Chapter 14 — A Long Shift Finally Ends

_July 4, 1989, McKinley, Ohio_

I had just enough time to finish my phone call and coffee before the x-ray results were back for Alicia Sanderson's ankle.

"I'd call this a Grade 2 sprain," I said, looking at the x-rays with Doctor Williams on the light panel in the Attendings' office. "That was the radiologist's assessment as well."

"Then it's unanimous," Doctor Williams said. "Treatment plan?"

"Wrap in an Ace bandage, crutches, rest with the ankle elevated, ice as necessary, Tylenol or Advil for pain, and a referral to a sports physiologist in the medical building next door for follow-up."

"Make it happen."

I took the x-rays from the viewer, then Tom, Mary, and I left the Attendings' office and went back to the exam room to discuss the results with Alicia and her mom. In the exam room, I put the x-rays on the light panel and turned it on, then explained what we'd found.

"Long-term, it should heal completely with no permanent impairment," I said. "I'm going to refer you to Doctor Jeong Kim, a sports physiologist. You should call his office today and make an appointment for Friday. Until then, rest, keep your ankle elevated, use ice to bring down the swelling, and take Tylenol or Advil for the pain. We'll give you crutches, and you can put no weight on your ankle at all until you're cleared by Doctor Kim to do so."

"When can I run?" she asked.

"Typically, about twelve weeks, but Doctor Kim will discuss that with you after he examines you, and he'll recommend a proper course of rehabilitation. It's very important you follow my instructions, and his, so you don't do any permanent damage to your ankle."

"That stupid dog!" Alicia growled.

"Tom, would you get me an Ace bandage, please?" I asked. "Then get a set of crutches. Alicia is tall, so she'll need the larger size."

He went to the supply cabinet and took out a package with an Ace bandage, opened it, and handed me the bandage, then left to get the crutches.

"OK to wrap your ankle?" I asked.

"Yes," she replied.

I wrapped the Ace bandage tightly around her ankle, using a clip to attach the loose end to the layer below it.

"Leave this on until you see Doctor Kim," I said. "I take it you haven't used crutches before?"

"No."

"Then let me explain. Mrs. Sanderson, you could go to Patient Services while we do this."

"OK," she agreed.

I gave her the discharge papers, and she left. I went through the proper usage of crutches, and when Tom returned, Mary and I helped Alicia practice until she had the hang of moving with them.

"You'll need to sit in the wheelchair," I said. "Policy again."

Alicia rolled her eyes and Mary helped her from the table into the chair, and set the crutches next to her.

"Tom will wheel you out," I said. "Good luck with your rehab."

"Thanks! You have a really soft touch!"

"Thank you," I said. "Tom?"

He wheeled her out and as soon as they were in Patient Services and out of earshot, Mary laughed.

"And just what exactly did she want you to touch?"

"Whatever it was, if I did that, it would result in me dying somewhere between climbing out of my Mustang in my driveway and the front porch of my house!"

"Mike?" Ellie called out. "Doctor Gabriel needs you in Trauma 1."

Tom, Mary, and I went to Trauma 1.

"You asked for me?"

"Probable surgical case. Rafiq is in Trauma 2. Can you do the consult?"

"Yes."

The ultrasound was set up, as he had used it for his assessment. I immediately saw fluid in Morison's, and said so.

"Let me call upstairs," I said.

I called the scheduling nurse and let her know, then Mary and I took the patient up to the OR, but given how busy we were in the ED, there was no way we could scrub in.

"Bummer," Mary said as we returned to the elevator.

"You'll get your chance," I replied. "I felt the same way, by the way. Always ready for more."

"It's your fault! You let me manage two cases and that made me want more!"

"It is addictive," I replied. "Or like Lay's chips — nobody can eat just one! Remember how concerned you were with missing the toddler with croup?"

"Yes, and obviously you didn't hold it against me."

"You accepted correction and committed not to making the same mistake a second time. That's all we can ask. You weren't given a chance to do any procedures in June?"

"Sutures only," she replied. "I was mostly with Doctor Townsend and Doctor Lewis, and they did everything."

"When you do your evaluation, make sure you note that. There won't be any negatives, and it will help Doctor Gibbs know how to help them."

"I was warned to not say anything seriously negative on evaluations."

"I was never given that advice, and I certainly wouldn't have followed it! Simply be truthful and honest. I want feedback, and if I'm doing something that interferes with your training, I want to know about it, and Doctor Gibbs should absolutely know about it."

"At the risk of you making my life hell because I sound ungrateful, I'd say more procedures!"

"As Doctor Williams said to me earlier, it's not news that med students want more procedures! I'm totally with you on that, and I'll do my best, though the rules are pretty strict about when I can let you handle things. Other times, it's a judgment call."

"Cute teenage girls?"

I laughed, "I did notice, but that wasn't a consideration. It was that I hadn't seen any sprains or fractures in your procedure book, so I felt you should watch one before I ask you to do one or teach one."

"I had seen them, but never had a chance to do anything."

"Next one, then," I said. "How are you on x-rays?"

"Other than the Preceptorship in Radiology and the plates we saw in class, I haven't had a chance."

"Then next set of x-rays, I'll have you look at them before I say anything to see how much you can discern. You notice I took them to Doctor Gabriel before I spoke to the patient, right?"

"Yes. Is that required?"

"In the sense that we're supposed to go to our Attending with anything beyond our comfort level, yes. I haven't seen enough films to be confident in my diagnosis, though I could rely on the radiologist if I elected to do so. I'd rather confirm the finding with my Attending, because every doctor makes mistakes or misses something, and that's as true of radiology as any other service."

We reached the ED and Ellie directed me to triage again.

"Fifteen-year-old male; line drive to the chest during a Little League game; large contusion just over the right nipple; vitals normal."

I accepted the chart and asked Mary to find Tom and meet me in Exam 2, which I saw was open on the board. She walked back into the ED and I went to the door of the waiting room.

"Nick Smith?" I called out.

"Me," a boy in a baseball uniform called out.

I went over to him and introduced myself.

"Is this your dad?"

"My coach," he said.

"Coach Nichols," he said. "I was concerned about the line drive, so I brought him in. I heard about an incident in Cincinnati last year where a kid died after a similar incident."

"You were wise to bring him in. There's a rare condition called comotio cordis that can occur with a blow to the chest at a specific point in the heart rhythm. Let's go back and I'll do an exam. Have you notified his parents?"

"They both work," Nick said.

"Then we'll call them once we check you out. Your coach can come back with you if you want."

"Yeah," he agreed.

The three of us went to the exam room where Tom and Mary were waiting. I introduced them, then went to the sink to wash my hands.

"Tom, history, please."

He completed the history, and then I did the physical exam.

"Everything appears to be OK," I said. "The bruise is pretty nasty, but I don't believe there are any other injuries. I do want to get an EKG just to be sure. If you'd take your jersey off, Mary will attach the leads."

Five minutes later, with a perfectly clean EKG, I was confident Nick was fine.

"You're good to go," I said. "Ice and either Tylenol or Advil for pain."

"Can I play?"

"As long as you're comfortable," I said. "Let me speak to my supervisor and we'll discharge you. Coach, you can use the phone there to call his parents."

Tom, Mary, and I went to find Doctor Williams, and I had Tom present the case.

"No x-rays?" Doctor Williams asked Tom.

"Uhm, Doctor Mike didn't think we needed them."

"And what do you think?"

"Well, he did a physical exam and ran an EKG and didn't find any signs of injury beyond the bruise."

"And what would we do for a broken rib?" Doctor Williams asked.

"Unless a lung or other organ was compromised, monitor and refer to his physician."

"And there were no signs of breathing trouble?"

"I didn't listen, but Doctor Mike said his lungs were clear."

"So, about the x-ray?"

"I don't think it's necessary because it basically wouldn't matter."

"Correct. Good report, Mr. Lawson. May I have the chart, please?"

Tom handed Doctor Williams the chart, and Doctor Williams returned it after making notes and signing it. We returned to the exam room and let Nick and his coach know they were OK to leave, and to return if Nick had any breathing problems or an irregular heartbeat.

"I wasn't sure what to say to Doctor Williams," Tom said after Nick and his coach had left.

"Never be afraid to say that you don't know," I counseled. "I get asked those same questions, only I'm expected to have the complete answer, not need to have it drawn out by questions. But you're a Third Year in your first clinical rotation, so you did fine. Eighteen months from now, you'd be expected to give the same answer, just complete in response to the initial question."

"You had questions like that?"

"All the time. And there were times when I had to say that I didn't know. What I figured out early on is that you have to _ask_ to be taught and you need to be both curious and proactive. Every Resident is different, and you'll find good teachers and ones that aren't good teachers. Your job is to figure out how to learn in _both_ cases."

"How? I mean, if the teacher is bad, how can the student learn?"

"By observing and generally making a nuisance of themselves with questions. If the Resident refuses to answer, you go to your Attending or your advisor at the medical school and let them handle it. But mostly, you should find a way. That's what I did when I had suboptimal teachers. They were good doctors, mind you, just poor teachers. Sometimes you have to go to someone else, and generally nobody will complain about you doing that."

"Is there any way to choose our Residents?" Tom asked.

"Not really," I replied. "And if you truly don't get along with your Resident, it's incumbent on you to find a way to get through the rotation. After all, you can't expect to like every doctor and no doctor is liked by everyone."

"Even you?" Mary asked, with a twinkle in her eye.

"Especially me! I am, as a number of Attendings and Residents will attest, a pain in the ass."

"But you graduated first in your class!" Tom protested.

"Which has nothing to do with not being a pain in the ass! Part of it is what I said before - make a nuisance of yourself, if necessary, to learn. I sure did. Most of the time, it showed the Resident or Attending how serious I was; other times, it simply pissed them off. I've had Residents do thing which might be considered retaliatory or punitive and my response was to grin and bear it."

"Like what, if you can say?" Mary asked.

"A Resident who decided he didn't like me and assigned me shifts that knowingly conflicted with church attendance and only assigned me every single bit of scut available."

"That's not right."

"No, it's not, but I won the battle by not letting it faze me or affect my attitude. In fact, it actually ensured I was the cheeriest I'd been on any Third Year rotation!"

"An interesting way to get revenge," Tom said.

"Indeed. That Resident was more perturbed that I wasn't upset than I was perturbed by the hazing. That is how you deal with the BS."

"Mike?" Ellie called out. "Doctor Williams would like to see you."

The three of us went to his office.

"Your neuro consult gorked," Doctor Williams said. "Expect to be called in front of the M & M a week from Friday."

"Thanks for letting me know," I said.

We left his office and went to the lounge, got a bottle of water, then I basically collapsed onto the couch. I'd been on for twenty-nine hours and had no sleep, and I could feel it. I wondered how I'd get through the concert, let alone the two or three hours afterwards.

"What happens now?" Tom asked.

"You mean the M & M? Have you been to one?"

"No."

"You should attend as many as possible, even coming in if you aren't on shift. If you are, ask for permission to go. It'll usually be granted. You, too, Mary."

"I've been to a couple," she replied.

"Good. The answer to your question, Tom, is that it's a question-and-answer period about interesting or difficult, or, in this case, cases with bad outcomes. What will happen is I'll present the case, then answer questions from other doctors about the management of the case. They'll critique my handling of it, give advice, and try to find the root cause of the problem."

"Why don't you seem nervous?" he asked.

"First, it's not adversarial, but second, think about what I did."

He was quiet and shook his head.

"I insisted Doctor Mastriano write her order on the chart," I said.

"Whoa! That was self-defense?"

"Very much so. In my opinion, she was wrong, so I made her put it in writing. She'll be roasted at the M & M, even though it's not adversarial."

"Roasted how?" Tom asked.

"For sleeping," Mary interjected. "She was more interested in not being disturbed than spending five minutes examining the patient."

"That about sums it up," I said.

"Mike?" Ellie said from the door to the lounge, "Doctor Williams needs you. EMS is three minutes out with a young drowning victim."

"Lord have mercy," I said aloud. "Be right there, Ellie."

"Survival rate?" Tom asked as I got up.

"During the Summer? Near zero if not revived at the scene. During Winter, one in four due to the effects of hypothermia."

We hurried to the ambulance bay, grabbing gowns and gloves on the way.

"EMS is performing CPR en route," Doctor Williams said, conveying that anything we did was likely going to be futile.

"Intubation and EKG?" I asked.

"Yes. Is your student ready for that?"

That question reinforced what I'd surmised.

"Mary is capable," I replied. "I'll guide her."

"Good," Doctor Williams said. "Tom, EKG and monitor."

"Yes, Doctor."

"Mary, tell me the steps for intubation, please," I said.

She took a deep breath, let it out, then said, "Select the correct endotracheal tube based on the patient's physiology, then gently open the patient's mouth, insert the laryngoscope blade, and slide down right side of mouth until the tonsils are visible. Move the blade to push the tongue centrally until the uvula is visible. Next, advance over the base of the tongue until the epiglottis is seen.

"At that point, advance steadily until the tip of the blade is at the vallecula and the epiglottis is visible below it. Lift gently forward and upward to raise the epiglottis and reveal the arytenoid cartilages and vocal cords. Once the cords are visible, insert the tube in the groove of the laryngoscope so that the cuff passes the vocal cords. Once the tip of the tube is at the glottis, remove the stylet and gently advance until the cuff is past the vocal cords. Inflate the cuff to protect the airway from secretions and form a seal around the tube. Then confirm placement."

"Textbook answer, almost word for word," I said. "How do you confirm placement?"

"With a ventilator or bag at one breath every five or six seconds, checking for chest movement and bilateral breath sounds."

"Correct. And if you don't hear them?"

"Reposition the tube, usually withdrawing slightly, unless no sounds are heard, in which case you remove the tube and begin again.

"Good. Do exactly that. Remember, slow and smooth is the fastest way, even though is sounds contradictory."

"Because it's more important to get it right than to be fast and get it wrong."

"Exactly. Thirty seconds sounds like a short amount of time, but it's really a long time in the scheme of things. Again, I know that sounds contradictory, but it's true. If the patient is conscious, what drugs?"

"How old?" she asked.

"Around ten," Doctor Williams said as the Fire Department EMS squad pulled into the driveway.

"For adults, it's weight based," she said. "For a ten-year-old, there's a set dose in my book."

"Look it up now," I said.

She did as the squad came to a stop.

"Ten-year-old male found floating in a pool; unresponsive and not breathing; no vitals; CPR performed after recovery."

I was positive the boy was dead, but that didn't mean we wouldn't try.

"Trauma 1!" Doctor Williams ordered. "How long down?"

"At least twenty minutes," the paramedic said as we rushed the gurney with a firefighter performing CPR while the other paramedic bagged him.

In the room, the six of us quickly moved him to the treatment table and Nurse Amelia took over bagging while I relieved the fireman who was performing chest compressions.

"Intubation kit to Mary!" Doctor Williams ordered. "Mike, stop compressions."

I did as Nurse Jenny brought the kit to Mary, who picked up the laryngoscope and the pediatric endotracheal tube.

"No heart sounds," Doctor Williams announced. "Mike, resume compressions. Jenny, stat pH!"

Tom worked around me to get the EKG leads attached, Amelia got an IV into the boy's arm, and Jenny drew blood for the pH test. As they did that, I watched as Mary used the correct technique to get the tube inserted.

"I'm in!" she said.

"Connect the vent and set it to ten per minute," I said. "Once it's on, I'll stop compressions so Doctor Williams can listen."

"Asystole," Doctor Williams declared. "An amp of epi down the tube, please."

Nurse Amelia squirted the contents of a pre-prepared syringe into the tube, then Mary connected the vent to the tube. I stopped compressions, and Doctor Williams listened.

"Good breath sounds, resume compressions."

We tried for another ten minutes, and couldn't get even a blip on the EKG, nor any heart sounds, and the pH test showed a level incompatible with life.

"Stop compressions, Mike," Doctor Williams said, then listened one last time. "Time of death 11:44."

"Lord have mercy," I said.

"Is there nothing else we can do?" Mary asked.

"No," Doctor Williams said. "After two doses of epi, continual CPR, and a dose of bicarb, his pH level is so low that even if we could get his heart started, he'd be in multiple organ failure. If he was in the water for more than five minutes, he'd have severe brain damage. He was likely dead when the paramedics got to him."

"I'll get the death kit," Amelia said.

"Tom, Mary, have you seen a death kit routine?" I asked.

"No," they both said.

"Then stay and watch. I'm going to go shower and change and Kylie Baxter will be your Resident for the next four hours."

They acknowledged me and went out into the corridor. Kylie came up about two minutes later.

"You look like shit," she said.

"We just lost a ten-year-old drowning victim. Mary Anderson and Tom Lawson are with Amelia in Trauma 1 to witness their first death kit."

"What a shitty way to end the morning."

"Yeah. I'm going to shower, change, and head to the lake. We don't have any patients on the board at the moment, so go see Doctor Williams."

"See you in about four hours," she said.

"Thanks."

I let Ellie know I was leaving, went up to the surgical locker room, showered, dressed, and then headed out to my car for the drive to the lake. I met Kris and Rachel near the band shell, as we'd planned.

"Dada!" Rachel exclaimed happily when she saw me.

I took her from Kris, hugged Kris with one arm and we exchanged a quick kiss.

"How are you doing, Mike?" Kris asked.

"I'm beat," I replied. "And down."

"Bad?"

"Ten-year-old drowning victim didn't make it. That was right before I left."

"Lord have mercy!"

"Yeah," I replied.

"Do you have time to eat with us?"

"Yes."

The three of us sat on a blanket not far from the band shell and quickly ate a picnic lunch before I and the other band members met in the small room set aside for us.

"You look beat, Mike," José said.

"I think I feel worse than I look," I replied. "No sleep since about 5:00am yesterday."

"That's just crazy!"

"Yeah, and I'm also on an adrenaline low because we had a bad trauma right before I left. Ten-year-old boy drowned."

"Damn," he said.

"Yeah."

"How many patients have you seen since your shift started?" Sticks asked.

"I have no clue," I replied. "If I stop and think about it, I could probably count, but I don't keep track. I was constantly busy from 0600 yesterday until I left about forty minutes ago."

"Are you up for playing your signature song?" Kim asked.

"I don't know," I replied. "All I can do is hope my autopilot works."

Fortunately, it did, and I got through the concert with only a few mistakes, but nothing too terrible. When we finished, Kris and Rachel came to see me, I kissed and hugged them, then headed back to the hospital, feeling more tired than I'd ever felt in my life.

"You OK, Mike?" Kylie asked when she saw me. "I can stay."

"No. Go get your nap before your next shift starts. I'll gut out the last two hours. Anything on the board?"

"Badly torn ACL waiting on Ortho. The films are pretty clear, but you know the rules."

"I do. See you in two hours."

She headed for the Internal Medicine on-call room, which would otherwise be empty during the day so she could nap undisturbed, and I went to find Tom and Mary.

"How did it go?" Tom asked.

"I fumbled through a couple of songs, but otherwise, OK. How long did Ortho say they'd be on the consult?"

"At least another thirty minutes," Mary said. "They only have one Resident in the hospital and she's busy."

"Did Doctor Baxter provide any pain medication?"

"Oxycodone PO, after consulting with Doctor Williams."

I nodded, "Necessary for any Schedule II or III drugs. Patient details?"

"Male, forty-nine, playing touch football with his buddies at the lake."

"He's going to regret that," I replied.

"Not as much as he's regretting his wife's reaction. She's all over his case about 'behaving like a kid' when he's 'old enough to know better'."

"Maybe give her a sedative?" I suggested.

Mary laughed, "She's the classic shrew, and I'm saying that as a woman. She annoys _me_, and I usually agree that guys exercise poor judgment."

"I'm a guy and I agree with that! Hang around the ED enough and you'll see all the evidence you need!"

"Sorry to change the subject," Tom said, "but what electives did you take?"

"I doubled emergency medicine, plus surgery, cardiology, ICU, and pathology."

"Pathology? Why?"

"As Doctor Roth put it, where else can a medical student or intern handle a scalpel every single shift? It was good practice, both in terms of using surgical tools as well as honing my diagnostic skills. I would recommend against the ICU because I was bored to tears. There are basically no procedures, just monitoring, admissions, and transfers. I had thought it would be interesting, but it wasn't."

"What would you have done instead?"

"Probably internal medicine," I replied. "My other option would have been pediatrics. I didn't feel OB was necessary because I was allowed to do normal Fourth Year stuff during my Clerkship."

"How?"

"By being totally prepared, knowing my stuff, and _asking_. Remember that last one. Show you know your stuff and ask. You'll get plenty of negative responses, but all it takes is one positive one. Another good option would be the Free Clinic, especially if you're going into private practice, as you'll see the same kinds of urgent, but not emergent, cases."

"Why doesn't the hospital set up something like that and direct patients who don't need emergency treatment there?" Tom asked.

"Mary?" I prompted.

"It's illegal to direct someone away from the ED without first giving them an exam and providing stabilizing treatment. The hospital attorney who spoke to us made it clear that even a sign encouraging people to use a clinic could be a violation."

"Seriously?" Tom asked.

"Seriously," she said. "It _might_ be OK to put up a sign that had comparable wait times, but you can't actively encourage them to leave without risking an EMTALA violation."

"Which is why we're seeing an increase in patient presentations in the ED," I said. "We can't ask about the ability to pay because EMTALA says that doesn't matter. There's a debate about whether we can ask for insurance information, which we might be able to, so long as no weight is assigned to insurance or lack of insurance during triage and initial treatment. And it's all speculative at the moment because we're still waiting on the final rule from HHS. But the attorneys insisted we create a policy first, so it's in place when the rule is promulgated."

"Mike?" Ellie said from the door to the lounge. "Do you have time to take a severe sunburn?"

"With this pasty skin, that's about two minutes without sunscreen for me!"

Ellie laughed, "We northern European types burn to a crisp!"

"In the waiting room?"

"Yes. Exam 6 is free."

"We'll handle it, thanks. Mary, go fetch our patient, please. I'm going to use the facilities and I'll meet you in the treatment room. Tom, go with her. Mary, start a chart with history, please."

They left, and I went into the bathroom, emptied my bladder, washed my hands, then washed my face. Once I finished, I went to Exam 6 where Mary was speaking with a teenage girl who on first glance had second-degree sunburn.

"Hi," I said. "I'm Doctor Mike. Mary?"

"Cindy Sundstrom, sixteen," Mary said. "Fell asleep in the sun at Lake Milton."

"Continue your H & P, please," I instructed.

There was nothing remarkable about the young woman's history, and her vitals were slightly out of range, with her pulse at 90 and her BP at 90/60.

"What do you want to do?" I asked Mary.

"IV Ringer's for dehydration, aloe gel, and NSAID for discomfort."

I nodded, "Good plan. Advise your patient."

"Cindy, you're dehydrated, and drinking water won't resolve that as quickly as we would like, so we're going to give you an IV with something called Ringer's Lactate, which will ensure your electrolytes are in balance. We'll also apply aloe gel to your sunburn, and we can give you some ibuprofen to help with the pain."

"Do I really need an IV?" she asked.

Mary looked to me and I nodded, then I said, "Yes, you do. We could try giving you oral electrolytes, but they aren't as effective. Your sunburn is severe, with some blistering, and it covers most of your front, except where your bikini covers you. That can be dangerous, though not life-threatening. Are your parents here?"

"No. They're in Toledo until late tonight. I was with friends."

"Do you have someone to stay with you at home until your parents arrive?"

She smirked, "My boyfriend, but I don't think my dad would approve."

"Being a dad, I suspect you're right, though my daughter is only two. What about another friend?"

"Yes, my best friend. She's in the waiting room with my boyfriend."

"Mary, complete your physical carefully, then treat as you proposed."

Cindy winced when Mary listened to her heart, which Mary reported sounded fine. I needed to confirm, so I did a repeat auscultation and confirmed no problems. Fifteen minutes later, Nurse Jackie came in to apply the aloe, and once that was complete and the entire liter of IV fluid had run in, we discharged Cindy to her friend and boyfriend, with instructions to come back if she felt sick, her skin turned purple, or she was in intense pain, and to see her doctor on Thursday for follow-up.

"She's going to be a hurting puppy," Mary said when we returned to the lounge. "At what point would you admit a patient?"

"She was close," I said. "But her vitals weren't totally out of whack and she had no signs of edema, no nausea, and no coronary or pulmonary compromise. Also, her face wasn't burned because of her hat. She also urinated, which was a positive sign as well. Absent that, I might have kept her longer."

"So it's a judgment call?" Tom asked.

I nodded, "As is just about everything we do except things which can be absolutely confirmed by specific tests. We use differential diagnosis to narrow down the possibilities, then make a judgment call as to the likely cause of the collection of symptoms we've observed. But the most obvious answer may not be correct."

"So what do you do?"

"As much as you can to narrow down the diagnosis, then decide your best options. You've heard the saying 'medicine is an art, not a science', I'm sure."

"Yes."

"It's partly true," I replied. "There is a lot of science, but there is also an art to successful diagnostic skills. That's especially true when clusters of symptoms point in very different directions. Sometimes you go with the most likely answer simply because you don't know and can't prove it's NOT the most likely thing. The key is to avoid taking any actions that might be adverse if you're wrong.

"You can't always do that, but that is the best approach. Something like 95% of the cases you see will have fairly obvious, correct diagnoses. The other 5% will be a mix of difficult diagnoses or cases where the obvious answer is wrong because the correct answer is statistically rare. It's those 5% that are candidates for Morbidity and Mortality conferences.

"A good example is the UTI versus STD diagnosis. We acted as if it was a UTI because that was our best evidence. But, and this is super important — patients lie. While not suggesting this is the case, the young woman could have cheated on her boyfriend, or been more promiscuous than she reported. If she'd reported a dozen partners, what would I have done differently?"

"Assumed it was probably an STD, right?"

"I'd have leaned more that way, yes. Mary, why would I not have assumed?"

"Because multiple partners means an increased risk for UTIs, along with HPV."

"Exactly. My counsel for her for no intimate relations had a double purpose. Mary?"

"Both to wait for the UTI to clear, but also to limit the chance she'd spread an STD."

"And remember, this isn't judgment about her behavior, simply about the risks associated with having multiple sex partners."

The phone on the wall rang and Tom answered it and said it was Doctor Taylor calling for me.

"Hi, Vince," I said. "What's up?"

"I spoke to Cutter. He'll speak to Northrup. Anything Mastriano adds to your file will be removed once Northrup speaks to her."

"Thanks."

"You're cleared completely."

"Thanks again."

I hung up, then went to sit down.

"Everything OK?" Mary asked.

"It appears so…"

"Mike," Ellie interrupted from the door of the lounge. "No rest for the weary! Four-year-old with a bee sting being brought in by EMS. Anaphylactic reaction, treated by epinephrine autoinjector. Trauma 2 is open. Three minutes.

"Thanks, Ellie."

Tom, Mary, and I got up, left the lounge, put on gowns and gloves, and headed to the ambulance by.

"Treatment plan?" I asked Tom.

"Uhm, mainly supportive for anaphylaxis," he said. "ABC, then monitor, with IV antihistamine if warranted, and albuterol via inhaler if needed."

"Very good. EKG?"

"I'm not sure."

"Only if indicated by tachycardia or signs of tamponade, or severe pulmonary distress. Just the pulse oximeter unless I say otherwise. Mary, be prepared to intubate, but I don't expect you to need to, given someone had an EpiPen handy."

"Those things are lifesavers," she said. "A friend of mine college had one, and it saved her life after she accidentally ate strawberry jam."

"EMS has started carrying them as a regular part of their drug box, and it's made surviving severe allergic reactions much more common," I said. "I think every school nurse should have them, along with every cop. I think the same is true for naloxone, which the paramedics carry, but currently there is no approval for untrained people to administer it."

"That's the OD drug, right?" Tom asked.

"Yes. It's also called Narcan, which is the name you've probably heard. It's fast acting and can reverse the effects of opioids within minutes."

The EMS squad turned into the driveway and pulled up.

"John Tyler, four, stung by a bee; parents administered EpiPen almost immediately; pulse 110; BP 130/80; resps good at eighteen; PO₂ 99% on nasal canula; GCS 15. Mom is in the squad with him."

"Trauma 2!" I said.

They unloaded John, I introduced myself, and we took him to Trauma 2 where five of us moved him to the trauma table as his mom came into the room.

"How are you feeling, Josh?" I asked.

"My arm hurts where the bee stung me," he said. "But mom shot me, so I didn't die!"

"Where did you inject the EpiPen?" I asked his mom.

"Right thigh."

"Josh, I need to listen to your heart and lungs, then my friend Tom here will remove the stinger and wash your arm. OK?"

"Yes."

Other than his fast pulse and slightly high blood pressure, both of which were likely related to the epinephrine injection, he was in very good shape. Once I finished the exam, Tom used topical anesthetic, then removed the stinger with a pair of tweezers, irrigated the small puncture with saline, then put a dab of triple antibiotic on it before covering it with a small bandage.

"You can take Josh home," I said to his mom. "He's in no danger, but I'm going to give you an emergency inhaler with albuterol in case he has any breathing trouble. Two pumps is sufficient, and then call 9-1-1. I doubt you'll need it, but I just want to be safe."

"Can I still see the fireworks?" he asked.

"That's up to your mom," I said.

"Is it OK, Doctor?" she asked.

"There's no medical reason he can't go, though please don't let him run around, and absolutely avoid bees. Do you have a second EpiPen?"

"No."

"OK. We'll get you one of those as well. You should follow up with Josh's doctor just to let him know what happened. He can call here for the treatment records, and he may or may not want to see Josh."

"Thanks, Doctor."

"You're welcome. Give me about ten minutes to fill out the paperwork and we'll have you on your way with the inhaler and a new EpiPen."

"Thanks again."

Tom, Mary, and I left and went to the nurses' station where I filled out the appropriate forms, updated the chart, and then went to Doctor Williams to sign off, which he did. That completed, I retrieved the albuterol inhaler and EpiPen from the drug room and took them to Mrs. Tyler.

"Any other questions?" I asked.

"No. Thank you very much, Doctor."

"You're welcome!" I replied, then turned to Josh and asked, "What's your favorite candy?"

"M&Ms!" he declared.

I pulled a small packet from my fanny pack and handed them to him.

"Only when your mom says it's OK to eat them."

Mrs. Tyler laughed, "Go ahead, Josh. And what do you say?"

"THANK YOU!" he exclaimed, the ripped open the pack and began munching M&Ms.

"You can stop by Patient Services on your way out," I said.

"Thanks again," she said.

Tom escorted them to Patient Services, and I went back to the lounge where Kylie was waiting.

"I am out of here," I said. "So are Tom and Mary. Nothing on the board. We just discharged a bee sting."

I left the lounge, let Ellie, who was also going off shift, know I was leaving, and she walked with me towards the locker room.

"I'm upstairs," I said.

"Bummer!" Ellie exclaimed. "See you later in the week."

"See you then."

I walked upstairs, showered, dressed, then left the hospital, got in my car, and headed home.