Chapter 83: I Had A Brain Operation!

April 3, 1989, McKinley, Ohio

"How was your first day back in «SAMU»?" Kris asked when Rachel and I arrived home.

"A typical shift," I replied. "Nothing overly exciting, just the usual steady stream of injuries and rule-out MIs — heart attacks."

"Why do you call it 'rule out'?"

"Because the assumption is that they are having some kind of coronary event, and we run tests and do exams to determine if it's actually a heart attack. Many things cause symptoms similar to a heart attack, but given a heart attack is generally the most potentially serious ailment, we rule that out before searching for another cause. At least once a week, someone comes in with a case of indigestion that mimics a heart attack."

"Are you happy now that you're back in «SAMU»?"

"Yes, though I had expected to have Felicity as my Third Year, but they assigned a guy named Tim who is, to say the least, a poor medical practitioner."

"But this is the end of the year, «non»?"

"It is. He failed one rotation and received a sub-par evaluation in another. Two failures would mean repeating the year or being dismissed from the medical school. Doctor Gibbs decided I was the best person to supervise him. Of course, Doctor Billings, the Resident, is our supervisor, and Doctor Gibbs is our Attending. Doctor Gibbs felt that if he didn't improve working with me, he couldn't improve."

"You're that good?" Kris asked with a sly smile.

"You sure think so!" I replied.

Kris laughed softly, "I didn't mean at THAT!"

"I did!"

Kris rolled her eyes and said, "Dinner is in about fifteen minutes."

"OK. I showered after my shift, which is normal for me when I'm in the ED, so I'm just going to change into comfortable clothes."

I set Rachel on the rug, then went upstairs to change and returned downstairs to help with the final preparation for dinner. We had a nice meal together as a family, I read to Rachel, we said our evening prayers, and then put Rachel to bed. Kris and I relaxed together for about an hour, listening to classical music, before heading up to bed.

April 4, 1989, McKinley, Ohio

"Mike, paramedics are four minutes out with an MI," Nurse Wendy announced just after 9:00am. "Doctor Billings said to meet her in the ambulance bay."

"On it!" I declared. "Tim, let's go."

We left the lounge, donned gowns and gloves, and hurried to the ambulance bay.

"Mike," Doctor Billings said, "I'll want a monitor and a 5-lead. Wendy, CBC, Chem-20, and enzymes."

"Yes, Doctor," I said.

I liked the idea of stating the action plan before we got to the trauma room, and decided then and there that would be my approach. It made perfect sense and could save important seconds. The plan could easily be changed if the patient presented differently from how EMS, as we were now calling the paramedics, reported, which happened occasionally.

"Tim," I said. "I'll explain how to hook up the EKG. You should take notes, and I suggest drawing a diagram to study."

"I have an excellent memory," he said.

"I find, even with a good memory, writing things down is key to remembering."

"Mike is right," Doctor Billings confirmed.

The ambulance pulled into the driveway, interrupting our conversation as we 'put on our game faces' as Doctor Gabriel liked to call preparing for treating the arriving patient. Bobby hopped out of the squad and gave the vitals as he moved to the back to open the doors.

"Oscar Goldberg; fifty-seven; chest and arm pain post exertion; diaphoretic; BP 180/110; pulse tachy at 120; resps labored at 17; PO₂ 94% on 5 litres; nauseated but no emesis; oriented times three; no history of cardiac events."

"Trauma 2!" Doctor Billings ordered.

Bobby, his partner, Doctor Billings, Wendy, Tim, and I rushed Mr. Goldberg to the trauma room, and we got to work.

"Mr. Goldberg, I'm Doctor Billings, and we're going to take good care of you!"

Wendy disconnected the portable oxygen bottle and replaced it with a mask connected to the hospital system, which allowed Bobby and his partner to leave. I quickly cut away Mr. Goldberg's shirt to attach the EKG leads. I worked around Doctor Billings auscultating Mr. Goldberg's heart and Wendy drawing blood, explaining for Tim where each pad went and what color each lead was and what it represented. To my annoyance, Tim wasn't taking notes in his notebook, but I would deal with that later.

"Tim, take the blood to the lab," Doctor Billings said. "Stat. Wait for the results."

He frowned but accepted the tray with the three tubes of blood from Wendy and left the trauma room as I turned on the EKG monitor.

"PVCs," I said. "Run of six. V-tach. Pulse is 120."

"Mr. Goldberg, do you smoke?" Doctor Billings asked.

"No," he rasped.

"Drink more than two cups of coffee per day?"

"No."

I saw something on the monitor and announced it, "Peaked T-wave, suppressed P-wave. Suggests possible hyperkalemia."

"Foley, Mike. We'll need to see his urine elimination."

"Kidney failure?" I suggested.

"That is the most likely differential given the EKG."

I assessed the patient, got the correct Foley from the supply drawer, put on fresh gloves, and, with assistance from Wendy, inserted it, connected it to a collection bag, and watched for urine flow.

"Very low flow," I said.

"Mr. Goldberg, how long ago did you last urinate?" Doctor Billings asked.

"Couple hours," he replied.

"Are you on any medication?" she asked.

"No."

"Mike, differential?" Doctor Billings inquired.

"Acute renal failure, based on the EKG and lack of urine, possible tumor or carcinoma."

"I agree. Call for a nephrology consult."

"Yes, Doctor."

I stripped off my gloves, discarded them, then went to the phone and dialed Internal Medicine and asked for a nephrology consult. The nurse promised a Resident would be down 'immediately', which I reported to Doctor Billings.

"Wendy, Ventolin by nebulizer to bring down his potassium," Doctor Billings said. "Mike, dosage?"

"20mg is the standard, but is contraindicated by tachycardia. I'd start with 10mg and monitor."

"Good call; Wendy, 10mg."

"Yes, Doctor," she replied.

Doctor Lucas, a nephrology Resident from Internal Medicine, arrived with his Third Year, who smiled at me. Sophia and I nodded to each other as Doctor Billings reported our findings to Doctor Lucas. He began his exam, and two minutes later, Tim returned with the lab results.

"What do they say?" Doctor Billings asked.

"I didn't look," Tim replied. "I got them and came back."

She grabbed the papers from him and flipped to the second page.

"Hyperkalemia," she announced. "Potassium is 7.2; BUN 32; Creatinine 2.0; normal ratio."

That was definitive that Mr. Goldberg was suffering from some kind of severe renal problem.

"Almost no urine in the bag," I announced, checking it.

"I'll take him," Doctor Lucas said. "Mr. Goldberg, you're suffering from kidney failure. We're going to admit you to figure out what's causing it. I'll see you upstairs shortly. Sophia, bring him up, please."

"Yes, Doctor," she said.

"Tim, call for an orderly," Doctor Billings said. "Mike, you can disconnect the EKG. He won't need a portable for transport."

I acknowledged her, then began disconnecting the cables. Wendy switched him to a portable oxygen bottle, and about three minutes later, an orderly arrived, and the six of us moved Mr. Goldberg to a gurney for transport, then Sophia and the orderly rolled him out of the trauma room.

"How'd you learn to read EKGs?" Doctor Billings asked when Wendy had left Trauma 2.

"During my Preceptorship in Cardiology, I asked Doctor Strong to teach me, then continued learning during my Sub-I. I'm curious why you didn't ask yesterday with the MI."

"Any medical student should be able to identify ST elevation! Knowing that peaked T-waves with suppressed P-waves is hyperkalemia and likely caused by renal failure is something I wouldn't expect a Fourth Year who matched for emergency medicine to know."

"It's on the flash cards I study because every time I encounter something new, I add it to my study deck, and I saw a similar case earlier this year. I study a random group of about a hundred cards every day out of something like 3000 total cards."

"And I thought I was crazy about how much I studied!" Doctor Billings said, shaking her head.

"Where did you go to med school?" I asked.

"UC. Is it true you did a Sub-I in pathology?"

"It is. Doctor Roth suggested it because it would allow me to use a scalpel every shift for two months, something that isn't possible on any other service, and something even surgical Residents don't do."

"Strange, but brilliant," Doctor Billings said. "You're Matched for trauma surgery, right?"

"Yes. I'll serve two years in the ED, then begin a surgical Residency, but with an assignment to the ED. The ultimate goal is for the ED to be able to do central lines, chest tubes, and other similar procedures without the need to have a surgical consult."

"Tim," Doctor Billings said, "draw a diagram of EKG placement and bring it to me, please."

"After seeing it once?" he asked.

"You took notes, right?" she asked.

"Er, no," he replied.

"Weren't you told to?"

"I thought I'd see a few more before you asked."

"You thought wrong," she said firmly.

Wendy stuck her head into the room, "Doctor Billings, toddler with a jelly bean in his nose in Exam 2."

"Thanks, Wendy," Doctor Billings said. "Mike, I hear you're the 'kid whisperer', so you take the lead and I'll observe. Confirm with me before any treatment."

"Of course, Doctor."

Doctor Billings, Tim, and I went to Exam 2, where we found a very annoyed mother and a clearly cross toddler who appeared to be about three years old. I picked up the chart and quickly reviewed it.

"Hi, Mrs. Jones," I said. "I'm Mike, a Sub-Intern. What seems to be Timmy's problem?"

"Besides being a three-year-old boy?" she asked.

"That's a temporary condition, but I'm not sure the cure is better!"

"My husband does act like a toddler most days!" she declared.

"OK to examine Timmy?" I asked.

"Yes, of course."

"Hi, Timmy," I said. "I'm Mike. What's wrong?"

"My mom made me come here! I hate doctors!"

"Well, then it's a good thing I'm not a doctor!" I replied. "I won't be one for two months! Why did your mom make you come here?"

"Because I put a jelly bean in my nose."

"Why did you do that?"

"Because I wanted to!"

I couldn't help but laugh, and Doctor Billings laughed as well, while Mrs. Jones simply shook her head.

"How is Billy's general health?" I asked as I warmed my stethoscope in my palms.

"No self-respecting virus or bacteria would come near him! He's a one-kid wrecking crew!"

"I think you're suffering from a condition known as 'parent of a toddler'," I replied. "There is no known treatment except time. Has he had all his vaccinations?"

"Yes. And he sees his pediatrician on the normal schedule."

"Good. Timmy, I'm going to listen to your heart and lungs, OK?"

"You're not going to give me a shot, are you?" he asked suspiciously.

"No, but I will use a tool with a claw to reach up into your brain and yank that jelly bean out!"

"COOL!" he exclaimed.

"Oh, for heaven's sake!" Mrs. Jones groaned. "TWO toddlers!"

"I did say that the cure wasn't necessarily better! Timmy, OK to take off your shirt?"

"Yes. Can I see the claw?"

"Tim, would you get a four-prong foreign body forceps, please?" I requested.

"Which ones are those?" he asked.

"The ones with the blue plastic handle with three rings and a claw with four thin metal elements. In drawer 2C."

I helped Timmy take off his shirt, washed my hands, put on gloves, then auscultated his heart and lungs.

"Strong bilateral breath sounds, strong heartbeat, no murmurs," I announced.

I checked his pulse, then his BP.

"Pulse 72 and strong; BP 110/70."

Tim brought me the sealed see-through package with the tool, and I showed it to Timmy.

"You're going to stick that up my nose? COOL!"

His mom groaned again, but so long as Timmy was happy, I was happy. Of course, there was one possible complication, and that was that the jelly bean was too far into his sinus and that he might need a surgeon to perform the removal. I could, with my skills, only manage if it was only a short way into the nasal cavity. To confirm, I picked up the otoscope, put on a clean speculum and checked both nasal passages.

"I see the obstruction in the right nasal passage," I said. "About a centimetre in, so I'll be able to extract it. Left passage is clear. With your permission, Doctor Billings."

"Proceed."

I tore open the package, adjusted the handle, and slipped my fingers through the rings.

"Lie down, please," I said to Timmy. "And hold very still. I want to make sure I only get the jelly bean, not your brains!"

Timmy coöperated, and I carefully maneuvered the thin metal elements into his nose, slipping them past the jelly bean. Once it was in place, I pulled back on the center ring using my middle finger, causing the elements to tighten around the candy, and once I was positive I had secured it, I gently extracted it, and put it into a metal basin on the instrument tray.

"Got it!" I said to Timmy.

"Cool! Can I have it?"

I was convinced that if I gave it to him, he'd eat it, which would not really harm him, but would likely make his mom completely lose it.

"It's medical waste," I said. "That means it has to go into that red bin over there and be burned up! You don't want it mutating and coming alive!"

"Whoa!"

"You need to promise me something," I said.

"What?"

"That you won't put anything smaller than your elbow into your nose!"

"My elbow won't fit in my nose!"

"Correct! Promise?"

"Do I have to?"

"If you want these," I said, pulling a bag of Skittles from the pocket of my lab coat.

"I promise! I promise!"

"And you only eat these after you have your lunch, OK?"

"Yes! I promise!"

I handed him the bag of Skittles, then made a guess about his mom and pulled a Nestlé's Crunch Bar from my pocket.

"I find that moms usually feel better after chocolate therapy," I said, handing it to her.

"You are smooth!" she declared. "Do you have children?"

"A twenty-month-old daughter who rules my life with an iron fist!"

"How do you feel, Timmy?" Doctor Billings asked.

"OK! I had a brain operation!"

We all laughed, and I used the otoscope to verify there was no injury to Billy's nose.

"No internal trauma," I announced.

"Good. Fill out the discharge form for my signature," Doctor Billings said. "Have a good day, Mrs. Jones, and good luck!"

"Thanks!" Mrs. Jones said.

Doctor Billings left, and I filled out the paperwork, then went to get her signature, and returned to the treatment room.

"No follow-up is necessary unless Timmy complains about persistent pain," I said. "It's OK to give him children's Tylenol or Advil, but if the discomfort lasts more than thirty-six hours, he should see his pediatrician, or you can bring him back here."

"Thanks, Mike. What do you say, Timmy?"

"Thanks, Mike!"

I handed Mrs. Jones the discharge papers, helped Timmy put on his shirt, then directed them to Patient Services.

"Do you always carry candy in your lab coat?" Mrs. Jones asked.

"I do! I find it helps with kids who would rather be anywhere but a doctor's office or the hospital. And with brave moms, too!"

She laughed, "Thanks again!"

"You're welcome."

Tim and I left, I turned in the chart at the nurses' station, then went to find Doctor Billings.

"How did you know he wouldn't freak out about the 'brain' comment?" Doctor Billings asked.

"Because he's a healthy three-year-old boy! And as gross as it seems, he'd have eaten that piece of candy I removed from his nasal passage!"

She shuddered and stuck her tongue out in a gagging motion, "Sickeningly, I think you're right! I see why they call you 'kid whisperer'. He liked you right away!"

"And in three months, I'll be the enemy! It was not being a doctor that did it."

"Very good job. Add that to your procedure book, and I'll sign it."

"Will do," I replied.

The rest of the morning was quiet, with just one walk-in, which turned out to be a sprained ankle, which was wrapped by Wendy. Because we were on the same shift, I called Medicine to see if Sophia could join me for lunch, which, fortunately, she could. We met in the cafeteria about ten minutes later.

"What electives did you finally decide on?" I asked.

"Double in OB/GYN, one in the neonatal ICU, one in the ED, one in surgery, and one in pediatrics."

"Still planning on San Francisco?"

"Yes," Sophia confirmed. "Robby has been in contact with Stanford, so we can make it all work out."

"Awesome for you, though we'll miss you guys.

"And we'll miss you! How is your ED rotation going? Word is you have the class idiot as your Third Year."

"Anyone who thinks they're smarter than they are is VERY dangerous. I won't comment further."

"I understand. How is Miss Rachel?"

"That's Tsarina Rachel to you, peasant!" I chuckled.

Sophia laughed, "Why am I not surprised you treat her like a princess?"

"Right, because it's not like she demands to be treated like a princess or anything!"

"Things are good between you and Kris?"

"Better when there's nothing between us!" I said with a grin.

"It's April and the 'newlywed effect' hasn't worn off?" Sophia asked with a smirk.

"It didn't for the entire time I was married to Elizaveta!"

"You and your horny teenagers!"

"Says the young woman who was a self-admitted horny teenager!"

"Guilty as charged and no apologies!" Sophia exclaimed. "Back to medicine — any interesting cases?"

"Toddler with a jelly bean up his nose. I told him I was going to reach up into his brain and pull out the jelly bean. He thought that was cool; his mom, not so much!"

"Boys!" Sophia said, shaking her head. "And men just have more body mass and more money!"

"I did say that I wasn't sure that the cure for 'toddler boy' was an improvement."

"No kidding!"

We finished our lunch, and Sophia went back to Internal Medicine while I returned to the ED just in time to join Doctor Billings for EMS bringing in a pair of MVA victims. They consumed a good part of my afternoon, and both were admitted, one to ICU and one to Medicine, and just after 6:00pm I went to daycare to get Rachel so we could go home.

April 6, 1989, McKinley, Ohio

On Thursday, I had lunch in the cafeteria with Antonne and his study group.

"I need to apologize to all of you for only having 30 minutes," I said. "And to Conchita for Rachel being in daycare!"

"I suppose I'll forgive you this time!" Conchita declared.

"How does it feel to be in your final rotation?" Danika asked.

"Good," I replied. "The nice thing about a second Sub-I at the end of the series, in the department where you Matched, means being treated almost like a PGY1. I'm allowed to run every minor trauma and some moderate ones. Obviously, the most critical ones are handled by more experienced physicians, but that'll be true even when I'm a PGY1."