neuro," Mary declared. "I'm going to insert a chest tube."
"I'll make the call."
I went to the phone and dialed Orthopedics and wasn't surprised when a medical student answered.
"This is Doctor Mike in Trauma 2," I said. "We need a consult stat for a pulseless leg following an MVA."
"I'll send the Resident immediately."
"Thank you."
I hung up, then decided to call for the neuro consult because we'd need a spinal assessment before surgery to repair her left leg. I made the call, and even more surprising, a Resident answered the phone.
"Neuro; Doctor Cassidy,"
"Terry, it's Mike Loucks. I need a neuro consult stat for an indifferent Babinski following an MVA."
"I'll be right down."
I hung up and let Mary know the consults were on their way.
"Can you assist with the chest tube, Mike?"
"Nurse Mike, at your service," I said. "Tape the tube? I can suture as well."
"Both, please."
I retrieved the instruments from the tray, put in four sutures, then taped the tube and connected the Thora-Seal while Mary continued assessing the patient.
"PO₂ 94%," Tom announced.
"Another unit of plasma," Mary requested. "Joy, get it from the refrigerator and give it to Tom to connect. Mike, I think we may want a central line just in case."
"Prep and I'll guide you. Let me check on Isabella, and I'll be right back."
I quickly went to Trauma 2 to check on the pregnant patient.
"Significant spotting," Isabella announced. "OB is delayed."
I suppressed a groan.
"How long?"
"Another five minutes."
"Fetal heartbeat?"
Isabella shook her head.
"My baby is dead?" the woman asked, tears rolling down her face.
"We don't know," Isabella said. "We're waiting for an OB to come check you. Don't panic, please, it's not always possible for us to hear a heartbeat in the Emergency Department with all the equipment and noise."
Which was technically true, but given the other sign, I suspected the worst.
"Doctor Mike!" Olivia exclaimed, coming in the door. "Doctor Mary needs you!"
I quickly left Trauma 2 and asked Olivia to find either Doctor Varma or Doctor Wernher to help Isabella until OB arrived, then went into Trauma 1.
"Belly is rigid," Mary announced. "She's going to need an ex-lap."
"Too many things wrong here," I said.
I quickly verified Mary's findings and was sure the patient had blood in her abdomen.
"I'm ready for the central line," Mary said.
"You know the procedure. I'll watch. Ask if you need help or have questions. Tom, call up to surgery, please, report ALL the conditions and let them know she'll need an emergency ex-lap."
"Right away, Doctor."
"Bob Kluszewski, Ortho," the Resident said, coming into the room with his student.
"Hi Bob," Mary said. "I'm Mary Anderson. Karen Mueller, fifty; T-bone MVA; tachy at 100; BP 90/60; PO₂ 94% on O₂; crush injuries to the left extremities and left ribs; significant impact injury left side of the head; unresponsive to stimuli; chest tube and central line; two units of plasma. Needs an ex-lap and neuro consult; left leg pulseless at the ankle and knee."
"Spinal injury?"
"Unknown. Neuro is on their way. I could not clear the C-spine."
"Let me call my Attending," he said.
Terry Cassidy came in just then and announced himself.
"Bad one, Terry," I said.
Mary repeated the vitals and treatment, and Terry quickly moved to examine the patient. This was a case that needed an Attending, not four Residents, so I left the trauma room and went to find Doctor Wernher, who was in with Isabella.
"Doctor, I'll help Isabella; they need an Attending next door."
"Why?"
"The patient is a train wreck; someone is going to have to decide between an ex-lap, orthopedic repair of a pulseless left leg, and an indifferent Babinski on both feet. Central line and chest tube are in."
"OK. You stay with Doctor Mastriano. Who's next door?"
"Doctor Anderson, Doctor Cassidy from Neuro, and Doctor Kluszewski from Ortho."
"I'll take care of it!"
He left, and OB still hadn't arrived, and if things went south, which they could, we'd need more help. I let Isabella know I'd be right back and went out to the nurses' station.
"Who else is on?" I asked Nurse Pearson.
"Nurse Martin, Nurse Compton, and Nurse Garrett."
"Where are they?"
"Nurse Martin is assisting Doctor Varma, Nurse Compton is assisting Doctor Baxter, and Nurse Garret is on her contractually guaranteed break."
"We need help in Trauma 2. Come with me."
"My assignment is the nurses' station!"
"And I'm telling you a patient needs you. I do not give a fig about your work rules, your contract, or anything else. Your job is the same as mine — to care for patients — and I expect you to do it. Now, get into Trauma 2!"
"No, Doctor."
I'd had it with the nurses' attitudes, even though I supported them.
"Either you get into Trauma 2 and be a nurse, or I will absolutely write you up for disobeying a direct, patient-care order from a doctor, and your contract will NOT save your butt. Now, do it!"
She glared at me, but she did move towards Trauma 2 just as Al stuck his head out,
"DOCTOR MIKE! COME QUICK!"
I sprinted the last few steps and saw a blood-soaked sheet. The only possible cause for that would be an abruption.
"BP bottomed out," Isabella said. "We need a central line for rapid infusion."
I looked up at the monitor and saw 50/--, which at least said she had some blood volume.
"Karla, assist me!" I declared. "Get me a central line kit, NOW! Al, Betadyne — don't waste time, pour it on! Isabella, get her on a vent! If we can't control the bleeding, she'll need an emergency hysterectomy."
Everyone sprang into action and began working to save Ms. Mueller's life. Five minutes later, we had a measurable BP, but Ms. Mueller was still bleeding.
"Al, call up and tell surgery we have a twenty-four-week pregnancy with placental abruption, and bleeding is uncontrolled. We're replacing volume, but she'll need an emergency hysterectomy."
He moved to the phone just as Barb Sullivan from OB arrived. I filled her in, and after an exam, she concurred that the baby was not viable and a hysterectomy was necessary. Al, Barb, Olivia, and I escorted Ms. Mueller to the OR, where Doctor Roth was waiting. We turned the patient over to his team, then left the OR.
"What took you so long?" I asked Barb.
"Half our nurses called in sick. Residents are having to do a good portion of the nursing tasks."
"Half of ours are out as well."
"This is a shitshow," Barb observed.
"You can say that again! I need to get back downstairs."
Just as I was about to go downstairs, Mary, Bob Kluszewski, Terry Cassidy, and Al brought up the other patient.
"Mike, they want me to scrub in because they're short nurses."
"OK. I'll take care of the ED. Al, come with me."
He, Olivia, and I returned to the ED, where I found a very angry-looking Margaret Teasdale waiting for me. Rather than have the argument I knew was coming in public, I invited her to the consultation room.
"Did you threaten one of my nurses?"
"No," I said. "I promised to write her up for refusing a direct order relating to patient care."
"I'm filing a grievance against you on her behalf."
"Do what you have to do," I replied. "Patient care takes priority over everything, including your salary dispute. If you can't recognize that, I'm not sure what you're doing here."
"Excuse me, Doctor?!"
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