Chapter 44: Like Mother, Like Daughter

October 3, 1988, McKinley, Ohio

"Mike Loucks, Fourth Year," I said to Krista, the clerk sitting at the Pathology desk.

"Doctor McKnight is not here yet," she said. "He asked that you collect the labs, summarize them, and complete the toxicology report forms."

"I'll get right on that," I said.

"Use Locker #7."

"Thanks."

I went to the locker room and changed into the dark blue scrubs used by Pathology. I locked the locker, then headed to the lab to collect the Pathology lab reports. Once I had the stack of papers, I returned to Pathology, got the charts and the correct forms from Krista, and sat down at the desk in the small office to prepare summaries and toxicology reports.

Of the nine reports, only one showed anything of more than passing interest, and that was cocaine in the system of a twenty-one-year-old man who had died in a bar fight. The levels were high enough that it could have affected his heart, and the autopsy notes showed that he had, indeed, had a heart attack. I saw in the notes that the County Prosecutor was waiting for the results, which made sense. I carefully filled out the form with the details from the lab report, then clipped both into the chart.

"Morning, Mike," Doctor McKnight said from the door of the office.

"Good morning, Doctor McKnight. I have the summaries, the charts, and the necessary tox screen form completed."

"I was sure you'd have no trouble with them. Doctor Lawrence is in Autopsy B, if you'd join her. She's going to do orientation for our four Third Years, two on my team, two on her team. Once that's finished, you and two of the Third Years join me in Autopsy A."

"Will do," I said.

I handed him the charts and went to Autopsy B.

"Mike Loucks," I said to Doctor Lawrence. "Fourth Year."

"Claire Lawrence," she said. "PGY1. Nice to meet you. These are Laurie, Will, Stan, and Walt, Third Years."

I greeted each of them, then listened as she went over procedures and policies, all of which I was familiar with from my stint in Pathology as a Third Year. After she completed the introduction, we went to the desk so that Krista could make copies of our driver's licenses, which were needed because, in some cases, what we were doing was collecting evidence. Once that was done, Doctor Lawrence sent Laurie and Walt with me to Autopsy A to join Doctor McKnight.

"Mike, would you please take Laurie and Walt and retrieve Ms. Mosley from unit #3?"

"Right away, Doctor," I replied, then turned to the Third Years and said, "Follow me."

We went down the hall to the room with the refrigerated drawers, moved a gurney in front of unit #3, then opened the door.

"This slides out, then we move the body to the gurney," I said, grabbing the handles on the drawer and sliding it out all the way. Laurie and Walt helped me move the body onto the gurney, I closed the door to the unit, and then we wheeled Ms. Mosely into Autopsy A. Once we were there, we moved her body to the autopsy table, I removed the sheet, then placed modesty cloths across her breasts and groin. I then picked up the chart.

"Rebecca Mosley, twenty-three; presented in the ED with severe anaphylaxis; treated with intramuscular epinephrine times 3; went into V-fib; defibrillated times 3; asystole; CPR and adrenaline times 2 failed to revive her."

"Ms. Lewis," Doctor McKnight said to Laurie, "What is anaphylaxis?"

"A rapid onset condition due to allergic reaction," Laurie replied.

"Possible causes, Mr. Jones?" Doctor McKnight asked Walt.

"Any number of things from medication to insect stings to food," he replied.

"Mike?"

"She has a MedicAlert bracelet, so that's where I'd begin."

"Go ahead."

I carefully removed the bracelet from Ms. Mosley's arm and flipped it over to read the engraving.

"Penicillin and procaine allergies," I read, "and asthma."

"We'll need to call for her medical records," Doctor McKnight said. "Laurie, you do that, please."

"Where do I call?" she asked.

"Call MedicAlert, give the ID number on the bracelet, and they'll provide you with anything they have via fax. They should have her physician's name as well. Krista at the desk can assist."

"OK," Laurie said.

I handed her the bracelet, and she left the room.

"Mike, we'll begin. Would you put a fresh tape in the cassette recorder and then scribe for me while I do the gross exam?"

"Yes, Doctor."

"Walt, you shadow Mike because you'll be scribing after today."

Two hours later, with the autopsy complete, Doctor McKnight signed the forms I'd scribed.

"Do you have any thoughts, Mike?"

"I'll state the obvious, and say she had an MI due to severe anaphylaxis. Without the endotracheal tube inserted by the ED, she would have asphyxiated. The cause of the anaphylactic shock has to wait on the tox screen because the needle mark on her left arm was not the result of any recorded medical procedures by the paramedics or the team in the ED."

"What do you expect the tox screen to show?"

"You want me to speculate?"

"Yes."

"A single venipuncture isn't indicative of an IV drug user. It's entirely possible she had a blood draw yesterday afternoon, and that it's a false clue. An analysis of her stomach contents is more likely to reveal a cause than the tox screen because we found no signs of inhaled or ingested drugs. In addition, we found no insect bites or stings, including inside her mouth, nose, and ears. My speculation would be food, not drugs."

"A reasonable answer," Doctor McKnight said. "I concur that the tox screen will very likely come back negative, but I've been fooled before. The odds are very strong that it was something she ate. We'll know in a few days, once the tox screen and analysis of stomach contents is complete, or at least have a strong indication. Starting tomorrow, I'll have you do some of the dissection work, as well as the final sutures."

"Thanks."

"Return Ms. Mosely to unit #3 and notify Krista that the funeral home can pick her up at any time."

"Will do," I agreed.

Laurie, Walt, and I moved Ms. Mosley back to unit #3, and I let Krista know she was ready to be picked up. Per a new protocol, Laurie, Walt, and I went to the locker room to scrub our hands and forearms and change into fresh scrubs. Once that was done, Doctor McKnight asked us to bring in the next subject, which was a routine case of an MI due to underlying health problems — obesity, Type 2 diabetes, and high cholesterol.

"Short description of this individual's health?" Doctor McKnight asked.

"Train wreck," I replied. "Morbidly obese, uncontrolled Type 2 diabetes, and lipid levels off the charts. I think the only question is why he didn't have his fatal MI sooner than he did."

"Ms. Lewis, why do we do an autopsy when it's obvious why the patient died?"

"Because it's policy?"

"No. Mr. Jones?"

"I don't know."

"Mike?"

"Because what is obvious isn't necessarily the complete answer. We might, in this instance, find evidence of an underlying condition which caused his other medical problems. In cases with significant underlying conditions, we ask family permission for an autopsy for educational purposes and to further the practice of medicine. We might discover, for example, something his personal physician, if he had one, had missed."

"Good answer. Let's begin, please."

"Martin Peters, fifty-two; presented in the ED with no vitals; CPR by paramedics; no shockable rhythm, so pronounced DOA."

Just over two hours later, we'd found no indication of anything other than the obvious conditions, and after returning Mr. Peters to unit #4 and notifying Krista he could be picked up by the funeral home, Laurie, Walt, and I washed up, changed scrubs, then went to the cafeteria for lunch.

"You're at the top of your class," Laurie observed after we got our food and sat down, "so I know you aren't trying to Match for pathology. Why are you doing a Sub-I?"

"I plan to match for the new trauma surgeon Residency slot, and a pathology Sub-I is the only chance I'll have to use a scalpel between now and PGY3. Doctor Roth, my surgical mentor, suggested it, and I decided it was a good idea."

"That's a slick move," Walt said. "I want to match for surgery; do you think it would be a good idea?"

"Have you done a surgical rotation yet? I mean, besides your Preceptorship?"

"No. I've had Internal Medicine and Psych so far. Emergency medicine is next, then surgery."

"When you do your surgical rotation, let whomever your Resident is know that you're interested in surgery and discuss it with them. You should do your best to develop a relationship with that Resident, and seek their input and guidance. That will give you the best chance of success. What specialty interests you, Laurie?"

"Internal Medicine, because I want to go into private practice. My plan is to join my dad's medical practice in Austin."

"I assume you'll want to match in Texas to simplify licensing?"

"That's the plan. Any advice on how to survive this rotation?"

"If you know your anatomy, you'll be fine. Mostly you'll scribe or draw, follow-up on labs and specimen analysis, and, as with every other rotation, whatever scut you're assigned. Do what's asked, answer questions accurately, and you'll have a chance to actually do some cutting by the end of your rotation."

"What electives did you choose besides this?" Walt asked.

"Emergency Medicine times two; Surgery; Pathology; Cardiology; and ICU. The ED rotations are first and last. You should probably do one emergency medicine Sub-I and two surgical Sub-Is, but you'll work that out with your advisor."

We finished our lunch, then returned to Pathology, and our afternoon was similar to the morning, and at 6:00pm I collected Rachel from daycare, and we headed home.

When I checked the mail, I had letters from Ohio State and Indiana University inviting me to call to arrange for interviews. When I checked the answering machine, I had a message from Doctor Barton in Chicago inviting me to arrange an interview. He'd provided his home number, so once Rachel and I had eaten, I called him.

"Doctor Barton, it's Mike Loucks," I said when he answered.

"Hi, Mike. Thanks for calling back. I won't beat around the bush! What will it take to get you to interview with us here in Chicago?"

"I appreciate the offer, Doctor Barton," I said. "But I'm going to stay in McKinley. My entire support system is here, including friends, family, and church. In the end, I'm a boy from southern Ohio, and this is where I belong."

"I understand, but here, you'd have an opportunity to train with trauma surgeons, including Jessica Adams. I don't believe there are any trauma surgeons at Moore Memorial."

"There aren't," I replied. "But I believe the surgical and emergency medicine teams here will be able to train me."

"I don't dispute that, but don't you think it would be better to work with already trained trauma surgeons?"

"In a vacuum, yes; all things considered, no. I'd be unhappy in Chicago, and I wouldn't have my friends and family close by. You have yours with you, right?"

"Yes, my wife and kids."

"In my case, it's my parents, my sister, and my new half-siblings."

"Your parents divorced and remarried?"

"Yes. My dad and his wife have two young children, and my mom and her husband are fostering a girl who had a baby at fourteen and wanted to keep her. They're in the process of adopting the teenager."

"Belinda is my third wife, and I have other children, so I know about complicated families. I won't keep you, but if you change your mind anytime before the end of January, call me and I will make sure you have an interview."

"I really do appreciate the opportunity, Doctor Barton. Greet Jessica for me, and if she's ever in this area, have her look me up."

"I will. I'm sure you'll see each other at trauma conferences in the future. Keep in touch, Mike."

"Thanks, Doctor Barton."

"You're welcome."

We said 'goodbye' and I hung up, then read to Rachel before we said our evening prayers, and I put her to bed. I called Kris for our evening chat, filled her in on my day, she let me know about her day, and when we finished, I headed up to bed.

October 4, 1988, McKinley, Ohio

On Tuesday morning, we didn't have any autopsies to perform, so I had a chance to call and arrange my interviews with Ohio State and Indiana University. First, I went to Endocrinology and confirmed with Clarissa that she'd received her letters, which she had, and we looked over the calendar and agreed on a few possible days in the range provided by the letters. Once we'd done that, I returned to Pathology to place the calls and schedule our interviews.

That accomplished, I went back to the lounge, and a few minutes later, Doctor McKnight came in and let us know he had authorization for an autopsy, so Laurie, Walt, and I retrieved the subject from the refrigerated units, and brought him to Autopsy A.

"Laurie, you scribe," Doctor McKnight said. "Walt, give us the details, please."

"Lester Conway, thirty-two; found unresponsive by co-workers; transported by private ambulance; no vitals on arrival, no shockable rhythm, pronounced DOA. Blood chemistry shows lipids and blood sugar in acceptable range."

"A mystery for us, then," Doctor McKnight said. "Laurie, what would you look for?"

She thought for a minute.

"Stroke, ruptured intracranial aneurysm, ruptured aortic dissection, or ruptured abdominal aortic aneurysm."

"Mike?"

"Those are the obvious ones, barring traumatic injury or drug overdose. Given he was found unresponsive at work, chemical exposure is also possible."

"Then let's begin. You do the gross exam. I'll handle the cranium and step you through it. You'll do the chest and abdomen."

The first order of the autopsy was to note the medical equipment that was preserved along with the body.

"IV, left arm," I said. "IV bag contains about a half litre of clear fluid; bag is marked as lactated Ringer's. Venipuncture appears normal, and no evidence of it not being properly in the vein. OK to remove it?"

"Yes."

I did so, placing the bag, tubing, and needle on the counter.

"Endotracheal tube, external placement appears good."

"Verify placement with ultrasound," Doctor McKnight instructed.

I walked over to the ultrasound machine, rolled it close to the table, powered it on, set the controls, then spread gel on Mr. Conway's chest. Once that was done, I used the wand to locate the end of the trach tube.

"Textbook placement," I replied, looking at the image on the screen.

"Permission to remove it," Doctor McKnight said. "Ms. Lewis, please clean the ultrasound wand and return the machine to its storage spot."

I removed the trach tube and placed it on the counter, announcing that it had no obvious blockages so that Walt could record that.

"Five EKG pads, properly placed," I said. "OK to remove them?"

"Yes," Doctor McKnight agreed.

I did so, setting them with the other items. I then removed the modesty sheet so I could examine the catheter.

"Last item is a Foley catheter," I said. "It appears to have been properly inserted, and there is a small amount of urine in the bag, light yellow in color."

"Remove it."

I did so, then began describing the condition of the body so that Walt could record the details.

"Overall state of the body is grossly normal, with no obvious signs of trauma, and no obvious defects. Genitalia is properly formed and average in size."

I replaced the modesty sheet, then continued.

"Scar on his left forearm, just below his elbow; not recent. Scar on his abdomen consistent with an open procedure, and located such that it would appear to have been an appendectomy; also not recent. A tattoo of an anchor on his right forearm."

I retrieved an otoscope and several tips, and performed a basic examination of Mr. Conway's eyes, ears, and nose, finding nothing remarkable, with the sclera of his eyes being clear. Next, I examined Mr. Conway's mouth, seeing the first thing which was grossly abnormal.

"Significant tooth wear," I said.

"Indicative of?" Doctor McKnight prompted.

"Without a medical history, I'd suggest stress, which is a typical cause for grinding teeth, especially during sleep."

"What else could cause it?"

"Some neuromuscular diseases. In addition, stimulants have been reported as a potential cause," I replied, "but the evidence is scant, and I recall that no studies have reached any firm conclusions."

"What's the overall condition of his mouth?"

"Other than excessive wear, his teeth appear to be clean and cared for. I see what appears to be a recent filling."

"Based on?"

"It's resin, not mercury amalgam."

"OK. Continue."

"Tongue, gums, and palate appear grossly normal," I announced.

I moved on to check his fingernails and toenails.

"Fingernails are clean, trimmed, and not discolored," I said, then checked his feet and reported the same thing.

"What's your overall assessment?" Doctor McKnight asked.

"Overall, a healthy thirty-two-year-old male, minus the fact that he's on an autopsy table."

Doctor McKnight laughed, "That is a fairly major exception to being 'healthy'! So, given all of what you said, I find, grossly, no indication of disease or injury. Let's begin with the examination of the cranium and see if we can find what led to Mr. Conway's demise."

I watched as Doctor McKnight made the necessary incisions, moved the skin out of the way, and used a cranial saw to access Mr. Conway's brain, explaining each step of the procedure as he performed it.

"Blood in the CSF," Doctor McKnight announced. "Ms. Lewis, what is the significance of blood in the subarachnoid space?"

"A subarachnoid hemorrhage, usually due to an aneurysm."

"Pathology and mortality rate?"

"I don't know."

"Mr. Jones?"

"About twenty-five percent die before reaching the hospital; of those who do reach the hospital, more than half die within thirty days. It's more common among women than men, and is more common with age, though nearly half of patients are under sixty."

"Good answer. Mike, instance and treatment?"

"About one in ten thousand each year. Treatment depends on grade, with anything from monitoring to medication to control blood pressure to an external ventricular drain. Surgery is possible in some cases, and has been successfully performed since the 30s. Long-term prognosis is generally poor, as Walt noted, with mortality rates exceeding fifty percent, and those who do survive often have long-term effects of what is technically classified as a stroke."