Chapter 56: Learn It

June 14, 1987, McKinley, Ohio

"Mr. Pearson, I have your test results," I said. "Your blood sugar and cholesterol are slightly elevated, and your thyroid antibodies are close to the top of the typical range. For all of those, you should follow up with your personal physician. We also detected a weak pulse in your right ankle, and we recommend you follow up with a cardiologist. As for your dizziness and nausea, all indications are that you're suffering from vertigo. We recommend you follow up with an Ear, Nose, and Throat specialist. And, lastly, I strongly encourage you to stop smoking completely. Even an occasional cigar dramatically increases your chance of heart or lung disease."

"No treatment?"

"You'll need further testing," I replied. "And that is best coördinated by your personal physician, who can provide continuity of care — that is, see you regularly and track your progress. He'll work with the specialists to ensure you have the proper tests, receive a full diagnosis, and coördinate your care. We can't do that in the ER. May I ask if someone drove you here this morning?"

"My wife."

"OK. With the dizziness, you want to avoid driving until you speak to your family physician."

"Easier said than done."

I nodded, "I understand, but if you move your head quickly, or stand up quickly, or bend over, you might actually have a syncopal event — what you would call fainting. Discuss that with your family physician and your ENT. I strongly encourage you to call your physician today. Do you have any questions for me?"

"I don't think so. From what you said, I need to speak to a specialist to get any answers."

"That is our recommendation. I'll get you a copy of the test results. I need to do one further test on your right leg, if that's OK."

"Sure."

"I'll need to remove your shoe and sock. Just stay lying down, please."

I put on fresh gloves, removed his shoe and sock, then got a sterile neuropathy probe, which was just a very fine needle on a small plastic handle. The test was simple — touch the needle to his foot, ankle, calf, and shin and ask him to tell me when he felt it.

"No neuropathy," I said when I finished. "Doctor Boyd will do a quick exam and write a discharge order, then you can be on your way."

"Why him and not you?"

"A doctor has to complete the discharge exam, and, because Doctor Boyd is a Resident, he needs to have the Attending sign off on the discharge order."

"That's a hell of a lot of bureaucracy!"

"Only an Attending physician is licensed by the State of Ohio to work unsupervised," I replied. "The three of us are at different stages in our medical training."

"I thought a doctor was a doctor."

"Outside a hospital, that's generally true, as anyone practicing independently is licensed similarly to an Attending Physician at the hospital."

"How are they trained?"

"For a GP, usually in Internal Medicine at a hospital, very likely with a stint in the ER. For example, Doctor Taylor is a surgical Resident and I'm a surgical Clerk, but we're covering the ER as part of our training. Doctor Boyd is a Resident in emergency medicine, and is assigned to the ER."

"Things I never knew. Thanks for taking the time to explain it."

"You're welcome. The nurse will let you know when it's OK for you to go."

Doctor Boyd did the discharge exam, confirmed my orders on the chart, then took it to Doctor Gibbs to sign off.

"One observation," Doctor Boyd said. "And that's the amount of time you took with the patient."

I nodded, "Because I had the time. If I hadn't, then I would have given quick answers and moved on. It's not ideal, but it is the job."

"Just so long as you're aware. Let Julie know Mr. Pearson is ready for discharge."

"Yes, Doctor."

I went to the nurses' station and handed Nurse Julie the chart, explained that Mr. Pearson was discharged, and asked her to copy his test results so they could be attached to the discharge instructions he'd be given. Once I finished, I joined Doctor Boyd and Doctor Taylor in the lounge.

The rest of the morning was relatively quiet, and I assisted on a pair of cases and chased labs. The afternoon was busier, though there was only one real trauma case — a roofer who had fallen off a building. Fortunately for him, he'd landed in bushes and only had a broken leg plus scratches and contusions. At 6:00pm, when my official shift ended, I called Elizaveta to let her know I was on the way home.

June 18, 1987, McKinley, Ohio

"You kicked over a hornet's nest," Doctor Smith said on Thursday evening when Elizaveta and I joined him and Doctor Forsberg for dinner.

"That wasn't my intent."

"Hogwash!" Doctor Smith objected. "That was exactly your intent! When you spoke to Doctor Mertens, you knew what she would do."

"How bad is it?" I asked warily.

"I was blamed for the forced resignation of the Medical Director."

"Sorry about that," I said.

"Not as sorry as I am! The other physicians voted for ME to be the interim Medical Director!"

"How is that my fault?" I asked.

"Because you're my patient!" he replied.

"Sorry."

"No, you're not!"

"You did the right thing, Mike," Doctor Forsberg interjected. "John's nose is bent out of shape because he swore up and down he'd never, ever be Medical Director. He hates paperwork with unbridled passion!"

"And yet, medicine runs on paperwork!" I countered.

"Charts are one thing," Doctor Smith said. "Insurance company and government paperwork are another thing altogether!"

"How did Doctor North take it?" I asked.

"Not well. He was upset you complained, and even more upset when the other doctors demanded he step down as Medical Director. I'm going to guess he'll leave the practice."

"I really am sorry about that outcome," I said.

"He dug his heels in against the entire rest of the staff, so it's on him. Even relenting to allow each doctor to decide was too far for him."

"How are we supposed to learn?" I asked.

"He objects to the entire concept of Preceptorships. He didn't have them, so..."

"That article I showed you from the cardiology journal."

"Yes. And you're going to run into that when you make your proposal for your Residency. There will be doctors who object purely on the grounds that they weren't trained that way and in their experience, nobody has ever done it that way."

"Handwashing," I said, shaking my head.

"That is a very instructive situation, and it's repeated over and over whenever there are innovations. That's especially true when it comes to computers."

"I'm right there with them!" I chuckled. "Though I see their utility and the potential for them to provide useful information very quickly, so I'll tolerate them."

"Ignore Mike," Elizaveta teased. "He has a serious mental block when it comes to computers."

"Not uncommon for physicians," Doctor Forsberg observed. "Mostly we don't take courses that use them and certainly don't take programming courses."

"I was roped into one by a girlfriend at Taft," I said.

"And you earned an A!" Elizaveta said.

"Only because Kristin took pity on me and spent hours tutoring and explaining!"

"Changing topics, how have things gone with your first rotation?" Doctor Forsberg asked.

"Very well. Doctor Roth is allowing me to assist with suction and retractors, and I'm doing the usual med student tasks. We're covering the ER this week, so I'm on call."

"Let's hope we finish our dinner!" Doctor Smith said.

June 19, 1987, McKinley, Ohio

"Ambulances four minutes out!" Nurse Doreen called out early on Friday afternoon. "Head-on MVA on Route 50 with four victims."

That was going to necessitate 'all hands' — two Attendings, five Residents, and four medical students. Everyone gathered in the ambulance bay except Jack, a Fourth Year, who was tasked with monitoring the three patients already in the ER while Doctor Gibbs and Doctor Williams ran the traumas. The other problem was that there were only three complete trauma rooms, so an exam room would have to be pressed into service, most likely for whoever was the least injured.

"Mike, please page Doctor Roth and Doctor Lindsay," Doctor Gibbs ordered.

I went back inside, picked up the phone, called the surgery nurses' station, and relayed the request. Nurse Lydia let me know both doctors were in their respective offices and she'd send them down right away. I went back to the ambulance bay just as the first ambulance turned into the driveway.

"They're on their way down," I said.

The ambulance pulled up and the paramedic driver hopped out.

"Male; about twenty; unrestrained MVA; significant head injury due to impact on the windshield."

He opened the doors to the ambulance and his partner helped bring out the gurney.

"Pulse thready at 50; resps shallow at 12; LOC at accident site; GSC 3; BP 100/50; Likely broken ribs."

"Mike, page neurology and cardiology. We're going to need them."

"Yes, Doctor!" I declared.

I sprinted to the nurses' desk, used the phone to first call for a neuro consult and then for a cardiology consult, stating both times that the patient was in critical condition. By the time I finished, three gurneys were being rolled into the trauma rooms, and the fourth ambulance had just pulled into the ambulance bay as the others cleared. I found Doctor Gibbs in Trauma 1 with Doctor Boyd, and a First Year named June.

"On their way," I said.

"Go help Vince and Nelson with the last ambulance," Doctor Gibbs ordered.

"Right away!"

I stopped at the nurses' station to let them know the consults should go to Trauma 1 just as Doctor Roth and Doctor Lindsay arrived. I directed them to Doctor Gibbs, then went to the ambulance bay.

"Male; about three; restrained MVA; taken from his car seat by me. No obvious external injuries; pulse tachy at 110; BP 130/70; resps 18 and strong."

I could hear that last bit because the three-year-old was VERY unhappy, and was crying for his mother, who I assumed was one of the two victims I'd seen brought in.

"Mike, call pediatrics, please," Doctor Boyd said. "Just precautionary."

"On it!"

I made the phone call, then joined Doctor Boyd and Doctor Taylor in Exam 3, where Doctor Boyd was doing an exam.

"Mike, go see how his mother is," Doctor Boyd instructed. "Discreetly."

"Yes, Doctor."

I left the exam room and checked Trauma 3, but that was a male victim, so I went to Trauma 2 where I found Doctor Roth, Doctor Lindsay, and a Fourth Year named Ken.

"Doctor Boyd asked for a status," I said quietly to Ken.

"Two lower extremity fractures, one a compound femur; bleeding is under control; vitals are stable; no severe abdominal, chest, or head injuries. She was given morphine in the field."

"OK, thanks."

I went back to the exam room and Doctor Boyd stepped away so we could converse quietly.

"Her worst injury is a compound femur," I said. "But vitals are stable. Bleeding is under control. No head, neck, chest, or abdominal injuries appreciated. The paramedics administered morphine."

"Thanks."

Just then, Doctor O'Neill from pediatrics arrived.

"Hi, Mike," she said. "What do you have, Doctor...?" she asked.

"Boyd," he replied.

He ran through the vitals and the results of his exam. Doctor O'Neill examined the patient and agreed that other than being very upset, our young patient had not suffered any injuries due to being properly restrained in his car seat. His elevated vitals were likely due to adrenaline and emotional distress, which would resolve on their own once he could see his mom or some other relative. Doctor O'Neill signed the chart and left.

"Mike, stay with our young friend here," Doctor Boyd said. "I'm going to go see Doctor Gibbs."

He and Doctor Taylor left, and I spent about forty minutes as a babysitter before the young man's father arrived and Nurse Peggy brought him in.

"Keith Milton," he said.

"Hi, I'm Mike Loucks," I said. "I'm a medical student. Your son is doing fine."

"And my wife? The nurse wouldn't say anything."

"Let me go ask the doctors working on her, OK?"

"Sure."

He picked up his son, whose name I learned was Joey, and I went to the trauma room only to find it empty. I hurried to the nurses' station to inquire.

"She's being airlifted to Columbus because she needs an orthopedic surgeon," Nurse Ellie said. "The doctors are on the helipad right now."

I asked Nurse Ellie to come with me, and we went to the exam room. Nurse Ellie stayed with Joey while Mr. Milton and I stepped into the hallway.

"Your wife is being airlifted to OSU because she needs an orthopedic specialist to repair a compound fracture of her femur. The last report I have is that her vital signs were stable, and that she had a second fracture, but I don't know the details."

"Compound fracture? Like broken in multiple places?"

"A compound fracture is one where the bone is protruding from the skin," I replied. "It's a serious medical condition, but it can be repaired. The doctors will have more details for you."

"Do you know what happened?" he asked.

"Other than the fact that it was a head-on collision, no. I'm sure there's a police officer here who can tell you more."

"Could you find him or her for me?"

"Sure."

I checked with the nurses' station and was told that a Sheriff's deputy was in the lounge, so I went to let him know that Mr. Milton had some questions. He returned to Exam 1 with me.

"A pickup truck crossed the center line and struck the car your wife and son were in head on," the deputy said. "We believe the driver of the pickup was drinking and lost control."

"Motherfucker!" Mr. Milton growled. "Where is he?"

"In the morgue," the deputy said. "His passenger is in critical condition."

I wasn't surprised about the driver, because GSC of 3 was a strong indication of severe brain injury. Not being belted, he was lucky, or unlucky depending on how you looked at it, to have lived long enough for the paramedics to arrive, let alone make it to the hospital.

"How is your son?" the Deputy continued.

"He's fine, according to Mike here."

"Med student, right?" the deputy asked.

"Yes. Once the pediatric specialist examined Joey and was satisfied he wasn't injured, they left him with me until Mr. Milton arrived."

"Am I free to leave?" Mr. Milton asked. "I need to get to Columbus."

"Doctor O'Neill wrote a discharge order for Joey," I replied, "so yes, though if you wait a few minutes, I'm sure Doctor Roth will give you a better idea of your wife's condition."

"Thanks. I think I'll do that."

"Let me make sure he knows you're waiting."

I hurried to the elevator, rode it up to the roof, and saw the helicopter lifting off. I waited for Doctors Roth and Lindsay to come to the door.

"Mrs. Milton's husband is here and would like an update. He knows she's being airlifted to Columbus, and that she had a compound fracture of the femur and her last vitals were stable."

"That's still the case," Doctor Roth said. "Where is he?"

"Exam 3."

The three of us took the elevator down, along with the two orderlies who had helped load Mrs. Milton into the Flight-for-Life helicopter, likely the same one which had flown Jocelyn to Columbus the Summer before my Freshman year at Taft. Doctor Roth spoke with Mr. Milton, basically repeating what I'd said earlier. Mr. Milton left, and Doctors Roth and Lindsay went back up to the surgical floor. I found Doctor Gibbs in the locker room, changing scrubs after a shower.

"How did the second one do?" I asked.

"No seat belt, resulting in severe head injuries and a flail chest. He's in the ICU. I'd give him less than a ten-percent chance of making it until morning."

"For once, the drunk driver got the worst of it," I observed.

Doctor Gibbs nodded, "It sure does seem like they survive or have less severe injuries in the majority of cases. Was your friend hit by a drunk driver?"

"No. The driver had a stroke. Everything Jocelyn could find out showed he had no warning signs. Just one of those crazy things."

"Strokes are the worst, really. We don't have any truly effective treatments, though some investigational drugs are available. And they often strike completely without warning. Sorry to stick you with scut and the boring case."

"That's part of my education, too," I replied.

"I'd call you a suck-up, but you're anything but that.

"Doc, as a Third Year, I'm living a privileged life. I don't think it could get any better, and I know it can get worse."

"And it will. Count on it."

June 21, 1987, McKinley, Ohio

"Are you finished with being on call?" Mark asked when we gathered for a late dinner with our group on Sunday evening.

"No. I'm on call until 6:00am, and then I start my regular shift. In three weeks, I'll have the night shift instead of days."

"That's got to suck," Elias declared.

"Not as bad as when I'll have thirty-six-hour shifts with essentially no break. The only way I'd get paged during my off hours as a Third Year, would be something beyond what happened on Thursday. I told you about that on Friday evening. How was your first week as an electrician?"

"I'm the 'gofer'!" he said. "I suppose it's the electrician's version of what you call 'scut'. Carry spools of wire, make sure the necessary parts are available, fetch them from the bins, take inventory, and all the other stuff the more senior guys don't want to do."

"That pretty much sums it up," I agreed. "What they're measuring is whether or not you're a team player, and you're willing to put up with what amounts to low-grade hazing while keeping your eye on the prize."

"Dinner is ready!" Tasha announced.

Mark, Elias, and I joined the four women at the table, and after I gave the blessing, we all dug in.

"One thing is sure," Mark said. "No Orthodox man will EVER go hungry!"

We all laughed.

"Nor be unsatisfied in the marriage bed if he marries a Russian woman!" Tasha teased.

"Natalya Vasilyevna, don't be uncouth!" I said.

"Really?" she asked mirthfully. "'Uncouth'?"

"That is what the usual Russian word we use means!"

"What?! You can't even say it now?"

"I don't use Russian at all," I said. "You know that!"

"Well, what I said is true either way!"

"It's not just Russian women," Mark smirked. "Scandinavian women, too!"

Alyssa blushed, but she laughed with everyone else.