Chapter 62: You're a Very Smart Young Woman

December 9, 1988, McKinley, Ohio

"Way to go, asshole!" Felicity growled when she came into the lounge. "I'm on probation!"

I had a choice between ignoring her or making a point, and I decided it was better to make a point.

"All of us are on probation," I replied. "That's what clinical rotations are about. If you didn't understand that before, well, now you do. You have to ask yourself one question. And that question is, what is more important to you? Hating me or being a doctor? It's time to prep Mr. Gómez for his angio. You can come along or not; you can learn or not. Either way, Mr. Gómez will be in the cath lab in just under thirty minutes."

"God, you are SO full of yourself!"

This time I followed Father Roman's direction and said the Jesus Prayer forty times, silently, before responding.

"No, I'm following Doctor Javadi's instructions and departmental policy. I have demonstrated my ability to review a chart and properly prep a patient for a procedure, and ensure they get to the operating room or cath lab where the doctors take over. Medicine is much harder than you appear to think it is, and as Doctor Getty said, we've barely scratched the surface.

"And yes, 'we', because while I know more than you do about clinical work, what I don't know would fill thousands of volumes. I'm a neophyte, and I'm only a year ahead of you. But I am a year ahead, and that makes a huge difference because I've completed six Clerkships and three Sub-Internships. Real learning — and I mean the things that you need to know to work as a Resident — only truly comes during your Sub-Internships. Now, I'm going to prep Mr. Gómez. Come along and learn in the ward, or don't, it's totally up to you."

I got up and left the lounge, certain Felicity would follow, as if she didn't, that would be the final nail in her coffin, so to speak. At a minimum, she'd be suspended, and it would only go downhill from there. If she wanted to be a doctor, she'd have to find a way to at least tolerate working with me. I didn't look behind me, but I heard soft footsteps, so I knew she was following me.

"Good morning, Mr. Gómez," I said when we walked into his room. "I'm Mike. Are you ready for your procedure?"

"If it'll stop the chest pain and keep me from having an actual heart attack, damn straight!"

"This is Felicity," I said. "We need to prep you for your procedure. If you're OK with it, Felicity will shave the inside of your thigh and attach EKG pads to your chest. We'll also insert an IV with plain saline to make it easier to administer sedatives and to allow quick administration of drugs in case of emergency."

"She's a student?" he asked.

"We both are," I replied. "I'm a Fourth Year Sub-Intern and will graduate in May. She's a Third Year, so has about eighteen months to go."

"You're not doing the procedure, are you?" he asked with a smile indicating he was teasing.

"No way," I chuckled. "I may get to stand in the corner and watch, but Doctor Tolliver will do the angioplasty. I can, on the other hand, read the vitals from the screen there and make sure your blood work has been done and has no anomalies."

"No time like the present," he said.

I made a note of the vitals from the monitor, then watched as Felicity prepared to shave Mr. Gómez. She did that, discarded the disposable razor in the sharps bin, then looked up at me.

"I don't know where all the pads go for the EKG," she said.

That simple sentence made it clear that she'd decided that being a doctor was more important to her than her feelings about me. If she could maintain that, she'd do fine and actually learn something. I pulled my cardiology notebook from the pocket of my lab coat, found the correct page, and handed her the notebook.

"The diagram shows where to connect the pads for the leads. In this case, we're doing a 12-lead, so follow the top diagram. You'd use the bottom diagram for trauma cases; it only has five leads."

"Can I ask why?" Mr. Gómez inquired.

"Mainly for speed and convenience. A 5-lead EKG provides plenty of information, and there are fewer wires to get tangled while treating a patient in a trauma room. Five leads are enough to see arrhythmia and to make judgments on treatment protocols. We're doing a 12-lead because it provides more information, and we're not concerned about entanglement for a standard, non-emergency procedure, as we would be in a trauma.

"The other reason is that most trauma doctors, which I'll be, don't know enough about cardiology to make use of the extra information in a 12-lead, and even if they do, don't have time to concern themselves with that data while they're busy trying to save the patient's life."

"Thanks."

"Felicity, you'll need to use the clippers," I said when she pulled down Mr. Gómez's gown to expose his chest.

She nodded, then picked up the electric clippers from the tray a nurse had set out for us, and removed the necessary chest hair so that the pads would make good contact. While she did that, I inserted the IV and hooked up a plain saline bag to it.

Once Felicity finished with the clippers, she changed into a fresh set of gloves, washing her hands in between, then opened a pack of ten EKG pads. She followed the diagram in my notebook and attached them to the correct spots.

"OK, I might be a plumber," Mr. Gómez said. "But I can count to twelve, and she only put on ten pads!"

"There are only ten electrodes in a 12-lead EKG," I replied. "Two of the leads are virtual and rely on principles of electromagnetism to derive their values. The formulas are in our cardiology textbook, but my knowledge of electricity is basically limited to plugging things in and turning on switches! I know even less about plumbing, though one could say you have a clogged pipe that needs to be snaked."

Mr. Gómez laughed, "I said that to Doctor Tolliver when he said I needed angioplasty."

Doctor Weiss, an anesthesiology Resident, came in just then, and introduced herself.

"Give me the good stuff, Doc!" Mr. Gómez declared.

"I promise you'll feel no pain and have no memory I was even here!" she declared.

She checked the chart, checked his vitals manually, and then administered a dose of midazolam, which would put Mr. Gómez into a state where he was still awake, but would also have no memories of the procedure.

"How long does it take to kick in?" he asked.

"About five minutes," she replied. "The sedative effect lasts about thirty minutes, so I'll give you another dose if the procedure goes longer. Mike, see you in the cath lab in ten."

I nodded my assent, then went to the phone to call for an orderly, and ten minutes later, Mr. Gómez was in the cath lab. I was permitted to scrub in, but Felicity had to return to review the charts for pre-rounds and present to Doctor Javadi. Just over an hour later, Mr. Gómez was back in his room, and hooked up to an EKG machine to ensure there were no arrhythmias introduced by the procedure.

"How are you feeling?" I asked.

"Spaced out," he replied. "Like when I was in High School in the 60s and, uhm, experimenting."

"That's an after-effect of midazolam and will go away in a few hours," I replied. "Doctor Tolliver said everything went perfectly, and he'll be in to see you to discuss it with you after lunch so that the effects of the midazolam have time to wear off."

"I don't remember a thing," he said.

"As Doctor Weiss said, it's a side effect of midazolam. I need to go to rounds, so if you need anything, just press the call button and a nurse will respond immediately."

"I'd prefer the cute nursing student from last night!" he said with a grin.

He was speaking of Stacey, who was cute, looked fantastic in her student nurse smock, and could probably get a rise out of a dead man.

"I think you might have to take a number and get in line," I chuckled.

"Just don't send me a battle-axe!"

"There aren't any on duty at the moment, so I think you're safe. Before I forget, Doctor Tolliver did tell your wife that you're OK, and the nurse will bring her here in the next few minutes."

"Thanks, Mike."

I left the room, reported to the nurses' station that Mr. Gómez was settled in his room, and Nurse Kelly said she'd bring in Mr. Gómez's wife. I thanked her, then went to the lounge to wait for rounds to begin.

"I copied the diagrams into my notebook," Felicity said, handing me my notebook.

"Good."

She said nothing else, so I let it go, and settled down with JAMA, and paged through looking for an interesting or relevant article to read until rounds. I found one on treatment of smoke inhalation, which was both interesting and relevant, and read until it was time for rounds. Three patients were ready for discharge, and Mr. Lucas, who was having the battery of tests, was having a CAT scan, as the other tests had so far proved inconclusive.

"Mike, see to the discharges, please," Doctor Getty said when we finished rounds.

He handed me the three charts.

"Right away, Doctor," I replied. "Felicity?"

She followed me out, and I went to the nurses' station to get the necessary forms, then went to see the first patient, Mrs. Martin.

"Mrs. Martin, Doctor Getty says you're ready to go home," I said. "I just need to take your vitals, fill out the discharge form, have it signed, and then your husband can take you home."

"Great!" she said enthusiastically.

"As soon as I finish, a nurse will come in to help you dress, and an orderly will come with a wheelchair."

"I think I can walk," she said.

"I'm sure you could, but hospital policy is for you to use a wheelchair until you get to the doors."

"Just do that, honey," Mr. Martin said from his chair. "Don't fight with the medical student who is just following orders."

I was SO tempted to snap to attention, click my heels and say «Jawohl!», as Mr. Martin looked like a former Marine, with a crewcut and steely eyes. I completed the exam, filled out the form, and we left the room. I let Nurse Kelly know Mrs. Martin was being discharged, and we went to see the second patient.

The routine was the same, just as it was the third patient, and when I finished, I took all the forms to Doctor Getty to sign. He did so, and I clipped them to each chart and took the charts back to the nurses' station. The final task was to repeat the discharge instructions for each patient, and once that was completed, I decided to have lunch.

"I'm going to the cafeteria," I said to Felicity. "You're welcome to join me if you wish."

"I'd rather not," she replied.

I shrugged and headed for the elevator. I was OK with her not socializing with me, so long as she completed her assigned tasks and listened to what I was trying to teach her. Copying the charts from my notebook was a good start, and I hoped she kept it up. I was happy to see Peter in the cafeteria, so once I got my food, I joined him at his table.

"How's life in surgery?" I asked.

"The same old, same old," he replied. "You know how it is — at least eighteen more months of not touching anyone or anything in the OR. At Emory, PGY2s routinely close, and even do minor outpatient procedures."

"Your interview is in January, right?"

"I had two phone interviews last week, and the face-to-face is on January 4th. I managed to schedule two other hospitals that same week, so I'll make it a mini vacation at home, have three interviews, and come back."

"How are things looking?" I asked.

"Who can say for sure?" Peter replied. "Everything seems good, and the fact that Emory is still having me visit after two phone interviews is a major plus. They have openings for a dozen surgical Residents, so I like my chances. Well, two of those are prelims, but I'll take that rather than Scramble outside Georgia."

'Prelims' or 'Preliminary Internships' were a non-guaranteed Residency slot. At the end of the year, the hospital could simply allow the contract to expire, and the individual would have to find a new slot. That was actually easier than waiting a year and trying for a permanent slot, and often led to a permanent position, as there were always Residents who washed out or transferred for various reasons.

"You're not worried about the temporary nature?"

"A bit, but that year of experience would help me be selected for an open Residency slot at another hospital. But that's a fallback if I don't Match at Emory or either of the other two hospitals. I take it everything is set for you?"

"Barring some bizarre, unforeseen circumstances, yes, which is why I'm interviewing at four other hospitals."

"How's your Cardiology Sub-I?"

"Other than a Third Year who thinks she knows everything because she was in the top three in her class, fine."

"I had one like that in my trauma rotation. Did Doctor Gibbs or Doctor Casper mention Bill Gannon?"

"He should have been a cop!" I chuckled. "Just as Deputy Chapel from the Hayes County Sheriff's Department should have been a nurse!"

Peter laughed, "Dragnet and Trek!"

"I didn't hear the story."

"Third year, who thought he knew everything he needed to know, and didn't need anyone telling him what to do, ruptured a urethra with a Foley because it wasn't inserted far enough before he inflated the balloon."

"What happened with the patient?"

"She died from unrelated sepsis about a week later. Untreated Type 2 diabetes with Stage IV sacral and right buttock ulcers. Obviously, the ruptured ureter didn't help, but it wasn't the cause of death. It was presented at one of the M & Ms you missed."

"What happened to Gannon?"

"Just a reprimand because he was a Third Year. And a note that he wasn't permitted to do any procedures without direct observation by a Resident or Attending for the rest of his rotation."

I nodded, "Makes sense. You get cut a lot of slack as a Third Year."

"What about yours?"

"On probation for what amounts to a bad attitude. She had the idea that textbook knowledge was sufficient, and she was disabused of that notion."

"I never realized how much I didn't know until we started our clinical rotations."

"Same here," I replied. "But all of us adapted quickly, and we all keep notebooks that could be turned into textbooks."

"If it isn't written down, it didn't happen," Peter replied, quoting our Practice of Medicine instructor when she was discussing the importance of updating charts.

"And my memory, as good as it might be, isn't good enough to remember everything I've been told or shown on every service at any point. Specialization is a benefit and a detriment, but there really isn't another way. Nobody could know literally everything about everything."

"I'll settle for knowing as much as possible about cardiothoracic surgery."

"Ditto for me and emergency medicine," I agreed. "I'll leave hearts to Maryam, babies to Fran, and long-term care to Clarissa!"

"Surgery for you, too, though."

"Yes. You, Nadine, and I will all have surgical training, but I won't ever be qualified as more than a general surgeon. You and Nadine will specialize in procedures I wouldn't even think of doing. How are things going otherwise?"

"Pretty good. I have to say I miss those chats in the steam room."

"Me, too. But I do not want to repeat anatomy!"

"Oh, hell no!" Peter declared. "That was brutal. We need to keep in touch as a group when we all go our separate ways for Residency. You, Fran, and Clarissa will be here, right?"

"Fran is looking at programs in Columbus as well as here, but she'll be in the area. I'm sure Maryam told you she's interviewing with five hospitals in Chicago."

"She did. And I'll be in Georgia, and it looks as if Nadine will be somewhere on the West Coast."

"Stanford, if she gets her way, but UCLA is on her list, as are hospitals in Portland, Seattle, and Denver. Denver is not exactly West Coast, but it's a lot closer than we are!"

Peter laughed, "True, but that's her fallback. She really wants an oceanfront Residency."

"I could see that, though I think I might like to do mine in the Ural mountains, if that were possible."

"I'm sure you could defect!" Peter suggested with a grin.

"My grandfather would put out a hit contract on me! And given the experience Kris' family had from the Bolsheviks, I'm not seeing her sign up for that! Now, if Gorbachev actually succeeds, well, that might be a different story."

"Seriously?" Peter asked.

"I've always wanted to visit Russia, but I don't want to visit the Soviet Union, if that makes sense."

"It does, actually. Maybe we'll get through this peacefully."

"I won't hold my breath, but I will pray for it."

"I don't pray, but avoiding a nuclear war is a pretty strong impetus to implore for help from a deity!"

"Amen," I agreed.

We finished our lunches, and Peter returned to Surgery while I took the opportunity to go to daycare to see Rachel, not wanting her to think I'd completely abandoned her. My timing was perfect, and I gave her a bottle before I had to return to Cardiology to complete my shift.

December 10, 1988, McKinley, Ohio

"Papa!" Rachel exclaimed when she saw me walk into Anicka's office on Saturday morning.

I picked her up, hugged her, and kissed her forehead.

"She was an angel," Anicka said. "She and Abigail get along really well. They insisted on sleeping together in the playpen I have in the music room."

"I'm glad they're going to be friends," I replied. "And girls seem more her speed at this moment than toddler boys."