Chapter 13: An Offer to Play House

June 6, 1988, McKinley, Ohio

"Ready to catch ambulance runs today?" Doctor Gabriel asked when I arrived in the Emergency Department on Monday morning.

"I am!"

"Paul and Nina are catching triage and walk-ins, and Melanie is the Fourth Year with us."

"Things seemed to have changed significantly with EMTALA."

"And more changes are probably coming. Third Years now pretty much only get scut — running labs, drawing blood, suturing, and so on. We'll try to make some exceptions for students who've already decided on emergency medicine, but given the rules for evaluation and treatment, except in extremis, Third Years won't do triage or work ups. That's why we only have two at any given time."

"I'm glad I had my Clerkship before those changes," I replied.

"More changes are coming; this is just the first attempt. I suspect it'll change within months."

"As the curse goes — 'May you live in interesting times'."

"True! Let's go over the basic intubation procedure. What drugs do we use?"

I'd reviewed the procedure and best practices the previous week when I'd had the time while sitting at the triage desk.

"Etomidate, at 0.3 megs per kilogram of patient weight. It's quick onset and lasts anywhere from three to twelve minutes. Succinylcholine at 1.5 megs per kilogram. It's also quick onset and lasts five to ten minutes."

"Good. Contraindications?"

"None for Etomidate. For Succinylcholine — hyperkalemia, wide QRS on the EKG, or burn injuries. An alternative would be used in those cases, or simply dispensed with if possible."

"How do you position the head?"

"In the 'sniffing position'," I replied. "The patient's head is elevated to a height of about ten centimetres, the neck is mildly flexed at the lower cervical vertebrae and extended at the atlanto-occipital joint."

"Next?"

"Select the correct endotracheal tube based on the patient's physiology, then gently open the patient's mouth, insert the laryngoscope blade, and slide down the right side of the mouth until the tonsils are visible. Move the blade to push the tongue centrally until the uvula is visible. Next, advance over the base of the tongue until the epiglottis is seen. At that point, advance steadily until the tip of the blade is at the vallecula and the epiglottis is visible below it. Lift gently forward and upward to raise the epiglottis and reveal the arytenoid cartilages and vocal cords.

"Once the cords are visible, insert the tube in the groove of the laryngoscope and slowly advance it. Once the tip of the tube is at the glottis, remove the stylet and gently advance until the cuff is past the vocal cords. Inflate the cuff to protect the airway from secretions and form a seal around the tube. Then confirm correct placement of the tube."

"How do we do that?" Doctor Gabriel asked.

"Attach a ventilation bag or ventilator and ventilate at about ten breaths per minute. Observe chest expansion and auscultate to confirm correct positioning by listening for bilateral lung sounds. If sounds are heard in only one lung, withdraw the tube slowly until sounds are heard in both lungs. If no sounds are heard, the tube is misplaced and should be removed. Bag the patient, then reinsert the tube correctly."

"Exactly right," Doctor Gabriel said with a smile. "One tip, and it's not always in the textbooks, is to never rock the scope because you could damage the patient's teeth. The other thing which you left out is you need to clear blood, mucous, or vomitus from the patient's mouth and throat. Otherwise, a textbook answer, which I would expect from you."

"Well," I grinned, "I'm going to put this in the same category as sex. Just because you've studied the technique doesn't mean you'll get it right the first time! Book learning isn't all it's cracked up to be when it comes to actually putting that learning into practice!"

Doctor Gabriel laughed, "An interesting way to make an important point. And I agree with you about it in both instances!"

"Anything you need me to do?" I asked.

"No. Feel free to pitch in if anyone asks, but you're primary on ambulance duty."

As if he'd uttered an incantation, Nurse Jenny called out that the paramedics were three minutes out with a possible MI. We quickly put on gowns and gloves and headed for the ambulance bay, along with Nurse Angie and a nursing student, Noelle.

"Jack Preston; male; fifty-two; diaphoretic; complains of chest pains and shortness of breath. Pulse 120; BP 90/50; resps labored at twenty-two; PO₂ 90 on 10 litres; ST elevations on the field EKG; saline IV TKO."

The field EKG was a new development for our paramedics, despite having been shown on Emergency! nearly two decades in the past.

"Trauma 1!" Doctor Gabriel ordered. "Mike?"

The paramedics began pushing the gurney to Trauma 1

"Cardiac enzymes; 5-lead; nitroglycerin for pain; cardiology consult for immediate transfer to the cath lab."

"Angie, nitroglycerin sublingually and stat cardiac enzymes; Mike, O₂, monitor, and EKG. Noelle, page Cardiology, stat. Let's go, people!"

We got Mr. Preston to Trauma 1 and the two paramedics, Doctor Gabriel, and I, moved him to the trauma bed as Lauren came into the room. I hooked up an oxygen mask to the building system, put it on Mr. Preston's face and adjusted the flow to match the ten litres per minute the paramedics had used.

Next, I removed the four pads from the field EKG and replaced them with the five I needed, then quickly connected the wires, ensuring I didn't have any crossed or reversed. I hit the power on the EKG, then connected the pulse oximeter to Mr. Preston's finger.

"Confirm ST elevations," I said. "PO₂ is 88% on ten litres; pulse 130."

I grabbed a blood pressure cuff and quickly checked Mr. Preston's BP.

"BP is 80/50," I said.

"Abbott, Cardiology," Doctor Barbara Abbot said, coming into the trauma room with Maryam following her.

"Mike, vitals bullet, please," Doctor Gabriel said as he continued his exam.

I repeated what I'd just announced.

Doctor Abbot took one look at the EKG and said exactly what I'd expected, "Cath lab, stat!"

"Mike, go with Doctor Abbot and her student, please," Doctor Gabriel said.

I smiled at Maryam, then unhooked the oxygen tube and connected it to a portable bottle, then removed the EKG monitor from the stand and put it on the trauma bed. I made sure no wires were dangling and Maryam and I pushed the trauma bed out of Trauma 1 following Doctor Abbot.

"HOLD THAT ELEVATOR!" she ordered as we got close.

Everyone who was in the elevator cleared out and we rolled the trauma gurney into it, rode up to the second floor, and quickly pushed the gurney to the catheterization lab where Doctor Getty was waiting with two nurses. Five of us moved the patient to the treatment table, and I disconnected the ER equipment while the Cardiology nurses began prepping the patient for an examination and probable catheterization.

I pushed the gurney from the lab, headed for the elevator, and rode back down to the ground floor, returning the gurney to Trauma 1 so that the nurses could prepare it for the next trauma. I returned the monitor to the stand, then went to find Doctor Gabriel.

"He made it to the cath lab OK?" Doctor Gabriel asked.

"So far, so good," I replied. "I'm positive he has significant blood vessel blockage. He's lucky he made it so far with a STEMI."

"It's all about how quickly they can get to us, and then if it's possible to perform a catheterization."

"They had the fluoroscope ready, and Doctor Getty was waiting, so hopefully this one will go better than the walk-in last week."

We had three more ambulance arrivals, two of which were accident victims transported as a precaution, and the third was a young girl in anaphylactic shock from a bee sting. Someone had administered epinephrine by EpiPen, something which was relatively new. It had certainly saved her life, but it was touch and go for about thirty minutes before she was breathing reasonably normally and we could have her admitted to Internal Medicine.

Maryam and I met for lunch, and as had become routine, Lauren Nichols, the Third Year, joined us.

"How is Mr. Preston?" I asked.

"Lucky," Maryam said. "By all rights, the occlusion should have been fatal. He has serious damage to his heart, but Doctor Getty thinks he'll survive and be a candidate for a transplant."

"That's a fairly long waiting list," I replied.

"It is," Maryam agreed. "And most patients on the list die before getting their hearts, but Doctor Getty thinks Mr. Preston will live long enough that he should get a heart."

"Smoker? Drinker?" I asked.

"No nicotine stains on his fingers and his BA was zero, but neither of those mean anything for sure. We don't know his family history yet. He'll be lucid enough to talk around 1:00pm, assuming he comes out of the anesthesia OK."

"There must be a huge curve in education," Lauren said. "What you guys are routinely discussing is almost like a foreign language."

"There is," I replied. "The books are good, and anatomy lab is great, but in the end, you learn by observation and by doing. There's a quote I've memorized, and I've also used a few times to ensure I get the training I need — Sir William Osler, co-founder of Johns Hopkins Hospital, and the doctor who created the first Residency program wrote 'Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words in the lecture room or read from the book. See, and then reason and compare and control. But see first.'"

"But we hardly get to do anything except scut," Lauren protested.

"Yes, but you're able to observe, take notes, and ask questions. Do that. And ask to be taught to do things. Your best bet is to go to one of the Residents with whom you're comfortable and talk to them about being allowed to do more. It will also help if you decide what specialty you want and let it be known, because then you'll get more procedures on that service."

"I just don't know," Lauren replied. "I want to do as many of my rotations as possible before I have to pick my electives."

"Then speak with Doctor Gabriel or Doctor Casper. Both of them are approachable, and ask them to allow you to participate in traumas, including things like inserting IVs, hooking up monitors, and so on. Show that you can do those things and you'll very likely get chances to do more."

"You have to be assertive," Maryam said. "You are responsible for your training as much as the doctors are. If you don't push, they'll give you the minimum to do, and that will hurt your progress compared to your peers."

"I thought they were supposed to teach us!" Lauren protested.

"They are, but the primary job of a doctor in the ED is to quickly treat patients and have them admitted or discharged. Teaching gets in the way, if you will. And not every Resident is a good teacher. Remember, too, that a PGY1 has exactly two more years' experience than you do, or in Maryam's and my cases, one year. If they aren't good teachers, that, combined with lack of experience, will make them want to, in effect, do it themselves."

"That is not what I expected," Lauren said.

"Me either," I replied. "But a combination of mentors and my own observation made it clear. I believe Maryam concurs."

"I do," Maryam confirmed.

We finished our lunch and Maryam went up to Cardiology while Lauren and I walked back to the Emergency Department.

"Thanks for letting me eat lunch with you and Maryam and for talking to me," Lauren said.

"You're welcome."

"OK to say that you suggested I speak to the doctors?"

"Absolutely."

The afternoon was busy, but I didn't have a chance to do an intubation. When my shift ended, I collected Rachel from daycare, where she seemed to very much enjoy being, then headed home to meet Maryam for dinner and a quiet evening together.

June 9, 1988, McKinley, Ohio

It wasn't until Thursday that I had a chance to do an intubation on the victim of a head-on collision.

"Don't rush it, Mike," Doctor Gabriel said as I began by sweeping the patient's tongue aside with the blade of the laryngoscope. "Thirty seconds is a LONG time."

I nodded and continued to call out the steps as I completed them, getting the tube in place. Nurse Angie attached the ventilator while I listened to the patient's lungs with my stethoscope.

"Good breath sounds bilaterally," I said.

Doctor Gabriel checked and nodded, "Agreed. Check reflexes, please."

I did, as Doctor Gabriel and Nurse Angie continued their exam, and unfortunately for the patient, found indifferent Babinski signs on both feet.

"Vanderberg, Neuro," Doctor Lucy Vanderberg said, coming into the room with a student.

Doctor Gabriel gave the report and after a quick exam, Doctor Vanderberg accepted the patient onto her service, but straight to the OR for a decompressive craniectomy.

"A little slow," Doctor Gabriel said after the patient had been taken to the OR by orderlies. "But being deliberate the first few times is good."

"I was a bit nervous," I replied.

"That was true when you did your first Foley and your first sutures, right?"

"Yes, though more this time than with those. Taking extra time with sutures or a Foley isn't life-threatening the way it could be with an intubation."

"Repetition will build confidence; the key is not becoming overconfident. THAT is when things will go to Hell every time. Given your choice of specialty, you should learn to do central lines, but that requires a surgeon or cardiologist. The same is true for needle aspirations for pericardial tamponade. We have to call Cardiology or for a surgical consult for those, but I'll strongly suggest you be taught as soon as possible."

"Thanks."

"Remember your responsibility a year from now — teaching means not doing procedures you want to do so your student can gain experience. Not all of them, of course, but enough that you both gain experience. When you feel very comfortable with a procedure, you can just do it occasionally to keep practice."

"Suturing?" I asked.

Doctor Gabriel laughed, "Generally, no, but we could. I've done a few now and again just to keep my skills from atrophying too much. The same with IVs and Foleys. Mostly, those are when we're seriously overloaded and stretched thin."

"I'm not sure about the changes for Third Years," I said.

"Me, either, but this is where we are until legal and medical administration figure out the ramifications of the changes in the law. And from what I can tell, your Clerkships were atypical because Doctor Gibbs took you under her wing, as did Doctors Roth and Strong."

"You know my take on that."

"I do. And when you're a Resident, you can bend the rules as you see fit. Bend, mind you, not break."

"I still find it strange that a year from now I'll be a Resident. It always seemed so far in the future, and now it's basically around the corner."

"From everything I've seen, you're going to make a fine physician, Mike. Just keep doing what you're doing."

"Thanks."

I sat down and updated my procedure book with my first intubation!

June 10, 1988, McKinley, Ohio

On Friday evening, after a busy day at the hospital, I took Rachel to my in-laws. Given how much Rachel was enjoying being in daycare and interacting with other toddlers, I'd changed my plans, and rather than taking her to my in-laws twice a week, we'd agreed she'd spend Friday nights with them, and I'd either pick her up on Saturday after band practice, or on Sunday morning, depending on my plans. That gave them time with her and gave me a break of at least one night per week.

Once Rachel was settled with Anna and Yulia, I spent a few minutes with Viktor, then headed home for my evening with Oksana. She arrived about fifteen minutes after I did with a crock pot of vegetable stew with lentils, bread, and salad, a perfect fasting meal, even though I wasn't keeping the Wednesday and Friday fasts strictly.

"Rachel isn't here?" Oksana inquired when I carried the crock pot in from her car.

"No. She's going to spend Friday evenings with my in-laws. She likes daycare so much, and she interacts with the other kids, so I felt it was better to keep her there, and then have Friday nights off. This weekend they'll keep her until Sunday morning because Code Blue is playing a wedding gig tomorrow night."

Oksana put the bread in the oven to warm it, and plugged in the crock pot, then put the salad in the fridge.

"About twenty minutes," she said.

We went to the great room and sat on the couch together.

"Have you thought more about what you asked to do?"

Oksana laughed softly, "It's all I've thought about for the past ten days!"

"I do need to ask what you meant when you said you wanted to do it 'my way'."

Oksana blushed slightly, bit her lower lip, then said, "I'll do anything you want to do, even ... you know, with my mouth."

"Are you sure?" I asked.

"You have no idea the thoughts going through my head!" Oksana said with a nervous laugh.

"How long did you plan to stay this evening?" I asked.

Oksana smiled, "My parents are in Philadelphia visiting my dad's brother and his wife. I can stay the night. I want to sleep in your arms, if you'll let me."

"I will," I replied. "May I ask what happens after tonight?"

"My parents have a trip to California planned in July!" Oksana replied.

"And you want to play house?" I asked.

Oksana laughed softly, "That sounds fun! I just wish you wouldn't have to work so much for the next ten years. Things might have turned out differently."

"Just the other day I said something to one of the doctors who is training me that I couldn't believe I'd be a doctor in a year, but you're right that I'll still be training for another ten years or so. Just seven years ago, it seemed like forever until I graduated from medical school; now it's less than a year away."