Good Medicine - Residency II
Copyright© 2025 by Michael Loucks
Chapter 44: Proper Priorities
August 1, 1990, McKinley, Ohio
"I'm not even sure what to say about that," I replied.
"Me, either," Detective Rehling replied. "Family Services received an anonymous tip a few days ago and visited the house this morning, but nobody came to the door when they knocked. About an hour later, a neighbor called us because the young woman had come out of the house screaming her dad was trying to kill her baby."
"All things being equal, she's not behaving the way I would expect if that were the case. She answered my questions about being hit and told me about trying to call 9–1–1."
"All I'm doing is reporting what Family Services told us," she replied.
"OK. I'm going to suggest Melinda call for a psych consult."
"Still hoping for that drink, Doc!"
"My schedule has been insane due to the difficulties here at the hospital. Let me speak to Melinda, please."
I ducked back into the trauma room and asked Melinda to join me in the consultation room.
"What's up?"
"You should call for a psych consult once you have her upstairs. Detective Rehling says they believe the baby is the result of incest."
"Brother?"
"Father."
"I'll castrate him myself!" Melinda growled. "No parent..."
She stopped and shook her head.
I nodded, "I know, and I agree. Family Services supposedly received an anonymous report. Do you think she's acting as if she were a willing participant or she was abused?"
"No, but we're not the experts."
"Which is why I suggested the psych consult."
"Coming from you, that's basically an undeniable request. You and psych are not exactly going to be buying each other beers."
"Detective Rehling wants to buy me a beer," I replied with a smirk.
Melinda laughed, "If you were single, I would buy you a beer for the same reason. But you're married, and that is not a game worth playing."
"Agreed."
We left the consultation room, and a few minutes later, Melinda and her student moved the patient upstairs.
"Mike?" Gary, a Third Year, said, "Doctor Liu needs you right away!"
I followed him into Exam 3, where Doctor Liu was with a male patient.
"Hi, Mai," I said. "Surgical consult?"
"No. Mark Nygard, twenty-eight. Felt dizzy following a short run. Just experienced unexplained V-fib, converted with a single shock. Labs are not back. BP 120/70; pulse 65; PO₂ 95%. No history of heart trouble. Cardio consult requested."
"Hi, Mr. Nygard; I'm Doctor Mike. Do you run a lot?"
"I'm a triathlete. I'm training for the Chicago Triathlon later this month."
"What's your training regimen?"
"Swim an hour on Mondays; bike two hours on Tuesdays; run an hour on Wednesdays; swim and bike an hour each on Thursdays; run 10K on Fridays; Saturdays are cardio in the gym; Sundays are a long swim or long run. I've gone beyond those for the last two..."
He slumped back, and the monitor blared.
"V-fib!" Bruce, a Fourth Year, called out.
"Charge to 150!" I ordered. "Paddles to Doctor Liu!"
Mr. Nygard converted immediately, and I looked at the monitor.
"Wide QRS and peaked T waves," I observed. "He's hyperkalemic! I suspect at least 7.7. Becky, a gram of calcium gluconate IV push!"
"Don't you want to wait for the labs?" Doctor Liu asked.
"It's rhabdo, and he's in renal failure," I said firmly. "If he codes again, we might not bring him back. Becky, do it! Mai, what's rhabdomyolysis?"
"A condition in which damaged muscle breaks down rapidly, often due to high-intensity exercise over a short period! Wow!"
"And how does that cause renal failure? You might need to think back to university biochemistry."
She considered for a moment.
"Excess protein resulting from muscle breakdown enters the bloodstream. When it reaches the kidneys, it causes a strain that reduces their filtering efficiency. The protein basically functions as a dam because it forms tight aggregates when it enters the renal tubules. In addition, the increased intracellular calcium has a greater time to bind due to the blockage, allowing for renal calculi to form.
"That causes urine output to decrease, allowing for a build-up of uric acid inside the kidney. The increased concentration of uric acid allows the iron from the aggregate protein to be released into the surrounding renal tissue. Iron then strips away molecular bonds of the surrounding tissue, which eventually will lead to kidney failure if the tissue damage is too great."
"Exactly right!" I confirmed.
Becky administered the calcium gluconate, and a few seconds later, the EKG moved to normal sinus rhythm.
"OK," I observed. "Becky, 10 units of insulin and 25 grams of glucose. Mai, why?"
"To shift the potassium intracellularly. He'll need hemodialysis to clear it."
"Yes. Get that set up, please."
Before she could ask her student to make the call, the phone rang, and Gary answered it.
"Labs are ready," he said.
"Ask about potassium and creatinine, then go get them," Mai ordered.
He did, then announced, "Potassium 7.8; creatinine 5.7."
"You called it perfectly, Mike," Mai said. "Amazing. Gary, call Renal so we can get him on dialysis, then retrieve the labs."
"All yours, Mai," I said.
I filled out and signed the chart, then returned to the lounge. Things were quiet for about forty minutes until Mai came to the lounge.
"Doctor Wernher would like to see you."
"About?"
"I just presented Mark Nygard."
I was positive he was going to question my acting before the labs came back, but I was confident in my diagnosis. I followed Mai to Doctor Wernher's office.
"You asked to see me?" I said.
"Yes. Why didn't you wait for the labs on the rhabdo?"
"I felt we didn't have time. He'd coded twice. The EKG was definitive, absent labs — wide QRS complex and peaked T waves following collapse after a short amount of exercise. I felt the risk associated with giving the calcium gluconate was minimal compared to a third V-fib arrest."
"And if he had been hypercalcemic?" Doctor Wernher asked.
"Contraindicated by EKG," I replied. "That would have been a short QT interval, not a wide QRS. Peaked T waves made it definitive."
"Doctor Liu, please give us the room," Doctor Wernher said.
She left, closing the door behind her.
"Ballsy call," Doctor Wernher said, "but I can't have my Residents being cowboys."
"I'm not sure how to respond to that statement," I said.
"I'm not sure there is a response to give," Doctor Wernher observed. "I wasn't saying you're a cowboy, because you know exactly where the line is, and while you like to scuff it, you don't cross it. You can back that up, but you know the saying about being a real doctor."
"Do you actually believe that to be true?"
"No. That saying should never be uttered by someone who has gone through medical training. We absolutely will all lose patients at one point or another, but we don't kill them, no matter what lawyers say."
"Are you concerned about anyone being a cowboy? Or cowgirl?"
"I'm always concerned about PGY1s, especially when I didn't have a chance to interview them."
"Dutch," I said with a smile, "Do you trust my judgment?"
"Yes, but I know you treat students who are known quantities differently from how you treat ones with whom you aren't familiar."
"Touché. I will say that I've observed all of the new Residents at one point or another in the past two months, and all of them seem to match my impression from the interviews. I'm going to surmise your concern is someone besides Mary Anderson trying to emulate me?"
"The thought had crossed my mind."
"If that's a concern, you can always point to the red scrubs and the very different training Mary and I have. That said, I do believe emergency medicine specialists should do a cardiology Sub-I, just as I believe surgeons should do a pathology Sub-I."
"You're rowing against the current there. There is serious discussion of eliminating pathology as a required rotation."
"I read that, and it's a huge mistake. There is significant value for any diagnostician; for a surgeon, where else can they cut before PGY3?"
"Present company excepted, of course," Doctor Wernher said with a smile.
"I freely admit the program here is based on my skills and abilities, and that I was a known quantity. That's why I basically hand-selected Mary Anderson, and I intend to do the same thing next Spring. I have my eye on a few possible candidates, and at least two people have expressed interest."
"The way you carefully choose your words says that at least one of them is not a student."
"That would be correct, and I suggested a conversation with Owen, given I have neither the authority nor the ability to change anyone's Residency contract, nor would I even try without approval from the Medical Director. That's a very dangerous road to travel."
"Look who's become an Establishment guy!" Doctor Wernher said with a grin.
"Normally, I'd say those were fighting words, but there is value in order over chaos. I do think the system should change, but I also agree that our current system has turned out plenty of good physicians, and continues to do so, even if it doesn't meet my Platonic Ideal of a training program."
"Is there another Resident in the entire country who would use the phrase 'Platonic Ideal' when discussing medical training?"
"Well, if there were, they'd likely be an Orthodox Christian, given the entire West has followed Aristotle into a blind alley from which there is no escape!"
"Going back to what you said before about EKGs — how would you do that, given there are limited numbers of Sub-Is, and we're also going to have Matches who aren't from McKinley Medical School?"
"A cardiology rotation isn't the solution," I said. "But I think as part of the training program for PGY1s, we could institute educational sessions, and we should do that. Being able to read an EKG will become increasingly important as patient loads increase. It could also cut out ten to fifteen minutes for treating certain conditions, including the one we saw today."
"Yes, and that goes back to my first point about not wanting cowboys on my service."
"It's a fine line," I replied. "All our Residents have shallow knowledge of things that might allow or even cause them to act. We have to trust our judgment of their judgment, teach them, and provide guardrails. The tricky question is where to place those guardrails to improve patient outcomes while minimizing risks.
"We do those risk assessments for every medical student and Resident, and record them in their procedure books. I think we can continue along those lines, where we sign off for someone to read and interpret EKGs, but we limit what treatments they are permitted to approve.
"It's not dissimilar to how we're handling EMS. They gather far more information for us now that every squad is being upgraded to Advanced Life Support, and they're receiving training in reading EKGs. They have defibrillators, but they're programmed to only work with specific shockable rhythms with specific charges, whereas ours are basically dial-a-yield."
Doctor Wernher raised his eyebrows, "You realize that's a term for nuclear weapons with variable yields, right?"
"Well, imagine how it would feel to get hit by a defibrillator if you were conscious!"
Doctor Wernher shook his head, "You have a very strange sense of humor."
"It helps me maintain what passes for sanity."
"Let me speak to John Cutter about the EKG training. Good save on the rhabdo."
"Thanks."
"Dismissed."
I left his office, and Doctor Liu came over to me.
"I didn't mean to get you in trouble," she said quietly.
"You didn't. Doctor Wernher and I were having another one of our frank conversations about medical training and how to run the best ED in the country."
"OK. I was worried because as soon as I said you had administered calcium gluconate without labs, he asked to see you."
"Understandably, because what I did was not something a typical emergency medicine physician would be expected to do, and most don't have the additional training to do it."
"Reading EKGs is a specialist skill," she observed.
"In the past," I replied. "How long has Emergency Medicine, as we know it, existed?"
"About twenty years."
"And what we have now looks nothing like the Shock-Trauma Unit at Cook County in Chicago. And when we move into the new ED, it'll change significantly again, with what are called telemetry beds and other new technology. We're going to be doing more and more in the ED, and that means former specialist skills will become common skills."
"You're only a year ahead of me; I feel like I'm so far behind."
I smiled, "I think you need a slightly different perspective. Think back to your first Sub-I compared to your first Clerkship, or compare yourself to your Fourth Year."
"True," she admitted.
"It's also the case I have a different specialty and a different training program, so it's not an apples-to-apples comparison."
"OK, but I could easily have lost him, whereas you wouldn't."
"I could compare myself to Shelly Lindsay with regard to surgery in the same way. I can manage a simple appendectomy with no complications. The first complication that arose, I'd be lost, except for general knowledge, which is nowhere near enough to be rummaging around in someone's gut! You did exactly what I would do — called for help. I'm curious why you called me rather than an Attending?"
"Nurse Martin suggested you because you could read EKGs far better than Doctor Mastriano or Doctor Nielson."
Dutch Wernher's standing order for using titles and surnames grated on me, but I couldn't say anything to Mai about it without creating unnecessary tension between Dutch and me.
"There's an important lesson for you there," I said.
"Trust your nurses."
"Always. They can make or break you. That's especially true of Becky and Kellie — Nurse Compton and Nurse Martin."
"Doctor Mike?" Nate called out. "EMS four minutes out with rollover MVA with lengthy extraction time. Doctor Baxter asked for you."
"Thanks, Nate."
I gathered my students, and then the three of us went out to the ambulance bay.
"Hi, Kylie."
"Hi, Mike. Surgical assessment, please. Can your student handle a Foley?"
"Gabby, Foley, and show Ron how to do it."
"Yes, Doctor."
Two minutes later, Roy jumped out of the cab and called out the bullet.
"Joe Crocket; eighteen; restrained driver of high-speed rollover MVA; tachy at 120; BP 80/50; PO₂ 92% on five litres by mask; severe contusion to the left temple; fractured left tib-fib; cervical collar and backboard; GCS 3; IV plasma plus saline TKO."
"Trauma 3!" Kylie ordered.
We all began moving.
"Mike, I'll handle head and neck, you handle torso and extremities."
"Will do!"
We quickly moved the patient to the trauma table, and the paramedics left as we began our work.
"Left pupil blown; right sluggish," Kylie announced. "Jackie, neuro consult! Mike, proactive mannitol?"
"Agreed," I said as I continued to assess the patient. "Seat belt sign!"
"V-tach!" Brett, Kylie's Fourth Year, announced.
"Kellie, mannitol, IV push!" Kylie ordered.
"Ron, ultrasound!" I commanded after palpating the patient's abdomen. "Then call for an OR."
"C-spine swelling," Kylie announced. "Jackie, call for a CAT scan, ED stat! Neuro will want one before we remove the collar."
The patient was the proverbial train wreck, and we called out additional injuries and symptoms — blood in the Foley bag, severe bruising, and an obvious tib-fib fracture. The ultrasound confirmed free fluid in the patient's abdomen.
"Cohen, Neuro," Rebekah Cohen announced as she came in with a male med student.
Kylie gave the bullet, and Rebekah performed her exam.
"CAT scan," she confirmed. "Mike, do we have time, or do we have to fix the belly first?"
"I think he's OK for the CT," I said. "His pressure has come up with additional plasma; I think the low BP was due to the lengthy extraction."
"OK. Let's go!"
She, Kylie, and their med students whisked the patient away. Rebekah was a qualified general surgeon and was working on her neuro certification so she could handle anything that came up during the CT.
"Will he make it, Doctor Mike?" Ron asked as we left the trauma room.
"Maybe," I replied. "If he does, he may well have serious neuro deficits."
"Mike?" Deputy Turner called out.
"Hi, Scott. What's up?"
"How is the MVA?"
"Bad shape," I replied. "Swelling around his cervical vertebrae, likely traumatic brain injury, internal bleeding, and a broken tib-fib. He's having a CAT scan, then will go for surgery, if he's stable enough. We did manage to bring his BP up with plasma and saline, so it probably comes down to the head injury. What happened?"
"Perp, who was fleeing from Jamie Evers, missed a curve on Ohio 50. It started as a routine traffic stop, but the guy drove off as soon as Jamie got out of his car. Lost it about a mile and a half later at about 75mph. OK if I head to Radiology?"
"Yes."
He left, and my students and I went to the lounge.
"On the list of dumb ways to die..." Gabby observed, shaking her head.
"Sadly, that list is seemingly endless," I replied.
The rest of the morning was calm, and I had lunch with Carl, Leila, and Roger Moore from OB. The afternoon was hectic, with several MVAs, though none of the patients were seriously injured. At 5:00pm, I went to find Loretta.
"How was your first day back?" I asked.
"Good, but you got all the excitement. Of course, you live for that."
"I don't deny being an adrenaline junkie."
"I heard about the hyperkalemia. Typical Doctor Mike move."
"I suggested to Doctor Wernher that everyone here be trained to read EKGs."
"And when someone does something that's beyond their skill level?"
"We discussed that, too."
"Hi, Mike; Hi, Doctor Gibbs!" Mary said, coming up to us.
"Call me Loretta, please. Good to see you, Mary! I'm very happy you Matched here."
"Not nearly as happy as I am!" I declared. "My star pupil!"
"I'd say now you know how I feel," Doctor Gibbs said, "but it would go to your head!"
"I know you love me," I chuckled. "How are you getting home?"
"Bobby's sister. I'm still hoping to convince Ortho I can drive."
"As I said on Sunday, listen to your husband and your doctors."
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