Chapter 53: Michael Loucks, Surgical Clerk

June 1, 1987, McKinley, Ohio

"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."
-Sir William Osler, co-founder of Johns Hopkins Hospital, creator of the first Residency program

Late on Sunday afternoon, I'd called the hospital and spoken to a nurse on the surgical service to find out what surgeries were scheduled for my team, asked for some basic details about each patient, and made notes. I'd thanked her and hung up, then took down a newly purchased 1984 edition of Schwartz's Principles of Surgery, and had reviewed the procedures.

Now, at 4:28am, dressed in slacks, shirt, and tie, as per Doctor Roth's instructions when I'd been on my Preceptorship, I approached the nurses' station.

"Michael Loucks, beginning my surgical Clerkship," I said. "I'm assigned to Doctor Roth."

"Doctor Lindsay, his Senior Resident, is in her office. She's expecting you. You've been assigned a locker, and your name is on it. Here's your badge."

"Thanks," I replied, accepting the badge from her.

I left the nurses' station and walked to the Resident's office, which doubled as the 'on call' room and had two cots as well as the desk. I knocked on the open door to get her attention.

"Good morning, Mike," she said. "Congratulations on the MLE."

"Good morning, Doctor Lindsay. Thank you."

"Here's your pager. If it goes off, call the four-digit extension listed. If it shows '99999', come straight to the nurses' station on this floor. If it shows '11111', go straight to the ER. That's not likely until you're on call. Change the batteries once a week, even if they appear strong."

"Got it," I said, clipping the device to my belt and strangely feeling more like a doctor by doing so.

"Go hang up your cloak," she said. "Your locker has your name on it, though with masking tape, not a permanent placard. Meet me in the lounge and we'll discuss pre-rounds."

"Yes, Doctor."

I went to the locker room and found Clarissa there. She was assigned to Doctor Jack Webber, and her schedule would match mine, except for the on-call rotations, as there was only one team 'on call' at any given time.

"Morning, Lissa!" I said, opening the locker, which had my name on it, and was next to hers,

"Morning, Petrovich!" she exclaimed as she attached her combination lock to her locker.

"Nice skirt!" I chuckled as I hung my ryassa in the locker.

"Doctor Webber's preference. He did say I could wear slacks and a blouse, but it was obvious this is what he prefers."

"It's not short enough," I chuckled, putting my bag into the locker.

"Oh, please!" Clarissa protested, laughing. "You've seen it ALL! Heck, you've TOUCHED it all!"

"As you like to say, I'm incorrigible, at least with regard to you."

"What happened to Doctor Mercer's warning about a 'moment of weakness'?" Clarissa asked.

"You and I have revised our thinking on that, and the risk simply isn't there."

I clipped on my badge, locked my locker with my combination lock, and we walked back towards the Resident's office.

"No, the risk is Erin!" Clarissa teased. "She's dying to be bedded by the handsome young medical student!"

"A fantasy of hers which will never come to fruition. What procedures do you have today?"

"Cardiac bypass with four veins. That's the day's work."

"No kidding. Four or five hours in the OR, at least, depending. Which cardiologist is running the procedure?"

"Getty. How about you? What do you have today?"

"This morning, surgical amputation of a foot as a result of uncontrolled diabetes; this afternoon, nephrectomy necessitated by cancer."

"Who's on your team?"

"Doctor Shelly Lindsay is the Senior Resident, Vince Taylor, a newly Matched PGY1, and Hope Fletcher, a Fourth Year. You?"

"Doctor Bill Blake is the Senior Resident, Paul Birch is the new PGY1, and Fred Aikens, a Fourth Year."

We reached the lounge where, in addition to Doctor Lindsay and Doctor Blake, two other Senior Residents were waiting. Just after we walked in, two more of our classmates walked into the lounge. The fifth would be on call, and had started the previous evening, and was likely sacked out in the ER on-call room or at home.

"Rounds begin at 6:00am, as I'm sure you're aware," Doctor Lindsay said. "And that's why you're here at 4:30am. Before rounds, you need to check each patient, both pre-op and post-op, verify that all ordered labs have come back, ensure medications have been administered, and generally make sure there are no surprises at bedside rounds."

"Following rounds," Doctor Blake continued, "pre-op prep is to be completed, and you'll remain with the patient and accompany them to the OR. You'll scrub in at that point, and today, you'll just observe. After today, the Attendings will begin to ask you to assist in minor ways."

"And," Doctor Lindsay said, "Grand Rounds and lectures on Friday afternoons at 2:00pm. No surgeries are scheduled."

The other team members had filtered in and got cups of coffee, and were introduced. The Residents left, leaving the Sub-Interns and Clerks.

"Come with me," Hope said to me.

We went to the large filing cabinets behind the nurses' station and retrieved the charts for our pre-op and post-op patients.

"They go easy at first," she said. "You only need to review Doctor Roth's patients. I have to review all of them, but we have a good system. All the students will get together and give the highlights. We're not expected to know as much as the Residents, so we get some slack. If we didn't do it that way, we'd have to be here before 4:00am."

"Got it," I said.

She handed me the first chart for the amputation. I opened it and compared the orders to the lab results and medications given.

"This looks correct," I said. "The overnight labs are back, and I believe they're in the correct range to proceed."

"Based on what?"

"I read the appropriate sections in Schwartz's Principles of Surgery last night, and reviewed my anatomy plates as well."

"You called in?"

"Yesterday afternoon. I learned during my Preceptorship to call to check the schedules and review the night before."

I flipped open the second chart and frowned.

"Hypertensive," I said, "but right on the edge of the range. Overnight labs look OK, otherwise."

I flipped a couple of pages in the chart.

"OK," I continued. "Secondary hypertension, which is likely a result of her renal cell carcinoma, so the surgery is indicated, even if there is a slightly higher risk."

"They weren't kidding," Hope said.

"Who?" I asked.

"Two guys I hang out with who are in your class. They said you should be at someplace like Stanford or Harvard."

"I'm from not too far from here and want to be here," I replied. "I figure my friends and neighbors need the best medical care possible, not just people who end up in large, well-known hospitals."

"Surgery?"

"Maybe. I was strongly leaning towards emergency medicine, but Doctor Roth encouraged me to consider surgery. I may split the difference with a combination emergency medicine/general surgery Residency, which is a relatively new thing."

"Specialists in emergency medicine are a new thing," she observed. "It was less than ten years ago that the ER was covered by surgical and internal medicine Residents in a rotation, rather than having specialists."

"What are you planning?"

"Orthopedics. It's the family business, so to speak — my dad, my grandfather, and my uncle are all orthopedic surgeons. You?"

"Mom is a legal secretary, Dad is a supervisor for the Property Division in Harding County."

"No doctors in the family?"

"No."

"Let's go back to the lounge. I take it you have a notebook?"

"I do," I said, taking my surgery notebook from the pocket of my medical coat.

"OK. As I said, today, just focus on our two patients. In the future, you'll want to make notes about all of them. You won't be expected to have everything memorized, so it's OK to use your notebook."

We sat down in the lounge with the other Junior Residents, who were called Interns in some hospitals, and the other medical students, and went through all nine scheduled surgeries, then reviewed all post-op patients. There were no missing labs or images, which was apparently not normal for a Monday morning. We finished the pre-rounds conference about 5:45am, just before the Attendings and the Senior Residents came in. After everyone got coffee, we started rounds.

As Hope had suggested would happen, Clarissa, I, and the other two Third Years weren't called on to answer any questions, though we all had our notebooks out and were jotting down information about our patients. When rounds finished, Hope and I went to Mr. Kingston's room to prep him for surgery.

"Good morning, again," Hope said when we walked in. "We're going to get you ready for surgery. Did Doctor Roth answer all the questions you had?"

"Yes."

"OK. Do you agree it's your right foot?" Hope asked, taking a felt-tipped marker from her pocket.

"Yes," Mr. Kingston said.

Hope drew two lines on Mr. Kingston's ankle, then initialed them.

"Mike, would you draw blood for a glucose test, please?"

"Yes," I replied evenly, hiding the fact that I was ecstatic about being asked to do it.

I went to the supply room and got the necessary tube, hypo, and phlebotomy needle, along with an alcohol wipe and tourniquet. I returned to the patient's room and quickly drew a tube of blood.

"Take that to the lab," Hope said. "Tell them 'surgical stat', and wait for the results."

"Got it," I said.

I put the tube into an emesis basin, as was the normal practice, and after disposing of the needle in the 'sharps' container, I hurried to the lab where I handed the basin to the tech.

"Surgical stat," I said. "This patient is being prepped now."

"Got it," the tech said, disappearing into the lab.

The results were back in less than five minutes, and I took the printout back up to the ward.

"225," I said.

"Write that on the chart please, and clip the results sheet to the folder, then take vitals."

I was ready to jump for joy, and after I updated the chart and initialed the entry, I took Mr. Kingston's pulse and blood pressure, counted his breaths, then took his temperature. I wrote everything on the chart and read out the numbers to Hope. They were all in the acceptable range, though his blood sugar had been high, which was not surprising given he'd let his diabetes go untreated for several years. The anesthesiologist, Doctor Kelsey, came in just then.

"Vitals, please?" he asked after greeting the patient.

Hope nodded to me.

"Pulse strong at 70; BP 128/72; resps 22; temp 36.7°C; labs are clear; blood glucose 225 after fasting."

"Very good, Mike," Doctor Kelsey said. "I see Owen convinced you."

"He did."

"Mr. Kingston, are you having any new symptoms?" Doctor Kelsey asked.

"No."

"Any weakness, shortness of breath, dizziness, or nausea?"

"No."

"Did you have a cold or influenza recently?"

"No."

"OK. I'm going to have the nurse give you some midazolam, and then these two will bring you to the operating room."

"Thanks, Doc."

He left and a few minutes later, a nurse came in with the midazolam, which she administered and noted on the chart.

"Ready, Mr. Kingston?" Hope asked.

"I am."

"Mike, would you call for an orderly, please? You can just use the wall phone behind you."

I picked up the phone and dialed the four digits listed for an orderly I read from the card attached to the wall next to the phone. I asked for an orderly to come to the room, and he arrived about two minutes later.

"Operating Room 1," Hope directed.

The three of us prepared the rolling bed and then set off for the operating room. We escorted the patient to the doors of the OR, then headed for the locker room to put on scrubs.

"Thanks for letting me draw the blood," I said.

She laughed, "At this point, that's the LAST thing I want to do, and Doctor Roth indicated you should do it. He and the Residents read your complete record last Friday. I know the feeling, by the way, because I was hyped to do it. Now it's something someone else can do."

We changed into scrubs, I hung my coat in the locker, and removed my wedding ring and baptismal cross. I locked them in the locker, then put on a surgical cap. Properly attired, Hope and I headed to the scrub room where Doctors Roth, Kelsey, and Taylor were at the three sinks.

"Mr. Kingston is in the OR," Hope said, despite it being obvious by just looking through the windows into the OR.

"Thank you, Hope," Doctor Roth said. "Mike, welcome to your first day in the OR!"

"Thanks."

"Hope, how did he do?"

"Perfect technique on the blood draw," she replied. "He knows how to properly take vitals as well."

"Good."

They moved away from the sinks and Hope and I scrubbed, were helped into gowns, goggles, masks, and gloves, then followed the doctors into the OR. I was directed to a spot where I could observe, understanding that it would be at least a short time before I was actually tasked with anything in the OR, but after eight weeks of boredom, the basic tasks I'd been allowed to do earlier had lifted my spirits.

After Mr. Kingston was hooked up to the monitors, the procedure began with Doctor Kelsey administering general anesthesia. Mr. Kingston's pulse in his right leg was checked at several points, and when Doctor Roth was satisfied, he asked Doctor Taylor, the PGY1, the steps of the procedure, then instructed Doctor Lindsay to begin.

Doctor Taylor had a task that was typical of a medical student or PGY1 — he held on to the foot that was being amputated. Hope and I both watched as Doctor Lindsay and Doctor Roth worked to divide the nerves and blood vessels, clamping the vessels to limit bleeding.

"Hope, what's our primary concern?" Doctor Roth asked as he and Doctor Lindsay exposed the bones.

"Ensuring that the bone is smooth, and that the flap will perfuse properly. Scar placement is extremely important to allow for a pain-free prosthetic."

"Mike, what are myodesis and myoplasty?" Doctor Roth asked. "And how do they differ?"

"They're techniques for stabilizing the muscles after amputation," I replied. "Myodesis is when muscles are attached to bone structures; myoplasty is when they are attached to each other. Myodesis generally creates a more stable result, and is preferred to myoplasty. There are other techniques as well, including tenodesis, which is more typical for knee surgery."

"Please tell me you called in for the procedure and looked that up," Doctor Taylor said.

"The kid follows directions," Doctor Lindsay said. "He did that during his Preceptorships."

"Never had those," Doctor Taylor said. "That would have made a tremendous difference in my Clerkships."

"Where did you go to school?" I asked.

"Rush Medical College in Chicago."

"Hope," Doctor Roth asked, "Do you know who Doctor Benjamin Rush was?"

"No, Doctor, I don't," she replied.

"Mike?"

"The only doctor with medical school training to sign the Declaration of Independence. There were three other physicians, but they never went to medical school — Josiah Bartlett, Lyman Hall, and Matthew Thornton."

"How the fu ... heck do you know that?" Doctor Taylor asked.

"Doctor Rush was discussed in our Introduction to Medicine course, including his seriously flawed theory of 'bleeding' to treat Yellow Fever, as well as his setting up the first known free dispensary in the US. For the others, it was curiosity that led me to look them up because I had always thought it was landowners, businessmen, lawyers, publicans, and other sinners."

Everyone laughed.

"Doctor Taylor, your Chicago is showing," Doctor Roth said. "Let's remember our decorum."

"Yes, Doctor. Sorry about that."

"You caught yourself; catch yourself sooner next time."

"Yes, Doctor."

The amputation procedure continued, finishing with the use of a bone saw, and then a grinder to smooth out the ends of the bones. Doctor Taylor deposited the severed foot into a basin, and the nurse took it away. He flexed his arms and stretched, trying to eliminate the stiffness that came with holding the same position for extended periods of time.

"Now, Doctor Taylor, what am I worried about with the nerves?" Doctor Roth asked.

"Neuroma. It's basically inevitable and there is no agreement on the best technique."

"Hope, what's a neuroma?"

"Any swelling of, or growth on, a nerve, in this case, due to the trauma of surgery."

"Mike," he chuckled, "how do I choose my technique?"

"You examine the field, assess the remaining nerves, then, based on what Doctor Taylor just said, you, well, go with your gut."

"Very good. Doctor Taylor, what choice would you make?"

"It's more about positioning in this instance," he replied. "You want to position the nerve ending in a well-cushioned soft tissue site away from the incision and any scar tissue. That helps avoid irritation from the prosthetic. In this case, with ankle disarticulation, you need to properly shape the distal tibia and fibula to ensure a proper fit for the prosthetic, but resecting as little bone as possible, and ensure the nerve is well protected."

"Hope, what are our post-operative goals?"

"Prompt, uncomplicated healing of the wound, which means controlling edema. Pain management is also key. The primary concern will be proper perfusion of the closed flap."

The surgeons worked to close the flap, checked for proper blood perfusion, then rechecked all pulses in the right leg. Satisfied, Doctor Roth asked Doctor Taylor to wrap the wound, and once that was accomplished, Doctor Roth declared the surgery over.