Chapter 17: Michael Loucks, Trauma Clerk

October 1, 1987, McKinley, Ohio

“Morning, Nate,” I said when I walked into the ER waiting room early on Monday morning,

“Hi, Mike! Good to see you, and I want to offer my condolences.”

“Thanks.”

“I have your badge and pager; make sure you change the batteries weekly. Doctor Gibbs said you should change and just get to work!”

“Of course she did,” I chuckled. “Thanks.”

“She’ll be in at 8:00am. Doctor Williams is the Attending and Doctors Schmidt and Casper are the Residents. Maryam is here, but I’m sure you knew that, and Jake and Trudy are the Fourth Years.”

He handed me the badge and pager, buzzed me through the door, and I headed to the locker room to change into scrubs.

“Hi, Mike,” Nurse Ellie said. “I’m sorry for your loss.”

“Thank you.”

She left without saying anything further, for which I was grateful. I quickly changed into my scrubs, clipped on my pager and ID, then went out to check the board.

“Hi, Deacon,” Maryam said, coming up next to me. “There is nothing pressing at the moment, just one patient waiting for admission to Medicine, and one being discharged.”

“How was the night?”

“Mostly quiet. The Medicine patient has an untreated infection and needs IV antibiotics. The discharge was a sprained ankle after stepping on a LEGO block.”

“Ow!” I replied wincing at the thought of how badly stepping on a LEGO block would hurt.

“He had a cut on the bottom of his foot, but it didn’t require sutures.”

“Anyone else come in?”

“Drunk college student; IV and discharged.”

“On a Thursday night?”

“On a Thursday night.”

“How is Doctor Schmidt?”

“He seems OK, but as I said, it was a quiet night, so I didn’t have much interaction with him. I didn’t even see Doctor Williams. The two Fourth Years are on twenty-four-hour shifts and mostly slept.”

“OK. I’m going to get a cup of coffee then sit in the lounge.”

“I’ll sit with you when you come back, but I don’t want to drink coffee when I’ll be going to bed in about five hours.”

I went to the cafeteria and got a cup of coffee and then went to the lounge where Maryam joined me. About ten minutes later, the door opened and Nurse Ellie stuck her head in.

“Maryam, the discharge papers are signed for the sprained ankle; Mike, paramedics five minutes out; car versus bicycle.”

We both got up and left the lounge, with Maryam handling the discharge while I got a gown from the shelf and headed to the ambulance bay where Doctor Casper was waiting.

“Hi, Mike.”

“Hi, Doctor Casper.”

“Sorry for your loss.”

“Thanks.”

“How was your OB/GYN rotation?”

“Laborious,” I replied with a smirk.

Doctor Casper laughed, “Good one. I see you still have your dry sense of humor.”

“Sometimes my options are only laughing or crying. I try to laugh when I can.”

“That’s good. Doctor Gibbs showed me your proposal. Gutsy.”

“Just following in the footsteps of those who have forged the way.”

“How do you know the Chicago ER Chief?”

“I met him when I interviewed at Indiana University. He tried really hard to recruit me, including offering scholarship money, but I had planned to attend McKinley Medical School from the beginning. When I called him, he encouraged me to interview for the Match. I basically fit his profile for what is being called a ‘trauma surgeon’. There are only a few programs like that, and Doctor Barton started two of them — Indiana and the University of Chicago.”

The ambulance turned into the driveway and cut the siren, and a few seconds later stopped in front of us. The paramedic driving hopped out and gave us the bullet as he moved to the back of the rig and opened the doors.

“Eighteen-year-old male; bike versus car; helmeted; conscious at scene; apparent right tib-fib fracture, splinted; multiple contusions; pulse 70; BP 110/70; resps 15 and normal; GCS 14; ten liters O2; saline IV; 15mg morphine”

“What’s your name?” Doctor Casper asked the patient as we wheeled him into the ER.

“Stan,” the patient replied weakly. “My leg hurts.”

“We’ll fix you up. Can you tell me what happened?”

“Guy opened his car door in front of me.”

It was ‘car versus bicycle’ but not the way I’d imagined, and it explained why he was hurt, but hadn’t suffered any serious trauma other than the fractured tibia and fibula. Two nurses were waiting for us in Trauma 2 and together with the paramedics, the six of us carefully moved Stan to the treatment table. The paramedics removed their oxygen mask and one nurse replaced it with a nasal canula at Doctor Casper’s direction while the other nurse hooked the IV bag to a stand then connected a PulseOx monitor.

“Mike, vitals, auscultation, and head trauma check, please. I’ll check the leg.”

I took the patient’s pulse and BP, listened to his heart and lungs, then checked his eyes, ears, and nose, and asked him his birthday, the current date, and where the accident had happened.

“Pulse is 78; BP 120/80; PulseOx 98% on nasal cannula; no detectable rattles; no detectable heart abnormalities; pupils responsive; no fluid in ears or nose; GCS 15, allowing for the morphine.”

“And absolutely a fractured tib-fib, but good distal pulses. Call for a portable x-ray and an ortho consult, please.”

“Yes, Doctor!”

I went to the phone and called Radiology, then called Orthopedics. That accomplished, I returned to the treatment table.

“Fill out the chart, please,” Doctor Casper said.

I picked up the metal chart holder and began writing in the vitals I’d taken, along with the x-ray order and the request for a consult. I asked the patient for more information to complete the chart — full name, birthdate, address, and personal physician.

“Is there anyone we should call?” I asked.

“My dad. He works for McKinley Ford in the service department.”

I wrote that down and per Doctor Casper’s direction, left the trauma room and gave Nate the information.

“He’s stable. He was wearing his helmet and his main injury is a lower-leg fracture. We won’t know more until the x-ray and consult.”

“OK,” Nate agreed. “I’ll place the call. Cops here?”

“Haven’t seen them. But he rode into an open door of a car, so I’m not sure the cops will do anything.”

“They have to take a report when the paramedics respond, but yeah, that sounds like an actual accident. Somebody opened the door without looking?”

“That’s what he says happened.”

“Had that with a motorcycle about two years ago. He wasn’t wearing a helmet, and was riding in jeans and a t-shirt.”

“Turned himself into an organ donor?”

“Yep. Let me make the call.”

I left and went back to Trauma 2. A minute later the radiology tech rolled the portable x-ray machine into the room, and once he was set up, we stepped out so he could take the images. When he was done, we could actually see the images on the screen, instead of having to wait for film to be developed.

“That’s going to need surgery,” Doctor Casper opined quietly. “See the displacement?”

“I’m surprised he’s not in more pain with only 15mg of morphine,” I said. “He doesn’t appear at all shocky.”

“High pain tolerance, though he did say his leg hurt. Ortho should be here shortly, but I’m positive they’ll take him. I don’t want to administer any more morphine. You know why, right?”

“It would limit the choices the anesthesiologist and surgeon have for the procedure.”

“Sometimes it can’t be helped, but in this case, I think that’s the right decision. What else would you do?”

“At this point? What the nurses are doing — clean up the scrapes and wait for the consult. Just last year, we had to airlift patients to Columbus for orthopedic surgery. I assume we’ll do the surgery here, given they hired an orthopedic surgeon as of September 1st.”

“Part of the overall expansion plan, and necessary to be a Level I trauma center. The requirements get tougher, and I suspect if your proposal is accepted, and the same thing is implemented in other hospitals following Indiana and Chicago, that will become a requirement. We still have to fly patients to Columbus or Cincinnati for some things we don’t offer.”

“Abrams, Ortho,” a Resident said coming into the room. “What do we have?”

“Eighteen-year-old male with a fractured right tib-fib from a bicycle accident,” Doctor Casper said. “Films indicate surgery.”

“Let me take a look.”

He looked over the images and nodded, “That’s going to require surgical repair. I’ll admit him to our service and schedule the procedure with Doctor Bradshaw.”

He left and Doctor Casper let the patient know he’d need a surgical repair of his leg and that the orthopedic specialists would answer any questions. Nurse Ellie came in with a man I assumed was the patient’s father as we were leaving.

“Report this to Doctor Williams, please.”

“Right away, Doctor.”

I went to the Attending’s office, and finding the door shut, I knocked.

“Come!” Doctor Williams called out.

I opened the door.

“Mike Loucks, Third Year. I have an admission report.

“Give it to me, please.”

“Eighteen-year-old male patient transported by paramedic ambulance to the ER after a bike versus car collision. Patient was helmeted and is GCS 15. Vitals are stable; multiple contusions; major injury is a fractured tib-fib confirmed by x-ray. Ortho accepted him to their service and will schedule surgery.”

“Good report, Loucks. May I have the chart, please?”

I handed him the chart, he flipped through the pages, then signed the last page before handing the chart back to me.

“Thank you, Doctor,” I said.

“I’m sorry for your loss,” he said.

“Thanks.”

I left his office and handed the chart to the duty nurse at the nurses’ station, and went back to the lounge to await the next patient. That happened about five minutes later, when I was called to assist Doctor Casper again, and Nurse Ellie brought a mother with a screaming toddler into Exam 3.

“What seems to be the problem?” Doctor Casper asked the clearly frustrated mother.

“I have no idea. He simply won’t stop screaming and crying like he’s in pain, but I can’t find anything wrong with him. I called his pediatrician, Doctor Nickerson, who instructed me to bring Zane to the ER.”

“If you can put him on the exam table, we’ll see if we can figure out what’s troubling the little guy. Nurse Ellie, let’s see if we can get his pyjama top off without cutting it.”

“Yes, Doctor,” Nurse Ellie replied. “Mike, would you assist me, please?”

I nodded and we managed to remove Zane’s ‘Superman’ pyjama top, despite him thrashing and crying.

“I think you two will need to hold him so I can do the exam,” Doctor Casper said.

“Any vomiting?” Doctor Casper asked the mother.

“No.”

“When was his last bowel movement?”

“Let’s see, I guess it had to be on Tuesday morning.”

Doctor Casper nodded and began assessing Zane, starting with his abdomen, as the most likely diagnosis for a toddler screaming in pain who hadn’t had a bowel movement for more than forty-eight hours was severe constipation or even a bowel obstruction.

“Some rigidity,” Doctor Casper said, then turned to the mother, “How is his fluid intake?”

“He drinks enough, I think.”

“How often does he urinate?”

“All the time!” the mother replied. “And all over the place! Boys are impossible!”

Doctor Casper nodded and smiled, “According to my girlfriend, it doesn’t change when we grow up.”

“No kidding,” the mom said dryly.

He continued the exam, though I was sure he had extreme difficulty in assessing Zane’s heart sounds, and likely his lungs, given Zane was still crying and thrashing.

“Mike, call Pediatrics, please. We won’t be able to get good films or put in an IV unless we sedate Zane, and I want a consult before we do that.”

“Differential is severe constipation or bowel obstruction?” I asked.

“Yes.”

Doctor Casper allowed Zane’s mom to pick him up, and I went into the hallway to make the call so that I could hear and be heard. I picked up the phone, dialed Pediatrics, and asked for a consult to rule out bowel obstruction in a toddler.

“Doctor Sumner will be right down,” I said. “Do you want an ultrasound machine?”

“Yes.”

I turned and left the exam room and retrieved a portable ultrasound unit and brought it back to the exam room. Doctor Sumner arrived and Doctor Casper filled him in. It was unusual for the Chief to do an assessment, but it was also time for rounds, so his Residents and Attendings would have been visiting patients.

As we had with Doctor Casper, Nurse Ellie and I held Zane while Doctor Sumner performed his examination.

“How are you doing, Mike?” he asked as he palpated the squirming Zane’s abdomen.

“Hanging in there,” I replied.

“We were all shocked and saddened. My condolences.”

“Thanks.”

“Let’s see if we can get an ultrasound,” he said. “Ghost, would you assist, please. Our nurse and med student have their hands full.”

I almost laughed out loud at the nickname for Doctor Casper. I knew about it, but I’d never actually heard anyone use it. Between the two of them, they managed to get an image which did show some kind of mass in Zane’s large intestine, though because he was thrashing, it was difficult to assess.

“I think we’re going to need to give him a sedative so we can do a proper assessment. Let’s give our tyke back to his mom to hold. Mike, would you go up to pediatrics and ask for nasal Versed, please.”

“That’s the spray, right?” I verified.

“Yes. There is no way I want to try to put in an IV, and the way he’s fighting us, even a needle is risky if we don’t have to do it.”

“Be right back,” I said.

I left the room, rushed past the elevators, and took the stairs to the third floor. I hurried to the pediatric ward and went to the nurses’ station.

“Mike Loucks from the ER. Doctor Sumner is asking for nasal Versed for a two-year-old patient.”

“One moment,” the nurse replied.

She went to the medicine cabinet, unlocked it with her key, took out a box, verified it, then handed it to me. I verified it was what Doctor Sumner wanted, thanked her, then hurried back down to the ER where I handed the unopened box to Doctor Sumner. He verified it was what he’d asked for, opened the box, and extracted a small squeeze bottle with a nozzle. With assistance from Nurse Ellie, he sprayed some in each nostril, then handed me the bottle.

“He should calm down a bit within ten minutes,” Doctor Sumner said.

True to his word, about eight minutes later, Zane actually fell asleep.

“He was completely worn out,” Doctor Sumner observed. “Let’s see if we can do a full exam. He should be asleep for a least an hour.”

Nurse Ellie took Zane from his mom and put him on the exam table. A complete exam was done, and on Doctor Sumner’s instructions, I drew two tubes of blood, which I took to the lab for ‘stat’ CBC assessment, then returned to the exam room.

“I believe it’s severe constipation,” Doctor Sumner said. “Let’s get an IV with Ringer’s started, give him some PEG, and see if that resolves the problem. I’ll take him on our service for observation.”

“What if that doesn’t resolve it?” Zane’s mom asked.

“There are a number of options, but I want to see the blood work and give the PEG a chance to work.”

“PEG?” she asked.

“Polyethylene glycol,” Doctor Sumner replied. “It’s a typical ingredient in many over-the-counter laxatives, and is the main ingredient in pre-colonoscopy solutions. Mike, start the IV, please. Ellie, would you get the PEG?”

I opened the supply cabinet and took out a bag of Ringer’s lactate along with a pediatric IV kit. I’d never done one on anyone younger than eighteen, so I was extra-careful, and thankfully got it inserted properly on the first stick. I hooked up the IV bag, verified the flow, and opened the valve.

Nurse Ellie returned with the pre-mixed bottle of PEG and poured some into a sippy cup for Zane to drink. She woke him and got him to drink the PEG solution.

“Mike, call for the orderlies to bring Zane up to Pediatrics, please.”

I made the call, waited for the orderlies to come to take Zane away, and once they’d put him on a rolling gurney, I headed for the lounge, but stopped when I saw Clarissa going into the locker room.

“Hey, Lissa,” I said when I entered.

“Came for your cheap thrill?” she asked with a smirk.

“Nothing about you is cheap!” I protested. “But please don’t say things like that here. If Nurse Ellie were to hear you, she’d take it as license.”

“She didn’t play games this morning?”

“No. She simply offered condolences.”

“I bet you anything Doctor Gibbs spoke to her.”

“Speaking of her, I should go see her. She should be in now.”

“How was your morning?”

“Not too bad. A bike accident and a toddler with severe constipation.”

“That sounds like a sh...”

“Don’t say it!” I interrupted, but offered a smile.

Clarissa laughed, “Bad jokes and puns are one way to keep sane!”

“How’s that working out for you?” I asked with a grin.

“Hmm, do I respond in Russian or in English?”

“English, please. I think I kicked my Russian regression.”

“Hi, Clarissa!” Maryam said coming into the locker room.

“Going off shift?”

“In about fifteen minutes,” Maryam said. “I just came in to use the facilities.”

She went into one of the private restrooms and shut the door.

“What happened with your patients?”

“Fractured tib-fib admitted to Ortho for surgery for the bike accident; IV and PEG to resolve the constipation and admission to Peds for observation and management.”

“Anything else?”

“I glanced at the board as I was moving around and saw a rule-out MI, a rule-out pneumonia, and a hand lac.”

“Lunch together if we can swing it?”

“Sure. I’m going to go see Doctor Gibbs.”

“Just when I’m stripping down to my undies?” Clarissa teased.

“Lissa...”

“Sorry. I promise to limit my teasing to private moments.”

“Thanks.”

I left the locker room and went to the Attending’s office where I found Doctor Gibbs with Trudy, one of the Fourth Years.