Chapter 32: A Big Whiff

November 16, 1987, McKinley, Ohio

“Grossly, I don’t find anything amiss,” Doctor Smith said when he completed the exam. “Your prostate is normal, you show no signs of disease, no signs of hernia, your blood pressure is fine, and you have strong distal pulses. The lack of spontaneous morning erections and nocturnal emissions is slightly concerning, but that could be stress related.

“That leaves blood chemistry. I can draw the blood, but you’ll get faster results by having the blood drawn in the ED and having the lab run it. I’m positive that’s covered by your health insurance from the medical school. If you have it done when you arrive at 6:00am tomorrow, you’ll have your results before I could even get the blood to the lab.”

“I’ll do that and make sure the results are faxed to you, as well as to Doctor Mercer.”

“My suggestion, and I know how silly this sounds, is to find a way to reduce your stress.”

“Know any other good jokes, Doc?” I asked.

“That is the usual advice,” Doctor Smith said with a wry smile. “I’m going to ask this as your physician, not as your friend, and no judgment, but have you tried?”

“No.”

“I assumed that was the case, but I had to ask. Next question — are you not trying because you’re concerned about your inability to perform?”

“That’s a good question,” I replied. “I’m not sure exactly why I turned down the offer, but that might have been part of it.”

“Let’s see what your blood work shows, and if it’s all within acceptable norms, I’m going to suggest you go back to see Doctor Mercer.”

“That’s more or less what I expected to hear,” I replied. “I’m reasonably certain there isn’t a physiological cause, unless it’s simply stress.”

“And the more you stress about it, the more likely you are to suffer from an inability to perform when you actually decide to. Changing subjects, how is Rachel?”

“She’s doing fine. Still waking up around 2:00am, but it’s been slowly slipping a bit later. Hopefully in a few months she’ll sleep seven hours and that will allow me to get a full night’s sleep.”

“How are you handling your next rotation?”

“Lara will stay those two nights I’m working, and if she needs a break, Doctor Blahnik, Serafima, or Alyssa will fill in. And my mom is available as well.”

“How are things with your in-laws?”

“I haven’t spoken to them since last week. Father Nicholas suggested I wait until he had a chance to speak to Viktor again. I should hear from Father tonight or tomorrow.”

“All of that adds to the stress. Are you sleeping OK? Minus the nightly feeding?”

“I think so. I don’t wake up tired and I don’t really have trouble falling asleep when I go to bed, or after feeding Rachel. The rocking chair helps, because it allows me to stay relaxed, and Rachel loves it.”

“Then I think we’re finished, unless there’s something you haven’t told me.”

“You asked all the right questions about diet, exercise, and any symptoms, then performed a physical exam, including the prostate exam. All that’s left is the blood work.”

“You probably won’t be surprised by the fact that doctors make lousy patients.”

“Elizaveta would never have allowed me to fall into that trap, and I can count on Clarissa, Lara, and Peter to ensure I don’t now.”

“Join us for dinner soon, please.”

“Probably in December, on one of the evenings of the days I don’t work.”

“Just let me know. I’ll speak to you tomorrow after you get your labs. CBC, Chem-20, and testosterone.”

“Got it. Thanks, Doc.”

“You’re welcome.”

November 17, 1987, McKinley, Ohio

“Do you have a moment?” I asked Doctor Gibbs when I arrived at the hospital on Tuesday morning.

“Of course. What’s up?”

“Doctor Smith wrote an order for blood work, and he felt it was best to have it done in the ED because we could get the results much faster.”

“You just had your physical, because you have to turn in the proof to start your rotations. What’s the concern?”

“Loss of libido,” I replied.

“You’re under tremendous stress, Mike.”

“I know. I spoke to my clinical psychologist, and she wants to rule out any physiological problems. All out an abundance of caution.”

“Why don’t you ask Ellie to draw the blood?” Doctor Gibbs asked with a slight smile.

“Oh, yeah, that’s a great idea,” I chuckled, shaking my head.

“OK. Maybe not. Ask Maryam, if that isn’t a problem.”

“It’s not,” I replied.

Well, for me. She might die of embarrassment if she asked why I was having the blood drawn, which I was sure she would. I could wait until Clarissa arrived, but that would be 10:00am, and there was no telling how busy I’d be, or if the lab might be backed up. I was positive Maryam wouldn’t gossip about it, something I couldn’t be sure of with regard to the nurses or the Fourth Years who were on duty.

“Do you have the form?” she asked.

I nodded and handed it over.

“CBC, Chem-20, T,” she read. “Just for completeness, let’s add an ABG and a sed rate.”

She made the notations, ticked the box marked ‘stat’, signed the form, and handed it back.

“Thanks,” I said.

I left her office and went to find Maryam, who was standing by the board.

“Anything critical?” I asked.

“No. A rule-out MI who will be released later this morning and a fist versus wall that resulted in a broken hand about to be discharged.”

“I need some blood drawn,” I said. “I have the order from Doctor Smith, counter-signed by Doctor Gibbs. Exam 2 is open.”

She nodded and followed me to Exam 2, and asked for the order so she knew which tubes to use and how many to draw.

“This is for basically every typical trauma blood test we run except alcohol and tox screens! What’s wrong, Mike?”

“My clinical psychologist wants to rule out any physiological causes for what might be a stress-related problem.”

Maryam was quiet for a moment, then blushed deep red.

“Oh! I, uhm, let me draw the blood.”

I nodded and sat down. She retrieved the necessary supplies and expertly drew the tubes of blood.

“Nice technique,” I said. “I barely felt it.”

“I’ll take these to the lab right away. Mike, remember what I said about wanting to help? If I can, please promise you’ll tell me.”

“I promise.”

She left to take the blood to the lab, and I went to the lounge to review my flashcards. About ten minutes later, Nurse Ellie came to the door.

“Mike, Doctor Gibbs needs you. Paramedics are three minutes out with an apparent suicide attempt.”

I nodded and put on a gown and gloves, then went to meet Doctor Gibbs by the entrance. The paramedics pulled up three minutes later.

“Kristy Miller; eighteen-year-old female; probable OD; BP 180/100; pulse thready; resps shallow at fifteen; temp 39°C; diaphoretic; GCS 7; O2 five liters by mask.”

“Trauma 1,” Doctor Gibbs said. “Any idea what she took?”

We began moving towards the trauma room.

“Cops grabbed everything they could find in her room. They’re right behind us.”

A McKinley police officer came through the doors to the waiting room with a plastic bag.

“Mike, take that!” Doctor Gibbs said, as the paramedics pushed the gurney into the trauma room.

The police officer handed me the bag, and I went into the trauma room where two nurses, a Fourth Year named Teri, and Doctor Gibbs helped the paramedics move the patient.

“Ritalin,” I said. “Methylphenidate, 10mg, 30 tablets, filled two days ago. None in the bottle.”

“Look it up in the PDR at the nurses’ station.”

I left the room and went to the nurses station and asked for the Physician’s Desk Reference. I quickly looked up the drug and the treatment for overdose, then went back to the trauma room where Doctor Gibbs was supervising Teri intubating the patient, passing Larry, another Fourth Year, carrying tubes of blood to the lab.

“Lorazepam and propofol,” I said. “Lorazepam — 2mg IV push; repeat every fifteen minutes up to 8mg. Propofol — 5mgs per kilo per hour.”

“Mary, set it up; estimate 55kg. Mike, Foley, please.”

“Ellie, 14 French,” I requested, as the young woman was small of stature.

She brought the kit, then cut away the patient’s pyjama pants to give me access. I carefully but quickly inserted the Foley, then connected it to a urine bag.

“No urine,” I reported after observing for a minute.

“Teri?”

“Renal failure is a sign of methylphenidate overdose,” Teri said. “Along with nausea, hyperthermia, coma, arrhythmia, and circulatory collapse.”

“SVT,” Ellie announced. “Run of five!”

“Teri, set up for gastric lavage. Mike, call for a cardiology consult, please.”

“Right away, Doctor.”

I placed the call and the duty nurse promised the Resident would be right down.

“PVCs,” Ellie announced. “Temp 40°C”

“100ml sodium salicylate solution, IV push,” Doctor Gibbs ordered. “Mike, six cooling packs, stat!”

I hurried to the supply room and got six chemical cooling packs, then rushed back to the ER and activated them.

“Head, neck, armpits,” Doctor Gibbs ordered. “Then get Doctor Casper, please.”

I placed the bags just as Doctor Strong came into the trauma room.

“What do we have?” he asked.

“Eighteen-year-old female,” Doctor Gibbs replied, “methylphenidate overdose. Febrile; hypertensive; PVCs and SVTs; acute renal failure; Ringer’s IV; lorazepam, propofol, and sodium salicylate onboard. Holding diuretics until we rehydrate her and see her labs.”

I left as he began his exam and returned thirty seconds later with Doctor Casper.

“Gastric lavage, Ghost,” Doctor Gibbs said. “Methylphenidate overdose.”

“Mike, assist, please,” Doctor Casper said. “I’ll teach you how to do this. Teri has done it before.”

I watched as he explained step by step how to insert the tube via the patient’s nose into her stomach, then withdrawing a small amount of fluid from her stomach. He had me use a pH test strip to verify that he was removing stomach contents, and once that was verified, he introduced warmed saline via the tube, then suctioned it out, repeating until the liquid was clear.

“Completed,” Doctor Casper said.

“Now we wait,” Doctor Strong said. “Digoxin, if the SVTs become persistent; diltiazem if her hypertension doesn’t resolve; Lasix if she retains fluids. Page me if you see any other arrhythmias.”

“Thanks, Carl,” Doctor Gibbs said.

“Need me for anything else?” Doctor Casper asked.

“No,” Doctor Gibbs replied. “We’ve got this.”

The phone rang, and I answered it, hearing from the lab that the blood work had been completed.

“Labs are done,” I announced. “I’ll get them.”

I went to the lab and picked up the results. I wanted to get mine, but I didn’t want to waste time, so I simply hurried back to the trauma room, scanning the results.

“Hypokalemia,” I reported when I walked into the room. “3.0”

“The Ringer’s should take care of that. We’ll do repeat labs in about fifteen minutes. Liver function?”

“BUN and creatinine within the acceptable range; crit 0.37; glucose 90; pH 7.5; ethanol 0.0; ABG shows O2 at 95%; bicarb 110. Those are the only items near the limits.”

“Well, at least she didn’t drink,” Doctor Gibbs replied. “That means she ought to make it. Mike, go find out if the police were able to contact her parents.”

“Right away, Doctor!”

I stripped off my gloves and gown and went to find the police officer who was waiting in the lounge.

“Officer, did you get in touch with Ms. Miller’s parents?”

“Yes. They’re on their way from Youngstown. How is she?”

“Doctor Gibbs believes she’ll make it, but you’ll need to speak to Doctor Gibbs if you need more information.”

“Thanks. You are?”

“Mike Loucks, Third Year medical student.”

“Thanks, Mike.”

“You’re welcome.”

I went back to the trauma room and informed Doctor Gibbs of what the officer had said.

“OK. When they arrive, bring them to see me. Teri will handle monitoring her.”

“Yes, Doctor.”

I left the trauma room and went to let Nate know to call me when the Millers arrived, then headed for the lounge, but was stopped by Doctor Nielson.

“Mike, twenty-one-year-old male in Exam 1. Would you do an H&P, please?”

“Presenting complaint?”

“Severe headache and nausea.”

“I’ll take care of it.”

I went to Exam 1, taking the chart from the rack outside the door.

“Good morning, Mr. Johnson. I’m Mike. Doctor Nielson asked me to get your medical history and perform a basic physical exam.”

“Medical student, right?”

“Yes. I’ve been trained to do the exam and I’ll report back to Doctor Nielson.”

“Sorry, I wasn’t questioning your ability, just wondering if you were a medical student.”

“What brought you to us today?”

“A severe headache and I’m feeling sick to my stomach.”

“Are you on any medication?”

“No. I never take anything other than an aspirin or two. They didn’t do anything for the headache.”

“Any alcohol intake in the last twenty-four hours?”

“A bottle of beer last night, but that’s it. I don’t drink much.”

“Any illegal drugs?”

“No. Never.”

“Do you smoke?”

“No.”

“What have you had to eat?

“Nothing for breakfast, because I wasn’t sure I could keep it down. Last night’s dinner was pizza.”

“Any changes in your sleeping habits?”

“No. I slept OK last night but woke up with the killer headache.”

Which was probably what was making him nauseated.

“Any recent medical procedures?”

“Just my physical for work about a year ago.”

“What do you do?”

“I work construction; drywall and finish carpentry, if you know what that is.”

“Moldings, baseboards, and that kind of thing. Anything change at work?”

“No. Well, we’re using kerosene heaters because of the weather, but they’re always properly vented.”

“Any family history of migraine headaches?”

“No.”

“Any family history of high blood pressure, heart disease, or diabetes?”

“None of those.”

“OK. Then let me do the physical exam.”

I washed my hands, put on gloves, and performed a standard exam. I didn’t appreciate any physical symptoms which might explain his headache. Once I’d completed the exam, I went to find Doctor Nielson.

“What did you find?” he asked.

“BP 120/70; pulse 70; no appreciable masses; no appreciable heart or lung problems; eyes, ears, nose, and throat clear. No drug or alcohol abuse, no family history of heart disease, hypertension, migraine headaches, or diabetes.”

“What do you want to do?”

“CBC, Chem-20.”

“Approved,” Doctor Nielson said. “Any thoughts?”

“He could be lying about drugs and alcohol, but I don’t get that feeling. I could run a tox screen.”

“I’d do that. We don’t want to go chasing a stroke or aneurysm when he tied one on last night or is under the influence.”

“Wouldn’t his BA be normal if he drank before sleeping?” I asked.

“Probably, but drugs will show.”

“I’ll add that to the order. I’ll draw the blood and bring you the order to sign.”

“OK.”

I went back to the exam room and explained to Mr. Johnson that Doctor Nielson had ordered blood tests. He allowed me to draw three tubes, one of which had a gray stopper necessary for the tox screen.

“How long will this take?” he asked.

“If the lab isn’t backed up? No more than an hour. We haven’t had many patients this morning and all the pre-op tests should have been completed an hour ago.”

“Can you give me anything for the headache?”

“We’d prefer to wait to see what your blood tests show, but I can ask Doctor Nielson. How many aspirins did you take?”

“Two Anacin this morning when I got up.”

“Regular or Extra Strength?”

“Extra Strength.”

“500mg of acetylsalicylic acid and 32mg of caffeine,” I said aloud as I wrote it on the chart. “Let me get this blood to the lab and ask Doctor Nielson if he’ll order anything for you.”

I left the exam room, delivered the tubes of blood to the lab, then went to see Doctor Nielson and explained Mr. Johnson’s request.

“What do you think?” Doctor Nielson asked.

“That we don’t know what’s wrong, so we want to be careful what we give him. Also, he took aspirin and caffeine less than two hours ago.”

“OK. What do you think about giving him two Tylenol 3”?

“I’d wait for the blood work,” I replied. “Mr. Johnson is lucid and while he says he has a killer headache and nausea, it doesn’t appear debilitating.”

“Very good, Mike. Come see me when you get the blood work results.”

“Will do.”

I went to the lounge and about ten minutes later, Maryam came in with lab reports.

“Everything is fine, Mike, including your,” she blushed slightly, “testosterone level.”

“It’s a good thing you’re going into cardiology,” I said with a smile.

“It’s ... different. You aren’t a patient.”

“Once I asked you to stick a needle into my vein to draw blood, I became a patient.”

“I suppose, but ... I guess I, no, never mind.”

“It’s OK, Maryam. I was teasing when I made the comment about cardiology. And you’ve obviously surmised the concern.”

“Is that why ... uhm, no, I can’t ask you that.”

“But I’ll answer,” I replied. “It is, but only indirectly. What the bishop wrote in his letter was entirely accurate, but he didn’t mention, because there was no need and no reason to cause extra turmoil, that I believe Rachel needs a mom.”

“Of course she does!” Maryam declared. “Oh! Sorry, that just sounded wrong.”

“You are very traditional, just as I am,” I replied. “And we both believe that it’s best for children to be raised by two parents, and that boys need fathers involved in their lives just as girls need mothers involved in their lives.”

“You plan to remarry?”

“Eventually, yes, though my major concern is for Rachel. Just right now, I’m struggling with my emotions, and Doctor Mercer, my counselor, wanted to rule out physiological problems for a complete loss of libido.”

“Uhm,” Maryam began, again blushing slightly, “don’t you think that’s because it’s only been about ten weeks?”

“I’m sure that’s a big part of it, but I’m not having the normal physiological occurrences typical of a man my age.”

“But...” she began, then stopped.

“Not in that context,” I replied gently. “Remember what was covered in our study of reproduction and typical male physiology unrelated to intimate activity.”