Chapter 9 — Three In One Day _July 3, 1989, McKinley, Ohio_ "Everything OK at home?" Clarissa asked as we sat down with our lunches in the cafeteria at a table away from most other people. "Why wouldn't it be?" "Nobody is _that_ mellow!" Clarissa protested. "Not only is she that mellow, we have permission to conceive naturally, if you want." "NO WAY!" Clarissa gasped. "SERIOUSLY?!" "No," I chuckled. "Of course not!" "That was mean, Petrovich! Even for you!" Clarissa exclaimed, but I could see in her eyes she wasn't upset. "How often do I have a 'gotcha' with you?" "Not very! So she's all good?" "She is. And as open-minded as my cosmopolitan French wife is, she's not open-minded enough to allow what I teased about. But she's fine with our agreement, and she's not reluctant or concerned." "She has no idea how badly you want to sleep with me, does she?" Clarissa asked. "Except I don't, for obvious reasons." "OK, _before_ you married! Both marriages, too!" "And yet, it wasn't about sex, which, by the way, is what would concern her, not the act, in and of itself." "So casual sex is OK?" "No, of course not, but it wouldn't _be_ casual with you, which both you and I know." She nodded and then asked, "How was your morning?" "Fairly typical for the ER, though I did get to put in a chest tube." "You wheedled it out of the on call?" "No. Doctor Taylor saw the red scrubs and the surgical 'S' on my badge and instructed me to do it because I was a surgical intern and was being supervised by an Attending, which is the letter of the law. There's a low-intensity war between Cutter and Northrup, and I believe Doctor Northrup lost the battle but might win the war." "How so?" "Cutter was so insistent that I'm a _surgical_ intern that Northrup is taking him at his word. Obviously I can't do anything I haven't been trained to do, but I can do chest tubes and emergency pericardiocenteses, because I have been trained to do those. I'm sure that will lead to further internecine combat, but so long as I can stay out of the line of fire, they can fight all they want." "Does he know about the tube?" "I'm not sure if Doctor Pace will report it, or if he'll see it on a chart review a week from now, but one way or the other, it will get back to him. Heck, Northrup might tell him just to tweak him." "You're _enjoying_ the politics?! What's next? Human sacrifice, dogs and cats living together…mass hysteria?!" "It's working to my advantage at the moment, and to Ellie's disadvantage!" "How so?" "My locker is in the surgical locker room!" Clarissa laughed, "Poor Ellie, she'll have to get her thrills some other way than seeing 'Big Mike'!" "She's never _seen_ Big Mike!" I countered. "Tell me she hasn't seen you in your briefs." "Fine, but she's never seen Big Mike ready for action and she never will!" "She'd redouble her efforts if she knew!" "Twice nothing is still nothing," I replied. "How is your shift going?" "A pair of interesting cases that have everyone stumped. I'm researching, but it would be so much easier if everything was computerized. Some stuff is, but not everything." "I'll be happy with remote telemetry beds," I replied. "But your challenges are somewhat different from mine." "I prefer the mental acuity tests to 'can I make the right decision in a split second to save a life'. I could do it if I had to, but you get off on it." "I don't think I'd go quite that far," I chuckled. "But I certainly prefer the adrenaline rush of the ED to the mostly intellectual exercise of Internal Medicine." "Including the walk-ins?" "I have to come down off the adrenaline high at least occasionally!" "Everything is pretty much exactly as we had hoped." "Minus Kitten not being here to see it," I said. "You suffered quite a bit to make it here, Mike, and sacrificed so much. I'm positive she's proud of you, and probably rolling her eyes at times." "Of that you can be sure!" We finished our lunches without interruption, which was something I wouldn't be able to count on for years to come. I walked Clarissa to the elevators, then headed back to the ED where Ellie asked me to catch some walk-ins. I found Len and Bob, then went to see Doctor Birch. "Where are my toddlers?" I asked. He laughed, "It does seem that way, doesn't it? They're in the lounge. Four students, all Second Years. No First years until August." "That's something, I guess," I said with a wan smile. Len, Bob and I went to the lounge and I introduced myself to the four students. I was tempted to call them by numbers — one, two, three, and four — but decided that was a bit too much hazing. "Your task today is simply to observe," I said. "Take notes, ask questions between patents, and stand out of the way. Next week, there will be a quiz." Three of the four groaned and I wanted to laugh, because as Second Years, they should have been ready for something like that. I led my small entourage to the admit desk and asked Alex what he had. "Puking five-year-old; sixteen-year-old with a rash that appears to be poison ivy; twenty-three-year-old construction worker with nail gun injury." "Nail gun injury?" "Right through his foot." "That's going to be surgical, so I'll take him." "Mr. Logan," Alex said, handing me the chart. "He's in the wheelchair. Vitals normal, only complaint is the nail in his foot." "Thanks. Len, you push the wheelchair." "Low man on the totem pole," he chuckled. "Got it." "Bob, history and physical. I'll confirm, then we'll discuss the plan of action outside the room." I looked up at the board and saw that Trauma 3 was open. Bob, Len, and I called for Mr. Logan, I introduced myself and my students, then Len and Bob took him to Trauma 3 while I went to the desk and asked for a nurse to join us. The four Second Years followed us and stood clustered in the corner of the room, and Alice, who Ellie assigned, followed me into the treatment room. Bob did a good job on the H & P, and I confirmed his exam. "Could I get something for the pain?" he asked. Because there was potential for surgery, the most I could offer was ibuprofen or acetaminophen, as any opiates would create potential interactions with a general anesthetic, should one be necessary. "Alice, 600mg ibuprofen PO, please," I requested. "Then irrigate and paint with Betadyne." "Right away, Doctor!" she said, making a note on the chart. "Mr. Logan, I'll be right back," I said. "Thanks, Doc." We stepped out, and I asked Bob for his plan. "Can you remove the nail?" He asked. "Technically, I could, but I've never done it before, so I need either a senior surgical Resident or surgical Attending to supervise. What's your plan?" "X-ray, then remove the nail, clean and irrigate, update tetanus, and a course of antibiotics. Ibuprofen or acetaminophen for pain." "Any idea about the procedure to remove the nail?" "No. I've never seen that done." "OK. Len, call for a surgical consult, please." Len went to the wall phone and made the call, and five minutes later, Doctor Rafiq arrived. "Charles Logan, twenty-three, penetrating trauma to the left foot from a nail gun; irrigated and Betadyne applied; recommend x-ray, extraction, tetanus, and a course of antibiotics. If the x-ray shows significant bone involvement, then an ortho consult. I'd like to do the extraction." "Have you done one?" Doctor Rafiq asked, sounding annoyed. "No, but I know the technique — lidocaine times four, clip the exposed portion of the nail distal from the point of extraction, remove with constant pressure, address any bleeding, apply topical antibiotics. No sutures unless surgical repair is necessary due to arterial or veinous damage." Doctor Rafiq glared at me but nodded his assent. "Len, call for a portable x-ray, please," I said, and the four of us went back into the room. "Mr. Logan, this is Doctor Rafiq, a surgeon. We're going to x-ray your foot to confirm it's safe to extract the nail without surgery. Just relax as best you can and we'll get the nail out as soon as possible." The x-ray tech arrived about five minutes later with the portable fluoroscope, which had a monitor that would give us a real-time image of Mr. Logan's foot. Doctor Rafiq and I examined the image. "Soft tissue only," I observed. "The nail is in the dorsal interossei between the first and second left metatarsal with no bone involvement." "I concur," Doctor Rafiq said. "Lidocaine times four, clip the three centimeters that extend through the plantar, then extract dorsally." "Proceed." "Alice, lidocaine times four, please, and a procedure tray." "Right away, Doctor!" "Mr. Logan, I'm going to numb your foot with lidocaine. Have you had any problems with local anesthetics, including at the dentist?" "No. I've had cavities filled and didn't have any trouble." The procedure was straight forward — I numbed his foot with lidocaine injected near the nail on both sides, then used 5¼ inch podiatric nail nippers to cut through the part of nail that was protruding from Mr. Logan's foot. Once that was completed, I grasped the upper end of the nail with 5½ Kellys, and slowly and carefully extracted it. "Minimal bleeding," I observed. "How are you feeling, Mr. Logan?" "OK. My foot is throbbing, but otherwise, not bad." "Great. Alice is going to irrigate and dress your wound and give you a tetanus shot. Do you have any allergies to antibiotics or have you had a bad reaction?" "No," he said, confirming what he'd told Bob during the H & P. "OK. I'll be back in a few minutes with your discharge instructions." "Thanks, Doc." Doctor Rafiq left, and the Bob, Len, the Second Years and I went to the Attendings' office to see Doctor Taylor. I reviewed the injury and procedure, and recommendation for 500mg amoxicillin three times a day for seven days. "Approved," Doctor Birch said, making a note on the chart and signing it. "Good job, Mike." "Thanks," I replied. "You'll need to stay off your foot for at least a week," I said. "Then follow-up with your regular physician. I'll fill out the necessary form for you to provide to your employer, and Patient Services will assist you with the Workman's Comp forms. Len, would you please call for an orderly with a wheelchair; Bob, get a set of crutches, please." "Right away, Doctor!" Bob acknowledged. "Will do," Len said. "Mr. Logan, have you used crutches before?" I asked. "Yeah, when I was sixteen, I broke my ankle." I filled out a prescription form, the first one I'd personally written, and handed it to Mr. Logan. "You can fill this at the hospital pharmacy or any other pharmacy of your choice. Make sure you take the antibiotics as prescribed and take them all, even if there are no signs of infection. For pain, you can use over-the-counter analgesics — Tylenol and Advil are good choices, and whichever one works better is fine." "What about Anacin? That's my usual go-to for pain." "If that works for you, and it doesn't cause you stomach problems, that's fine. We tend to recommend ibuprofen or acetaminophen, which are the ingredients in Advil and Tylenol, respectively, as they have fewer side effects." "Never had trouble with aspirin, and it's all I've ever used." "OK. Len will stay with you until the orderly arrives, then escort you to patient services. Do you need to call someone to pick you up?" "My foreman brought me in. He'll take me home." "OK. Keep your foot dry until you see your personal physician, but come back if you run a fever over 101°F, or you see any discharge beyond a small amount of blood or clear fluid, or a rash or redness that is spreading, come back right away." "Thanks, Doc." "You're welcome, have a nice day." "You, too." I left the room, and a minute later, Bob returned with a set of crutches, which he took into the trauma room for Mr. Logan. He came back into the corridor a few seconds later. "What was up with that surgeon?" he asked quietly. "He was giving you dirty looks the entire time." "Doctor Rafiq is unhappy that I was allowed to do procedures as a Fourth Year that he wasn't allowed to do as a PGY1, and doesn't agree with Doctor Roth's training program for me. Fortunately, he's not my supervising Resident." "Who would normally do the procedure you just did?" "Historically, only a surgeon, but in the past year the policy changed such that after a surgical consult, the trauma specialist can do it. If there had been any bone involvement, we'd have needed an orthopedic surgeon, and they'd have taken Mr. Logan up to the OR. Long term, a trauma surgeon would make the call, and then take the patient up, and consult with an orthopedic surgeon on the extraction and repair." "What if an artery of vein had been compromised?" "It depends on the volume of blood, but many times it would require a surgical repair. That's not something I could even contemplate doing for four or five years, at least." "How do you get your surgical training?" "After two years in the ED, I'll handle all surgical consults during my shifts and assist with any emergency surgery. I'll have some scheduled procedures as well, as I have to be sufficiently versed in them to pass my surgical Boards. It works out to about eight or nine years, including a Fellowship. Let's catch another walk-in. Len can join us when he's finished with Mr. Logan." We went to the triage desk and someone had taken the puking five-year-old, and two others had arrived, but neither was sufficiently urgent to jump the queue ahead of the sixteen-year-old girl with suspected exposure to poison ivy. "Miss Munroe?" I called out. A tall, athletic blonde who was standing, raised her hand. "I'm Doctor Mike," I said. "I understand you believe you've come in contact with poison ivy?" "Yeah, uhm, could I see a lady doctor? It's kind of in an embarrassing place." "Let me see if someone is available," I said. "If not, do you want to wait?" "Er, I guess it depends on how long." "OK. Hang tight and I'll see." Bob and I went back into the ED and I checked the board. Only Doctor Billings and Doctor Townsend were on shift, and they were in a trauma, so I walked over to Ellie to inquire. "It's a bad one," she said. "Stabbing victim." I contemplated offering to switch and take over for Doctor Townsend, a fellow PGY1, but Jill Munroe's situation wasn't serious enough to warrant interrupting a severe trauma. I began walking back to the waiting room. "Patients are allowed to do that?" Joe, one of the Second Years asked. I nodded, "Yes. For any reason, too. We, as physicians, cannot choose our patients, but patients can determine who provides their medical care, and yes, that includes for racist or sexist reasons, though in this case, I'd say modesty." "I didn't see the chart, obviously, so where is the rash?" "Her buttocks and upper thighs. I suspect you can work out how that might have happened." "I'd hate to be the guy and have it where I suspect he'd have come in contact with poison ivy!" Len declared. "I might need to ask you to swap with Leslie to limit the number of guys in the room. It's not about you, but about the patient. It's happened to me a few times." "Understood." "Let's see if our young woman will accept me as her doctor, or wants to wait. We'll need a female nurse if Miss Munroe does agree, and we'll probably end up calling for an OB/GYN consult." "Jill Munroe? Like _Charlie's Angels_?" "Never watched it. Which actress was that?" "Farrah!" Ken, another of the Second Years declared. "Seriously? You don't know that?" I chuckled, "I know about Farrah, but I never watched the show. My best guy friend had the poster of her in his room." "Who didn't?" "Me," I chuckled. "It didn't fit with the icons." "Icons?" "I'm Russian Orthodox. Anyway, let's see what she has to say." I went back into the waiting room with Bob and over to where Miss Munroe was standing in obvious discomfort. "Doctors Townsend and Billings, the two females on shift, are both in a trauma, and it might be some time before they can see you. You're free to wait if you like. If you'd be more comfortable, I can also have a female medical student assist me, instead of Bob." "How long do you think?" "I can't say, but the nurse said the trauma was bad." "There are only two women doctors in the hospital?" "Only two in trauma. I could call someone from OB/GYN, but you'd be in line behind any women in labor or needing pre-natal care, and that might take even longer. You could see your own OB/GYN or GP, if either of those is an option." She contemplated for a moment, "I'll wait." "OK." Bob and I returned to the triage desk and I let Alex know. "Want me to call OB and see if they have someone?" "Probably a good idea, as we have no idea how long Doctor Billings and Doctor Townsend will be. I'll take the rule-out broken ankle." He handed me the chart, and Bob and I went back to the waiting room. I first stopped to let Miss Munroe know that we'd called for an OB/GYN, but couldn't give her an ETA, then went over to Miss Lucy Knight, age nineteen, and sitting in a wheelchair. "Hi," I said. "I'm Doctor Mike and this is Bob, a medical student I'm training, and some other students who are observing. What happened?" "I missed a step and landed badly. I twisted my ankle. My mom thinks it's broken, but I think it's just a bad sprain." "We'll do an exam and an x-ray and see what's up. Is this your mom?" "Yes." "Mrs. Knight, we'll take good care of her and someone will come let you know when we've finished our exam." "Can I come back with her?" she asked. "That's up to Lucy," I said. "Sure," Miss Knight agreed. "Bob, if you'll do the honors," I said. "Exam 3 is open." Bob pushed the wheelchair, and we went to Exam 3 where I conducted the H & P. "I need to get an x-ray of your ankle," I said. "Is there any chance you're pregnant?" "What kind of question is that?" Mrs. Knight asked, sounding offended. "A required one," I replied. "We want to limit exposure of a fetus to x-rays, and we ask that question to help us determine the correct diagnostic procedures and decide on which medications are OK. I meant no disrespect at all. Lucy?" "No," she said. "No chance." "OK." I had Bob call for the portable x-ray, and twenty-five minutes later, after reviewing the fluoroscopy, I had Bob call for an orthopedic consult, as there was a hairline, non-displaced fracture of the ankle. I didn't think it needed to be set, nor did I think it needed surgical intervention, but all fractures required orthopedic review. "Your mom was right," I said to Miss Knight. "But it's a hairline fracture, so I don't think you'll need anything more than a cast, but I'm going to have a specialist from Orthopedics verify my diagnosis." "How long will I have to wear a cast?" she asked. "Let's wait for the orthopedist before we say anything definitive." "Are you a new doctor?" Miss Knight asked. "I finished my formal training about a month ago," I replied. "But I've been performing exams and doing procedures for over two years." "Is that why you're wearing red and everyone else is wearing blue?" "No, the red scrubs are because I'm a surgical Intern, but I'm assigned to the Emergency Department as a trauma specialist." "That seems strange." "My specialty is trauma surgery, which is a combination of emergency medicine and surgery, so I've trained in both areas, and my training will continue for another eight or nine years." "I thought you said you finished your training!" "I graduated from medical school a month ago, so now I'm a Resident instead of a Trainee Doctor," I said, using the lay term. "That means I'm properly trained, but need experience before I'm Board certified and could practice completely on my own, rather than be supervised by a senior doctor called an Attending." "But he's not here," she replied. "Supervision means I report to him or her, confirm my diagnoses, and then receive approval to perform any procedures that haven't been signed-off, which means I know how to do them and have demonstrated that to their satisfaction. To set your mind at ease, I've been doing basic exams for over two years, and I'm fully trained in everything I might need to do to help you." "So why call the other doctor?" "Because broken bones aren't my specialty," I replied. "If you were having a heart attack, I'd treat you but still call for a cardiologist — a heart doctor — to confirm my diagnosis and to continue your treatment after you left the Emergency Department. If you were having a baby, I'd call for an OB for the same reason. I'm sure you see an OB/GYN in addition to your regular physician, right?" "Yes." "For the same reason," I replied. "Your GP could do the exams, but he or she doesn't have the extensive training in gynecological concerns that an OB/GYN has. Trauma specialists, and trauma surgeons, which is what I am, focus on treating emergency cases, which means diagnosing and stabilizing a patient before we hand them off to another specialist. In your case, you won't need to be admitted, so I'll complete your treatment with help from a nurse once the orthopedist confirms my diagnosis." "Are you married?" she asked. "Yes, and I have a daughter who's almost two." "Jackson, Orthopedics," Doctor Valerie Jackson announced as she came in with a medical student in tow. "Doctor Mike Loucks," I said. "Lucy Knight, nineteen; vitals normal; complained of ankle pain after a missed step on a staircase. Exam shows swelling and tenderness, but no ecchymosis. Negative exam for Maisonneuve fracture. Fluoroscope shows a non-displaced hairline fracture right posterior malleolus." "Let me take a look," Doctor Jackson said. She reviewed the image, then examined Miss Knight's ankle. "Confirmed," she announced. "I recommend an orthopedic boot and normal ankle protocol." "Thank you, Doctor," I said. "Val, please. We're both PGY1s!" I nodded and she and her student left. "You're in luck," I said. "No cast, just an orthopedic boot. It fits snuggly and has Velcro closures. You'll be able to take it off to bathe, but you shouldn't put any weight on your ankle. You'll need to follow up with Doctor Jackson in two weeks to ensure the break is healing properly, and she'll decide exactly how long you'll need to stay off your ankle." "How long could it be?" Miss Knight asked. "That depends on a number of factors, but the norm for this type of fracture is six to ten weeks. Have you used crutches before?" "No." "I'll have the nurse who fits your boot show you how to use them. Let me get everything in motion and I'll come back and see you in a few minutes. What size shoe do you wear?" "Six." "OK. Bob, I'll write the order and you'll need to go up to Orthopedics and get a size-six boot, please. Just ask the duty nurse. Then get a set of crutches." "Will do." I wrote out the order on a prescription pad and handed it to Bob, then made notes on the chart. "Be right back," I said to Miss Knight. "Thanks, Doctor." "You're welcome." I stepped out and went to see Doctor Taylor, who reviewed the chart, made his notes, and signed it. "No pain meds?" he asked, handing me the chart. "I'd prefer to avoid any opiates if at all possible. I'll recommend ice and ibuprofen or acetaminophen, and have her come back if the pain is severe." "You're concerned about addiction?" "Very. I'm not about to deny pain meds to someone who needs them, but I'd prefer to take a staged approach. That's my personal preference, but if you tell me to prescribe something stronger, I won't fight you." "No, I don't disagree with you. We see too many drug seekers as it is. No need to create more, especially a teenager." I left his office and went to the nurses' station and asked Ellie for a nurse, and she assigned Jamie, the male nurse. He accompanied me back to the treatment room, and I introduced him to Miss Knight and her mom. "Jamie will show you how to put on the boot and use the crutches," I said. "You should elevate your ankle as much as possible, and ice it for twenty-minutes at a time, with twenty minutes between applications. I'm writing you a prescription for 600mg ibuprofen, which you should take every eight hours for the next week, then as needed. That will help with the pain and swelling. No weight on that ankle before you see Doctor Jackson in two weeks, and then follow her instructions. Any questions for me?" "No." I wrote out the prescription and gave it to her along with the discharge instructions, and then left Jamie to complete her care. "Mike?" Ellie called out. "Are you free?" "Yes," I replied. "Jamie will finish up." "Paramedics are three minutes out with a construction injury. Doctor Taylor needs you in the ambulance bay." "Let Bob and Len know where to find me," I said. "OK," she acknowledged. I put on a gown and gloves, called the Second Years follow me, and hurried to the ambulance bay where I found Doctor Taylor, Nurse Kelly, and Naveen Varma, a fellow PGY1. "Any idea what's coming in?" I asked. "Multiple penetrating trauma," he said. "That's all I know." "Surgical consult?" I asked. "That's way beyond my training and current skill set." "Already called. You intubate, please. Naveen, EKG and monitor. Kelly, hang two units, then a complete trauma panel; type and cross match." We both acknowledged his orders and two minutes later, Bobby jumped out of the cab of his rig. "Bad one, Docs!" he called out. "Jack Nelson, thirty-three; fell from scaffolding on to rebar. Thirty minute rescue requiring saws; significant penetrating trauma to chest and abdomen; BP 90 palp; pulse 120 and thready; resps labored; PO₂ 94 on ten liters; IV saline TKO; morphine x2; GCS 8." My eyes went wide when they pulled the gurney from the back of the right as I saw three rods of green rebar sticking out of the patient's torso. From their position, I was positive he had at least one compromised lung, and probably severe internal abdominal injuries. "Trauma 1" Doctor Taylor ordered. We moved quickly to Trauma 1 and carefully moved Mr. Nelson to the treatment table just as Doctor Roth arrived. "As soon as he's stable, we'll take him up," Doctor Roth said, then went to the phone. As Mr. Nelson was unconscious, I dispensed with the intubation drugs and quickly inserted the endotracheal tube and connected the vent, setting it on low pressure. "Right lung sounds only," I said. "Left one is penetrated," Doctor Taylor said. "V-Tach!" Naveen announced, to nobody's surprise. "What do you want to do, Owen?" Doctor Taylor asked Doctor Roth. "I can't do anything here, and a chest tube is like a fart in a hurricane at this point. Let's get him upstairs. OK to take Mike with me?" "He's your Intern!" Doctor Taylor replied. "As was made clear." "Forget the BS politics and leave that to the Chiefs. Mike, bring Mr. Nelson up." I acknowledged him, then quickly hooked up the portable EKG and portable vent. Fortunately, Len came in just at that minute. "Help me with the gurney," I said to him. "We're going to OR…" "Three," Doctor Roth confirmed. "See you upstairs." He took off at a trot, because he'd need to scrub in while Len and I fetched a gurney, and then everyone in the trauma room helped move Mr. Nelson to it. I instructed my Second Years to shadow Doctor Taylor, then moved out of the room. "Ellie," I called out as we rolled by, "I'll be in OR 3 with Doctor Roth," I said. "Have Bob work with Doctor Varma, please." "I'll tell them," Nurse Ellie confirmed. "You're doing surgery?" Len asked as we quickly moved towards the elevators. "Doctor Roth is, but he asked for me to bring up Mr. Nelson up, so I suspect he'll have us scrub in because this is exactly the kind of case I'm training for." "Is he going to make it?" "HOLD THAT ELEVATOR!" I called out. The staff who were about to get into the elevator cleared out of the way, and Len and I pushed the gurney into the waiting elevator. He hit the button for the surgical floor and the doors closed. "Whether he makes it will be up to God and Doctor Roth," I said. "He has at least one compromised lung, and multiple internal abdominal injuries. I'm not sure what will be first — fixing the lung or an ex-lap to see just how bad things are." "No x-ray?" "They'll use the surgical fluoroscope to get an idea, but only an ex-lap will reveal the extent. And they'll need to open him up to repair what they can. This one bar is in a position that might have compromised his liver, and if that's the case…" "He won't make it." "Let's just say it'll take more than extreme surgical skills. If you're a praying man, now would be a good time." "Do you pray for your patients?" "Silently for every one of them." The elevator doors opened, and we rushed Mr. Nelson to OR 3, where Nurse Penny and Doctor Lindsay were waiting. "Doctor Roth wants you to scrub in," Doctor Lindsay said as we carefully transferred Mr. Nelson to the surgical table. "What about my student?" I asked. "He's Third Year." "First rotation and never scrubbed in?" "Correct." "Send him back to the ED; we don't have time to sort out sizes and teach him to scrub." "Sorry, Len," I said. "Go back and see Doctor Varma." "OK," he replied. He left, and I went to the scrub room where Doctor Roth was finishing up. I realized I needed a surgical cap, so I stepped through into the locker room and retrieved one of mine from my locker, then Nurse Jackie helped me scrub and gown. Once I was finished with the scrub procedure, I went into the OR where Doctor Roth was discussing anesthesia with Doctor Vandermeer. "Mike," Doctor Roth asked when they finished the discussion, "how are your arm muscles?" "I lift free weights as part of my exercise routine." "OK, you're going to extract each piece of rebar once I view the scope. Smooth, straight motions, and then hand it to Jim, the Third Year who's standing by the door. Once that's done, I'll have you put in a chest tube while I begin the ex-lap with Shelly." "With a through-and-through penetration, that's not going to re-inflate the lung," I said. "No, but we'll need it and it's something you can do while we see if we can get the abdominal bleeding under control. I'll talk you through what to do after that." "OK." "What do we have?" Doctor Cutter asked, coming in. Doctor Roth looked at me and I gave the report. "Thanks, Mike," he said when I finished. "OK, Owen, what's your plan?" "Shelly and I are going to see if we can stop the abdominal bleeding after we remove the rebar. For the lung, I asked Mike to put in a chest tube, and we'll decide from there what approach." "Let me take the chest while you take the gut," he said. "Still want the chest tube?" I asked. "Yes," Doctor Cutter said. "He'll also need drains, which are similar, and we can teach you that, too. Interesting style choice on the cap." I'd chosen solid black surgical caps, which had a pocket for my pony tail. "The good guys wear black in my church," I replied. "You wore colored cassocks here." "That's permitted, but black is traditional." "He's ready," Doctor Vandermeer said. "But I don't like his BP or his tachycardia." "Let's see what we can do about that," Doctor Roth said. A masked medical student I didn't recognize wheeled the fluoroscope over and positioned it. Doctor Roth looked intently at the screen. "OK. Lung is compromised, but ribs are all intact, and the rod is a full six centimeters from his heart. Mike, extract the rod, please." I stepped over, grasped the rebar with both hands and pulled slowly, trying to keep the metal rod at exactly the same angle as it had penetrated Mr. Nelson's chest and once it was clear, handed it to Jim. "Some blood," Doctor Cutter observed. "But we'll manage it." The student repositioned the scope to Mr. Nelson's abdomen as Doctor Roth directed. "I do not like the looks of this," Doctor Roth said. "What do you think, Shelly?" "His liver is compromised," she said. "And there is free fluid, suggesting injury to the hepatic portal vein. Let's check the other rod, because he might well bleed out if we pull this one." "Agreed." The scope was repositioned to view the third rod and Doctor Roth shook his head. "His stomach is compromised and at least a partial resection will likely be necessary. We're going to be tied up for at least six hours, if not more. Penny, push our afternoon surgeries, please." "I'd suggest we can remove this bar," Doctor Lindsay said. "And then do the laparotomy so we have access to the portal vein when we pull the rod." "I'd say that's the best option," Doctor Roth said. "John?" "I don't have any better options for you," Doctor Cutter said. "OK," Doctor Roth said. "Mike, remove the second bar, same as the first." I nodded and moved into position and once again slowly and carefully extracted the rebar, handing it to Jim. "Moderate amount blood," Doctor Lindsay observed. "The liver injury is still primary." "OK," Doctor Roth agreed. "Mike, we're going to do this fast. We'll get him open, I'll signal you, and you get that bar out and get out of the way. Once that's done, you put in the tube then assist Doctor Cutter." "Yes, Doctor," I said. "Ten blade," Doctor Roth said to Nurse Penny. "Shelly, stand by with suction. And Kelly, I'll need the needle driver as soon as the rod is out." Nurse Kelly handed him the instrument and Doctor Lindsay picked up the suction. "Everyone ready?" "Move fast, Owen," Doctor Vandermeer said. "He's in bad shape." "Tell me something I don't know!" Doctor Roth snapped, then said, "Sorry. OK. Here we go!" He quickly made the necessary incisions and there was a LOT of blood. "Penny, hang two units on the rapid infuser!" Doctor Roth barked. "Mike, go!" I stepped up and grasped the rebar and pulled it out, quickly stepping back. "Suction!" Doctor Roth ordered. "Mike, chest tube, please," Doctor Cutter ordered as he used the fluoroscope to evaluate his next move. "Chest tube tray to me, please!" I requested. Nurse Amy brought it to me and I set to work. "BP is bottoming out," Doctor Vandermeer announced. "I'm working as fast as I can," Doctor Roth said. "Penny, hang a third unit." "V-Fib!" Doctor Vandermeer announced. "Paddles to Mike at 200!" Doctor Roth commanded. "Jim, pads!" Jim put the pads on as Amy handed me the paddles, then squirted gel onto them. "Charged!" Amy declared. "CLEAR!" I commanded. Doctor Vandermeer disconnected the vent, and I put the paddles on the pads and triggered the shock. "No conversion!" Doctor Vandermeer declared. "250!" I requested. "Charged!" Amy declared a moment later. "CLEAR!" I shocked him again. "No conversion," Doctor Vandermeer called out. "BP is unmeasurable. No pulse." "He's lost too much blood," Doctor Cutter said. "We're not getting him back." "Asystole," Doctor Vandermeer announced. "Call it, Owen," Doctor Cutter said. "God damn it!" Doctor Roth swore. "Time of death 14:49." What had been a frantic, noisy OR was suddenly quiet as machines were turned off and people filed out of the room to the locker room. "May I ask why you're so upset?" I asked Doctor Roth as everyone stripped off their scrubs. "Third one of the day," he growled. "The first one had an embolism; the second had a fatal MI." "It's just one of those days, Owen," Doctor Cutter said. "You have nothing scheduled for the rest of the day, so go home, relax, and tomorrow is a new day." "OK to return to the ED?" I asked Doctor Cutter. "Yes. We'll try to bring you up on traumas such as this, but it won't be every time because we can't leave the ED short-staffed." "Thanks, Doctor Cutter." I put on clean red scrubs, elected to begin wearing my surgical cap regularly, then headed back to the ED.