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 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 are 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, 12-lead 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 palp; PO₂ 93% on ten liters; 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 18 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 palp; PO₂ 93% on ten liters 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 don't want to be a trauma 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 speciality 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 cooperating."

"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."

"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 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, 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 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 speciality. Don't sweat the feeling, just take it into account next Spring when you chose your electives. That said, you absolutely want a Sub-I in trauma, 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 speciality 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 ever 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, 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 to not 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 is 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 canula; 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!"

And 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 blood. 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.

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.

"Fluid in Morison's pouch," I said. "Surgical case for sure. Run that unit in, please, Julie."

I handed Margie the transducer and went to the phone and called the surgical scheduling nurse while Julie connected the plasma bag to the IV.

"This is Mike Loucks in the ED. I have a surgical case I'm sending up for an ex-lap after an ultrasound exam showed fluid in Morison's."

"On whose authority?" she asked.

"Mine," I said. "I'm a surgical Intern. We'll bring her up in about five minutes. She's stable, with minor V-tach, but also inebriated. She can't wait, though."

"I'll have to check with Doctor Blake."

"Do that, but we'll be there in five minutes."

I hung up and turned to the team, "Portable monitor and portable oxygen, please."

"Orderly?" Margie asked.

"Tom and I will take her up," I said. "I don't think we should wait."

I quickly wrote my own consultation notes on the chart, signed it, and then we moved Ms. Bond to a gurney. Tom and I moved her from the trauma room to the elevators, and two minutes later were outside OR 1.

"Causing trouble already, Mike?" Doctor Blake asked.

"Hey, if Doctor Cutter insists I'm a surgical Intern, and I have the red scrubs and the S on my badge, I'm going to act like a surgical Intern!"

"What do we have?"

I ran through the report, including vitals and my findings with the ultrasound.

"EtOH levels?"

"They'll be ready in about five minutes. I'll have them call the OR so the gas passer knows what he's dealing with."

Doctor Blake laughed, "Painless?"

"I liked the movie and the TV show!"

"Give the chart to Ben. Can you scrub in?"

"No. We're a bit short in the ED, with just Doctor Varma and me working."

"Who's the Attending?"

"Mastriano."

"Say no more," he said, shaking his head. "We have this. Good catch, Mike. I'll let you know how it went."

"Thanks, Doctor Blake."

"Bill, please."

I nodded, handed the chart to Ben, a Fourth Year, then Tom, and I left to return to the ED. When we arrived, I called the lab and instructed them to call OR 1 with the EtOH levels and send the rest of the labs up when they had them.

"We have the level," he said. "It just came up. 0.22."

"OK. Call that up to OR 1, please. She's about to have an ex-lap."

"Will do."

I hung up and made notes in my notebook as I didn't have the chart to update.

"You cut at least fifteen minutes off the normal time in the ED," Margie observed, coming over to us.

"That's one point of the new trauma surgeon specialty," I replied. "Another is being able to do chest tubes, pericardiocentesis, central lines, and other things that usually require a surgeon. I can't do them all yet, and it'll be a few years, but long-term, we should dramatically improve patient care. I suspect, ultimately, that at least half of all trauma specialists will follow this new path.

"The other change that I'm sure you've heard about is that EMS paramedics are being trained to perform intubations and read EKGs, as well as eventually do chest tubes. And all of us will do ride-alongs that coincide with the training of the EMS paramedics in the ED. We should seriously improve patient outcomes will all of these changes."

"Mike?" Nurse Becky called out. "A deputy is bringing in an arrestee with a dog bite to the arm. They'll be here in about ten minutes. Doesn't sound serious."

"OK. Call me when they arrive, please, and put them in an exam room."

"I'll put them in Exam 5."

"Thanks."

She left, as did Margie.

"What do you think Doctor Blake meant by what he said about Doctor Mastriano?"

"I think she has a reputation and given she's an Attending, I think we should let the Attendings deal with it. I've stuck my nose a few places and had it figuratively whacked with a rolled-up newspaper."

"It doesn't seem to have hurt you."

"No, but it could have," I replied. "It's simply a matter of following protocol. I'll let either Doctor Gibbs or Doctor Gabriel know what happened, and if anything needs to be said, they'll say it."

"So you say _less_ as a doctor than you did as a medical student?"

"Let's just say that my advice is to follow my medical example, not my philosophical or political example. I had a penchant for tilting at windmills, and it took a dozen or so rolled-up newspapers to bring me to a point of being pragmatic and practical. It's more about the approach I take, rather than what I say or don't say, and that's what I'm trying to convey, albeit poorly, apparently."

"No, I understand it, I was just surprised by the fact that you say less from a position of relative power than in one where you totally depended on the approval of the people who you were speaking with."

"I learned. Everyone has different things to learn or change about themselves to become a good physician, beyond medical knowledge. Figure out what it is you need to learn or change, then do it."

"Good advice; now I just have to figure out what it is."

"That's the challenge."

We sat quietly for several more minutes, then Becky came to the door and let us know the deputy was here with his prisoner. Tom and I went to Exam 5.

"Hi, Deputy Foster," I said, looking at his name tag. "Doctor Mike Loucks."

"Hi, Doc. K-9 bite on his right arm during a raid on his farm a few hours ago."

"Let me take a look," I said. "Are the dog's shots up to date?"

"Completely."

"I'll need you to take the cuffs off," I said. "At least from the arm I need to examine."

"Stand up, Weisz," the Deputy said to his prisoner.

Mr. Weisz stood up and turned so the Deputy could remove the handcuffs, though he only removed the right cuff, then attached it to the railing on the treatment bed. It wasn't ideal, but I could work with it.

"Tom, bandage scissors, please."

He got them from a drawer and handed them to me.

"I need to cut away your sleeve, Mr. Weisz."

"Just do it."

I did and saw what was clearly a superficial bite.

"Could I get your full name and age, please?"

"Jim Weisz, thirty-six," he said.

"Tom, start the chart, please," I said.

"Mr. Weisz, have you had a recent tetanus shot?"

"Last year."

"Are you taking any medications?"

"No."

"Using illegal drugs of any kind?"

"I'm not saying shit in front of the deputy."

"I'm not asking specifics, just 'yes' or 'no', and if you've used anything in the past twenty-four hours."

"Never get high on your own supply," Mr. Weisz said.

He was quoting _Scarface_, a movie I'd never seen, but I knew the line.

"I'll take that as a 'no'," I said. "The wound is superficial, so we'll clean it, apply a topical antibiotic, and then a sterile dressing. You'll need to have the wound checked in seventy-two hours."

"He'll be in our lockup," Deputy Foster said. "Or the Feds might have him. There might be federal firearms charges."

"I'll give you instructions, which I expect the Sheriff to follow," I said firmly. "If the Feds have him, then it's on them."

"I'll make sure the duty nurse at the jail gets the paperwork," Deputy Foster said.

"Tom, saline, an irrigation basin, a tube of triple antibiotic, gauze, and an ace bandage, please."

Tom got the things from the cabinets and drawers while I washed my hands. I irrigated the wound, applied the triple antibiotic, which consisted of neomycin, polymyxin B, and bacitracin, then wrapped the wound in gauze and secured it with an ace bandage. I updated the chart, filled out a blank discharge form, and gave it to the deputy.

"He needs to keep it clean and dry," I said. "The ace bandage should keep it in place and clean, but it'll need to be wrapped if he's going to shower."

"What am I? A sack of potatoes?" Mr. Weisz asked.

"If you're in the lockup, you're not going to be able to care for yourself, and that means this deputy will convey the information to the nurse at the jail. She can't take your word for it. If you need a doctor, she'll call one, but your wound isn't serious. You're all set."

"OK to cuff him?" Deputy Weisz asked.

"It'll need to be in front," I said. "And don't tighten the cuff too tight on his right wrist."

"Stand up, Mr. Weisz," Deputy Foster said.

Mr. Weisz complied, Deputy Foster re-cuffed him, with hands in front, instead of behind, picked up the discharge papers, and then marched Mr. Weisz out.

"I don't get it," Tom said once they were out of the room.

"What?" I asked.

"You have a reputation as a soft touch and are always on the patient's side, but in this case, you weren't."

"We insist they remove handcuffs if they interfere with patient care," I said. "In this case, it didn't. Given there was no way I could admit Mr. Weisz, and nothing I could do to improve his situation except have the cuffs in the front, I did what I could. Had he been more seriously injured, I'd have insisted the cuffs be removed completely and would have handled things differently."

"Innocent until proven guilty?"

"Yes, of course, and if I were on a jury, they'd have to prove it to my satisfaction. But this isn't that. I have very little sympathy for people who sell drugs, and, to be honest, I'm tired."

"And you still have over twelve hours to go, right?"

"Yes. And with no sleep overnight, it's unlikely I'll get any before the end of my shift."

"Do you think it will change because of what happened in New York?"

"I think either the medical profession will change things or we'll be forced to change, and I'm not sure which will win out — preservation of relative autonomy or resistance to change. Even scientific ideas are often resisted. I'm sure you remember the primary example."

"The doctor who discovered that washing our hands and changing clothes cut infant and maternal mortality?"

"Doctor Ignaz Semmelweis," I replied. "Part of the problem was that he wasn't tactful in how he presented the information and thus met resistance. Several doctors have reminded me of that over the course of the past four years. Fast forward and there's resistance to my Residency, and a significant turf war is underway, but look at what happened with the MVA who needed an ex-lap. We cut somewhere between ten and twenty minutes from the time she presented until she was in the OR. That can be the difference between life and death."

"I heard you came up with this idea."

I chuckled, "I wish, but also I don't. Had I actually come up with it, I doubt I'd have made any headway. I cribbed it from a doctor who implemented it at Indiana University Hospital, and later at the University of Chicago Hospital, where he's Chief of Emergency Medicine. He tried to recruit me to the medical school at Indiana University, then encouraged me strongly to apply to Match in Chicago with him."

"That's a prestigious hospital; why not go?"

"Because I want to serve my community," I replied. "I was born and raised one county over, and I'd actually have preferred Matching at the hospital there, but they aren't a teaching hospital. It's also the case that my family and closest friends are all in Southern Ohio, and I needed the support system after my wife reposed."

"What's that word?"

"Reposed? It's the word Orthodox Christians use when someone's mortal life ends because death has no actual power over us, and because the believer is alive in Christ, in eternal union with God."

"Mike?" Nurse Peggy said, coming into the lounge, "EMS four minutes out. Car versus bicycle. They say it's bad."

"Wake Doctor Mastriano," I said.

"She gave express instructions…" Peggy protested.

"And I'm overriding them," I said, interrupting her, "If she has a beef, it's with me. Wake her. What room is available?"

"Take your pick, the trauma board is clear."

"Trauma 1, then," I replied. "Tom, let's go. Peggy, two nurses, please."

"Bonita and me," she replied.

The three of us left the lounge. Tom and I gowned and gloved and Peggy went to wake Doctor Mastriano. It was 5:40am, so only twenty minutes from her 'do not wake me up until' time, and frankly, I didn't give a damn if she was upset or not. I'd heard about lazy and indifferent Attendings, but I'd never run into one. Residents tended to be all over the map, but an Attending had passed their Boards, was licensed, and had survived Residency. There were doctors who were, in effect, eternal Residents, who were not 'good enough' to become Attendings, but Doctor Mastriano had demonstrated to _somebody_ that she was qualified.

"Tom, a lot will depend on how bad this is, but I'm likely going to need to intubate. Your job is to get the EKG and monitor going, then take the blood draw to the lab. Don't wait for anyone to tell you. If I change my mind, I'll tell you."

Peggy and Bonita joined us, both gowned and gloved.

"Doctor Mastriano is awake," Peggy said.

"OK. Bonita, stat trauma panel, and type and cross match. Tom will take the blood to the lab. Peggy, Foley, and then blood if we need it."

They both acknowledged my orders, and a minute later the EMS squad turned into the driveway and pulled up in front of us. Bobby jumped out and called out the vitals.

"Female, approximately twenty, hit-and-run while biking; pulse 120 and thready; BP 80 palp; lungs are compromised, PO₂ 91%, hard to bag; serious head injury; left arm and left leg fractured; GCS 3; IV saline TKO; cervical collar and backboard."

"Trauma 1!" I ordered.

We rushed the patient into the hospital and into the Trauma room, where Doctor Mastriano was waiting. I repeated the vitals as we moved the young woman to the trauma table.

"Doctor Mastriano, primary assessment, please," I said. "I'm going to intubate. Let's go, people!"

Everyone sprang into action, in what to an outside observer would appear chaotic, but which was actually a carefully choreographed ballet. Two minutes later, the patient was intubated, the EKG and pulse oximeter were attached, the Foley was in, two units of plasma had been hung, and Tom was on his way to the lab with the blood.

I was most concerned about the head injury, but it had to wait until we completed the assessment of the patient's internal injuries. There was blood in the urine bag, and her chest injury was impacting her breathing, and unless we controlled the internal bleeding and resolved the respiratory problems, she wouldn't live long enough for neuro to do anything.

"Bonita, ultrasound, please!" I ordered.

"No," Doctor Mastriano said. "Call for a surgical consult."

"I'm a surgical intern," I countered. "Bonita, get the ultrasound."

"And I'm an Attending. Do NOT touch the ultrasound. We need a surgeon."

"Bonita, get the unit," I said. "I'll make the call."

We'd waste precious minutes while someone came down from surgery, so I chose to interpret Doctor Mastriano's orders in the way most favorable to the patient.

"Hi, this is Doctor Mike in the ED. I need Doctor Roth or Doctor Cutter to authorize me to perform a surgical assessment."

"One minute," Nurse Penny said.

"Doctor, that is NOT what I told you to do!" Doctor Mastriano growled.

I put the phone on speaker and a few seconds later Doctor Roth came on the line.

"What's up, Mike?"

"You're on speaker. Car versus bicycle, significant internal injuries. I want to do the surgical assessment but Doctor Mastriano insisted I all for a consult."

"Doctor Mastriano," Doctor Roth said. "Mike is qualified and it'll save at least five minutes. He's authorized. Mike, call and let us know if you're bringing her up."

"Will do," I replied.

I pressed the button to disconnect the call and moved back to the trauma table as Bonita came in with the ultrasound.

"Doctor…" Doctor Mastriano said.

"Not now," I replied. "The patient is our focus. You can chew me out later if you feel it necessary."

Bonita squirted gel onto the patient's abdomen and chest, and I did not like what I saw at all. She had several broken ribs in a classic flail chest, and her heart and lungs were both compromised by those injuries.

"Fluid in the pericardium," I announced. "And in Morison's. Peggy, Bonita, splint the arm and leg, and let's get her up to surgery."

While they did that, I went back to the phone and dialed the surgical scheduling nurse. I gave her the details, and let her know we'd be up immediately. Tom had returned and assisted preparing the patient for transport. A minute later, Tom, Bonita, and I rushed the patient out of the trauma room and headed for the elevators.

"HOLD THAT ELEVATOR!" Tom called out, seeing people about to get on.

As per protocol, one person pressed the hold button while the other three moved out of the way. Two minutes later, we were outside OR 3 where Doctor Blake was waiting.

"What do you have for us, Mike?" he asked.

"Car versus bicycle," I said, then gave the vitals and the actions we'd performed.

"You and your student scrub in," he said. "I'll have you do the pericardiocentesis while Robert and I handle the ex-lap."

"OK. Tom, let's go. Just follow my lead, please."

We went into the scrub room where Doctor Robert Aniston, one of the new Attendings, was scrubbing.

"The famous, or is it infamous, Mike Loucks, right?" he asked.

"And my student, Tom Lawson. Nice to meet you."

"I'd shake your hand, but…"

"Yeah," I replied. "Tom, tear open a scrub pack. You did this for your Preceptorship, right?"

"Yes, but that was over a year ago."

I quickly ran through the steps to scrub, and he followed them. Five minutes later we were in the OR waiting for Doctor Kelsey from Anesthesiology to give the OK to proceed, which she did a minute later.

"I'll talk you through this, Mike," Doctor Blake said. "There's no time for fluoroscopy, so you'll need a cardiac needle with the electrical lead attached via alligator clip. Alice, syringe with a cardiac needle and lead to Mike."

"Bill," Doctor Aniston said, "I'm ready to open."

"Multitasking is my specialty!" Doctor Blake declared. "Go ahead, Robert. Mike, insert the needle between the xiphisternum and left costal margin, and direct it towards the left shoulder at a 40° angle to the skin. Go slowly, and as this is unguided, stop when you hear the warning tone, back off about 2mm, then aspirate. If you don't get fluid, advance the needle slightly and try again."

"Bill, tie off that bleeder," Doctor Aniston ordered.

I began the procedure, moving carefully with Doctor Blake splitting his attention between tying off bleeders and me advancing the needle. I got the tone and the cardiac monitor showed the heart reacting, so I backed off the needle and began aspirating.

"Blood in the pericardium," I said as the fluid began filling the large syringe.

"Pulse and rhythm improving," Doctor Kelsey announced.

"Keep going until the syringe is full," Doctor Blake said. "Then attach a valve in case we need to draw more fluid."

I did as instructed, handing the filled syringe to Alice , who put it in a tray and gave it to a circulating nurse to send down to the lab for analysis.

"Spleen is compromised," Doctor Aniston announced. "Complete resection. Liver lac, but it can be repaired. How's she doing, Jennifer?"

"Better," Doctor Kelsey confirmed. "But don't dawdle."

"Mike, we have this," Doctor Blake said. "Two more of these and we'll sign off on you doing the procedure in the ED."

"Somebody needs to let Doctor Mastriano know."

"Doctor Cutter will take care of that," Doctor Blake said. "You can scrub out."

"Yes, Doctor."

"Bill," he prompted.

"I'll get the hang of it eventually," I said.

Tom and I left the OR, changed into clean scrubs, then headed back to the ED, where an angry-looking Doctor Mastriano was waiting.