Chapter 11: Michael Loucks, Emergency Medicine Sub-Intern

June 1, 1988, McKinley, Ohio

"How's it going, Mike?" Nate asked when I sat down at the triage desk on Wednesday morning.

"Getting used to the changes required by EMTALA," I replied.

"More paperwork," he said. "And it changed my duties, which is why you're here. The hospital lawyers wanted Residents to do triage, but cooler heads prevailed. Everyone is afraid of the liability if something is missed."

"So they assign it to med students?"

Nate nodded, "You are completely immune to being sued personally, and you're working on the Attending's license. As strange as it sounds, the separation is enough to make the liability lawsuit more difficult."

"Wonderful," I said. "How are patient volumes?"

"Up about twenty percent because word is getting out that you don't have to pay if you're treated here. Not that we can't bill them, but we can't ask, not even for an insurance card, until we evaluate them and provide initial treatment. We have to treat and try to collect later."

"We are a public hospital," I replied. "But I know the money has to come from somewhere."

"Printing presses, if you're the Feds!"

"It sure seems like it," I replied.

"You can refuse to answer, but whom are you voting for?"

"I'm tempted to write in Mickey Mouse and Donald Duck!" I replied. "I don't like either Bush or Dukakis, though Dukakis isn't the nominee just yet."

"It's a foregone conclusion," Nate said. "Jesse Jackson won't get the nomination. Heck, Dukakis won't even choose him for VP. I was for Gary Hart, but denying an affair then getting caught with a girl on a boat named the Monkey Business proved he was too stupid to be president!"

"I'm not sure that's a barrier," I said, shaking my head.

"Hi," a woman said, coming up to the window that separated Nate's desk from the waiting area.

"How can I help you?" Nate asked.

"It's my mom," the woman said. "She's dizzy and doesn't recognize me. My husband and son are walking her in now."

"What's her name, please?" Nate asked.

"Jeannine Kelso," the woman said. "I'm Tiffany Franks."

Nate made an entry in his log.

"Any chest pains, sweating, or nausea?" Nate asked.

"No."

Those were the signs of an MI, which would have had her seen immediately.

"Any difficulty breathing?" Nate asked.

"No."

"All yours, Mike," Nate said.

I clipped a blank intake form to the clipboard, picked up a pen, got up, and went through the door to the waiting room just as a man and a younger man walked an elderly woman into the waiting room.

"I'm Mike," I said. "Please have a seat. I need to get some basic information. May I have her name and address, please?"

Mrs. Franks gave me her mother's name and address and I wrote them onto the form.

"Where am I?" Mrs. Kelso asked.

"Moore Memorial Hospital," I replied. "We'll take good care of you. Do you know your birth date?"

"What?" Mrs. Kelso asked.

"March 11, 1909," Mrs. Franks offered.

"When did the symptoms start?" I asked as I began filling out the triage form.

"The dizziness started this morning," Mrs. Franks said, "but she's been forgetful for a few days."

"How is her appetite?" I asked.

"Not very good, actually. She hasn't eaten much since the weekend. She says she's not hungry."

"Is she drinking enough?"

"I'm not sure, actually."

"Is she continent?"

"You mean, does she use the bathroom?" Mrs. Franks asked.

"Yes."

"She does."

"Has she been sick, injured, hospitalized, or seen a physician recently?"

"Her regular doctor about three months ago, and he said she was doing fine for a seventy-nine-year-old woman. She hasn't been sick, and I don't think she's been in a hospital in the past thirty years, at least. She had appendicitis when I was little."

"Has she fallen?"

"I don't think so."

"OK. I'll do a quick exam, then arrange for a doctor to see her."

"You aren't a doctor?" Mr. Franks asked.

"No. I'm a Sub-Intern, which is the last training phase before becoming a doctor. Sub-Interns do evaluations for non-critical patients. I have three years of medical training, plus an undergraduate degree, and I've been taught to do this, as well as suture, insert IVs, and other procedures."

"OK," he agreed.

I checked Mrs. Kelso's eyes with my penlight, then listened to her heart and lungs. I took her pulse, then retrieved a rolling BP cuff and meter from a small alcove. I took her BP, wrote it on the correct line on the form, then ran through the checklist of observed symptoms.

"I'll be back shortly," I said.

I left the waiting room and Nate buzzed me through the door. I went to find Doctor Gabriel, who was in Exam 3.

"Ready to present," I said when he looked over at me.

"Go ahead."

"Jeannine Kelso, seventy-nine; daughter reports dizziness as of this morning and cognitive issues for a few days; BP 140/100; pulse 80; resps regular; pupils equal and sluggish; continent; appears well-nourished, but daughter reports she's not eaten well since Sunday; fluid intake unknown."

"What cognitive issues?"

"She didn't know her birthday when I asked and asked where she was. Her daughter reports she didn't recognize her this morning."

"What are you thinking?"

"Differential is dehydration and lack of caloric intake; stroke; subarachnoid hemorrhage; or, subdural hematoma. No reported falls or injuries."

"What would you do?"

"CBC and Chem-20. If her electrolytes are low, which I strongly suspect they are, then oral rehydration, if possible, otherwise via IV. Monitor for any signs and symptoms of an intracranial bleed."

"Mixture for oral rehydration?"

"2.6 grams of sodium chloride, 1.5 grams of potassium chloride, 2.11 grams of sodium citrate, and 13.5 grams of glucose dissolved into a litre of water. If IV, then Ringer's lactate."

"Why not give her Ringer's to start with?"

"I prefer to minimize invasive procedures," I replied. "In this case, I don't believe there is sufficient risk to hook her to a cardiac monitor, nor to give her an IV if we can get her to drink the solution. If not, I'd order the IV."

"Approved. Use Exam 4. Fill out a chart and bring it to me to sign. OK to provide her with fluids before I sign the chart."

"Right away, Doctor!"

I went back to the desk, grabbed a blank chart filled it out, clipped my intake sheet to it then let Nate know I'd be using Exam 4, and that I should be less than five minutes and that he should call me if he needed me. I got a wheelchair and took it out into the waiting room.

"We'll take your mother into an exam room now," I said.

Mr. Franks and his son helped his mother-in-law into the wheelchair and I pushed it through the door Nate was holding. Nurse Peggy followed us into Exam 4, where we helped Mrs. Kelso onto the examination bed, and I raised the back so that her head was elevated.

"CBC, Chem-20, and some water to drink, please," I said to Nurse Peggy, then turned to Mr. and Mrs. Franks, "We believe your mother is dehydrated. We're going to run some blood tests, and if they show what we expect them to show, we'll give your mother oral rehydration therapy, which is water and electrolytes, as well as glucose. I suspect her blood glucose is low as well, which we'll see from the tests."

"Will a doctor examine her?" Mr. Franks asked.

"Absolutely. He'd do exactly what I've done, and I confirmed the tests and the proposed treatment. Once the test results are back, he'll review them, then come see your mother. Nurse Peggy will draw blood and make sure she's comfortable. We don't believe she's in any immediate danger."

"Thanks, Mike," Mrs. Franks said.

"Peggy, bring me the lab results when they're ready, please."

"Of course, Mike. I'll send Lauren to get them."

"Third year?" I asked.

"First day of her first Clerkship."

"Thanks."

Just as I sat down, the outside doors to the waiting room opened and an obese, middle-age man came through them.

"He'll go right back," Nate said. "Use Exam 1."

"Obese, sweating, and grasping his left arm," I observed. "Classic MI signs."

I got up and thought about a wheelchair, but I wasn't sure he'd fit comfortably, so I dispensed with that idea and went to the door to the waiting area and held it open.

"Come this way, Sir," I said.

He came to me and I led him to Exam 1.

"What seems to be the problem, Sir?" I asked.

"I think I'm having a heart attack," he said.

"Alice!" I called out to the Charge Nurse. "I need a doctor and nurse immediately for a rule-out MI."

"OK, Mike," she replied.

"What's your name, please?" I asked.

"Jim Callaghan," he replied.

"How old?"

"Forty-nine."

"When did the chest pains start?"

"About twenty minutes ago. I was on my way to work and drove here instead."

"Let's get you onto the exam bed," I said.

It took a serious effort for him to get onto the exam bed, but when he was settled, I set about hooking up oxygen and put a mask on him with a flow of five litres per minute. Doctor Gibbs and Nurse Ellie came in with a male medical student.

"What do you have, Mike?"

"Jim Callaghan; age forty-nine; chest pains; stated he believes he's having an MI. Brought him straight in; oxygen five litres by mask. Was about to get vitals."

"We've got it. Thanks!"

I left and went back to my desk and a few minutes later, a cute medical student with long black hair came up to me.

"Mike? I'm Lauren. I have Mrs. Kelso's labs."

"Thanks. How is your first day going?"

"I'm doing scut, what else?"

"That's how it starts. Hang in there. What specialty do you want?"

"I haven't decided yet. OK to ask you questions?"

"Of course. Just find me when I'm free."

"Thanks!"

She left, and I reviewed the lab results, which were what I had expected. I went to see Doctor Gabriel to report.

"I have Mrs. Kelso's labs," I said.

"Go ahead."

"Her symptoms are completely explained by the results. All electrolytes are below the normal range for her age, though none dangerously so. Her blood glucose is 68, which is consistent with lack of caloric intake, as reported by her daughter. I recommend oral rehydration, if possible, otherwise IV Ringer's, and a visit from a social worker with the family about proper care."

"I concur. Introduce me, then you can return to your duty station."

We went to the room where Nurse Peggy was with the patient and her family.

"Mr. and Mrs. Franks, this is my supervisor, Doctor Gabriel. He's reviewed the lab results and confirms what I described before about your mother's symptoms being related to not eating and drinking enough."

"Thanks, Mike," Doctor Gabriel said.

"You're welcome," I replied and left as he began speaking to the Franks.

The rest of the morning was relatively calm, with a steady stream of walk-ins, but not so many that we were overloaded. Clarissa, whose shift in Internal Medicine ended at 10:00am, stopped by to say 'hi' on her way out, but I didn't have much time to speak with her as I was busy with triage. At noon, I met Maryam in the cafeteria for lunch.

"I saw you when we came down for the rule-out MI," she said. "But you were busy."

"How is he?"

"He had a fatal MI just as we rolled his gurney off the elevator. We worked on him for twenty minutes, but an extra hundred pounds, a history of smoking and drinking, and lack of exercise did him in. His blood glucose was 250, so he likely had untreated Type 2 diabetes."

"Forty-nine," I said, shaking my head.

"Doctor Strong's comment was that there are quicker ways to commit suicide."

"Mike?" I heard from behind me and turned to see who it was.

"Hi, Lauren," I replied.

"OK to join you?"

"Sure. This is Maryam Khouri, Fourth Year. Maryam, Lauren; sorry I don't know your last name."

"Nichols," she replied.

"Maryam is planning on cardiology and I'm planning on trauma surgery," I said, then turned to Maryam. "Lauren hasn't decided on a specialty as yet. This is her first day of her first Clerkship."

They greeted each other, and we had a nice chat during lunch, then Lauren and I walked back to the ED together.

"Is she your girlfriend?" Lauren asked.

"She's part of my study group and is a close friend," I replied. "She's helped a lot since my wife died."

"I heard about that last Fall! It was so sad! You have a daughter, right?"

"Yes. She's in the hospital daycare."

"I don't know how you do it! It's tough just managing medical school."

"In the end, we all do what we have to do to be successful, both as future doctors and, in my case, as a parent. Ultimately, we all make sacrifices, which I'm sure you know."

"I have trouble just managing my own life, let alone having an infant to take care of!"

"Necessity breeds action," I replied. "And I've had plenty of help from friends and family. Earlier, you said you were from Kentucky. Were you born there?"

"Yes. Harlan County, one of the poorest counties in the US because the coal economy tanked in the 50s. A lot of people moved away, and the county has about half the population it did in 1950. It has one of the lowest life expectancies of all counties in the US."

"Do you plan to go back?"

"There isn't a full teaching hospital anywhere in Harlan. Access to healthcare is poor, and the entire area is served by small regional hospitals who take very limited numbers of Residents."

"Similar to my hometown, one county west of here. The advantage is that Cincinnati, Dayton, and Columbus were all relatively close, and we've had air ambulance and paramedic service for six years."

"Knoxville is about a hundred miles and Lexington is about a hundred and fifty. If I were to go back, it would have to be internal medicine or emergency medicine, though there isn't even a Level II trauma center in the region."

"Don't want to be a GP?"

"If I were willing to take chickens or a pig in exchange for medical care! Well, that and Medicare and Medicaid, for those who qualify. I'm not sure where I'll apply for Residency, but I think I need to decide 'what?' before 'where?' When did you decide on emergency medicine?"

"Fourth grade," I replied. "But I'm actually going for a newly designated Residency — trauma surgery."

"What exactly is that?"

"A Residency in general surgery combined with an emergency medicine Residency. I'll be assigned to the ED but supervised by the Chief of Surgery. It's an ED role which allows me to do more procedures than a regular ED doc."

"I've never heard of that."

"It's modeled on programs developed at Indiana University and University of Chicago. There's only one slot being created as a test, and if it works the way they intend, they'll add more in the future."

"How does it work?"

"Two years in the ED, then a general surgery Residency, but covering the ED for consults, there'll be another year in the ED mixed in there as well, for a total of eight or nine years, depending on a Fellowship. The next slot would be two years after I start, or three years from now. May I ask what electives you chose?"

"I didn't. I left them blank and will fill them in next March. Any suggestions?"

"An emergency medicine Sub-I can't hurt and will help in just about any specialty you choose. Beyond that, it really depends on what you want to do."

"Thanks," Lauren said as we arrived back in the Emergency Department and I went to find Doctor Gabriel.

"Got one for you already," he said. "Forearm lac in Exam 2. Nurse Ellie will assist."

"I'll take care of it."

I left and went to Exam 2, took the chart from the rack, then entered the room where Nurse Ellie was with a man in his early thirties.

"Hi, Mr. Tomkins," I said. "I'm Mike. Doctor Gabriel asked me to suture your arm."

"Hi," he replied. "They send the JV?"

"I'm a Sub-Intern, the last training phase before I'm a doctor. I've done dozens of these."

"He'll leave less of a scar than most of the docs," Nurse Ellie said. "He's good!"

"Thank you, Ellie," I said, going to the sink to wash my hands.

I put on gloves, then moved next to Mr. Tomkins to examine his arm.

"Ellie, I think we'll need eight sutures," I said, "May I have a suture kit with 4–0 nylon, please? I'll also need saline, an irrigation syringe, a basin, a syringe with a 25-gauge needle, lidocaine, Betadine, and a stick swab."

"I have everything ready for you, Mike," Ellie said with a smile, rolling a tray with all the items on it next to the exam bed.

"Thanks! Mr. Tomkins, do you have any allergies?"

"No."

"Have you ever had a bad reaction to anesthetic, including when you've had dental work?"

"No."

"Any family history of asthma?"

"None."

"Then, if you'll lie back, I'll get you stitched up and out of here as quickly as possible. Mind if I ask how it happened?"

"Training a moron kid in the shipping room. He wasn't paying attention and slashed me with a box cutter. I fired him before I came here. He wrecked 413 days without an injury at the paper mill."

"That's rough," I replied. "I'm going to inject lidocaine into the wound," I said. "It'll sting or burn a bit at first, but it'll quickly go numb and other than a bit of pressure, you won't feel the sutures."

Twenty-five minutes later, Doctor Gabriel checked my work and signed the discharge form for Mr. Tomkins. I checked the board and saw there were three patients waiting to be seen, two with minor injuries and one with a sore throat. Treating them took up the next three hours, with one of the injuries requiring a cast, which I did with Ellie's help. The sore throat appeared to be strep, so I called Doctor Gabriel to examine the patient and prescribe antibiotics, though the lab test would take overnight to confirm the diagnosis.

"Good job today," Doctor Gabriel said just before 6:00pm. "Feel like a doctor?"

"I certainly enjoy working semi-independently, even if it's on simple cases."

"Walk before you can run," Doctor Gabriel said. "I know you know that. Remember, it's all about building trust with your Residents and Attendings. A year from now, when someone says 'Doctor Loucks', they'll know they can trust you to either provide the correct care or call for help when you need it. You'll see the difference between you and someone who Matches here from another medical school right off the bat."