Chapter 26: A Proposed Way Forward

October 26, 1987, McKinley, Ohio

When I walked to the Attending’s office, I found both Doctor Casper and Doctor Gibbs.

“You missed the nine-year-old matchmaker,” I said to Doctor Gibbs.

“Oh?”

“His dad died when he was five and mom hasn’t dated anyone that has met with Charlie’s approval. He suggested me.”

“You did give her candy!” Doctor Casper said with a grin.

“Given someone in this room who is not named Mike or Doctor Casper ratted me out to Doctor Lawson, I felt it was the only thing I could do!”

“Loretta?” Doctor Casper asked.

“You know Attendings discuss med students at our bi-weekly meetings.”

“But it sounds like you took a negative view.”

“Should I stay for this?” I asked, feeling a bit uncomfortable.

“Get used to it,” Doctor Casper said. “Someday you’ll screw up and get pasted in an M & M. It comes with the territory and happens to everyone. This is mild.”

“What happens when a parent complains about giving their kid candy?” Doctor Gibbs asked.

“I’d write a damned prescription for the candy!” Doctor Casper replied. “Mike has the touch, Lor. Seriously. Does he get too involved? Sometimes. But for once, just once, I want to see a surgeon who actually has a personality and has a friendly, engaging bedside manner!”

“How did things go in psych?” Doctor Gibbs asked.

“I convinced Jenny to talk to Doctor Stern,” I said.

“What aren’t you telling me?” Doctor Gibbs asked.

“She asked if a girl could be a doctor, I said ‘yes’, and offered her a tour of the hospital if she spoke to Doctor Stern.”

“And Doctor Lawson upbraided you for bargaining with her, right?” Doctor Gibbs asked.

I nodded, “Yes, but Jenny is not a psych patient! She’s a distraught thirteen-year-old who lost her brother. They were very close and there’s something you don’t know, and neither does Doctor Lawson.”

“What’s that?”

“She was supposed to go with him this morning, but they had a small tiff so he left without her.”

“Survivor’s guilt,” Doctor Casper said. “She’s going to need counseling. Lor, I think you need to cut Mike some slack on this one. He did the right thing every step of the way. That little girl needed a doctor with empathy and she was lucky to find Mike.”

“Ghost, you know the reason we divide labor here. Mike wasn’t here when your leg lac came in.”

“And he responded to his page and was in the exam room in less than four minutes.”

“He has a habit of getting too involved,” Doctor Gibbs said. “That was in his evaluation from Good Sam.”

“And according to the Chief, in yours when YOU were a med student,” Doctor Casper said.

“For which I was regularly reprimanded.”

“Which makes it right for you to do it? Did you have any negative outcomes from being human? Has Mike?”

“And the Chief?” Doctor Gibbs asked.

“Doctor Lawson called for a consult, right?”

Doctor Gibbs laughed, “You know that was fiction.”

“And yet, he’s Chief of Psych, and asked you for help. You sent it. Let our Chief duke it out with Doctor Lawson if there’s a problem. That’s what happened with you at Good Sam, right, Mike?”

“Yes. I was doing what I was instructed to do by my Resident. She received a dressing down but didn’t let it bother her or deter her.”

Of course, that was because Doctor Kelly was going to leave Good Samaritan if the OB Chief kept his job.

“Did it interfere with you caring for other patients?” Doctor Casper asked.

“No.”

“I think that’s the determining factor,” he said. “You’ll need to learn to use your judgment as to how much time you can spend with a patient. Right now you need training and experience, and that comes from seeing as wide a variety of cases as possible and progressively adding to your skills. On your next ER rotation, you’ll learn to intubate. Unfortunately, that’s about the limit until you graduate.”

“Ghost, let me speak with Mike privately for a bit.”

He nodded, got up, and left the office, closing the door behind him.

“I’m getting seriously mixed messages,” I said.

“Because you’re a revolutionary. For a guy who swears up and down that he hates politics, you find more ways to get in the thick of things than any med student I’ve known. You have good instincts and good ideas, but you’re a bit too headstrong. If you cross the wrong Attending, he or she can make your life a living hell. It’ll be worse if it’s a Chief because they have veto power over the Match. If you’re viewed as a cowboy or not a team player, you’re toast.

“You’ll be a great physician, no matter what specialty you choose, but you need to think long and hard about your personality and how you want to practice medicine. You’re a natural with kids, so maybe you’re simply more naturally suited to pediatrics. The way you’ve handled the young patients is remarkable, and they like you. Perhaps that’s where you need to be.”

“I’ve wanted to be an ER doctor since fourth grade,” I replied.

“Which has you fixated on it, though Doctor Roth threw you a bit of a curveball. But are you suited to surgical practice? I don’t mean are you good at it, because you learn fast and have excellent skills for your level. And you have the primary traits for both surgery and the ER — confidence, composure under pressure, and assertiveness.”

“That last one gets me into trouble every time!” I replied.

“Yes, but it’s key for running a trauma. You can’t be,” she smirked, “Caspar Milquetoast.”

“Nice. I believe Doctor Ghost is even more assertive than you are!”

“He is. But back to you — it’s not about what you can do, or what you want to do, but about what you should do. You can change your electives all the way up to May, though extra ER rotations will never look bad no matter what you choose.”

“Are you telling me I’m not suited to the ER?” I asked apprehensively.

“I’m telling you to think long and hard about it. You don’t need to act like a surgeon, but you can’t act like a GP. You have time to think about it. What do you have after Pedes?”

“Psych and internal medicine. Then another trauma rotation. After that, my second surgery rotation, then psych, cardiology, medicine, and finally trauma.”

“Psych will let you spend a lot of time with patients.”

“I know I’m not cut out for that,” I replied. “Watching my friend with schizophrenia has driven that home.”

“Your skills would be wasted there, though as much as I hate to lose you, pediatrics might be your thing. Just think it through, because if you end up unhappy, you’ll be the exact opposite of the doctor you want to be.”

“Doctor Gibbs?” Nurse Teri said, “Paramedics two minutes out with a cardiac arrest.”

“Page cardiology, Teri,” Doctor Gibbs said. “Let’s go, Mike.”

We got up and headed to the ambulance bay, and sixteen minutes later, had the second ‘call’ of the morning.

“Still asystole on the monitor,” I announced after a dose of atropine was administered.

That was the procedure, despite the blaring alarm and the obvious flatline on the cardiac monitor.

“He’s been down twenty-five minutes, at least,” Doctor Strong said. “Doctor Gibbs?”

“Call it,” she replied, shaking her head.

“Time of death: 11:41,” Doctor Strong announced.

The patient, a man in his mid-fifties, had come into the ER in full cardiac arrest, with the paramedics administering CPR. He’d shown PEA — pulseless electrical activity — on the monitor, and neither CPR, four doses of atropine, nor two doses of sodium bicarb had resolved the PEA, and eventually asystole — the absence of ventricular contractions. He’d never had a ‘shockable rhythm’, so the defibrillator wasn’t even tried.

“Doctor Strong,” I said. “In my brief cardiology course during my first year, they suggested that defib was used in cases like this, ‘just in case’.”

Doctor Strong nodded, “In theory, an asystole patient could have fine V-fib, which isn’t properly displayed by the ER monitors, but he was in PEA first, and that’s not shockable, as I’m sure you know. The latest literature is calling into question routine defib for asystole patients because it simply doesn’t work. You know the survival rate for PEA and asystole, right?”

“Less than twenty percent with immediate intervention — CPR and atropine.”

“This appears to be a classic case of ‘dropping dead from a heart attack’. Obviously, we’ll wait to hear what McKnight has to say about the underlying cause, but it’s safe to say he died of a heart attack. Nurse, does he have anyone here?”

“I’m not sure,” Nurse Mary said. “Let me check with Kris.”

She left and came back a moment later.

“His wife and a co-worker.”

“Mike,” Doctor Gibbs said, “you know the drill. Mary, page the chaplain, please, and have him come down.”

She did, and the chaplain was available, and just under ten minutes later, I escorted Mrs. Brown into the consultation room where Doctor Gibbs and Doctor Strong were waiting.

“Doctor Gibbs, Doctor Strong, this is Mrs. Brown,” I said.

“Hi, Mrs. Brown. I’m Doctor Gibbs and this is Doctor Strong, and you’ve met Mike. Would you have a seat?”

“How is he? Mike wouldn’t say,” she asked, sitting down.

“Mrs. Brown, your husband was brought in by the paramedics in full cardiac arrest. Doctor Strong, who is a cardiologist, Mike, two nurses, and I all worked together to revive him, but despite using all our skills and abilities, we were not able to get his heart re-started, and he died.”

“Died?” she asked, obviously stunned by the news. “But he was only fifty-three! And he never had heart problems!”

“We won’t know for sure until we see the pathology report,” Doctor Strong said. “But your husband had a massive heart attack. That can happen even with no warning signs.”

“Can I see him?”

“Yes,” Doctor Gibbs said. “Mike will take you in. The chaplain is here, if you’d like to speak to him.”

Mrs. Brown shook her head, “My husband had no use for preachers of any kind and we haven’t been to church in going on two decades.”

“We also have counselors who aren’t religious, if you need to speak to someone.”

“No,” she said, shaking her head. “Just take me to him, please.”

Even though I had only had brief exposure to the Psych service, it was clear to me that Mrs. Brown was in shock, and at some point, which could be seconds, minutes, hours, or days, the weight of what happened was going to hit her.

“Mrs. Brown,” I said, “if you’ll come with me, please, I’ll take you to see your husband.”

She got up and followed me out of the consultation room.

“You’re going to see EKG pads, an IV, and a breathing tube,” I said. “We can’t remove those until the pathologist examines your husband to determine what caused his heart attack.”

“You don’t know?”

“No, we don’t. Doctor Strong is an excellent cardiologist, but we can only determine a limited set of facts from the monitors and external examinations. Did your husband smoke? Or drink to excess?”

“No. He’d have an occasional beer or glass of bourbon, but that’s it. And he went to the gym three times a week.”

I couldn’t speculate out loud, but I wondered what his lipid panel would have shown. We didn’t order one, just cardiac enzymes, Chem-7, and ABG — arterial blood gasses. Those had all shown results which indicated a massive cardiac event and, together with the monitor, made it clear that continuing to ‘flog’ the patient, as it was called, was useless.

Mrs. Brown spent about five minutes with her husband, holding his hand, and then I escorted her to Patient Services so she could make arrangements for him to be picked up by a mortuary. Once she was with them, I went to find Clarissa to see if she was free for lunch, which she was.

“Oh-for-two today,” I said.

“I heard about the High School kid. What was the other one?”

“Massive coronary at age fifty-three. Non-smoker, went to the gym three times a week, light drinker. PEA then asystole. Doctor Strong called it after about twenty minutes. I also sutured a nine-year-old who tried to climb a chain-link fence to retrieve a ball.”

“At least he didn’t rip off his OWN balls!” Clarissa declared mirthfully.

“True. Anything interesting for you?”

“A septuagenarian with a fractured hip. He was admitted and will likely need surgery.”

“I had a couple of tough conversations today,” I said. “One with Doctor Lawson in Psych, and one with Doctor Gibbs.”

“Why?”

“About whether I’m suited for emergency or should think about something that allows me to interact with patients the way I want to.”

“What happened this time, Petrovich?”

“The MVA’s little sister freaked out, and I helped calm her down. Psych took her and her mom, and the sister wouldn’t talk to anyone but me. Doctor Lawson called for a ‘consult’ to provide cover, but I still was on the receiving end of a talking to about it. Well, and the fact that I convinced the girl to talk to Doctor Stern in exchange for a hospital tour.”

“How old?” Clarissa asked with a tone of voice implying something that wasn’t even a thought.

“Get your mind out of the gutter, Lissa! She’s thirteen. It came about when she asked why we couldn’t save her brother...”

Clarissa interrupted me before I could finish my sentence.

“Massive head trauma and massive abdominal injuries after rolling his pickup while not wearing a seat belt? A full trauma team on site couldn’t have saved him from what I saw on the chart.”

“I agree. And what I was about to say was that we talked about her being a doctor. Some clown put into her head that only guys could be doctors and girls had to be nurses. I explained that wasn’t the case, then offered a tour of the hospital in exchange for her talking to Doctor Stern.”

“So what did you get in trouble for?”

“Bargaining,” I replied. “I know better than to do that with someone who has a mental illness, but this wasn’t that. You know the rest of it, I’m sure — too much time with a patient for someone working in the ED. Doctor Casper actually backed me up, but Doctor Gibbs made some valid points. She’s basically nudging me towards pediatrics.”

“Don’t do it, Petrovich! That is NOT going to make you happy. I can’t believe Doctor Gibbs would do that! You’re her star pupil! And Doctor Roth would have a conniption, especially now that you’ve submitted your proposal!”

“I know,” I replied. “But spending my entire career being frustrated about how surgeons and emergency medicine specialists interact with patients would interfere with being a good doctor.”

“Then you just need to find a way to adjust your thinking.”

“But can I? That’s such a part of me that I’m not sure I can change it. Fundamentally, it’s finding a proper balance that allows me to practice medicine the way I think it ought to be practiced, while ensuring optimal medical care. I totally get the points Doctor Gibbs is making about the role of Emergency Departments and how that differs from being a GP, or even Pedes or Internal Medicine.”

“Don’t make any hasty decisions, Petrovich,” Clarissa counseled.

“I’m not. I can modify my electives at any time, but even if I don’t, the ones I’m taking will be useful no matter how I decide to approach the Match. And you know I have to take into account Rachel when I make my decision as well. Being a GP would give me a rational schedule, and allow me to be more involved at church.”

“Jesus, Petrovich! That would be a waste of your talents!”

“That depends on which talents you are referring to,” I countered.

“Give it time, Petrovich. It’s sixteen months before you need to decide where to interview and for what specialty.”

“I won’t make a rash decision.”

“Good.”

October 30, 1987, Goshen, Ohio

“Hi, Mom!” I said when I arrived at Goshen High School and climbed out of the Mustang.

“Hi, Mike. Do you want me to take Rachel so you can carry your instruments and music?”

“Yes, please.”

My mom got Rachel from the car, along with her bag, and I got my guitar, balalaika, and the notebooks with my sheet music, and the three of us walked towards the school building.

“How was your week?” Mom asked.

“Too many losses,” I replied.

“Deaths, you mean?”

“Yes. Five total, which is more than any week since I started in the Emergency Department. Three from accidents, two from heart attacks. One of the accidents was a sixteen-year-old kid who rolled his pickup truck while driving to school.”

“Lord have mercy!” Mom exclaimed. “How do you deal with that?”

“I honestly can’t answer that question. I just do.”

Mrs. Kane met us at the door, expressed her condolences, then escorted us to the same room we’d use the previous times. Kim, Sticks, José and Dona were already there, and greeted us.

“We did our sound check,” Kim said. “Sorry we couldn’t wait for you.”

“I totally understand,” I replied. “Fortunately, I was able to leave the hospital right at 6:00pm and Lara met me in the hospital parking lot with Rachel.”

“Let’s run through a couple of songs,” José said. “We have enough time.”

“Hi!” Robby called out as he and Sophia came into the room.

José and I ran through I Write the Songs and Old Time Rock and Roll, and when we finished, the band plus Robby and Sophia took our places for the opening ‘Blues Brothers’ schtick. It was well received, as was our first set, and during the break, Angie came to the lounge to say ‘hello’. I gently maneuvered her away from everyone else so I could ask the question I wanted to ask.

“Have you been taking your medication?”

She nodded, “Yes. And Doctor Mercer agreed to cut it in half and see what happens.”

“Excellent,” I said. “How is it going?”

“About like when I stopped,” Angie said. “A bit of trouble sleeping, but it’s not too bad.”

That wasn’t going to get her what she wanted, but it also allayed my fears that she was regressing. Statistically, that was bound to happen at some point, though I hoped that she was one of the lucky few who actually recovered. Her current situation was far better than most, so, in that sense, she was already fortunate.