Chapter 59: I Need Some Advice

December 2, 1988, McKinley, Ohio

"Mr. Collins' cardiac enzymes show no changes which would indicate an MI," I said to Doctor Javadi, handing her the chart.

"Any changes on the EKG?"

"No."

"Your proposed diagnosis and treatment?"

"Unstable angina is indicated. Prescribe daily aspirin along with nitroglycerin for acute onset and advise to see his GP and refer him to a cardiologist."

"Write it up for my signature," Doctor Javadi ordered.

"Will do."

"Did you get any sleep?"

"About ninety minutes total since midnight," I replied. "I'm fine. Our shift has less than three hours to go."

"OK. Please verify that all the evening lab orders are in."

"Will do."

Felicity and I left the Resident's office and went to the nurses' station to get the charts on the fifteen patients we had under our care.

"What are we looking for?" I asked Felicity, handing her the first chart.

"We should match the lab orders on the chart with the pink copy of the lab order form."

"And?"

She scanned the right side of the chart, then looked at the lab order clipped to the left side.

"They match," she said.

"Including the times?"

"Yes," Felicity replied. "Why wouldn't they?"

"If the lab order form was from the previous set of tests."

"Have you had that happen?"

"Once, during my rotation in Internal Medicine."

We went through all the charts, and everything was in order.

"The labs need to be collected sometime before 5:00am," I said. "Usually, they aren't done until after midnight, so you need to make sure you include that in your handover to whomever comes on shift at midnight."

"Oh, please!" Felicity said, rolling her eyes. "Like I don't know that?!"

"I was simply reminding you of the task," I replied. "This is our first shift together, and your first in Cardiology, and I have a responsibility for ensuring you know what to do and when. A reminder is not a correction, but simply a way to ensure someone who is brand new to the service understands their responsibilities."

"Nobody speaks to YOU that way!" Felicity protested.

"Seriously? Do you think I don't know that Fourth Years are responsible for ensuring lab orders are completed? And yet, Doctor Javadi asked me to do it for the exact same reason I reminded you about the handover — this is my first shift with her, and she is responsible for ensuring I know what needs to be done. Nobody assumes, because the minute you assume, everything goes sideways!"

"Well, you don't need to remind me."

"Yes, actually, I do. If you have a problem with my teaching style, please take it up with Doctor Javadi or Doctor Getty."

"Oh, right, complain about the teacher's pet? I don't think so!"

Felicity was reinforcing my belief that she didn't have the temperament to be a physician, and she was going to be an impossible student.

"Whatever you think, I'll be graded on how well I teach you," I replied. "So, I'm going to keep reminding you and asking you questions until I'm satisfied."

"Wait! If I don't learn, you get in trouble?"

"If it was my failing, yes, but not if you refuse to learn because you act like you already know everything."

"Says the guy who thinks he knows everything!"

"That's simply not true. I know the things a Fourth Year in his fourth Sub-I is supposed to know, which includes everything a Third Year is supposed to know. That said, it barely scratches the surface of medical knowledge."

"You just accused me of what you said is OK!"

"It's the response," I replied. "In response to Doctor Javadi reminding me to check the lab orders, I said 'Will do'. You rolled your eyes and whined."

"I didn't whine," Felicity protested, in a tone that was at best a hairsbreadth from a whine.

"Fine. You didn't whine; you objected. The point is, you're going to be reminded of things over and over and over, so get used to it. Or go complain to Doctor Javadi. Those are the only two realistic options."

"So you say."

"Have it your way," I replied.

I took the charts to the lounge and reviewed them myself, ensuring all the labs had been properly ordered, with Felicity sitting on the sofa giving me the evil eye. I ignored her, and after I had verified everything was correct, I returned the charts to the nurses' station. The only thing left to do before the end-of-shift handover was one more blood draw for Mr. Collins, who, I was sure, had to be feeling like a pincushion.

I spent the final ninety minutes before Clarissa arrived for the handover reading The Lancet in the lounge. When Clarissa arrived, she was accompanied by Debbie Sherman, who I'd worked with in surgery.

"I'll do the handover," I said, taking out my notebook.

"Excuse me?" Felicity said.

"You heard me," I replied.

I reviewed all fifteen cases for Clarissa and Debbie from memory, though I had my notebook open to ensure I didn't miss anything, as Felicity fumed. When I finished, I went to the locker room to change, and Clarissa followed me.

"What was that?" she asked quietly.

"Later, please, Lissa," I said, concerned that Felicity might walk into the locker room.

My concern was warranted, as she came in not ten seconds later. I finished changing, gave Clarissa a quick hug, then signed out at the nurses' station. I waited for the elevator and was joined by Doctor Javadi.

"Good shift today, Mike," she said.

"Thanks."

"How did things go with Felicity?"

"Not well. When are you on again?"

"Sunday midnight, same as you. But thirty-six, not twenty-four."

"I won't be on shift on Sunday. I'll be going to Pittsburgh for my Match interviews," I said as the elevator doors slid open. "I do not look forward to those thirty-six-hour shifts,"

"Nobody does," Doctor Javadi confirmed as we stepped onto the elevator.

"You want to wait to talk until our next shift?" Doctor Javadi asked.

"Yes, please, on Wednesday," I replied, because I wanted to talk it through with Clarissa if I could.

We rode down to the ground floor, and rather than go straight out to the parking lot, I said 'good night' to Doctor Javadi and headed for the ED. Rachel was at Anicka's and Milena and Joel were there and had Abigail with them, so Rachel had a companion. Anicka would bring Rachel to me after band practice in the morning, so I didn't need to hurry home. Instead, I went to find Doctor Casper, who was on shift.

"Mike?" he asked, looking up from the chart he was updating, "what's up?"

"Got a minute?"

"Let me discharge this patient, then yes, barring a paramedic run or a walk-in bleeding to death or having an MI!"

Five minutes later, we went to the Resident's office, and I shut the door before I sat down.

"What's up?"

"I need some advice," I said, then explained the situation with Felicity.

Doctor Casper listened quietly until I finished.

"First, Mike, as far as I've observed, you're a good teacher. That said, not everyone responds to the same style. I'm not saying that's what this is, but you need to adapt your teaching style to the student. I don't teach you the same way I teach others. That said, it doesn't appear this has to do with teaching style; I only mentioned it because in about seven months, it's going to matter a lot more.

"As for the situation with Felicity, as a Fourth Year, your best bet it to simply go about your tasks, offer to teach her, and don't take the bait to get into philosophical discussions you can't win. That's not because you're wrong, but because she's not interested in hearing what you have to say, which I think should be obvious. Keep Doctor Javadi apprised and document everything in one of those dozens of notebooks you carry around!

"Now, here's the most difficult part for you, and it certainly was for me, but you have to let her fail. You only step in after she makes a mistake or omission, unless you see her putting a patient at risk. I understand you don't trust her, but you should have let her do the handover. That's how she'll learn and you can provide critiques after the fact, or corrections during, if she makes a mistake. By the way, a double-stick for an IV or a blood draw is not a mistake; even the best nurses have that happen on occasion.

"The most difficult thing in the world for a doctor to do is stand and watch someone who is not as skilled as they are do a procedure. And guess what? That is exactly the situation you'll be in for the rest of your career. But remember, until you're Chief of Emergency Medicine, there will always be someone more experienced watching you, and even the Chief is watched, after a fashion, by the Medical Director."

"You're saying I was mistaken to do the handover, right?"

"It's a judgment call, Mike, but in this case, you need to give her an opportunity to succeed. You prejudged that she'd fail. I suspect you're correct in your assessment, but if you provide negative feedback for her evaluation, she can counter that with you never giving her a chance. Then it won't matter if she would have failed or not — she's turned the tables on you and now you're the one under scrutiny."

"I take it that happens with Attendings and Residents?"

"It does, though less so in the ED than in any specialty that involves surgery, including neuro, cardiology, and orthopedics. You know the drill there."

"Instead of 'watch one, do one, teach one', it's more like 'watch a hundred' before you can do the first one."

"Why do you think that is?"

"Because," I said with a smirk, "surgery is the most demanding and exacting of all specialties."

"That is an argument that can be made," Doctor Casper replied. "Though we don't get many 'do overs' in the ED."

"Bouncebacks?" I replied.

"A reasonable point, though you know why that happens here, as opposed to hospitals like Cook County in Chicago."

I nodded, "If a patient doesn't meet the medical criteria, we send them on their way, not because we're rushed or overloaded and only do perfunctory exams of anyone who isn't bleeding to death or having an MI."

"The benefits of working at a hospital outside the inner city."

"Not to mention only rarely treating gunshot wounds," I said.

"True," Doctor Casper agreed. "We're more likely to have farm implement accidents or 'hold my beer' incidents than gangbangers with lead poisoning!"

"Or Joe Six Pack, who doesn't exercise, drinks a couple of beers every night, and eats a cheeseburger and fries for lunch every day and thinks the Diet Coke will prevent the heart attack or diabetes."

"Those happen in the city, too, but the headlines are always gunshots and stabbings because the news media follow the 'if it bleeds, it leads' mentality, and heart attacks because of poor diet and lack of exercise don't sell advertising on TV."

"Until somebody wants to advertise a drug that reduces cholesterol, causes weight loss, stimulates insulin production, or reduces blood pressure!"

Doctor Casper laughed, "Good point. What do you think about the controversy over Rufen?"

"The Motrin competitor? I'd have preferred the FDA not permit any direct-to-consumer advertising of prescription drugs, but I suspect the First Amendment won't allow them to ban it."

"You know where the real money will be made, right?" Doctor Casper asked with a smirk.

"From that smirk, I can only conclude one thing — prescription drugs that treat impotence."

"Imagine having a monopoly on a pill that provides erections!"

"Yeah, but it has to be a pill! You don't see people lining up for penile injections of phenoxybenzamine! You know the story of the proof, right?"

Doctor Casper nodded, "Giles Brindley, from the UK, dropped trou at the American Urological Association meeting in Vegas in '83 and invited everyone to inspect his chemically induced erection closely!"

"Fun fact about him, besides the exhibitionist antics — in the 1960s, he developed the 'logical bassoon', an electronically controlled version of the bassoon. I don't think it was ever sold, though."

"Sounds like a model for you — music and medicine."

"I actually don't know much more about him. I only know about the instrument because it was mentioned when we discussed his antics in our medical ethics course. Let's just say doing something like that is frowned upon!"

"You think? I just realized — don't you need to get home?"

"Rachel is with my music professor friend and I'll get her back at band practice in the morning. I'll get enough sleep before I have to get up for breakfast with Kris."

"Oksana and I will be at the wedding, though neither of us will need to use our 'plus guest'."

"I'm happy that's worked out."

"I'd never have expected to become a regular churchgoer, but it's growing on me."

There was a knock at the door, and Doctor Casper called out that it was OK to come in.

"Paramedics five minutes out with two MVAs," Nurse Jamie, the only male nurse at Moore Memorial Hospital, said. "Hi, Mike."

"Hi, Jamie," I replied. "I was just leaving."

"Not staying around for the excitement?" he asked.

"I just came off a twenty-four-hour shift in cardiology and I need some sleep before band practice!"

"When are you guys playing again?"

"At Taft on the 15th, but I believe it's sold out. We have a gig at Stirred not Shaken in February. Want me to reserve some tickets for you?"

"Two, please."

"Will do. You'll be able to pick them up any time after New Year's at the club."

"Thanks."

Doctor Casper and I shook hands, he headed towards the ambulance bay, and I walked the opposite direction towards the doors to the staff parking lot.

December 3, 1988, McKinley, Ohio

"Did you get enough sleep?" Kris asked after I greeted her on Saturday morning.

"About six hours," I replied. "And I had a ninety minute nap late yesterday evening."

"And Rachel is with Professor Blahnik, right?"

"Yes. That's the plan until you're available after school is out for you on the 23rd. Abigail is there, so they had some playtime, I'm sure. Joel and Milena plan to visit every Friday so the girls can develop a friendship."

"What do you do overnight?"

"In a ward, such as Cardiology, it's simply being available if a patient needs anything or if there is a consult in the Emergency Department. I'm also on the Code Team, which means I respond if a patient 'codes' which means they suffer cardiac arrest or severe arrhythmia."

"What do you do?"

"Perform CPR, administer drugs, and, if they have a shockable rhythm, use the defibrillator. We had one, and he didn't make it."

"How do you deal with that?"

"You mean death? I've had dozens of people die in my presence during the past three years, so, in one sense, I'm used to it. I say a silent prayer for them and their loved ones and move on to treat the next patient. I suppose the way to look at it is to say that without me, or people like me, being there, more people would die."

"But doesn't it affect you?"

"It did at first, but you simply get used to it, as I said. If you can't, then you need a specialty other than emergency medicine. But even that only goes so far, because people can die on any service, and GPs have patients die all the time, though usually not in their presence. Anyway, breakfast is ready."

We went to the kitchen and ate a Lenten breakfast of oatmeal with honey, fruit, and bread. After we ate, we cleaned up, I gathered my instruments and music, and we headed to Taft where Anicka was waiting with Rachel.

"DADA!" Rachel exclaimed when she saw me and toddled over.

I set down my instruments and bags and picked her up, giving her a kiss on the forehead.

"How's my big girl?" I asked.

She babbled, and I had no clue what she was trying to say.

"She and Abigail had a great time together last night and this morning," Anicka said. "They very much enjoyed the joint bath this morning in the big tub with lots of bubbles."

"She hasn't had too many baths," I replied. "Mostly she gets sponge baths because they're easier."

"I'll take her, Mike, so you can go practice," Kris said.

I handed Rachel to Kris, and Rachel made happy sounds. I left the women and went to the music room to meet the rest of the band.

"I confirmed both gigs at Stirred not Shaken," Kim said. "Mike, will you be able to trade if necessary?"

"In February and March, I'm in the ICU, so Kylie could cover for me, assuming she's not on shift. If she isn't able to cover, I'll see if I can trade, but it's entirely possible I won't be able to. For April and May, I'm in the Emergency Department, and the same applies, but at least there, it's easier because I'm on very good terms with all the Residents and Attendings."

"OK. We'll have to figure out a plan in case you can't make it."

"I'll do my best."

"We also have two Prom gigs and the Fourth of July gig confirmed. I have a list for you."

"Thanks," I said, taking it from her and putting it in my bag.

We had a good practice, and when we finished, I went to find Kris and Rachel, and then the three of us headed home. I stashed my instruments, and we headed to Kroger for the weekly shopping, and stopped at Hartman's Bakery for bread. When we arrived home, we put away the groceries, ate lunch, and then Rachel went down for her afternoon nap.

"You start work at midnight on Nativity, right?" Kris asked.

"Yes, and I'd like to get a nap before I go on shift, if at all possible."

"When do you want to exchange gifts?"

"What's your tradition?" I asked.

"Usually after the Divine Liturgy on Nativity. We'd go home, open gifts, then have a meal."

"Maybe the best thing to do for this year is for Rachel and me to join you and your parents, if that's OK with them."