Chapter 42: Do You Hear What I Hear?

September 10, 1985, McKinley, Ohio

"Hi, Mike," Doctor Gibbs said when I walked into the Emergency Department on Tuesday afternoon. "You know, I never asked if you prefer Mike or Michael."

"Either will do. At church, the people my age and younger call me 'Deacon Mike'."

"Then 'Mike' it is. Get changed, please."

I went into the locker room, quickly changed into scrubs, put on my lab coat, clipped on my ID, and draped my stethoscope around my neck. I went back out to find Doctor Gibbs standing near the admitting desk.

"I was going to ask you about the stethoscope because you didn't have it last time," she said. "You most likely won't use it for some time, but you should have it at all times when you're seeing patients, even during these observation periods."

"I will," I replied, then, remembering something I'd heard the previous Tuesday, asked, "What's on the board?"

"Nothing. I just released two and admitted one."

"So what do you do?"

"As a Resident? Sleep! That's the most important lesson I can teach you. When you're an Intern or Resident, you sleep at every opportunity. That's especially true during your PGY1 — first post-graduate year — when you have thirty-six-hour shifts. But I got plenty of sleep last night, so I'm OK."

"What happened with Krissy?"

"Inoperable tumor. She was referred to a specialist at Ohio State for treatment."

"If it had been caught sooner?"

Doctor Gibbs shrugged, "I can't say. It's not my area of expertise. Neuro doesn't think she'll live out the year."

"Lord have mercy!" I replied. "If somebody had just reviewed her charts..."

"Or if she'd done what she was told to do nearly a dozen times and seen a personal physician."

"Yeah," I said, shaking my head.

"Would you like some free advice?"

"Sure. That's what I'm here for, right?"

"Yes. The advice is 'shit happens'."

"Because if I get bummed about everyone who dies, I'll end up drinking or taking drugs to forget."

"Pretty much. You seem like a caring guy, and you'll drive yourself nuts if you don't accept 'shit happens' as a reason."

"But what about lessons?"

"What lesson could we learn from Krissy?"

I frowned, "You told her what to do, and she didn't do it. And we talked about why you can't treat her properly, well, the way a personal physician would."

"Exactly. While we have a lull, let me give you the tour and introduce you to people. This is Nate, our admitting clerk. Nate, Mike Loucks, med student."

"Hi, Mike," he said, extending his hand.

I shook hands with him.

"Hi."

"Nate has paramedic training and does immediate triage for patients who don't come via ambulance."

"You just told me the quickest way to be seen by a doctor in the ER is to call an ambulance," I replied.

Both Nate and Doctor Gibbs laughed.

"He figured THAT out quickly!" Nate observed.

"This one might actually be a keeper," Doctor Gibbs replied.

We moved away from the admitting desk to the nurses' station.

"Mike Loucks, med student, meet Susan Lewis, nursing supervisor."

"Welcome to the circus," Nurse Lewis said, "though all three rings are quiet at the moment!"

"Thanks."

"Is he safe?" Nurse Lewis asked.

"Yes. This one actually follows directions. And asks good questions. And he's interested in emergency medicine. More importantly, he wants to practice in the area."

"Excellent!"

We moved away.

"Are med students really that bad?" I asked.

"You have NO idea! As I said last week, I can figure out fairly quickly which ones can survive the Emergency Department. Mike, this is Ellie, one of our nurses. Ellie, Mike, the med student."

"Where'd you find HIM?" the gorgeous redhead with green eyes asked as she looked me up and down.

"A stray I picked up last Tuesday," Doctor Gibbs teased.

"Nice to meet you, Ellie," I said.

"Welcome and good luck!" she said with a wink, then moved off.

"Biggest flirt in the hospital," Doctor Gibbs said quietly.

"No!" I deadpanned. "Really?"

"And that gold ring on your left hand is no deterrent."

"No, but the threat of my wife cutting off my balls and feeding them to me certainly is!"

Doctor Gibbs laughed, "Now you've created a challenge for Ellie!"

"She'll just have to be supremely disappointed," I replied deadpan.

Doctor Gibbs laughed again, and we walked down the hall to an office with 'Attending' stenciled on the door.

"Doctor Carlton?" she said to the Attending who was reading a chart.

"Yes, Loretta?"

"You met Mike, my med student, last Tuesday but weren't introduced. Michael Loucks, Doctor Jerry Carlton."

"Hi, Mike. First Preceptorship?"

"Yes."

"Any idea what you want to do?"

"Emergency medicine. That's been my goal from fourth grade."

"Wow!"

"Doctor Gibbs?" Nate called out, interrupting us. "Paramedics are two minutes out. Fireman with smoke inhalation and a burn victim."

"Burn victim in Trauma 1; fireman in Exam 1!" Doctor Gibbs replied. "Page the pulmonology Resident and the Burn Unit, please! Where is Doctor Mendez?"

"In the break room."

"Have him take the fireman. Mike, come with me to the ambulance bay."

I followed her down the hall to the doors, and we stepped outside, where I heard the distant sirens.

"Depending on how bad the burns are, this could be very disconcerting. If you have to puke, grab an emesis basin. Don't be embarrassed, either — a lot of people puke from the smell and the sight."

"It's really that bad?" I asked.

"You have no idea," she replied.

Doctor Mendez joined us as the sirens grew louder, and a few seconds later, I saw the first Fire Department ambulance turn into the access road leading to the ambulance bay. It pulled up, and a paramedic jumped from the driver's seat and moved to the back of the ambulance. Doctor Gibbs motioned, and I followed her.

"Sixteen-year-old female; unconscious; severe burns of her extremities; pulse tachy at 152; resps shallow at 27; BP 80/55; PO₂ 91%; pupils responsive; ten litres oxygen by mask."

"Got it!" Doctor Gibbs said as they started wheeling the young woman into the ER.

The second Fire Department ambulance pulled in behind the first as I followed Doctor Gibbs. We went straight to Trauma 1, where two nurses and a doctor were waiting for us. I moved to the corner, grabbing an emesis basin from the counter, just in case. I watched as they moved the girl to the treatment table, and then Doctor Gibbs washed her hands and put on gloves.

"Masks, please," the other doctor, whose name tag read 'Evans', announced.

Everyone, including me, got a mask from a set of boxes which also held gloves of various sizes as Doctor Gibbs communicated the information she'd been given, and they got to work checking her vitals.

"Subclavian central line," the other doctor announced. "Get the surgeon. Five-lead EKG."

A nurse ducked out and returned with a surgical Resident.

"I have it," Doctor Blake, the surgical Resident, replied.

A nurse brought her a tray, and Doctor Gibbs picked up a pair of scissors and cut the girl's T-shirt off. As Doctor Blake prepared to put in a large-bore IV, the other doctor and nurse began cutting away gauze loosely wrapped around the girl's hands and forearms as well as the remnants of her blue jeans. I smelled what had to be burnt flesh, and my stomach rumbled. Despite my trepidation, I shifted slightly so I could see and nearly lost my lunch, as Doctor Gibbs had warned might happen. Fortunately, I kept it down, but I kept the basin handy.

'Lord have mercy!' I prayed silently. The girl's hands were horribly burned, though her legs were 'only' red and blistered. I noticed, for the first time, that her light brown hair had been singed as well. She began moaning, and I saw her eyelids flutter.

"Estimate weight at about 55 kilos," the 'burn' doctor said. "Ringer's at a litre per hour; 2 milligrams morphine, IV push."

"Got it, Doctor Evans," the nurse helping Doctor Gibbs replied, moving to get the IV bag and drugs.

"Foley, 14 French," Doctor Evans announced.

Doctor Blake finished the central line, and the nurse hung the IV bags and adjusted the flow rate. The nurse began attaching EKG leads, and Doctor Gibbs took a pair of scissors and cut the girls' panties to gain access to insert a urinary catheter. Every instinct told me to look away, but I forced myself to watch as the catheter was inserted.

"CBC, ABG, Chem-20, urine dip," Doctor Evans called out.

The nurse assisting him retrieved a tray of instruments and began drawing blood. Doctor Carlton came into the room.

"What do you have, Loretta?"

She gave him the vitals and described the injuries.

"How's the fireman?" she asked.

"He should be fine. It's Bobby Murphy. He went in to rescue the girl without his breathing gear because there was no time. They're going to keep him overnight for observation.

"Do we know the girl's name?"

"Faith Thompson," he said. "Her parents are outside."

"We're about ready to move her to the Burn Unit," Doctor Evans said. "I'll go talk with them. She's going to need reconstructive surgery on her hands, probably in Columbus. Her legs should heal without any scars."

"Mike," Doctor Gibbs said, "go with Doctor Evans to observe, please."

"Yes, Doctor," I replied.

A minute later, I followed Doctor Evans out of the trauma room, removed my mask as he did, and followed when Nate directed him to the girl's parents.

"Mr. and Mrs. Thompson? I'm Doctor Evans."

"How is she?" a nearly frantic woman asked.

"Let's go into the consultation room and speak."

We quickly moved to a small room, and the three of them sat at the table while I stood against the wall.

"This is Mike, a medical student," Doctor Evans said.

I nodded.

"Doctor, how is Faith?" her father asked.

"She's being treated and is stable. She has second-degree burns on her legs, which should heal with minimal intervention. She breathed in smoke but doesn't appear to be in respiratory distress, which means she's not having severe difficulties in breathing. Her main injury is severe burns to her hands, which will need to be evaluated further before I can tell you more."

"How bad?" Mr. Thompson asked.

"Third-degree burns on her hands and lower forearms. Honestly, I can't give you a prognosis just now. Our goal in the emergency room is to stabilize Faith, and in a few minutes, we'll take her to our Burn Unit for a complete evaluation. I promise to tell you as much as I know as soon as I know it. Mike will take you up to the second floor and show you where you can wait."

I had no clue where the Burn Unit was nor even how to get upstairs. I wondered what I should do, and after a moment's thought, I decided to ask Nate. I thought I could do it in such a way as not to give away my ignorance in front of the girl's parents, which I was worried would concern them.

They got up and left the room, and I walked over to the admitting window.

"I need to take Mr. and Mrs. Thompson to the Burn Unit waiting area," I said, pleading with my eyes for help.

"OK. It's quickest if you come through the Emergency Department and use the elevators on your left to get to the second floor."

"Thanks," I said as he buzzed us through.

I turned left and walked down the hallway to the elevators. I pressed the call button, and when the elevator arrived, I pressed '2'.

"How long have you been in medical school?" Mr. Thompson asked.

"This is my third week," I replied. "And my second here at the hospital."

"They throw you right in?" Mrs. Thompson asked.

"Only as an observer," I replied. "That's why they asked me to escort you — so the doctors and nurses could keep working on Faith as well as the fireman they brought in who rescued your daughter."

"Will he be OK?"

I knew the answer, but I had no idea if I could give it or not, and decided it was better not to.

"I'm not a doctor, so I can't really say. I was in the room with your daughter. I'm sure if you ask someone in the Burn Unit, they can call and find out for you."

"The doctor, is he telling the truth about Faith?" Mrs. Thompson asked.

"I don't think I'm qualified to answer that question," I replied carefully.

"Honey, he's been a student for three weeks," her husband said gently.

I said a silent prayer of thanks when I saw a sign directing me to the Burn Unit. I followed the signs until we came to a nurses' station and a small waiting room.

"I'm Mike Loucks, a medical student. Doctor Evans asked me to bring Mr. and Mrs. Thompson here."

"Thank you," the nurse, who was about my mom's age, said, "I'll take it from here."

She got up and came around the desk.

"I hope everything turns out well," I said.

"Thanks, Mike," Mr. Thompson said.

I left and retraced my path to the ER via the elevators. I returned to the trauma room just as Faith was being moved to a gurney, then Doctor Evans, a nurse, and two orderlies left with the gurney.

"You managed to keep your lunch down," Doctor Gibbs observed.

"It was a very close thing," I replied.

"How are you with blood?"

"It doesn't bother me. I learned that in fourth grade."

"Oh?"

I told her the story, and she nodded.

"Burns are probably the worst, though motorcycle accidents are right up there. Especially the ones where no helmets were worn."

"People survive that?"

"You'd be surprised, but mostly, we docs call them 'donorcycles' because the brain injuries are so severe that organ donation is the only end result. But the injuries can be pretty gruesome."

"What's the worst you've seen?" I asked.

"It was during my first emergency medicine Sub-Internship. A pair of teens were hit by a train they tried to race in their car. Remember — trains win all ties."

"I believe that! What happened?"

"They both somehow lived long enough to get to the hospital. Crushed legs, multiple broken bones, skull fractures, severe lacerations, and so on."

"How could they have lived?"

"I still don't understand it, but it happens. Let's go see the fireman."

I followed Doctor Gibbs down the hall to the examination room.

"Hi, Bobby," she said to the shirtless fireman who was reclining on the treatment table, his head and chest elevated, and an oxygen tube under his nose.

"Hi, Lor! How's the little girl?"

"Other than her hands, she should be fine; her hands need evaluation. Do you know what happened?"

"A kitchen fire. Most likely, hot grease ignited. I'm not quite sure what happened beyond that because when we arrived, the house was nearly fully involved. A neighbor told us she was inside, and I knew if I didn't go in to get her immediately, she wasn't coming out. I was right, too, as the roof started collapsing a few seconds after I carried her through the front door."

"Another reprimand?" Doctor Gibbs asked.

The fireman laughed, "I seem to collect them. But every time, I've made the right call, even if I violated procedures. Who's your shadow?"

"Mike Loucks, a medical student."

"Hi, Mike; I'm Bobby."

"Hi! That young woman is lucky you don't care for the rules!"

"I only have one rule, Mike, and that is nobody dies in a fire I respond to if there's anything I can do about it."

"Then, if I ever need the Fire Department, I hope you're working!"

He coughed slightly, then said, "Thanks."

"Let me take a quick listen," Doctor Gibbs said.

She washed her hands, then had him lean forward and breathe and listened through her stethoscope.

"Bobby, do you mind if I let Mike listen?"

I was surprised because she'd basically just told me I wouldn't get a chance to do that for some time, but I wasn't going to protest!

He laughed, "Hell no! I've been a guinea pig for student nurses doing IVs, and all he's going to do is listen!"

"Mike, wash your hands, then put on your stethoscope, and I'll indicate where you should listen on Bobby's back. But first, rub your hands on it to warm it up a bit."

I did as she instructed, making sure my hands were clean, then put the earpieces of my stethoscope in my ears and placed the diaphragm of the stethoscope on the fireman's upper back.

"Hold it with three fingers around the bell," Doctor Gibbs said. "You only need to press lightly so it makes good contact. Bobby, deep breath, please."

I listened intently and heard sounds like newspaper being crumpled. Each time Doctor Gibbs had me move the stethoscope I heard the same sounds, sometimes louder, sometimes softer, listening in a total of eight places.

"What did you hear?" she asked.

"Like someone crumpling newspaper or maybe tin foil. But it's faint."

"Those are called 'crackles' and are normal symptoms for smoke inhalation, intentional or otherwise."

"So cigarettes or fire?" I asked.

"Yes. In this case, it's relatively minor and should resolve in a few days. We'll keep Bobby overnight to make sure no real damage has been done, but his blood gas looks good, and he's not showing any signs of cardiac problems. Bobby, mind if I let my student listen to your heart?"

"If you let me take you out Friday night!"

Doctor Gibbs laughed, "You've been asking for a year! Do you ever give up?"

"No!" he declared firmly.

She smirked, "What do you think, Mike?"

"Permission to be honest?"

"Yes."

"From my perspective, I really wish you'd go on a date with him! From your perspective, he seems like a nice guy, looks pretty good, and from my perspective, I really want the chance to learn."

They both laughed.

"He's my boyfriend!" Doctor Gibbs declared mirthfully. "We're just messing with each other and you. Let me show you the positions. First, the base right area, which is the second intercostal space to the right of the sternum. That's the best place to hear the aortic valve. You'll hear two sounds — the first at the beginning of ventricular systole and the second at the end of the ventricular systole. Bobby's heart sounds normal, so right now, I can't tell you to listen for anything wrong. Just get a feel for how it sounds."

"Yes, Doctor."

She helped me find the right place, and I heard a regular 'lub-dub', which was almost comical because it was the cartoon sound used for a beating heart. The rhythm was regular and I felt it was about seventy beats per minute, but I really had no clue what I was listening for.

"What would I hear if something were wrong?" I asked.

"Irregular beats, whooshes, gallops, plops, or clicks. You might also hear a murmur, but that's much too complex to explain until you learn your cardiac physiology. Move to the base left, the second intercostal space to the left of the sternum. That's where you hear the pulmonic valve."

I did and heard pretty much the same 'lub-dub' sound.