Chapter 12: The Patient Is Our Focus

July 4, 1989, McKinley, Ohio

Mr. Temple's lab results came back and, as I'd suspected, showed absolutely nothing outside the normal ranges for a man of his age. I updated the chart and added some diagnostic notes.

"Now what?" Mr. Temple asked.

"We'll keep you until 6:00am to monitor you, but if there are no signs of problems on the EKG or with your vitals, we'll send you home, and you should follow up with your personal physician. He or she can get your records from the hospital and take it from there. I'll also write a referral to a cardiologist so Medicare doesn't give you grief. If you like, I can turn down the lights, and you can try to get some rest, though someone will come to check on you regularly."

"Could I get something to drink?" he asked.

"We're fresh out of Scotch," I replied. "But I'll have the nurse get you some ice water or orange juice."

"Orange juice, please."

"Someone will bring that to you right away."

Tom and I left the room and went to the nurses' station, where I asked Jackie to see that Mr. Temple received a bottle of orange juice and to take vitals every thirty minutes.

"Is that on the chart, Doctor?" she asked.

"It is," I replied. "Well, not the juice, but the vitals."

She laughed, "Which is, of course, what I meant. I'll note the juice when he drinks it."

"Thanks. Is Doctor Varma still busy?"

"Three patients," she said. "One admission and two monitoring."

The dispatch phone rang, and she picked it up, wrote notes on her notepad, then hung up.

"EMS four minutes out with an MI."

I looked up at the board, "Trauma 2 is free. Have a nurse meet us in the ambulance bay, please. Tom, let's go."

We gowned and gloved and headed to the ambulance bay.

"I've never had ten hours like this," he said. "All last month, it was mostly calm overnight."

"I had a few nights like his during my clinical rotations, but they weren't all that common. We are seeing more visits overall since EMTALA passed, but that's not really responsible for overnight. The hospital expansion will barely keep up with the demand at the rate we're going."

"Then what?"

"Waiting times increase, as they have in New York City, Chicago, and LA, and to a lesser extent, Cleveland."

Nurse Kelly came out to the ambulance bay to join us.

"Kelly, I'll want a trauma panel, cardiac enzymes, and blood gas," I said. "Tom, EKG and monitor, then Foley if the patient is unconscious."

Both of them acknowledged my orders, and a minute later, the ambulance pulled up.

"Leroy Gibson; fifty-nine; working third shift at the water treatment plant; complained of severe chest pain, then collapsed; tachy at 120; BP 80/50; PO₂ 93% on ten litres; diaphoretic and non-responsive. Saline IV TKO."

"Trauma 2! Tom, cardiology consult first."

"Got it!"

We rushed Mr. Gibson into Trauma 2, and the five of us moved him to the treatment table. Tom called for the cardiology consult while Kelly switched the oxygen feed, and I listened to Mr. Gibson's heart and breathing. Tom finished the call and came over and began cutting away Mr. Gibson's shirt, then attached the EKG and pulse oximeter.

"What do you see?" I asked when he turned on the machine.

"It's not a sinus rhythm," he said. "But I don't know more."

"ST elevations," I said, pointing to the phosphor line on the monitor. "STEMI. Kelly, given his estimated weight, 350 megs ASA IV push."

"ASA 350 megs IV push," she repeated.

"Tom, put in the Foley, please."

"I've done exactly one," he said.

"Then you know how. I'll watch and correct anything you've done wrong."

"What size?" he asked.

"Try 16 French," I said. "But cut away his pants and underwear before you get the catheter, as he might not be average in size."

Tom cut away the clothing, I estimated my judgment had been correct and told Tom. He retrieved the correct Foley and did a competent job of inserting it without need for correction.

"Urine in the bag," he said. "Light yellow, no pink tinge."

"OK. What would you do next?"

He shook his head, "I don't know. You gave him an ASA bolus, he's breathing on his own even if his PO₂ is a bit low and short of an angiogram, I don't know what to do."

"That's it, actually. Cardio will take him and do exactly that, though they might do a cardiac echo instead or in addition. We've done what we can — he has a heartbeat, is breathing, and has the monitor."

"Shore, Cardiology," a PGY1 with a female Third Year medical student I didn't recognize in tow.

"Hi, Patrick," I said, looking at his name tag. "Mike Loucks. We have Leroy Gibson, fifty-nine; working third shift; complained of severe chest pain, then collapsed; tachy at 120; BP 80/50; PO₂ 93% on ten litres by mask; diaphoretic and non-responsive. EKG shows classic STEMI. ASA 350 megs IV push; Foley is in with urine in the bag."

"He needs to lose about forty kilos," Doctor Shore said, as he examined Mr. Gibson.

"At least," I agreed.

"Nicki," he said, "call upstairs and tell them we need the cath lab and an Attending."

"Yes, Doctor Shore!" she said, going to the phone.

"I'll take him," he said. "Did your Attending sign off on the chart?"

"No," I replied. "I'm authorized to handle MIs. You can verify that with Doctor Strong or any of the other senior Residents or Attendings. Who's your Attending?"

"Doctor Blackburn."

"He's new, so he might not know, but if he has questions, he can call Doctor Bielski or Doctor Getty to confirm."

"I need the signature."

"OK," I replied. "Let me go wake up Doctor Mastriano. Tom, switch to a portable monitor and stay with Mr. Gibson until he's in the cath lab. I'll be right back with the chart."

I left the trauma room and knocked on the door to the Attendings' office, waited fifteen seconds, then opened the door.

"What?!" Doctor Mastriano asked without getting up.

"Cardiology won't take my STEMI without your signature."

"You're authorized."

"You explain it to the PGY1 cardiologist and his new Attending, who wasn't trained at Moore Memorial because they insist on you signing off."

"Give me the short version."

"Morbidly obese fifty-nine-year-old male complained of severe chest pain, then collapsed at work. EKG shows classic STEMI. ASA IV push."

"Give me the chart," she demanded.

I did, she sat up, took off her sleeping mask, scribbled her approval below my admission note, and handed it back. She put her sleeping mask back on and reclined again, so I left without a word and returned to Trauma 2.

"Signed off," I said, handing the chart to Doctor Shore.

"Then let's go!"

We transferred Mr. Gibson to a gurney, and Doctor Shore, Nicki, and Tom left to take him to Cardiology. I updated the board, then went to the lounge to get a bottle of water. I considered coffee and decided to pour myself a mug. I drank the bottle of water down, then took my mug of coffee with me to triage.

"Nothing, I see," I said, seeing an empty waiting room.

"Doctor Varma took the last patient about five minutes ago."

"OK. At 0600, you'll switch with Nanette, Doctor Varma's Fourth Year."

"What happened to the man with the syncopal episode?"

"He had one short run of A-fib, but everything else is normal. Smoker's lung, though he quit twenty years ago."

"Wait, if he quit..."

"A pack a day from age fifteen to age fifty," I said. "The damage is often permanent. If he hadn't quit, he'd be in far worse shape, assuming he was still alive. We'll monitor until 0600, then street him if nothing changes. I'll refer him to his personal physician and a cardiologist, but this could be something as simple as a brief bout of vertigo because he had a slight, undetectable viral infection."

"Common cold?"

"Yes. But that's just speculation, as I didn't find any symptoms or signs except the crackles in his lower lungs. He may have had a bout of A-fib when he got out of bed, might have stood up too quickly and had his BP drop, or any number of things, none of which we can justify looking for in the ED. His personal physician is best qualified to manage any testing and investigation in consultation with specialists as necessary."

"And right there is why I'm not sure I want to be an emergency medicine specialist. It would drive me nuts."

"Me, too! And it's a VERY short drive! But this is what I've wanted to do since fourth grade. And I've had several doctors remind me of that 'feature' of my chosen specialty because it bugs the heck out of me."

"So why do it?"

"I like the adrenaline rush," I replied. "It's my drug of choice!"

Both Mary and Nurse Bonita, who was taking a few hours at the triage desk, laughed.

"Fourth grade?" Mary asked.

I explained the playground incident and how that had set my course for the rest of my life.

"I didn't decide on medical school until halfway through college when my biology prof at Bowling Green suggested it," Mary said.

We were interrupted as Deputy Schmidt came into the waiting room. Mary buzzed him through, and he came over to the triage desk from the inside rather than the waiting room side.

"I had to admit your victim," I said. "He had a seizure, and neuro took him."

"Well, shit. We did grab the other two dirtbags, and I do have the bartender's statement."

"No security cameras?"

"Outside only, nothing inside. But one of the guys we grabbed has hand injuries consistent with being in a fight. Any idea what happened with Mr. Firth?"

"I could only speculate. If you go up to neuro, they can give you more details, but I doubt he'll be able to give a statement any time soon, or perhaps ever."

"He could die?"

"Yes."

"Then we'll hold the scumbags on attempted murder charges, which means we keep them locked up unless they can raise bail."

"Four white guys?" I asked.

"Yep. According to the bartender, Dirtbag #1's girlfriend talked to the vic, and Dirtbag #1 and his friends took exception."

"Someday, this racist BS is going to stop," I said. "And that day can't come too soon."

"Don't hold your breath, Doc. This bar has Confederate flags on the walls."

I shook my head, "That's not the symbol of freedom from an oppressive government certain moronic elements think it is. I could see the Gadsden Flag, but the Confederate battle flag makes no sense. Anyway, at least the bartender is coöperating."

"Their liquor license is under supervision for serving underage on at least four occasions in the past two years."

"I'll keep my opinions of stupid laws to myself," I chuckled.

Deputy Schmidt laughed, "And you just gave your opinion! Anyhoo, I'll go up to neurology and see what they have to say. Thanks for taking care of Sam earlier."

"You're welcome. I take it you heard the shooter survived but is in critical condition."

"Yeah, he'll spend a long time breaking rocks for shooting at a deputy. The County Prosecutor will throw the book at him. The sick part is that he'd probably have been able to plead out the drug rap and get off with a short stint in the county jail. Now he'll do hard time."

"What pills?"

"A whole pharmacy! Uppers, downers, you name it. And a kilo of pot."

"Mule?"

"Good guess. He was coming up from Eastern Kentucky on his way to Columbus."

"Harlan County?" I asked.

"OK, how did you know that?"

"A fellow med student is from Harlan County and told me about it, and another of my fellow students Matched at a regional medical center there."

"Who the heck volunteers to go there?"

"Well, the one who was from there wanted to go back to serve her community; the other one didn't Match last year and took anything she could find."

"Washed out?"

"No, she graduated but had some personal problems that blocked her from Matching to any of the hospitals of her choice. This time, she cast her net as wide as possible to Match."

"Makes sense. I'd have taken a job with any department who would have hired me for my first job, even with one of those Southern cracker J. W. Pepper sheriffs!"

I laughed, "Live and Let Die and The Man With the Golden Gun! Maybe a bit of Buford T. Justice."

"Smokey and the Bandit? He was just incompetent, not an asshole!" Deputy Schmidt retorted. "I need to get upstairs."

"See you later, Deputy," I said.

He left, and as there were no patients, I went to the lounge and sat down for the first time since dinner, which had been about ten hours earlier. Tom returned from Cardiology and plopped down on the sofa next to me.

"He's in the cath lab. I returned the portable monitor to the alcove."

"Good. How are you holding up?"

"Fine. I've only been on for ten hours or so. You've been on twenty-two, right?"

"Yes. And fourteen to go, though, as I said, I'll duck out for four hours, and Kylie Baxter, who went off shift at midnight, will cover for me."

"How long have you had your band?"

"Roughly four years," I replied.

"I need to get to a gig of yours. Got any lined up except later today?"

"We'll play at Taft in August and Stirred Not Shaken in September. We only took the one Summer gig because of my schedule. We play school dances and clubs and end up with about ten gigs a year in total. We'd play more, but we all have full-time jobs."

"Doctor Mike?" Nurse Becky said from the door to the lounge. "EMS ten minutes out with DUI MVA."

"How many?"

"Just the driver, per the dispatcher."

"OK. What's free?"

"Trauma 1 and 3."

"I'll take 3," I said. "I'll need a nurse, please."

"OK. Margie will meet you in the ambulance bay in a few minutes."

"Thanks."

She left, and I finished my cup of coffee.

"Wake Doctor Mastriano?" Tom asked.

"Let's see how bad it is first," I replied.

"How do you stay so calm? I feel like I'm about to have a panic attack every time I cover an EMS run."

"You're only five weeks into your first clinical rotation," I said. "It's normal. By this time next year, you'll feel a lot more comfortable. The problem is that what you learn in the classroom is theory, and here, the rubber meets the road. It's easy to do diagnosis in the classroom with no real pressure, but here, well, either you thrive on the pressure and get off on the adrenaline high, or you pick a different specialty. Don't sweat the feeling, just take it into account next Spring when you choose your electives. That said, you absolutely want a Sub-I in emergency medicine, as it applies to every single specialty, and you'll see a wide range of cases."

"You're like ice, though. I mean, totally unflappable."

"It's a personality trait," I replied. "Look at the other doctors in the ED who you admire. Are any of them emotional or wimpy?"

"No. You're all like automatons. Well, except for, never mind."

"You're entitled to your opinion, and I won't repeat it."

"Doctor Lewis seems awfully high-strung," he said.

"And he'll either get past it or burn out and quit or switch to another specialty for his PGY2."

"People actually quit? After they Match?"

"They do. I heard about a PGY3 quitting at Cook County from Doctor Taylor. They literally just walked out of the ED one day, saying they quit and never came back."

"But that's seven years! Twelve if you count college! How do you not know?"

"Everyone has a breaking point," I replied. "I'd hit mine in pediatric oncology, which is why I want to stay away from there, period. Doctors who can do that for their whole careers are pretty amazing. I sure couldn't."

"Why?"

"I couldn't deal with kids dying on a regular basis, or worse, in some ways, telling them they're going to die, and you can't do a damned thing about it. Let's go meet the ambulance."

We left the lounge, gowned and gloved, and went to the ambulance bay.

"But people die in the ED," he said.

"Yes, they do, but nearly all of our patients leave here alive or with a chance. In oncology in general and pediatric oncology specifically, most of their patients are dying and are likely to die. At least here in the ED, I have a fighting chance to do something other than administer IV poison in doses just low enough not to kill the patient in the hopes it'll kill the cancer cells. It's barbaric, but we don't have any better options. Radiation therapy isn't much better — microwave the tumor or whatever in the hopes you can kill it before the patient dies from radiation sickness or other organs fail. The only thing worse is psychiatry."

"How so?"

"Whereas oncology is barbaric, it's modern, while psychiatry is medieval and cares more about docile patients than anything. A close friend of mine, well, more, because she was a girl I intended to marry, was diagnosed with schizophrenia while we were undergrads, and the treatment she received was right out of the Soviet psychiatric hospitals — drug them into docility and lock them away. The only reason she's not institutionalized is because I've fought tooth and nail to prevent it. And that has taken serious resources and good lawyers."

"Becky said you needed me," Nurse Margie said, coming out into the ambulance bay.

"Yes. DUI MVA, so trauma panel plus EtOH. Tom, EKG plus monitor, then Foley if the patient is unconscious. I'll intubate if necessary and conduct a primary exam."

The ambulance pulled into the driveway and came to a stop in front of us.

"Kimberly Bond, nineteen, unbelted driver; alcohol on her breath and open container in the car. Hit a telephone pole at low speed. Incoherent but conscious; tachy at 115; BP 100/70; PO₂ 98% on nasal cannula; resps labored at 20; multiple contusions; head hit the windshield; fractured left wrist; possible internal injuries; IV saline TKO; no meds as she's feeling no pain."

"Trauma 3," I said as the five of us moved off. "Tom, do the Foley once you have the monitors hooked up."

"Do you need help, Mike?" Nurse Becky asked.

I considered, "A second nurse would help, but I don't need another doctor right now."

"Julie will be right in."

Five minutes later, Ms. Bond was connected to the various monitors, but I forewent the intubation as she was breathing on her own. I did have Tom put in a Foley, and when nurse Julie came in, she assisted by covering the patient with a sheet and then scribing as I continued my exam.

"I think we need a neuro consult," I said. "And orthopedics, but I suspect she's bleeding internally. Margie, would you get the portable ultrasound, please?"

"You aren't going to call the surgical Resident?" she asked.

I smiled, "See these red scrubs? I am the surgical Resident!"

I was going to make use of that by simply calling up to get Ms. Bond an ex-lap if I felt she needed one, rather than bothering the on-call surgical PGY1 for a consult who would have no more experience or skills than I did.

"Right away, Doctor."

"What do you see on the EKG, Tom?" I asked.

"I think this is V-tach."

I nodded, "Yes. But it's not high enough to warrant intervention just yet. Why is her BP low?"

"Alcohol impairment or blood loss, possibly both. That's why you want the ultrasound."

"Yes. Julie, get me a unit of plasma, please, and type and cross match. Surgery will need to know that."

"Hang the plasma?"

"No, just get it on the stand. If I see fluid in her belly, we'll give her the plasma. Everything else, except her wrist and forehead, are superficial."

"Hi again, Doc," Deputy Schmidt said, coming into the trauma room.

"Are you the only guy working the entire county?" I asked.

He laughed, "No, but they knew I was here and asked me to arrest the driver."

"Consider her under arrest, but I hope you'll forego the cuffs. She's likely going to need surgery."

"She doesn't look like she's going anywhere, so no problem."

"Soft restraints if we need them," I said to Tom and Julie and noted on the chart she had been placed under arrest.

Margie returned with the ultrasound, and after we set it up, she squirted gel onto Ms. Bond's stomach, and I put the transducer against Ms. Bond's skin and moved it around.