Chapter 57: First Code

December 2, 1988, McKinley, Ohio

I was a bit disappointed at not going on the consult with Doctor Javadi, but the realization that I was responsible for fourteen patients quickly overcame any disappointment. It was true that Doctor Bielski was on duty, but he was sleeping, and that meant I was expected to deal with anything that arose, and to wake him only if a patient was dying. Anything else I was expected to resolve, or bring to Doctor Javadi's attention.

I left the office when she did and went to find Clarissa in the lounge, where she completed the handover. There was nothing remarkable, so we hugged, and she left to head home. My first task was to get a complete overview of the patients, so I went to the nurses' station and asked for all the charts.

Nurse Maggie handed me fourteen charts, which I took to the lounge to review. I wrote summaries into my notebook, and, finding nothing out of the ordinary, I returned the charts to Maggie, then went room to room to check the monitors. I knew nurses did that on a regular schedule, but I felt it incumbent on me to see for myself. I noted each patient's vitals in my notebook, then returned to the lounge.

"Mike?" Nurse Maggie said, coming into the lounge about fifteen minutes later. "Doctor Javadi is bringing up an MI; Room 29."

I nodded, "I'll meet her there."

I got up and went to room 29, which was actually 329, and verified that the cardiac monitor was in place. I also verified that the necessary supplies and equipment were available — EKG pads, nasal cannula, and IV kit. I found nothing missing, and nothing amiss, which meant the nurses had done their usual diligent work to ensure the room was prepared.

Doctor Javadi, John, and an orderly brought in the male patient about five minutes later, and we were joined by Nurse Steph and her student Beth. The six of us moved the patient to the bed.

"Steph, ten litres of oxygen by mask, please," Doctor Javadi requested. "Mike, show John how to hook up the monitors, please."

"Yes, Doctor!"

She began a repeat physical exam, and I waited for Steph to switch the patient from the portable oxygen bottle to the room oxygen. Once she'd done that, the orderly left with the gurney. The patient already had EKG pads, so we just needed to attach the correct leads to each pad. I had John do everything, guiding him each step of the way as he attached the EKG leads, the pulse oximeter, and the automatic blood pressure cuff. Once they were attached, I had him press the 'start' button, which initiated the measurements.

"ST elevations on the monitor," I said. "Pulse 80; BP 140/100; PO₂ 91%. STEMI?"

"That is my diagnosis," Doctor Javadi replied. "Steph, please get repeat labs — Chem-20, ABG, and cardiac enzymes. Do them again in two hours."

"Yes, Doctor," she replied.

"Mike, monitor the patient until I see the results of the labs. We'll do a cardiac echo in the morning. John, stay with Mike and listen to him."

"Yes, Doctor," I acknowledged.

"I will," John answered.

Doctor Javadi left, Steph did the blood draw and sent her student to take them to the lab. I pulled over a stool and sat down next to the monitor.

"This is your first cardiology Sub-I, right?" John asked.

"Yes."

"How did you learn to read an EKG such that you could make a diagnosis?"

"During my Clerkship, I asked Doctor Strong to teach me. I can teach you the basics, given we have about thirty minutes before the labs come back. You came on yesterday morning, right?"

"0500," he replied.

"Did you get any sleep?"

"No, and I probably won't because by the time we're done here, there will only be a few hours left on my shift."

"Pro tip — on shifts longer than twelve hours, sleep when you can, even if it's at odd times. Back to the EKG, do you know how to print a strip?"

"No, but I'm going to guess it's that button marked 'Print'!"

I chuckled, "You'd be surprised at how many people don't figure that out. Go ahead and press it, and it'll give you a six-second strip."

He did that, tore the strip from the monitor as I instructed, then offered it to me.

"Take a look and tell me what you know."

"Zero," he replied.

"I disagree. What's his pulse, and I don't mean from the digital display on the monitor screen?"

"It's a six second strip, and there are," he counted, "eight peaks, so 80. Why does the monitor show 82?"

"Think about that and tell me."

"Uhm, because his heart rate is variable, and we're just looking at a six-second strip."

"Correct. What else do you see?"

"Well, the distance between the peaks isn't identical, and the, uhm, wave form, I guess, isn't the same for every peak."

"Good. Variability is normal, even for healthy people. It's when there is wide variability that it becomes a concern. What else can you determine?"

"I honestly don't know what I'm looking at beyond the perfunctory information we had in class."

"Use your powers of deduction. What do you know? Think back to algebra."

He pondered for a moment, then nodded.

"If the strip is six seconds long, then I can see that there are," he counted, "30 larger blocks, so they must be about a fifth of a second long."

"Exactly. And a bit more math tells you the smaller blocks are about four hundredths of a second. The vertical measurement can't really be deduced, so I'll tell you that ten small blocks in height are a millivolt."

"Got it."

"What do you know about a heartbeat?" I asked.

"Just what we were taught in class, really, which isn't all that much, at least with regard to an EKG."

"There are three important points in a heartbeat — Q, R, and S. The Q-wave is this downward dip immediately before the spike. That spike, the R-wave, is the tallest spike on the strip. Following the spike is the S-wave, which is a dip below the baseline. You'll also see a small peak before the Q, which we call P, and one following the S, which we call T.

"These peaks are irregular, which you noticed, and is your first clue something might be wrong. You can use this method both for regular or irregular heartbeats. With current monitors, we mostly just look at the numbers, but you can find the box-counting method in your cardiology textbook, and you'll need to know it for your exams. I hope you bought it."

"I did, but I haven't cracked it open yet."

"Another pro tip, read ahead. You should have started reading the cardiology text two weeks ago, and then you'd know most of what I just said."

"Sorry."

"No need to apologize; now you know. What clinical rotations did you have before this one?"

"Pediatrics, Psych, and Internal Medicine."

"Cardiology and surgery are very different from those three in that you absolutely cannot survive without reading the specific textbooks. For surgery, you need to read up on the procedures the night before because you will be quizzed. Being unprepared will cause you to receive a poor evaluation, and could cause you to fail. For your first shift, call the night before and ask the duty nurse which procedures will be done. That will show you have initiative."

"I'd have never thought of that."

"Neither did I, and nobody told me. Remember that, and pass on the knowledge."

"Will do."

"Do you know what STEMI means?"

"No."

"It's an ST-Elevation Myocardial Infarction. Think about what I've said, and tell me where you would look on the strip."

"The S and T waves, right?"

"Yes. Those are the ones that follow the highest peak, or R. We don't have a normal strip to compare this to, but on this one, the ST segment is elevated. It's about three times as high as it ought to be. In addition, on this strip, we see a wider than normal QRS complex."

"You didn't say that when you gave the readouts."

"That's true, because I had a fairly good idea what was going on. The nurse told me Doctor Javadi was bringing up an MI, so it was a matter of which type. Because the QRS complex was about 0.1 seconds in duration, that meant most likely it was not a bundle branch block. Your textbook will have more examples, and you should talk with Doctor Strong or Doctor Javadi and get them to show you actual sample strips and work through them with you."

"You can know specifically what's wrong simply from the EKG?"

"Notice I said 'likely', and that's why Doctor Javadi ordered more tests, along with planning a cardiac echo in the morning. She'll also put him on a 12-lead, which provides even more information. For now, we keep him stable, the nurse administers the appropriate drugs, and we watch and wait."

"That's it?"

"That's it. Doctor Javadi either doesn't think he needs the cath lab or that he's not stable enough. My guess is not stable enough, because if you look at the monitor, you see the P-wave is varying, which is a sign of atrial fibrillation. Hand me the chart, please."

He took the chart from the table and handed it to me. I scanned it.

"They gave him ASA in the ED," I replied. "You know what that is, right?"

"Aspirin, basically."

"Yes. And his cardiac enzymes are consistent with a moderate-to-severe MI. The chart says to give him heparin in the case of continued A-fib, so I need to see the nurse. Stay here, and if the monitor alarm goes off, call a code. You know how to do that, right?"

"Dial 333 and give the room number."

"Yes. And start chest compressions immediately and continue until the code team arrives."

I left and went to the nurses' station and spoke to Maggie.

"Mr. Clausen in 29 is showing signs of A-fib, and the chart indicates heparin."

"I'll send Steph in to administer it."

"Thank you."

I returned to the room, and a few minutes later, Steph arrived with the necessary medication, checked the chart, then administered the heparin. She updated the chart, then left John and me to monitor the patient.

"Could you have administered the heparin?" John asked.

"In a trauma, absolutely. On the ward, it's a nurse's responsibility, and I'd have to ask her for the drugs and the hypo no matter what. In a trauma room, they're right there in the cabinet or fridge. The only things locked up are the Schedule drugs and things like rape kits. In the ward, everything is locked up."

"Why has nobody taught me any of this stuff?"

"I learned early on that you have to ask. In your two clinical rotations so far, you were doing intakes and also doing rounds and patient care, which is different from trauma, acute care, critical care, or surgery. I suspect you did OK on those two rotations because they are, literally, by the book. Now that you're on this service, the landscape has changed. Fundamentally, Residents are busy, and unless there is some specific thing that they need to teach you, they'll simply assign you to things like pre-op and post-op checks, taking vitals, and transpo. Let me ask, what did you do on the consult?"

"Stood out of the way and watched."

"Did you take notes or ask questions afterwards?"

"No."

I pulled my cardiology notebook from my pocket and handed it to John.

"This is the notebook I started during my Preceptorship in Cardiology. It is, in effect, an abridged cardiology textbook. I have one for each service, and I study them regularly. I also have my clinical notebook, which contains summaries for every patient. I'm about to update it for Mr. Clausen."

"But you just started at midnight, right?"

"Yes, and the first thing I did was get the charts, review them, and write summaries. I then went to each room and wrote down the current vitals. If Doctor Javadi or Doctor Bielski ask me about a patient, I can answer, either from memory, or I can pull out my notebook and give them a summary."

"I'm going to ask again — how come nobody has told me any of this stuff?"

"Ultimately, you are responsible for your education. If you're passive, you're going to get scut because the Resident certainly doesn't want to do it. If you aren't assertive, you won't learn. Do you know what specialty you want?"

"Internal medicine," he replied. "My uncle is a GP in Toledo, and I want to join his practice as soon as I get my license."

"Then you want to focus on diagnostic skills and H&Ps. Trust me, if you make it clear you're happy to do those, you'll do plenty of them. Ask questions that fill out your diagnostic skill set, and make a notebook, or set of notebooks, and review them. It'll make you a better GP."

"You're the one who is doing the new dual-track surgery and emergency medicine, right?"

"Yes."

"You talk like a Resident."

"I'm preparing to be one in six months. And you'll be one in eighteen months, which means you need to begin preparing as well. When you join your uncle's practice, you'll be on the front lines of healthcare, and every single patient you see is one who will have proper continuity of care. And that means you need to be an expert diagnostician and have an excellent bedside manner."

"You're the first person to not look down on me for wanting to be a GP instead of a surgeon or cardiologist or whatever."

"Continuity of care is vital, and the most common referral I have heard made in the ED is 'see your personal physician'. Where do you want to Match?"

"Cleveland or Toledo, but I'll also apply in Columbus and likely here."

Steph came in with the lab results, which I reviewed.

"Troponin 12µg; CK-MB to CK ratio is 6.6%."

I looked at the chart and compared the values and saw both rising, as was to be expected.

"Stay here," I said to John. "I need to report to Doctor Javadi."

I left the room and went to the Resident's office where Doctor Javadi was resting on the couch.

"I have the labs," I said.

She sat up.

"What do they show?"

"Both troponin and the CK-MB to CK ratio are rising, as would be expected a few hours after an acute STEMI. Troponin rose from 7µg to 12µg, and the CK ratio from 5.8% to 6.6%."

"How's his EKG?"

"A period of A-fib, but Steph administered heparin per the chart, and it resolved. Otherwise, still showing ST elevations. May I ask why he didn't go straight to the cath lab?"

"Too much time between his MI and when I saw him. According to his wife, he had severe chest pain for nearly an hour before they called the paramedics."

"An hour?"

"He didn't tell her until it became unbearable."

"Wonderful. Why not take him to the cath lab?"

"In my judgment, he wasn't stable enough for the procedure before the PCI window ended. I'm sure you saw the ASA on the chart. The goal now is to keep him alive until we can do a cardiac echo in the morning. I set it up for 0700."

"Are you considering moving him to the ICU?"

"It's a wash, really. I'm right here, so if he codes, I'm sixty seconds closer if he's in the ward than in the ICU. He's not on a vent, and honestly, the only difference is the full-time nursing attention, which I can mimic with you and John."

"OK. I'll let John get some sleep then. I napped before I started my shift, and he hasn't had any sleep."

"Thanks, Mike. Don't hesitate to call me if there are any EKG changes."

"Including A-fib?"

"Yes. I don't want to give him more thrombolytics unless I absolutely have to."

"Got it."

She lay back down on the couch, and I went back to the lounge to get my cardiology textbook, then went back to the patient's room and instructed John to get some sleep. He left, and I settled into the recliner with the reading light on and began reading. About fifteen minutes later, Mr. Clausen groaned and stirred, and his eyes opened.

"Where am I?" he asked, his words muffled by the oxygen mask.

I put my book down and moved to his bedside.

"The cardiac unit of Moore Memorial Hospital," I replied. "You had a heart attack."

I used layman's terms, as we'd been instructed, rather than telling him he'd had a ST-Elevation Myocardial Infarction.

"How bad?"

"Bad enough," I said. "We've given you blood thinners, and we'll do an ultrasound of your heart in about four hours."

"Wife?"

"I didn't speak with her; let me call the nurse to find out."

"'K."

I pressed the call button, and twenty seconds later, Beth, the student nurse, came into the room.

"Mr. Clausen is asking about his wife," I said.

"She's here, in the family lounge."

I considered my options, and decided not to bother Doctor Javadi for an exception, and certainly not to wake Doctor Bielski.

"If she's awake, have her come in for two minutes," I said.

"Are you sure?" Beth asked. "Shouldn't you check with Doctor Javadi?"

"Just do it, please. I'll note it on the chart."

"OK."

She left, and I made the proper notation on the chart. Two minutes later, Beth returned with Mrs. Clausen.

"Only two minutes," I said quietly. "I'm bending the rules as it is."

She nodded and went to her husband's side. She kissed his forehead and then spoke quietly into his ear. Honoring my request, she left less than two minutes later.

"Thanks," Mr. Clausen said.

"Get some rest, please."

He closed his eyes, and I sat back down with my book. The rest of the very early morning was quiet, and other than the nurses coming in to check the IV bag and note vitals on the chart, and draw blood for morning labs, there was no activity in the room until Doctor Javadi showed up at 0600, just after I'd completed saying my morning prayers silently.

"Morning," she said. "Anything?"

"Vitals have been consistent since the A-fib resolved. Angel was in to draw blood for morning labs about ten minutes ago. The two-hour labs showed increases in troponin and the CK ratio, consistent with a major cardiac event."

"OK. Felicity relieved John, and she's in the lounge. Take her on pre-rounds."

I nodded, went to the lounge to put my book away, and introduced myself to Felicity.

"Mike Loucks, Fourth Year."

"Felicity Howard, Third Year. This is my first shift on this rotation."

"What did you have before?"

"Internal Medicine, OB/GYN, and Psych," she replied.

"We have fifteen patients to pre-round, so we need to get started. Do you have a notebook?"

"My procedure book."

"You should get a notebook to use for rounds. I find writing a brief summary and noting vitals is a good way to be able to present to the Resident and be sure you're providing accurate information. You should also have a per-subject notebook to record everything you learn that isn't in our textbooks."

"I have the subject notebooks, I just don't carry them with me."

"OK. Let's go."

Pre-rounds for fifteen patients took just over forty-five minutes, and we reported to Doctor Javadi, who stepped out of Mr. Clausen's room into the hallway so we could go over the pre-round patient status report with her. We'd just about finished when the technician arrived with the equipment for the echocardiogram.

"How do we handle this with rounds which start in five minutes?" I asked.

"Doctor Strong should be here," she said. "I'll ask him to cover the cardiac echo because I'm expected to lead rounds with Doctor Getty. You two need to come with me."

As if summoned, Doctor Strong appeared from around the corner.

"Morning, Leila, what do we have?"

"Hi, Carl," she said. "Mike?"

"Fifty-seven-year-old male post STEMI; treated with ASA, heparin, and high-flow oxygen, per protocol, as the patient was not stable enough for PCI before the window expired. Most recent vitals — pulse 86; BP 140/110; PO₂ 93% on ten litres by mask; good urine production. Brief bout of A-fib, resolved with heparin. Most recent cardiac enzymes from around 0300 were climbing, indicative of MI. EKG shows ST elevation, consistent with STEMI. Echo ordered to assess damage to the heart. Blood was drawn for new enzymes about twenty minutes ago."