Chapter 45: A Tactical Error

December 3, 1987, McKinley, Ohio

Doctor Rosenbaum, Doctor Olson, and Doctor Sumner conducted rounds on Thursday morning with Jerry, Nelson, Heather, and me. Doctor O'Neill had office hours, so she was in the medical offices where I'd spent Tuesday. We visited each patient and reviewed their cases. Just as we were leaving Billy's room, the social worker came in to talk to him. The X-rays had been clear, and his abdominal tenderness had been diagnosed as a bruised muscle, which could have happened the way his mother had described.

"Mike," Doctor Rosenbaum said when we finished rounds, "get morning labs from all the patients who need them."

"Right away, Doctor!" I replied,

If he was going to give me scut, I was going to do it happily and cheerfully, and absolutely not give him the satisfaction of seeing me annoyed. The only downside of that was that he might become annoyed that I wasn't annoyed, and that almost made me laugh out loud, as I remembered The Princess Bride and 'I clearly cannot drink the wine in front of you!'."

There were three patients who needed lab work — a fourteen-year-old boy who had surgery to remove an intestinal blockage due to Crohn's disease; a six-year-old boy recovering from viral pneumonia; and a fifteen-year-old girl recovering from bacterial meningitis, but no longer contagious. I drew blood, updated their charts, then carried the blood to the lab.

When I returned to the floor, I saw the nursing shift change had occurred, and there were two nurses and a nursing student at the nurses' station. I said 'good morning', introduced myself, and memorized their names — Judy, Leslie, and Joy, who was the student.

"See you on Saturday night," Doctor Olson said, as his shift was finished. "Doctor Wolfe is the Resident today."

"See you Saturday," I replied, then went to the lounge where Nelson was sitting on the couch.

I greeted him, picked up my book, and managed to read two pages before Joy came to the lounge to say there was a consult, and that Doctor Rosenbaum had said Nelson should go with Doctor Wolfe. I was, it appeared, going to be sidelined. I could deal with that, as according to the schedule, Doctor Rosenbaum would only be in the hospital at the same time as I was on Thursdays, from 7:00am to 5:00pm. What concerned me was who would write my evaluation.

Doctor Rosenbaum was in the ED for the consult, so I went to the Chief's office to see Doctor Sumner.

"Hi, Mike," he said when he saw me at his door. "What can I do for you?"

"I was curious as to who would be writing my evaluation?"

He frowned, "Come in and shut the door."

I did, then sat when he nodded to by his desk.

"Obviously you're concerned about something."

I'd made a tactical error, and I had to think quickly about how to avoid causing a serious problem. I decided I could simply comment on Doctor Rosenbaum's public statement, though the problem was that Heather might refuse to corroborate even those facts. I simply had to tread carefully.

"Doctor Rosenbaum made some comments this morning that indicated there might be a philosophical conflict."

Doctor Sumner nodded, "Do you know about an organization called Americans United for Separation of Church and State?"

"I do. They have a reputation for being anti-Catholic, though from what I understand, that isn't really true anymore. From what I've heard, they think that the Constitution prohibits any interaction between church and state, when what it really says is there can't be a state church and that the government can't interfere with religious practices. I actually said that to Doctor Rosenbaum after he made a disparaging comment about the clerical robes I used to wear."

"I was going to ask you about that when we had a chance to speak privately."

"I elected to resign my position after Elizaveta died," I replied. "It was a combination of simply not having the time, as a single dad, to devote to my duties, combined with the fact that clergy aren't permitted to marry or remarry."

"I don't think I've seen a more shocking occurrence in my entire tenure here, which stretches back eighteen years. Yes, of course, there have been sudden deaths, but almost always from accidents. A young person dying like that, well, I don't have to tell you. What did Seth say that caused you to respond?"

"That I was smart to have ditched my clerical robes. When I said I was following my bishop's instructions, he made the comment that religion and medicine don't mix, and that this was a public hospital."

Doctor Sumner nodded, "A sentiment he's expressed before. I mentioned the lobbying group because he's a member. There was a brouhaha three years ago about the hospital employing a chaplain paid for out of public funds. In the end, it was defused when an anonymous donor created an endowment to fund the chaplaincy and the chapel operations. I thought we were on solid ground, but nobody wanted to go to court and risk losing."

"I honestly don't want anything to happen to Doctor Rosenbaum," I said. "He's entitled to his opinion. I just want to know what I'm up against, so to speak."

"I'll formally assign it to Olson," Doctor Sumner said. "You'll spend more time with him because of the way the schedules worked out."

"I appreciate that. Thank you."

"I do have one piece of advice, if you want to hear it."

"Always."

"Rosenbaum isn't the only one with those opinions in this hospital. They're a minority, but you know as well as I do that, when it comes right down to it, Match choices are purely subjective. My advice is to simply ignore Doctor Rosenbaum and not engage him on this topic."

"A plan of action I had already. Any future comments will simply be like water off a duck's back — they will pass without official notice."

Doctor Sumner smiled, "Very wise, Mike. Seth is an excellent physician, and you can learn a lot from him."

Assuming he was interested in teaching me, of course. But I couldn't say that aloud at this point.

"May I ask about the usual patient load?"

"A dozen. We're down to eight this morning, which is on the low end, especially with football season in full swing. We get four to six rule-out concussions every season, though having been to my son's games, I'd say we should probably have that many after each game, but the coaches all seem to have studied at the John Madden School of Coaching!"

"'Rub some dirt on it' isn't very effective against brain injury," I replied.

"No, it's not, and one day the NFL will wake up to this issue, or they'll be woken up. Have you spoken to anyone in neurology?"

"No."

"Ask them about brain injury in football players sometime. You're here until 8:00pm, right?"

"Yes."

"Then you won't likely see any football injuries. Those mostly come in after 8:00pm, even if they occur early in the game because the ED has to evaluate them before we're called. And since you don't come back here until Wednesday evening, all those 'rule-outs' and less serious injuries will have been released."

"I have a question, if I may."

"Of course."

"During my shifts, is there anything I should do during downtime except study or read?"

"On this service, we encourage patient interaction. Feel free to visit the patients and check on them. The kids all need that, and with only two or three nurses and a student on duty for a total of twenty beds, medical students are a big help in keeping their spirits up! You won't get in any trouble for spending time with patients here, so long as you keep up on any assigned tasks."

"Thanks."

"Oh, we do frown on candy bribes up here," he said with a smile. "I think that's great in trauma, when you're about to street the kid, but it messes with diets here."

"Understood. I don't have my candy supply with me, as I wasn't sure. And I would have asked the nurses."

"They'll be happy to eat any sweets you have!" Doctor Sumner declared. "Especially Peggy! She's a regular chocoholic!"

"An addictive substance for which there is no treatment!" I chuckled. "I know a few chocoholics myself. I prefer hard candy."

"Until you end up with Type 2 diabetes! Watch your sugar intake, especially soft drinks. And just be smart about your candy."

"Good advice."

"You don't smoke, do you?"

"No way! The old men at the church have tried for years to get me to smoke cigars with them, but I've steadfastly refused. They love their vodka, too, but I teetotal with rare exceptions, and have support from Doctor Evgeni Petrov which helps me resist the 'get obliterated after the Paschal service' tradition that many Russian and Greek men follow!"

One of those rare exceptions had occurred recently with Anicka and a bottle of wine. That was the epitome of a worthy exception, as it would never happen again, and the exception wouldn't lead to license.

"A good policy for anyone in trauma or surgery, given the need to be available for emergencies. We don't have too many of those on this service."

"Thanks for taking the time to speak to me," I said.

"No problem, Mike. I'll let Doctor Olson know he'll be writing your evaluation."

"Thanks again."

We shook hands, and I left his office, checking my watch to see if the labs might be ready, but it would likely be another half hour. I went to the lounge and picked up a medical journal and flipped through looking for an article to read, and found one on the psychological effects of hospitalization on very young children that looked interesting.

I made it about halfway through the article before Joy came to the lounge to let me know that the labs were ready. I put down the journal and went to the lab, retrieved the results, and scanned them as I made my way back upstairs. Everything looked to be in the proper ranges for all the patients, which was good. That meant simply clipping the results to the chart and transcribing the key numbers onto the chart form. I started with the Crohn's patient.

"Hi, Jim," I said, walking into his room. "Your labs look good."

"Cool, but when can I get out of this dump?"

I picked up the chart and clipped the lab results to the right side, then flipped a page to see the last notes that had been made.

"According to Doctor Olson's notes, you've had a bowel movement, so if your labs are good, which they are, then tomorrow. We'll check them later today and tomorrow morning, and so long as nothing changes, you can blow this Popsicle stand!"

I began writing the key numbers on the chart — blood glucose, red and white counts, hematocrit, and platelet count.

"Is this what you do? Take blood and update charts?"

"I do whatever I'm assigned, but what I can do is limited because I'm a Third Year in medical school. I can suture, insert IVs, give injections, take vitals, hook up monitors, and so on. Soon, I'll learn to intubate and do other procedures. Interested in being a doctor?"

"Fuck no! If I never see the inside of a hospital again, it'll be too soon!"

"I don't think I'd make a very good patient," I said. "Is there anything I can get you?"

"A date with the student nurse?" he said hopefully.

"Well, you're only fourteen, and she's about twenty, so the law would frown on that!"

"Dude, I am not going to complain to the cops if she gives me a sponge bath!"

"Oh, I'm sure," I replied with a grin. "And of course, you'll return the favor, right?"

"To get a look at her mammalian protuberances? You bet!"

"Well, well, well," I chuckled. "A man of culture. Do your parents know you're a Frank Zappa fan?"

"They're my dad's albums! Mom doesn't know!"

"What's your favorite album?"

"Sheik Yerbouti," Jim replied. "Though Joe's Garage is awesome, too."

"What else do you like?"

"George Carlin."

"Me, too! Of course, I had to hide his tapes, along with my Zappa albums and tapes, from my parents. Is your dad a George Carlin fan?"

"His tapes. Mom can't stand Carlin."

"So she has no taste!" I commiserated. "Besides the date, which I don't think I can arrange, anything you need?"

"Nah, I'm good. Thanks."

"I'll see you later, then."

I left his room and saw Joy at the nurses' station and decided to at least make what was sure to be a futile attempt so that I could tell Jim I'd tried.

"I asked Jim if I could get him anything," I said to Joy, "and he said a date with the student nurse."

She laughed softly, "He's such a flirt! But he's only fourteen!"

"That's what I told him, but I had to ask, so I could tell him I did. He did suggest mutual sponge baths!"

"I bet he did! Unfortunately for him, he can get out of bed and use the shower in his room."

"I read his chart, but I figured a fourteen-year-old who's a fan of Zappa and Carlin deserved me at least asking on his behalf!"

"His buddy snuck a Playboy in on Tuesday. Doctor Olson confiscated it. For the articles, of course."

"Of course!" I agreed. "Anyway, I have two more patients to see."

I left the nurses' station and went to the room with the six-year-old viral pneumonia patient.

"Can I get out of here?" Karl asked, in what I was sure would be a regular refrain from every patient in the ward at one time or another.

"Let me check your chart," I said,

I clipped his test results in, flipped to Doctor Sumner's notes, and nodded.

"It says today if your lab test results are OK, which I believe they are. I'll speak to Doctor Sumner in a few minutes and let him know."

"Cool!"

I left his room and went to the final patient room — the fifteen-year-old recovering from bacterial meningitis.

"Hi, Alicia," I said. "Your lab results look good."

"What does that mean?" she asked.

I picked up her chart, clipped the lab results to it, then flipped through it.

"Mainly that the results of your CBC, or Complete Blood Count, shows that the number and type of red and white blood cells are within range. According to your chart, you have one more day of IV antibiotics, and then Doctor Sumner will evaluate you and decide when you'll be able to go home."

"I'm so pissed because I'm missing stuff at school! I'm on the cheer team!"

"Hayes County High?" I asked, as I transcribed the key test results.

"Sophomore. Did you go to Hayes County?"

"Harding County," I replied.

"We kick your butt in football every year!"

"And we return the favor in basketball and volleyball," I replied. "Is there anything I can get you?"

"Can you sneak a Wendy's Frosty into the hospital?"

"Probably not," I replied. "They're pretty touchy about what you eat."

"I'm DYING for a Frosty!"

"Besides that?"

"I'd say sneak me out of here, but that medical coat says you're on the enemy team!"

"Wow!" I exclaimed. "Seriously? The people who saved your life are your enemies?"

She rolled her eyes, "And who won't let me out of prison!"

"You have to finish a full course of antibiotics, even if you show no symptoms and there's no detectable bacteria in your spinal fluid."

"If I have to have one more tap, I'm going to kill someone!"

"I hate to break it to you, but you'll need one more to confirm you're clear."

"Great," she groused.

"I'll warn my friend Clarissa, who comes on shift when I go off at 8:00pm tonight! Anything I can get you besides the contraband?"

"No."

"Then I'll see you later."

I left her room and went to speak with Doctor Sumner.

"Karl's morning labs came back with nothing out of range, and it appears his pneumonia has cleared. According to his chart, he's due for release."

"Did you do an exam?"

"No. I wasn't instructed to."

"Let's go do that and you can fill out the discharge paperwork for my signature and we'll get him out of here as soon as his parents show up, which should be in the next thirty minutes."

We went to Karl's room and Doctor Sumner observed while I checked Karl's breathing, pulse, and blood pressure, as well as his eyes, ears, nose, and throat.

"Breathing is clear," I replied. "No appreciable signs of illness."

Doctor Sumner nodded, then listened to Karl's breathing.

"I concur," he said. "Karl, as soon as your mom and dad get here, you can leave."

"Yes!" he exclaimed, pumping his fist.

Doctor Sumner and I left the room, and I went to the nurses' station to get a discharge packet. I spent fifteen minutes filling out what amounted to a summary of the diagnosis and treatment, as well as the results of the latest labs and our final examination. Once I had all the blanks filled in, all the proper boxes checked, and had written three paragraphs of prose in the section marked 'discharge summary', I took the forms and Karl's chart to Doctor Sumner for his signature.

"Nice, concise summary," he said. "I see you failed Handwriting 101 because what you wrote is completely legible! I'll recommend a remedial course!"

"Just out of curiosity, what happens when these aren't legible?"

"Doctors who truly can't write legibly dictate into pocket tape recorders and pay a medical transcription service for chart summaries. They actually have an office in the administration wing. I like to have the entire discharge form filled out, but all that's technically necessary is a discharge note on the chart and a signature. The paperwork can be turned in any time within seventy-two hours. The nurses will inform Patient Services by phone as soon as the patient is discharged."

"I've heard rumors that some doctors take weeks to get their chart reviews and summaries turned in."

"It happens, and then the Chief of whatever service it is will get grief from Patient Services. Technically, the Medical Review Board could get involved if someone simply blows it off, but I've never seen that happen. Attendings in that situation will dump it all on their Residents. Some Attendings do that anyway."