Chapter 39: First Contact

September 3, 1985, McKinley, Ohio

"Michael Loucks," I said to the nurse at the Emergency Department admitting desk at Moore Memorial Hospital. "I'm starting my 'Preceptorship' today with a Doctor Gibbs.

"One moment," she said.

She placed a phone call, and almost immediately, a young woman in scrubs and a medical coat came out from the doors to the left of the admitting desk.

"Loucks?" she called out.

"Here," I answered.

"Loretta Gibbs. I'm a 2nd year Resident. What's with the getup?"

I had on my grey cassock and short medical coat, having left the ryassa in the car.

"I'm a Russian Orthodox deacon," I replied.

"Interesting. Let's get you some scrubs, and then I'll do your orientation."

She led me through the door and down a hall past treatment rooms to a door which had a sign which read 'Lockers'. We went in.

"Pick an empty locker. Did you bring your own lock?"

"Yes, in my bag," I said, holding it up.

"OK. Scrubs are on the shelves behind you. Showers are in the back. I hope you aren't too modest because this is a shared locker room. There are curtains on the showers, and the usual practice is either have a towel covering your body or wear underwear when going back and forth from the showers to the lockers."

"Got it," I said with a nod.

I went to an open locker, took off my medical coat, removed my shoes, cassock, and shorts, grabbed a set of large scrubs, put them on, put on my shoes, and then pulled on my coat. I put my clothes and bag in the locker, got out my lock, locked it, then clipped on my student ID.

"OK," Doctor Gibbs said. "Orientation. Sit or stand where I tell you, keep your mouth shut, move out of the way if you're in the way, don't touch anything, and pay attention. Save any questions for after a patient's treatment is completed. Ready to go?"

"Sure," I replied, suppressing a chuckle at the perfunctory 'orientation'.

"Then let's go."

I followed Doctor Gibbs out of the locker room and down the hall into a treatment room, where I saw a man on a treatment table with EKG leads, an IV, and an oxygen tube under his nose.

"Mr. King, this is my medical student, Mike. Mr. King presented with non-specific chest pains. EKG showed ST elevation, and the diagnosis was unstable angina. He's stable and being monitored and waiting for a transfer to cardiology for a full evaluation."

She checked his EKG, looked at the monitor for his pulse and O₂ levels, made some notes on the chart, and then we left the room.

"Two-pack a day smoking habit and drinks a six-pack on Sundays during the game," she said as we walked down the hall to the next treatment room. "Those are two big risk factors."

"Did you do blood tests?"

"Yes. Blood enzymes confirmed the diagnosis, but those take too long to come back to wait on them for treatment when the patient presents with non-specific chest pains and has an abnormal EKG. You're brand new, right?"

"My second week at McKinley Medical School."

"Then a lot of what you see and hear will likely just go over your head, but the goal is for you to watch what goes on and get a feel for the flow of the ED. I saw on your data card you're interested in emergency medicine?"

"Yes."

"Ask questions, as I said, but in the treatment room, you're an observer. You know it's basically illegal for you to perform any procedures, and you aren't covered by malpractice insurance, right?"

"Not until we get to clinical rotations. They were quite clear about that."

We went into another treatment room.

"Hi, Jimmy," Doctor Gibbs said to a boy of about ten. "This is Mike. He's a medical student who's here to observe. How is the arm?"

"It hurts!"

He had a splint on his left forearm, and it was folded across his chest. Doctor Gibbs checked his chart and made a notation.

"I'll have the nurse give you some stronger pain medication. They should be in to put your cast on in a few minutes."

A woman came into the room who I assumed was the boy's mother.

"Hi, Mrs. Ackerman," Doctor Gibbs said. "This is my medical student, Mike. I just wrote an order for some stronger pain medication for Jimmy, and a nurse will be in to put on his cast momentarily."

"Thank you, Doctor."

"Jimmy," Doctor Gibbs said, "next time, keep hold of the monkey bars!"

He laughed and grimaced, and we left the treatment room.

"Risk factors?" Doctor Gibbs asked me.

"Ten-year-old boy," I chuckled.

"Exactly! But what else would you look for?"

"Signs of abuse, I would guess."

"Correct. Bruises, broken bones, cuts, burns, and other obvious signs. You'd also check to see if he'd had previous admissions. In this case, he hasn't been here before, and a call to his family physician didn't result in any suspicions."

We continued down the corridor.

"How many doctors are on duty?" I asked.

"Four Residents and an Attending. The ED chief is in his office, and the Chief Resident is on call. We can get backup from ED-qualified docs in surgery or internal medicine if we need them for a mass casualty."

"Doctor Gibbs?" a nurse called out. "Paramedics two minutes out with a pin-in MVA. Adult male victim. Other driver has only minor injuries."

"Thanks, Elena! Mike, follow me to the trauma room. There's a stool in the corner with your name on it. Sit there."

"Yes, Doctor."

"You're not going to faint or puke at the sight of blood, are you?"

"No."

"Keep it that way!"

We continued down the hall past the admitting desk and nurses' station and into a larger room with an examination table in the center and all manner of equipment in the room. As I sat down on the stool in the far corner, I identified the EKG, defibrillator, and portable X-ray machine, but there was other equipment I didn't recognize, along with numerous drawers and cabinets which lined the walls, and what appeared to be ports to connect oxygen built into the walls. A nurse came in and took a paper-wrapped tray from a locked drawer, opened it, and put it on a stand. A second nurse came in and unlocked a cabinet with drugs, and a minute later, Doctor Gibbs came in. Almost immediately, two paramedics burst into the room with a patient on a gurney.

"Male; mid-forties; tachy at 110; resps shallow and labored at 20; pressure 110/70; pinned in his vehicle after being t-boned in the driver's door; abrasions to his left arm and a minor laceration on his scalp; complaining of severe pain in his left leg and moderate pain in his left chest; wearing a seat belt; extrication took ten minutes after we were on the scene."

"OK, I have it," Doctor Gibbs said as she, the two nurses and two paramedics moved the patient onto the examination table.

"Sir, do you know your name?" Doctor Gibbs asked.

"Of course I do," he growled. "It's Oscar."

"OK, Oscar. Let us get you checked out."

The nurses hooked up a pulse and oxygen level monitor, and took his temperature and blood pressure while Doctor Gibbs washed her hands, then put her stethoscope in her ears and listened to the patient's heart and breathing, nodded her satisfaction.

"Elena, we'll do a portable chest and left leg, but no head; CBC and Chem-20." She looked up at the monitor, "PO₂ 98% room air."

Elena made a blood draw and pressed a button on the wall, which I assumed would summon someone to take the blood to the lab.

"Oscar, we're going to get some X-rays," Doctor Gibbs said.

She moved the X-ray machine into place.

"Everyone out!" she commanded as she put on a lead apron.

I scrambled from the room to stand with the nurses while Doctor Gibbs took X-rays of the patient's chest and left leg. When she pushed the machine away, the nurses went back in, and I followed them, sitting again on the stool. She removed the film from the X-ray and handed it to an orderly who had appeared. Elena also handed him the blood and asked for results 'stat'.

"Can you tell me what happened?" Doctor Gibbs asked as she began doing a more thorough exam, checking his eyes and ears.

"Jackass ran a red light and t-boned me!" Oscar declared.

She continued with her exam, and Oscar winced as she gently checked his chest and groaned when she checked his left knee.

"We'll need ortho, Elena," Doctor Gibbs said.

"Yes, Doctor."

Elena moved to the phone and dialed, asking for an ortho consult in the ED. The second nurse began cleaning the scalp laceration while Doctor Gibbs checked Oscar's reflexes. Once she was satisfied, she addressed the other nurse.

"Felicia, you can remove the collar. There are no signs of concussion, neck, or spinal injury."

"Doc, can I get something for the pain?" Oscar asked. "My knee hurts like a mother ... uh, hurts bad!"

"I can give you something to take the edge off, but I want to wait for the orthopedist to evaluate you before I prescribe anything stronger."

"What's wrong?"

"Well, besides the minor cuts and bruises, you have a pair of broken ribs and a dislocated knee."

She wrote an order on the chart and asked the nurse to give Oscar an IV painkiller, which she did just as another doctor came into the room and introduced himself.

"I'm Doctor Yockey; I'm an orthopedic surgeon," he said to the patient. "What do we have, Lor?"

"This is Oscar, who was in a traffic accident. He was t-boned and pinned. Complaining of severe pain in his leg and moderate pain in his chest. My evaluation shows two broken ribs and a dislocated knee. Vitals are good, though breathing is labored due to the rib injury."

"Oscar, I'm going to take a look at your knee. Lor, did you get an ABPI?"

"No. Distal pulse was good, and there was no discoloration or swelling above or below the knee."

"Let's do one to be safe, please. Elena, would you get an ankle pressure, please? And then a brachial pressure?"

The nurse acknowledged the order, then put a blood pressure cuff on Oscar's ankle and took his blood pressure. Once she'd done that, she removed the cuff and then repeated the process on his upper arm. She read off the results to Doctor Yockey.

"Ratio is just less than 0.9," he said. "I don't think there's vascular damage, but I'm going to order an angiogram to be sure. X-rays?"

"I took them because the portable X-ray machine was here," Doctor Gibbs said. "You should have a 'wet read' shortly."

The phone rang, and Elena answered it, then called Doctor Yockey to the phone. He listened and hung up.

"Your lips to God's ears," he said. "There's significant ligament damage. Let's get him prepped for the angiogram. Elena, call the surgical floor and let them know I'm going to need an OR."

"Yes, Doctor!"

"OK, Oscar, we're going to take you to the lab and do an angiogram. I'll explain along the way. Felicia, would you call the orderlies, please?"

The nurse acknowledged his request and left the room. While we waited, Doctor Yockey did a more complete exam, and when the orderlies arrived, he left with Oscar, and I followed Doctor Gibbs out of the room.

"What did you see?" she asked me.

"What amounted to a high-speed, shortened version of a physical — blood pressure, temperature, heart, eyes, ears, nose, mouth, and blood drawn. Then, X-rays, a careful evaluation of his chest and knee, and reflex tests. What's ABPI?"

"A ratio of blood pressure in his ankle to the pressure in his arm; it showed a slight possibility of bleeding, though his pulse was strong, and there was no discoloration of his lower leg and no obvious compartment syndrome — loss of blood flow due to tissue swelling, with a variety of other complications and factors.

"So why did Doctor Yockey order an angiogram?"

"As a precaution. Something on the order of ten percent of knee dislocations result in amputation, often due to vascular damage, which is a serious indication of potential negative outcomes."

"Ten percent seems high to me as a novice."

"Well, on the other end of the spectrum, about half of knee dislocations resolve without medical intervention. But in this case, with ligament damage and possible bleeding, it's likely surgical. What did you see on the monitor?"

"His pulse was elevated, but his oxygen levels were good. You said his breathing was labored due to fractured ribs."

"Risk?"

"Uhm, to the lungs, I would guess. Maybe a puncture or laceration? Or, I think it's called a 'collapsed' lung, if I remember from Emergency and Medical Center."

"Things have changed a bit since 'scoop and run' shown on Medical Center! And yes, a collapsed lung is a danger. Why did I feel it was OK to remove his cervical collar?"

"Your examination showed no sign of concussion, he had good reflexes, and he wasn't complaining about his head, just his chest and knee. I'm guessing feeling pain is a positive sign."

"Yes. If that knee weren't extremely painful, I'd have looked for further neurological damage. But remember, in a trauma, our job is to stabilize the patient and hand them over to the other services."

"What about the chart?"

"I reviewed it when I wrote the drug order and signed it. I'll review it again tonight after my shift ends and make any notes of things I didn't make earlier. We often don't have time during trauma treatment. Let's continue; I have one more patient to check, one of our regulars."

"Regulars?"

"She shows up about every month or two with some kind of complaint. Never the same thing, and never with any diagnosable medical condition."

"Mentally ill?" I asked.

"Probably, but she's gainfully employed and takes care of herself, so nobody can make her see a headshrinker."

"I'm actually acutely aware of that. I have a very close female friend who was recently diagnosed with schizophrenia."

"I suspect that's what we have here, but I'm an emergency medicine Resident, not on the Psych service. And she refuses to even talk to them. So we listen, and after we examine her, sometimes give her Tylenol, then we send her on her way."

"How long has this been going on?"

"About three years, I think."

I shook my head and followed Doctor Gibbs into an exam room where a young woman of about twenty was waiting.

"Hi, Krissy," Doctor Gibbs said. "This is Mike, my medical student. He's observing. How are you doing today?"

"I have ringing in my ears."

"Well, let's see what's going on."

She washed her hands, then took an otoscope from the wall, attached a disposable speculum to it, and looked into Krissy's left ear, then replaced the speculum, and looked into Krissy's right ear. She changed to a fresh speculum then, looked in Krissy's nose, and then, removing the speculum, into her throat, using a tongue depressor for the latter exam, and finally used an ophthalmoscope to check her eyes.

"I don't see anything obvious," Doctor Gibbs said. "But I'll have an ENT Resident check to see if I missed anything."

"Thanks, Doctor."

We left the room, and something I'd read when I was investigating Angie's illness percolated to the front of my mind and caused me to recall something I'd read when trying to find information about Angie's illness.

"Doctor Gibbs, I know I'm supposed to keep quiet, but would you ask Krissy if she's smelling anything strange?"

Doctor Gibbs stopped short, "A brain tumor?"

I shrugged, "Just something I remember from when I was researching my friend's illness. And a doctor at church pointed out that patients often don't volunteer information which is very relevant."

Doctor Gibbs turned, and I followed her back into the room.

"Krissy, what do you smell right now?" Doctor Gibbs asked.

"Burnt toast. Why?"

"Just a question, that's all," Doctor Gibbs said. "Let me get the ENT Resident. He'll be a few minutes."

We left the exam room.

"She's going to need a Neuro consult," Doctor Gibbs said. "Burnt toast or burning rubber are common phantom smells for certain kinds of tumors. Not bad for your first day in the ED!"

"What about her previous visits?"

"I'll have to review the chart again, but I'm going to suspect that each time she presented with something that COULD indicate a tumor, but with no other signs, it's a difficult diagnosis to make. And there's no guarantee, either. She could have found that symptom in a medical text, too. And tinnitus is difficult to confirm because you're relying on the patient's subjective statements. But, your question was a good one. You might actually make a decent doctor someday."

"Gee, thanks," I chuckled.

"You have seven years to prove yourself, Mike. And you're going to have to prove it every single day, in every class, in every lab, in every Clerkship, and every other bit of your training. I'm hoping for an Attending role in eighteen months, but I have to survive those eighteen months."

"I thought things got better after your first year."

Doctor Gibbs laughed, "Sure; twenty-four-hour shifts are an improvement over thirty-six-hour shifts, and seventy-two-hour weeks are an improvement over ninety-hour weeks. But until you're an Attending, you can't practice independently or without supervision, and you can't really change programs."

"I haven't seen the Attending."

"I haven't done anything that needs his approval, and Doctor Yockey, an ortho Attending, took over the trauma once he came in. If I'd needed my Attending for any reason, he'd have come right in. Let me get an ENT and neuro consult set up."

We went to a room marked 'Lounge', which had a fridge, a TV, a table, and a few chairs. She went to the phone on the wall and placed two calls.

"If you Match for trauma, a room like this plus the on-call sleeping room will be your home away from home for your first two years," she said. "My advice? Get eye shades and foam earplugs so you can get some sleep between traumas."

"How busy is the Emergency Department?"

"Anywhere from a ghost town to Riverfront Stadium on Opening Day. Today has been quiet. While I wait on those consults, let me show you the rest of the ED and introduce you to everyone."

"Can I ask why the perfunctory 'orientation' and the change of attitude?"

Doctor Gibbs smiled, "It lets me figure out in the first ten minutes if the student can follow directions. If they can, then I'm Doctor Jekyll; if not, I'm Ms. Hyde. The first good sign was you changing into scrubs without batting an eye. You also waited to ask your question about Krissy in the corridor."