Chapter 84: Let's Put On Our Game Faces, Please

April 8, 1989, McKinley, Ohio

"June 17th," José said when he and Sierra came into the music room at Taft for band practice.

Kris and Rachel had plans with Lyudmila, so they hadn't come to band practice, and we'd do our grocery shopping after lunch, rather than before.

"That's after Kris, Rachel, and I return from our belated honeymoon, so we'll be there. Is Code Blue playing?"

"We're going to go with a DJ," Sierra said.

"Then we'll just be able to party!" Sticks declared. "Where?"

"José's mom's parish," Sierra replied. "St. Andrew's in Milford."

"I suppose I can deign to set foot in a Papist church," I said theatrically.

José laughed, "Neither Sierra and I are serious, but my mom is, so you know how that goes!"

I nodded, "Hispanic women are not known to accept contrary opinions! And neither are Irish women!"

"And he better remember that!" Sierra declared with a silly smile.

"Worse," José said with a goofy smile. "My future mother-in-law is from the Old Country! County Kildare!"

I had the inkling that his Irish mother-in-law would give Russian mothers-in-law a run for their money.

"How did you become Lutheran, Sierra?"

"My dad," She replied. "He was serious enough about it, and Mom decided it was OK to go to his Missouri Synod church."

"And all of you will be happy to know that a full Mass wedding is still shorter, by hours, than a normal Sunday Liturgy at any Orthodox church! Oh, and you get to SIT at my mom's church!"

"As if that's a positive?" I asked.

"But you do get exercise — stand, kneel, sit, repeat!" José added.

"Let's forget church and practice!" Kim suggested.

We all agreed, so I unpacked my instruments and music, and checked the tuning on my guitar. We began practice, and two hours later, I packed up my instruments and music and headed home. My wife and daughter would not be home until after lunch, so I put on a CD of Mozart piano concertos and sat down with the latest edition of The Lancet and began reading.

I read until the Mozart CD finished, then put in one of Chopin's Nocturnes and read until it finished. As the last notes of Chopin: Nocturne in E Flat Major Op. 9 No. 2 faded, I put away The Lancet and went to the kitchen to make my lunch. I had just finished eating when Kris and Rachel arrived home, and I greeted them both with a kiss and a hug.

"How was your morning?" I asked.

"We met up with Oksana and the four of us bought new outfits for Pascha. How was band practice?"

"About the same as always. José and Sierra did say they're marrying at Jose's mom's parish in Milford, and the date is after we come back from Tennessee. I added it to the calendar. You had lunch out, as planned, right?"

"Yes. Rachel just needs a clean diaper, then we can go grocery shopping."

"I'll take care of it," I said, taking Rachel from Kris.

I took my daughter upstairs, changed her diaper, put on a clean outfit, then carried her downstairs. We did our family grocery shopping, stopped at the bakery, and then headed home for some time together before Vespers.

April 10, 1989, McKinley, Ohio

On Monday morning, after breakfast and morning prayers, Rachel and I left the house for the drive to the hospital. As was the norm for weekdays, I turned her over to Marcie at daycare, and then headed to the ED to change into scrubs and get the handover from Kylie.

"It was a very quiet night," Kylie said. "Only one patient of mine on the board at the moment, out of three total — an alcoholic who put his arm through a plate glass door. It was too complicated for me to suture, so Doctor Sumner from Plastics did the repair. The patient will be ready for release when his EtOH is under 0.05. Social Services has a rehab bed for him, if he'll go."

"OK. How many patients did you treat last night?"

"Two besides the drunk; an MI who is in cardiology, and a discharged fender-bender with contusions. And now I'm outta here!"

She left, and I went to check in with Doctor Billings. Once I had let her know I had arrived and taken over from Kylie, I went to check on the inebriated patient. He was asleep, and wasn't on a monitor, so I simply looked at the chart to see his most recent vitals, which a nurse had checked at 5:30am. I didn't want to disturb the patient, as in about thirty minutes a nurse would wake him to draw blood, so I went to the lounge.

"Morning, Tim," I said when I saw him in the lounge.

"Morning," he replied flatly, then returned to reading the newspaper.

"You know," I said, "it's up to you, but this is the time you should be reading medical journals or studying."

Tim didn't respond, so I sat down with the latest issue of The Journal of Emergency Medicine. I didn't get very far before Ellie came into the lounge and said that Doctor Gibbs would like to see me. I got up and went to the Attending's office.

"Come in, Mike, and shut the door, please."

I did as she asked and sat down across from her.

"What day do you leave for your honeymoon?"

"June 3rd. Why?"

"Patience, Grasshopper! Did you plan to take shifts between graduation and then?"

"No. I figured I'd take the time off while I could. Is there some kind of scheduling problem?"

"No. We plan for not having Fourth Years the last two weeks of May. There's a new training protocol for trauma physicians that includes ride-alongs with paramedics. It hasn't been formalized as yet, but Doctor Northrup thinks you'd be an excellent test subject and could do it during the week following graduation."

"What would that involve?"

"You'd be assigned to an EMS team and respond with them. You'd need to attend a one-day Saturday seminar given by the paramedic training programs at Columbus State Community College to familiarize you with EMS procedures, and then you'd be temporarily credentialed as a paramedic. Your twelve rotations, including three in the ED, give you sufficient training hours and two years of classroom instruction in medical school easily exceeds the education requirements. It has the added advantage of qualifying you to fly as a 'Flight Surgeon' without making further helicopter ride-alongs."

"I'll have my MD before the ride-along," I replied.

"Yes, but you won't on the day of the seminar."

"What downside are you not telling me?" I asked.

Doctor Gibbs laughed, "Honestly? There isn't one, unless you consider bunking at the firehouse for four twenty-four-hour shifts a downside."

"Would it be purely observation?"

"No. And, while it might seem strange, you'd be qualified to do a procedure the paramedics currently cannot do — intubation."

"I read there's a training program for that being established."

"Yes, starting in the Fall, paramedics will do the equivalent of an abbreviated trauma rotation. Once they've demonstrated they are able to successfully intubate in the ED under supervision, they'll be certified to do it in the field."

"Just out of curiosity, what about supplies? They don't carry intubation kits, succinylcholine, or etomidate in the squads."

"You'd have your own specialized medical kit that will contain the additional things you'd need."

"And I can do that without supervision?"

"Yes. You'll potentially be doing intubation without direct supervision on July 1st, and not much changes between now and then, except you'll be an actual MD."

"So my very first actions as 'Doctor Mike' would be with the paramedics?"

"Yes, though they wouldn't call you 'Doctor' in the field so as not to confuse anyone or create a problem. You'd wear standard paramedic attire, not a lab coat or any other indication of your special status. Remember, this is all just a pilot for a future program, so we're still working out the details."

"I like the idea of cross-training paramedics in the ED and for trauma physicians to see the paramedics work in the field."

"ED Nurses, too, eventually," Doctor Gibbs said. "And I know you've heard that the Internal Medicine, Surgery, and Cardiology Residencies are being modified to have formal rotations in the ED. You're the first, though your plan is different from how it would be for a normal surgical Resident, because you'll serve two full years in the ED."

"You make it sound like a prison sentence!" I chuckled.

"Some Residents who aren't trauma specialists will see it that way! I see this as a natural development of a specialty that is less than twenty-years-old, performing a service that was proposed only thirty years ago. The first trauma specialist completed their Residency in 1975, only ten years before I completed mine. And professional paramedic training with accreditation and certification only started about fifteen years ago."

"I was surprised to learn that UC had the first Residency program for emergency medicine. I would have expected it to have been in Chicago or Baltimore, given that's where the first 'Shock-Trauma' units were established."

"Interestingly, and you may know this from your interview," Doctor Gibbs said, "UC has the oldest medical school west of the Allegheny Mountains, and is, according to their research, the second oldest public college medical school in the US in continuous operation."

"I looked that up after my interview," I replied. "Maryland is first. I'd say that's impressive."

"What do you think?" Doctor Gibbs asked.

"I think I should check with Kris to ensure marital harmony," I replied. "If she's amenable, I'll agree."

"Good. You'd be paid a stipend of $250 per shift, by the way, and the uniforms would be provided at no charge."

"Well," I said with a goofy smile, "that's an hourly pay rate about double what I'll receive as a Resident!"

Doctor Gibbs nodded, "Sick, but true. Just be happy you're being paid a surgical Resident's salary and not a trauma Resident's, which would make that comparison even worse!"

There was a knock at the door and Doctor Gibbs called out for whomever it was to enter.

"Multiple-victim MVA," Nurse Wendy announced. "EMS is five minutes out with at least three being transported."

"Thanks, Wendy. Let's go, Mike. Time to earn our pay!"

"For YOU, maybe," I chuckled as we both got up. "I'm still paying for the privilege!"

We gowned and gloved and met Doctor Billings, Doctor Gabriel, and Doctor Foulks in the ambulance bay, and were joined by nurses and medical students, including Tim.

"Four patients," Nurse Jean called out to us from just inside the ambulance bay doors. "All trauma rooms are clear, as is Exam 2."

"Three most severe in the trauma rooms," Doctor Gibbs announced, then turned to Doctor Foulks, "Nick, you and Al take the least severely injured to Exam 2."

Four patients arrived in three ambulances, and Doctor Billings, Tim, and I were assigned a twenty-four-year-old male patient with a compound fracture of the lower leg, in addition to the usual contusions and lacerations found in moderate-speed accidents. The patient was, per protocol, on a backboard and had a cervical collar, was on a saline IV, and had been given morphine in the field.

"Tim, Ortho consult, stat!" Doctor Billings ordered. "Mike, monitor and neural assessment; Penny, cut away his jeans, please, then CBC and Chem-20."

Everyone sprang into action, and I hooked up the basic monitor while Doctor Billings auscultated the patient's heart and lungs.

"Tachy at 110," I called out. "Slightly hypertensive at 136/90; PO₂ 98% on 3 liters."

I then began the neuro assessment, reporting my findings as Doctor Billings began examining what could only be described as an ugly compound fracture. Tim took the tray with vials of blood from Penny and left for the lab.

"No fluid in either ear," I called out. "Nasal passages clear; Pupils reactive but sluggish."

I picked up a reflex hammer and used the metal handle to do a Babinski, announcing the results, "Babinski normal. Neural assessment is normal."

"Good. Clear the C-spine and remove the cervical collar if indicated."

I performed a basic check, but a detailed check would require x-ray imaging or a CAT scan.

"No apparent loss of muscle tone not attributed to morphine; no distention or swelling of the neck."

I rechecked his heart and lungs by auscultation, then re-checked his pupils.

"No signs of cardiac or respiratory distress, pupils still sluggish due to morphine. All physical signs point to no cervical injury."

"I concur," Doctor Billings said. "Remove the cervical collar."

"Yes, Doctor."

I carefully removed the cervical collar and set it aside.

"Miller, Ortho," Doctor Tim Miller announced. "What do we have?"

"Compound fracture of the lower right leg involving both the tibia and fibula. Patient is stable with tachycardia and mild hypertension despite morphine in the field."

"Let's get him upstairs! Jack, call for an OR assignment, an orthopedic surgeon, and an anesthesiologist, please. Then call for an orderly."

His medical student, Jack Greer, moved to the wall phone and placed the call.

"Do you want us to put in the Foley?" Doctor Billings asked Doctor Miller.

"It'll save time if you do it while we wait for the orderly."

"Mike, Foley," Doctor Billings directed.

Tim had returned, so I made sure I explained each step as I performed it, with assistance from Penny. I was happy he took notes, though if he didn't study, that wouldn't do him much good. Ten minutes later, the patient had been whisked away for emergency orthopedic surgery, and I made sure the chart was updated, complete, and legible, before taking it to Doctor Billings so she could review it and have Doctor Gibbs sign off.

The two least injured patients, both backseat passengers in the car, were treated and would be released after several hours of observation, but the front seat passenger had died due to massive head trauma, as she hadn't been wearing a seat belt. Along with diet, exercise, and regular checkups, wearing a seat belt was a primary way to reduce the need for hospital services. It was such a simple, logical thing that I could hardly fathom why anyone would even consider riding in a car without wearing a seatbelt.

"They ought to bring Driver's Ed students to the morgue to see MVA fatalities," I said to Doctor Billings. "Maybe that will get the point across about seatbelts."

"And motorcycle riders should see the effects of riding in blue jeans, a t-shirt and no helmet."

"People 'feel the need for speed'," I replied.

"Even Tom Cruise was wearing a leather jacket in Top Gun!"

"Because bomber jackets are cool," I replied. "Dennis Hopper didn't wear a motorcycle helmet in Easy Rider, though at least he wore buckskins."

"I assume you approve of Ohio's mandatory seatbelt law passed back in '86?"

"Yes, though I'd prefer primary enforcement, not secondary. The cops should be able to pull you over for any unbelted passenger, front or back seat. Driving is a privilege, and if you don't follow the laws, the cops should be able to ticket you without having to see you violate some other traffic law first."

"I take it you opposed the repeal of the motorcycle helmet law in '78?"

"I was more worried about getting my driving license and getting laid than I was about politics!"

Doctor Billings laughed, "Typical of a fifteen-year-old guy!"

"Are you implying fifteen-year-old girls aren't interested in driving licenses or sex?"

"Not the same way guys are!"

"I beg to differ, but sticking to the original topic, I agreed with anyone under-18 having to wear a helmet, obviously, and I'd like to see the law reinstated. The moniker 'donor cycles' is not without substantiation. Or, as we often hear — 'What do you call a person riding a motorcycle without a helmet?'"

"An organ donor," Doctor Billings said. "So they do serve a useful social purpose."

"Ouch," I chuckled. "Not that it's not true, but still."

"What about personal freedom?"

"Again, driving is a privilege, and the State of Ohio can set reasonable conditions for driving on public roads."

"Not a typical attitude for this area of Ohio," Doctor Billings observed.

"If you think I'm out of step, you should speak with my wife! Let's just say French socialism and Ohio politics do not line up in any way!"

"That should lead to some interesting discussions at home."

"You could say that," I replied.

"Walk in bee sting in Exam 4," Penny said from the door to the Resident's office.

"Take it, Mike," Doctor Billings said. "You're authorized to extract the stinger if it's there. Call me if there are any signs of anaphylaxis. Penny, assist Mike, please."

I confirmed I understood, went to the lounge to get Tim, and then Penny, Tim, and I went to Exam 4.

"Good morning," I said to Kimberly, a young woman who was about sixteen with a swollen cheek. "I'm Mike, a Sub-Intern, and this is Tim, a medical student. Is your parent or guardian here?"

"Mom is in the waiting room," she said. "She can stay there! She freaked out when the school called her."

"Penny, do we have a signed treatment form?" I asked.

"Yes."

"OK. Kimberly, is it OK to examine you?"

"Sure."

I washed my hands, put on gloves, and examined the swollen area, but couldn't see if the stinger was still embedded.

"Magnifying glasses, please," I requested.

Penny retrieved the glasses with loupes and put them on my face so I didn't have to touch them. I looked again and saw a small portion of the stinger embedded in the wound.

"There's a small piece of the stinger in your cheek," I said. "Let me check your vitals again, then I'll remove it if that's OK."

"Go for it," she said.

I checked her pulse, breathing, and BP, then auscultated her heart and lungs. Other than a slightly elevated heart rate, everything seemed fine.

"Micro forceps, please, Penny."

She handed me the smallest set of forceps we had, and I carefully grasped the stinger and removed it, dropping the tiny piece of organic material into the metal basin on the instrument tray.

"All set," I said to Kimberly. "How do you feel?"

"OK, I guess, but I look like a chipmunk!"

"You don't appear to be allergic, so the swelling will go down within twenty-four hours. I'll give you some antihistamine and something for the discomfort, and then you can go."

"OK."

"Topical antibiotic," I said to Penny. "Also, 5ml of Benadryl and two tablets of ibuprofen, please. I'll get Doctor Billings to sign off."

I wrote everything on the chart, then left the room to find Doctor Billings. I reported to her, she signed the chart after asking several questions to ensure I'd checked properly for anaphylaxis. She also signed the discharge form, and I returned to Exam 4.

"Doctor Billings signed off," I said to Penny, who administered the drugs and topical antibiotic.

"I seriously could have done this myself," Kimberly groused. "Benadryl, Advil, and a pair of tweezers!"

I smiled, "Even doctors don't treat themselves if they're smart. You could have had an allergic reaction to the bee sting, which could have led to potentially fatal anaphylactic shock. I agree there was no need to 'freak out', but I think moms do that in general."