Chapter 23: A Train Wreck

October 19, 1987, McKinley, Ohio

“Mike? What are you doing?” Nurse Mary asked.

“A glucose stick test per Doctor Gibbs’ instructions.”

“May I speak with you, please?”

“As soon as I finish this,” I replied.

The meter showed a small reduction in Mr. Blaney’s glucose levels, and his vitals had been OK except for his elevated blood pressure, so it was safe for me to step out into the hallway.

“What’s the problem?” I asked.

“Hospital protocol does not allow glucose meters in the Emergency Department. We’re to use the lab only.”

“I was following Doctor Gibbs’ instructions,” I replied. “The meter and test strips were in the drawer in the treatment room.”

“The hospital protocol says they can’t be used unless the lab is unable to process the tests in a timely fashion. That has never happened.”

“Let’s go see Doctor Gibbs,” I suggested.

We went to the Attending’s office, where I knocked on the frame of the open door.

“Doctor Gibbs? Do you have a moment?”

“What is it, Mike?”

“Nurse Mary felt I was violating hospital protocol by using a glucose stick test when the lab was able to run the tests.”

“In a timely fashion,” Doctor Gibbs replied. “They can’t turn the results around in fifteen minutes from the time we draw the blood. I have standing orders from Endocrinology to use stick tests when administering IV insulin to ensure no adverse reaction. That is what they do in Endocrinology.”

“With all due respect, Doctor,” Nurse Mary said, “the letter from the Medical Director forbade that in the Emergency Department.”

“Mike, follow my instructions, please. Mary, stay here.”

“Yes, Doctor,” I said, and headed back to Trauma 2.

I recorded the glucose number from the meter on the chart, then went to find Clarissa so we could get coffee. We went to the cafeteria, and by the time we returned, I needed to check on Mr. Blaney. His blood glucose numbers were coming down, and his vitals were still good, except for the elevated blood pressure.

“What’s it show?” he asked.

“Your blood sugar is coming down,” I replied, “but these meters have limited accuracy. The repeat lab test we’ll do in thirty minutes will give us a better idea.”

“Why do an inaccurate test?”

“Because what matters is the relative number. So, let’s say it’s off by 10% from the lab. That doesn’t matter because we’re only looking at the trend, not at the absolute numbers.”

“How low before it’s not dangerous?”

“That depends on a number of factors,” I replied. “But the textbook says below 300 is not a medical emergency. You were at 330.”

“And now?”

“Trending down. Once Doctor Gibbs sees the next set of lab results, she’ll discuss the next steps with you.”

“You seem to know your stuff, so what do you think?”

“I think I’d be dismissed from the medical school if I answered that question. I’m not legally permitted to give a diagnosis or provide medical advice, except insofar as I am repeating what a doctor has authorized me to say.”

“You can’t even give an unofficial opinion?”

“To Doctor Gibbs or one of the other physicians, but not to a patient. The State of Ohio is concerned you might act on something I’ve said, and at this point, my experience is extremely limited. I’ve only been on clinical rotations for about ten weeks. Before that, it was almost all book learning and lab work, plus a few hours one afternoon each week observing in the hospital or at a medical practice.”

“What happens next?”

“Doctor Gibbs called Endocrinology for a consult. A Resident will come down to see you once we have your next set of blood test results.”

“Can’t be more specific?”

“No. And neither could Doctor Gibbs at this point. We’ll know more about an hour from now, when the next set of labs come back.”

“I guess I’ll just have to wait.”

“I’ll be back in about ten minutes for the next glucose test.”

I left the room and went to see if Doctor Gibbs was available. She was in the Attending’s office, and speaking with Clarissa, who acknowledged me on her way out.

“Welcome to hospital politics 101,” Doctor Gibbs said. “A battle between the Lab Director, the Endocrinology Residents, the Endocrinology Chief, and the ED Chief mediated by the Medical Director. And sides keep shifting except between the ED docs and the Endocrinology Residents. My choices are to not do fifteen-minute checks or wait an hour to see if the therapy is working. I’m acting in the patient’s best interest and not making medical decisions based on the glucose meter.”

“Should I be concerned?”

“No. I wrote the order on the chart after confirming with the Endocrinology Resident.”

“I do not want to get caught up in hospital politics,” I replied.

“Then turn in your badge and medical coat and go do research. Every single medical advance is met with resistance, and requires a fight with entrenched ideas. What you call politics is the way we advance medicine. An avoidance strategy will harm your patients AND harm medical advances. If you won’t fight for your patients, then you should go home and find something else to do with your life.

“And before you walk away, I’m going to point out that you are just fine with politics when it’s to your advantage. You didn’t have any qualms about submitting a controversial, ground-breaking proposal that created a specialized Residency program solely to your own benefit, at least in the short term. But guess what? It’s an advancement in medicine that will benefit your patients, and you’ll have to fight for it when the proposal is presented to the Hospital Board.

“Go take a walk and ask yourself which it’s going to be — Doctor Mike Loucks, MD, or Doctor Mike Loucks, PhD. I’ll point out that PhD programs are equally ‘political’, maybe even more so, as you define politics, so think long and hard about that. Come back after you’ve run the one-hour glucose panel. Dismissed.”

I nodded and left her office, realizing I’d really stepped in it. I knew from my studies that medical advancement was almost always controversial, right down to something so obvious and simple as handwashing. It boggled my mind that a field which was almost wholly dependent on science was full of people who were resistant to scientific advances. It was one thing to be skeptical; it was an altogether different thing to actively resist change because it was change.

Another thing that frustrated me was the crazy shifting of alliances, with each service jockeying for advantage. If it were patient-focused, I’d be fine with it, but it wasn’t — it was about prestige, power, and control, and that drove me nuts. As far as I was concerned, the only thing that mattered was improving outcomes for patients. Certainly, there were other factors to consider, including funding and regulation, but ultimately, whatever was best for the patient should determine the proper course of action.

As always, there could be differences of opinion on what was best for a patient, and that was the place for healthy debate and fact-based analysis, including M & M conferences, discussions after rounds, and consultations between services. The goal was a consensus on how to best treat the patient, though if there were options, those ought to be presented to the patient, along with the pros and cons, to help them decide which way to proceed.

I really didn’t need to make a decision, as I knew the answer before Doctor Gibbs’ stern talk. But what I had to do was, in effect, shut up and deal with it. As I walked down the corridor to the hospital doors which led to a large grassy expanse, it hit me just how much losing Elizaveta meant to my medical career.

She had been the perfect disinterested party who could look at things without bias from being part of the medical community in some way, and could speak to me openly and freely, just as I could to her. While there were a few things I couldn’t reveal to her, there was quite a bit of leeway granted to discussions with spouses.

I left the building and walked along the path which circled the grassy area. The cool Autumn air was refreshing after the sterile smell of the hospital, which clung to my lab coat at all times. The trees had turned and soon they’d be brown as Winter weather set in, even though the solstice, the official start of the season, was still two months away. I checked my watch and after five minutes, I had to return to the ER so that I could check on Mr. Blaney.

His glucose levels continued to come down slowly with the insulin infusion, with our goal of getting him below 300 appearing to be on target. I left and went to the lounge where I sat on the couch and pulled out the random assortment of flashcards I’d put in my pocket before leaving home. I went through them for about ten minutes, then returned to Trauma 2 to draw blood for the glucose panel. I asked Doctor Gibbs to sign the order, then hand-carried the tube to the lab.

I returned to the ER and went to the lounge, as Doctor Gibbs had specifically told me not to return until I had the labs. I ran through my flashcards again, as it was obvious to me I wouldn’t get any further assignments, except perhaps scut, until I spoke with Doctor Gibbs about my long-standing aversion to politics.

Twenty-five minutes later, Nurse Ellie came to tell me that the lab results were ready. I went to the lab, retrieved the results, and looked them over as I returned to the ER. Mr. Blaney’s blood glucose was now 280 — still high, but he was no longer in immediate danger. I found Doctor Gibbs in Exam 1 and let her know I had the results.

“What are they?” she asked.

“Glucose is 280,” I replied.

“Call Endocrinology to come see him. They should admit him, but it’s possible they’ll send him home with instructions to see his physician and an endocrinologist.”

“Why would they do that?”

“It depends on their assessment,” Doctor Gibbs replied. “I think, given his weight and cholesterol levels, they should admit him, but you never know.”

“And the carotid ultrasound and angiogram?”

“If he’s admitted, Endocrinology will consult with Cardiology; if not, that will be up to his personal physician. Call me when the Endocrinology Resident arrives.”

“The IV bag will need to be changed in about five minutes,” I replied.

“Let me have the chart, please.”

I handed it to her, she wrote the order, and I left her office. First, I called Endocrinology for a consult, relaying the results of the glucose panels and the lipid panel, as well as the fact that the patient was morbidly obese. The nurse said it would be about fifteen minutes, which I acknowledged, then realized I needed another pre-mixed insulin solution. I let the duty nurse know, and she said she’d have it for me when I came up.

Five minutes later, I was back in the ER and went into Trauma 2 to change the IV bag.

“Get the results?” Mr. Blaney asked.

“We did. We’re waiting for the Endocrinology Resident, who should be along shortly.”

“Why all the different docs?”

“Each has their own specialty,” I replied. “Emergency Medicine doctors are trained to stabilize patients, then either send them to follow up with their personal physician or transfer them to another service. For example, if someone comes in needing sutures, we do that, then have them follow up with their GP to have the sutures removed. On the other hand, if the injury is serious, we’ll either send them to surgery or Internal Medicine once they are in stable condition.

“In your case, we used insulin to treat your hyperglycemia, which was what we would call the ‘emergent’ problem. Once you aren’t in immediate danger, we call someone who specializes in treating someone with high blood sugar and high cholesterol to complete an assessment and decide the next steps.”

“So you’re only trained in the ER?”

“No. I just came off an OB/GYN rotation and next I’ll go to Pediatrics. All medical students do a core set of rotations to expose them to the main specialties. Then we have electives, which I’ll use for surgery and emergency medicine. I’ll apply for an Emergency Medicine Residency, but there is no guarantee I’ll get it. I could end up in another specialty, depending on the needs of the hospitals to which I apply. Ultimately, something called the National Match happens, and I’m assigned to one of the hospitals.”

The door opened and a female Resident entered.

“Metz, Endocrinology,” she said. “Where’s your Resident?”

“Doctor Gibbs, my Attending, is handling this case. Let me get her.”

I left Trauma 2 and returned a minute later with Doctor Gibbs.

“What do we have, Doctor Gibbs?” Doctor Metz asked.

“Mike?”

“Forty-eight-year-old male presented with complaints of chest pain and shortness of breath. EKG showed no signs of MI, confirmed by blood enzymes. Patient is morbidly obese; pulse 75; BP 180/100; glucose was 330 on arrival, titrated to 280 after a bolus of ten units of insulin and a litre of IV insulin solution; total cholesterol 290; LDL 240, triglycerides 520.”

“Let’s get fresh vitals and I’ll do an exam,” Doctor Metz said.

I took Mr. Blaney’s blood pressure and pulse and reported those to Doctor Metz.

“Mr. Blaney, do you smoke?” Doctor Metz asked.

“No.”

“Drink alcohol?”

“Yes.”

“How much?” Doctor Metz asked.

“A couple of beers in the evening after work, maybe three or four on weekends.”

“Do you exercise?”

“No,” Mr. Blaney replied.

“What do you do for work?”

“I’m a Tax Accountant.”

“Married?”

“Divorced.”

“OK,” Doctor Metz said. “Let us discuss the next steps and then I’ll come back and speak to you.”

Doctor Gibbs, Doctor Metz, and I went to the lounge.

“He’s going to need a cardiologist, pulmonologist, and nutritionist,” Doctor Metz said. “The best person to coördinate that is his personal physician. I’ll write a prescription for insulin and arrange for one of my medical students to instruct him in injecting himself.”

“You’re not going to take him?” Doctor Gibbs asked.

“Admission to our service won’t make a significant difference now that his blood sugar is below 300. You know we’re not in a position to coördinate long-term care, so it makes sense to discharge him with instructions to see his physician.”

“He has significant cardiac and pulmonary risk factors,” I offered. “They indicate admission.”

“Did anyone ask you?” Doctor Metz snapped. “You’re what? Third year? Just be quiet and listen!”

“Excuse me, Doctor Metz,” Doctor Gibbs said, “you’re a new Resident, I’m an Attending, and Mike is my med student. He’s encouraged to speak up and you will NOT speak to him that way!”

“Either way, we’re not taking your train wreck on our service,” Doctor Metz replied.

I wanted to say something, but I likely could only make things worse, no matter what I said.

“Write that up,” Doctor Gibbs instructed Doctor Metz, handing her the chart.

Doctor Metz wrote her orders on the chart, signed it, and handed it back to Doctor Gibbs. The three of us went back to Trauma 2 and Doctor Metz explained her treatment plan.

“We strongly suspect you have Type 2 diabetes,” Doctor Metz said. “That means your body is not generating sufficient insulin. You need to see your personal physician right away, and discuss with him or her the next steps, which should include complete evaluations by an endocrinologist and a cardiologist.

“I’m going to prescribe injectable insulin which you should use until your doctor instructs you otherwise. I’ll send someone down to teach you how to do it and write a prescription which the hospital pharmacy can fill. You’ll also need to carefully watch your diet. We’ll give you some basic guidelines, but your doctor should refer you to a nutritionist who specializes in Type 2 diabetes. Do you have any questions?”

“Injectable? As in, give myself a shot?”

“Yes. We’ll teach you how to do it, as well as how to use a glucose meter.”

“And my chest pains?”

“Your EKG was clean, and your blood tests didn’t show elevated cardiac enzymes. A cardiologist will probably want to do a stress test — that’s basically having you walk on a treadmill while connected to an EKG. They may also order an angiogram, which is a test that looks for narrowing or blockage of the blood vessels around your heart.”

“You can’t do those?”

“We could, but it’s almost always better to have your personal physician coördinate your care. Most insurance companies won’t cover hospitalization for those tests unless you’ve had a heart attack or have some other need for critical care.”

And that explained a good part of it — insurance. I wondered how much that factored into the decision, as one of the biggest problems the hospital had with funding was patients who either had no insurance or for whom insurance didn’t pay for the procedures. A system such as the one in Canada or the ones in Europe avoided that problem, though in every case there were limited resources which constrained what doctors and hospitals could do. I didn’t have a solution, but to me, the ability to pay should have no bearing of any kind on medical care.

“Who is your personal physician?” Doctor Gibbs asked.

“Doctor John Smith,” he replied.

“See him right away,” Doctor Gibbs said. “Call for an appointment as soon as you’re discharged. Let them know you need to see him today, if at all possible, but no later than Wednesday.”

“OK,” Mr. Blaney replied.

“Johanna will come see you shortly,” Doctor Metz said. “Do you have any questions?”

“Plenty, but I’ll ask Doctor Smith.”

“Good luck, Mr. Blaney,” Doctor Metz said.

The three of us left the room, with Doctor Metz returning to Endocrinology, and Doctor Gibbs and I going to her office.

“May I ask a question?”

“I’m not angry with you, Mike,” Doctor Gibbs said, “I just wanted you to get your head out of the clouds. What?”

“Why did Doctor Metz refuse to take a patient who is clearly in need of our help?”

“The official answer is that she’s right about his personal physician being best suited to coördinate care, but her comment about ‘train wreck’ is the actual answer — she’d spend the next two days babysitting him and doesn’t want to.”

“You’re joking?”

“Sadly, no. And she can justify her decision, so there really isn’t anything that we can do to change that. Sure, I could call her Attending, but how do you think that will go over?”

“About as well as her telling me to shut up.”

“Exactly.”