Chapter 20 — You Were Proud of Me!

_April 30, 1990, McKinley, Ohio_

{psc} "Thanks for not throwing me under the bus," Paul Lincoln said when I arrived in the ED on Monday morning.

"What I said was the honest truth," I replied. "Nothing that happened in the ED was responsible for the patient coding on the table following surgery. And nothing that we might have done would have prevented the outcome. He was unlucky. The mortality rate attributed to anesthesia is around eight per million, or less than one per 100,000 surgeries. That's down significantly from the 50s when it was something like sixty per 100,000. Anything for me?"

"Diabetic abscess in Exam 3 waiting on Medicine; concussion in Exam 2 with stable vitals being monitored until 6:00am. That's it."

"Then I'll see you tomorrow morning!"

He left, and Mary came out of the lounge.

"Morning!" she exclaimed. "I'm ready to go."

"Then get a chart, and let's get to work."

We saw seven patients, admitted the diabetic abscess, and streeted the concussion. Just before 9:00am, Nate let me know that Mr. Crowe wanted to see me. I had a sinking feeling as I made my way upstairs to the admin wing. Mr. Crowe's secretary sent me right into his office.

"Morning, Mike."

"Morning, Leland. Malpractice suit?"

"Unfortunately, yes. I was served this morning with a suit and a subpoena for medical records and charts. I believe as soon as those are tendered, you, Dutch Wernher, Paul Lincoln, Chuck Boyd, Ralph Burnside, and John Flynn will all be named personally. Right now, you're all referred to as 'unknown medical staff'."

"Wonderful."

"The hospital will defend you, but you have the right to have personal counsel. If you want to confer with Miss Coates before you answer my next question, I'll understand."

"I have no practical objection to a settlement with no admission of liability. Philosophically, I object, but I understand that a settlement is the pragmatic course of action."

Mr. Crowe laughed, "You were the one I was worried about."

"Honestly? We should win this one, hands down. But a jury will see an otherwise healthy male in his mid-thirties who died at our hands, and nothing you say will be able to dissuade them from holding us responsible, even if there was literally nothing else that could have been done."

"Exactly right. If they were to go to a Medical Review Board, they'd dismiss it immediately as 'one of those things'. By the way, please do NOT use the phrase Doctor McKnight used in the M & M."

I chuckled, "It did sum everything up quite nicely, but I understand, and I won't."

"Thanks. Will you accept service via me?"

"Yes. It's silly to have a process server try to serve me in the ED."

He slid a form across his desk.

"Read this and sign it, please. You're doing nothing except agreeing to service via the hospital's legal counsel, that is, me."

I read the form, and it was quite clear that it was solely to allow the plaintiff to serve me and that no other power was granted. I signed and dated it and handed it back to Mr. Crowe.

"Anything else I need to be concerned about at the moment?" I asked.

"No. Between you and me, you and Mary Anderson are the only ones completely in the clear. The true attack will be against Paul Lincoln and Ralph Burnside. In fact, the last thing the plaintiff's counsel would want to do is put you on the stand because you moved with alacrity and made the correct diagnosis, then got him into surgery."

"I have to ask…"

Mr. Crowe smiled wryly, "Same church, different pew, as it were. The attorney is Amanda Temple, a partner at Volstead and Braun."

"Wonderful. Will Mary be named?"

"It's unlikely. To name a medical student, they'd have to prove that the student took some specific action he or she was prohibited from taking and which was contrary to best medical practices. That said, Miss Anderson assisted with the surgery, so it's possible. In cases such as this, it's Anesthesia with their butt hanging in the breeze, which is why their malpractice rates are so much higher than any other specialty except neurosurgery."

That made sense, given that there were significant adverse reactions to anesthesia, though those rates were coming down significantly, as I'd noted to Paul earlier in the day.

"I heard bitching from the OB Residents that their rates are going up significantly."

"You mentioned how juries respond to healthy men in their mid-thirties dying; imagine a baby."

"Out of curiosity, what would have happened had things gone south with the baby I delivered?"

"Nothing good, that's for sure. That's why it's now a dismissible offense for the on-duty Attending to fail to send at least an OB nurse to the ED upon request, and then, that's only acceptable if every Resident is mid-delivery."

"I knew about the new policy but not the potential punishment."

"The liability if something goes wrong is effectively unlimited. It's whatever the plaintiff can convince the jury to return, and no matter how much it is, no judge is going to reduce the award for what I think are obvious reasons. We settled a case about two years ago for a million dollars. We got off cheap."

"I didn't hear about that."

"It was settled before the suit was filed, and the settlement was private."

"It must have been a firm other than Volstead and Braun. That's not their style."

"No, it's not. And you're correct."

"I need to get back to the ED. I'll call Melody and speak to her, but I won't retain her at this point."

"OK. I'll keep you posted."

I left his office and returned to the ED.

"What's up?" Mary asked.

"A malpractice suit over the hot appy who coded on the table."

"I'd say we didn't do anything wrong, but I suspect that doesn't matter."

"You suspect correctly," I confirmed. "Right now, it's just the hospital, but they sent a subpoena for charts and records, so I expect to be named, along with Doctors Lincoln, Boyd, Wernher, Burnside, and Flynn."

"What about me?"

"Anything is possible, but you and I are probably the only ones who are completely safe from any negative fallout. Paul was unlucky; Burnside is the most likely to be the main target."

"What happens now?"

"We wait. The hospital will offer a settlement with no admission of liability, and if they take it, that'll be the end, given everything I heard in the M & M. Sure, someone could file a complaint with the State Medical Licensing Review Board, but you were there — what did anyone do wrong?"

"Nothing. It was almost exactly like the textbook."

"Bingo. And you heard McKnight say that he reviewed all the drugs used, and there were no contaminants, and they were authentic. His analysis was correct, though 'one of those things' is a better way to say it in public. Don't worry about it. Chalk it up to bad luck, fate, karma, Satan, or whatever you wish, and get the next chart."

"Who or what do you blame?"

"Imperfect knowledge of human physiology. We know a lot, and I mean a tremendous amount. We don't know even more. It's my friend Robby's job — Sophia's husband — to work on that."

"He's going to teach and do research at Stanford, right?"

"Yes. Get the next chart, please."

"Hold up on that!" Nate called out. "EMS three minutes out with multi-victim MVA. Trauma 3 and 4 are open. I'll notify Doctor Casper and Doctor Townshend."

"Let's go, Mary," I said.

We hurried towards the ambulance bay, donning gowns, gloves, and goggles, and Kellie joined us in the ambulance bay, with Sue Townshend and her two students and Ghost joining us.

"Two victims," Ghost announced. "One in very bad shape. Mike and I will take that one in Trauma 3; Sue, you take the other one in Trauma 4 and ask for Doctor Wernher if you need help,"

We acknowledged him and waited for the approaching EMS squads to arrive, which they did about a minute later. Bobby jumped out of the squad.

"Jane Doe, about twenty; restrained head-on, high-speed MVA with lengthy extraction. Tachy at 120; BP 90/60; intubated PO₂ 92%; GCS untestable; neck brace and backboard; crush injuries to both legs; abdomen rigid; severe laceration of left temple; IV saline TKO."

"Trauma 3!" Ghost declared. "Mike, surgical assessment; Kellie, full trauma panel; Mary, EKG and monitor. Move!"

We began moving, and I called out to Ellie that I needed an ultrasound. GCS reported at 'untestable' was a result of being intubated and having no response to pain. In the trauma room, Bobby and Sam helped us move the patient to the trauma table, and everyone sprang into action. Nurse Jackie quickly cut away the patient's clothes, and Ghost and I began our exams.

"Belly is rigid," I announced. "Flail chest."

"Left pupil is blown," Ghost announced.

"PVCs!" Mary announced. "Run of seven."

I auscultated the patient's chest and announced, "Muffled heart sounds! Kellie, syringe with cardiac needle and an alligator clip!"

"PEA!" Mary announced.

Kellie handed me the syringe, and as quickly as I could, I performed a blind pericardiocentesis and aspirated pinkish fluid, filling the syringe.

"Blood in the pericardium," I announced. "Kellie, catheter and valve to me!"

"Weak heartbeat," Ghost announced.

"She needs surgery, but we need to stabilize her," I announced.

"Tell me something I don't know!" Ghost growled, but I knew it wasn't directed at me. "Leslie, call for a stat neuro consult!"

I inserted the catheter to drain fluid from the pericardium.

"Absent breath sounds, right side," Ghost announced. "Mike, chest tube. Kellie, hang a bag of plasma."

"Jackie, chest tube tray to me!" I ordered.

Nurse Jackie acknowledged my order and brought me the surgical tray.

"Neuro on their way!" Leslie announced.

"Mary, Foley!" Ghost ordered.

Mary went to get the kit, and the heart monitor blared.

"PVCs!" I announced.

They resolved after about five seconds, and I worked to put in the chest tube.

"Foley is in," Mary announced. "Blood in the bag!"

"Mary, call upstairs," I said. "She's going to need an ex-lap, at least. Ask for two Attending surgeons!"

"Right away, Doctor!" Mary acknowledged.

"Ghost, I think this is the best we're going to get," I said.

"I agree. She's not stable, but she's not going to live with her internal injuries. Leslie, get a gurney!"

The heart monitor blared.

"V-Fib!" I exclaimed! Paddles to me; charge to 150!"

Kellie brought me the paddles, and when the defibrillator had charged, I called out, "Clear!" and administered the shock.

"Normal sinus rhythm!" Ghost observed.

"Protocol is to wait five minutes," I said. "She doesn't have it. We'll have to risk moving her."

"Agreed," Ghost said. "I'll put that on the chart."

"Kellie, portable vent; Mary, portable monitor," I ordered.

They made the changes, then the team carefully moved the patient to the gurney. I'd clear her neck in the OR, as we needed to get her on the table soon, or she was going to bleed out. Mary, Kellie, Leslie, and I quickly moved the gurney out of the trauma room towards the elevators.

"HOLD THAT ELEVATOR!" Mary commanded loudly as we moved towards it. As per protocol, someone held the doors open while everyone else cleared the way. We got into the elevator, and the doors closed. We got to the surgical floor without incident and quickly moved to OR 3, which had just been cleared from a morning surgery.

"Unstable twenty-year-old female," I announced to Doctors Roth and Aniston. "Restrained head-on, high-speed MVA with lengthy extraction. PVCs and V-Fib in the past five minutes. Pulse 65; BP 80/50; intubated PO₂ 92%; neck brace and backboard; crush injuries to both legs; abdomen rigid; flail chest; cardiac catheter and chest tube."

"Hell of a case you brought us," Bob Aniston observed.

"I know, but she's not going to live if we don't resolve her internal bleeding. I'm going to clear her neck."

"Mary, scrub in," Doctor Roth commanded.

She went to the scrub room while I cleared the patient's C-spine. I was satisfied I could safely remove the cervical collar and did so, then went to the scrub room.

"PVCs!" I heard someone call out from the OR.

"She's not going to make it, is she?" Mary asked quietly.

"It'll take a miracle," I replied, then said a quiet prayer.

Mary and I entered the OR to find Doctors Roth, Aniston, and Burnside debating how to proceed. Eventually, they decided on ketamine only, to ensure she didn't come to during surgery, which I felt was low risk, but I wasn't an anesthesiologist.

"Mary, your job is a second set of eyes on the monitors," Owen Roth said. "Have the defibrillator ready. Mike, you assist Bob and me. Stand in the third position, and be prepared to Bovie."

Mary and I acknowledged his orders, got our equipment, and moved to the correct positions.

"Here we go!" Owen announced.

As I had feared, and as I was positive Owen expected, the patient's BP bottomed out as soon as he opened her belly, and we couldn't get blood into her fast enough, nor ligate and Bovie bleeders, before she coded. We worked for five minutes to try to revive her, but it was futile.

"Time of death, 10:02," Owen announced.

"Lord have mercy," I said quietly.

"She never had a chance," Bob Aniston observed. "Getting her into the OR alive was a miracle of its own."

"Agreed," Owen Roth said. "Mike, you and Mary can return to the ED."

We left the OR, removed our surgical gowns and our masks, and left the surgical floor to return to the ED.

"You kept on your surgical cap?"

"I'm thinking of wearing them full-time," I replied.

"Why?"

"Partly style, partly to cover my hair in the ED."

"Is it true I can choose any color surgical cap?"

"Yes. There are no restrictions except you can't display any symbols."

"Maybe yellow and blue."

"Swedish flag?"

"Yes. And different from everyone else. Would it be considered a symbol if it had what amounted to a plus sign in yellow and the rest blue?"

"I can't imagine that would be a problem. The flag has a single-bar cross, so you aren't making it a flag. Ask the surgical charge nurse for the number of the supply company and call them. You have to pay for your own, if you want anything other than the standard red."

"OK."

"Lost her?" Ghost asked when we arrived in the ED.

"Yes. She bled out. I need to let Doctor Wernher know."

"I'll come along. Sorry I snapped at you."

"Lack of sleep?" I asked.

"Right the first time. Baby Ghost does not care if Daddy needs sleep!"

"Been there, done that, signed up to do it again!"

"I don't know how you did it by yourself."

"I didn't. I had help from half a dozen young women. Without that, I'd never have managed."

We reached Doctor Wernher's office, and I rapped on the jamb.

"Yes, Doctor?" he said.

"I need to report a patient who coded on the table."

"Come in."

The three of us entered, and I presented the details of the case.

"Good report," Doctor Wernher said. "I'll review the chart. Doctor Roth was the one who called it?"

"Yes. The surgical service rule is the most senior physician makes the final call, no matter who was lead surgeon."

"OK. Thank you. Dismissed."

We left his office and Nate called out to us.

"The young woman's parents are here," Nate said.

"I don't even know her name," I replied.

"Crystal Monroe."

"Mary, bring in Mr. and Mrs. Monroe. Ghost, I'll take the lead, given she coded on the OR table."

"OK," he agreed.

We went to the consultation room, and Mary brought in Mr. and Mrs. Monroe. I invited them to sit, and Ghost and I sat with Mary standing behind us.

"Good morning, Mr. and Mrs. Monroe. I'm Doctor Mike, and this is Doctor Casper. The young woman with us is Mary Anderson, a Sub-Intern."

"How is our daughter, Doctor?" Mr. Monroe asked.

"She was brought to us by the paramedics, and Doctor Casper, Mary, and I, along with a team of nurses, assessed her injuries, which were severe. We were unable to stabilize her in the ER, so I arranged to take her for immediate emergency surgery. A team of three surgeons, including me, worked on her, using every capability we have, but her injuries were too severe, and she died."

"NO!" Mrs. Monroe screeched. "NO!"

She turned and buried he face in her husband's chest, and he put his arm around her.

"What injuries?" Mr. Monroe asked, his face set.

"At a minimum, a severe concussion, a number of broken ribs, internal bleeding, and both her legs were badly broken. I was with your daughter the entire time, and I can walk you through what we did, if you like."

"That's not necessary. Can we see her?"

"Mary will escort you to pathology," I said. "Do you have any further questions for us?"

"No, Doctor. Thank you."

We stood, and Ghost I and I left the consultation room, while Mary escorted the Monroes to pathology.

"What happened with the other victim?" I asked.

"Coded and couldn't be revived. Male, around the same age, with similar injuries. He was driving the car with our patient. The driver of the other car was DOA at the scene."

"Please tell me it wasn't on US 23 at Ohio 159."

"One and the same."

"The county needs to do something about that immediately," I said. "Reduce the speed limit and put a stop sign before the curve on Ohio 159."

"Too simple! The county will never do it!" Ghost declared. "Mind if I asked why you were called to Legal?"

"The unexplained code on the appendectomy."

"Malpractice? You?"

"Mr. Crowe figures it'll be a shotgun suit against the hospital and everyone involved. All he asked today was for me to sign a release allowing me to be served through the hospital rather than personally. You know the hospital will make a no-admission settlement, and I won't stand in the way of it."

"I figured you for manning the barricades!"

"It's unwinnable," I replied. "We can't use 'shit happens' as a defense, even in its non-earthy version, even though it's true. What's a jury going to do with a deceased patient where the doctors all throw up their hands and say, 'We did everything right, and this is just one of those things'?"

"You can't believe that's OK."

"I didn't say it was," I replied. "It's simply an acknowledgment of how a jury of twelve fine citizens will see things, no matter what we say when Arthur Braun's law partner makes us out to be evil incarnate."

"That jackass? Again?"

"Yes, except this one, they win."

"I hate to say it, but you're right."

"Want to know the worst part?"

"What's that?' Ghost asked.

"The money we give them will fund the next suit against Moore or McKinley Medical School."

_May 2, 1990, McKinley, Ohio_

On Wednesday afternoon, Leland Crowe called and asked me to come up to his office.

"Ken Webber?" I asked when I entered his office.

"Yes. As expected, the claims were revised to name all the physicians involved. Miss Anderson will be subpoenaed, but she's not named, which is also true of all the nurses involved."

"Are you going to try to end it before the depositions?"

"Of course."

There was something about his tone that indicated that wasn't the case.

"But they rejected your offer to settle and want to depose everyone."

"Very perceptive," Leland said. "Do you want your own counsel?"

I considered, then shook my head.

"That would imply I had something from which to protect myself and that I didn't want to sink with the other staff."

"Thank you. As I mentioned on Monday, you and Miss Anderson are the best witnesses for our side and the worst for theirs. I'm not at all concerned about your depositions. Just keep everything factual and don't speculate."

I smiled, "As you know, this isn't my first rodeo. Sadly, it won't be the last, either."

"Unfortunately, you're right," Leland said. "We'll begin scheduling depositions in about a week."

"Just let me know," I replied.

"I will."

I left his office and returned to the ED, where Mary was waiting for me.

"You're not named," I said. "But you are going to be deposed."

"Oh, joy," she said flatly.

"All you have to do is state what you observed and use the exact same strategy I used as a student — you are prohibited from making any medical judgments or diagnoses, except for didactic purposes. And you're on the side of the angels, because you and I are completely in the clear. Paul Lincoln and Ralph Burnside are the ones they'll go after — Paul for streeting the patient, and Ralph for being the anesthesiologist. It's always the anesthesiologist who takes the fall for outcomes such as this one. That's why their malpractice insurance rates are so high."

"Do you know how the hospital pays the settlement?"

"The County self-insures, so it's the taxpayers who are on the hook. Fortunately, it doesn't come out of the hospital budget."

"That was my concern, obviously."

"How about we see some patients, Miss Anderson?"

"Absolutely!"

_May 3, 1990, McKinley, Ohio_

"How is Kris doing?" Mary asked when I arrived at the hospital on Thursday morning.

"She's due in about seven weeks, so I'd say she's doing about as you would expect — tired and starting to be more uncomfortable."

"I know you're taking time off; how will that work?"

"You'll effectively be an ED Resident for the time I'm away. My goal is to teach you to do chest tubes and pericardiocenteses as expediently as possible. If there are enough opportunities before Charlotte Michelle makes her debut, you'll be able to do those so long as there's an Attending in the room. That all depends on what patients we receive."

"It's perverse, but I find myself hoping there will be patients who need surgical procedures."

"Join the club," I replied. "The thing that I realized is that the patients are going to present no matter what, and they're going to need procedures. Every medical student and Resident thinks in generally the same way. Don't beat yourself up about it because, in a sense, you're only asking that they arrive at a time that allows you to be trained.

"Going back to the question about my time off — if you need someone to talk to, Shelly Lindsay is to whom you should go. In fact, you should go to her if you need a female perspective on anything. And if you want to check on anything I'm saying that isn't directly related to procedures, Clarissa Saunders is your best choice. She's the one who keeps me on more or less the straight and narrow."

"More or less," Mary agreed with a twinkle in her eye.

I chuckled, "She does say she can't leave me unattended for more than a few seconds without me finding some way to get in trouble."

"In my experience, what usually got guys in trouble involved beer, cars, and trying to impress girls. You don't have any of those vices! Well, you drive a fast car, but I don't recall hearing about any tickets or accidents."

"I'm almost teetotal and devoted to my wife, which eliminates two of those! But my trouble is usually related to speaking truth to power, not trying to show off."

"When do you drink?"

"Basically, only on special occasions, given my hours. There really isn't a safe window to drink, especially given I'm carrying a pager. You'll be issued one on June 1st. But, I see several charts in the rack. Let's see some patients."

Our first two patients were routine — a sprained ankle and a broken finger. Our third was a twenty-one-year-old Taft student, Jack Burns, whose vitals were reported by the triage desk — pulse 72, BP 110/70, temperature 38.7°C, and PO₂ 99%.

"Good morning," Mary said. "I'm Mary, a Sub-Intern, and this is Doctor Mike, my supervisor. What brings you to us today?"

"A cough that won't go away, and it feels almost as if I have something stuck in my throat, you know, like a pill that you don't quite swallow correctly."

"Did you take anything this morning that might cause that?"

"No. I've had the feeling for a few days."

"Do you have trouble drinking or eating? Or difficulty swallowing?"

"No."

"Have you vomited recently?" Mary asked.

"Not since I had a stomach virus about a year ago; something was going around campus."

"Have you felt nauseated? As in, you felt sick to your stomach?"

"No."

"Are you on any medications?"

"No."

"Have you had a fever recently?"

"No."

"Any chest pain? Either persistent or related to the cough?"

"Not pain, but pressure."

"Alright," Mary said. "I'd like to do a physical exam, if that's OK with you?"

"Sure," Jack agreed. "That's why I'm here."

Mary conducted a primary exam, including checking Jack's eyes, ears, nose, and throat using an otoscope, then checked his heart and lungs via auscultation. Once she'd completed those, she had him lie down so she could check his abdomen by palpation.

"Doctor Mike and I are going to step out and discuss our next steps," Mary said upon completion of the exam.

She and I stepped out into the corridor.

"What's your plan?" I asked.

"CBC and Chem-20, and a five-lead."

"Based on?" I inquired.

"The EKG is to rule out cardiac causes; the blood tests because the exam was grossly normal, as you heard me call out."

"What do you suspect?" I asked with a knowing smile.

"GERD," she replied. "But in order to make that diagnosis, I have to check for infection and rule-out any heart trouble."

"How did you come to GERD?"

"It's one of my diagnostic flashcards; you know, the ones someone told me to never be without and study constantly!"

I chuckled, "That guy sounds crazy!"

"You won't get any argument from me!" Mary declared.

"Or me," I replied with a grin. "Let's assume it's GERD. Speculate on the cause."

"College student who isn't overweight? Gallstones, hernia, or drug-related."

"You didn't ask about illegal drugs during your exam."

"He was perfectly lucid, his eyes were clear, and there were no lesions or membrane damage in his nose or mouth, and no track marks on his arms."

"What does your gut tell you?"

"Drugs. I mean, it's possible he has a hernia, but I didn't detect anything on palpation, and he isn't complaining about pain; the same for gallstones. A rare cause of GERD is sleep apnea, but he doesn't have any of the main risk factors – obesity, large neck circumference, age, or enlarged tonsils or tongue."

"Excellent diagnostic work. Have a nurse draw blood and put him on the EKG for ten minutes."

Mary smiled and nodded, and we went back into the treatment room.

"Jack," Mary said. "In order to help us diagnose your complaint, I'm going to have a nurse draw blood, then we're going to put you on a heart monitor for ten minutes."

"Heart monitor? Why?"

"You reported non-specific chest pain, and we need to rule-out any heart problems. I don't think you have any, but we need to make sure."

"OK."

Mary asked Shelly, a nursing student, to draw the blood for the lab tests, and once that was completed, Mary hooked up the EKG.

"Normal sinus rhythm," she said. "I'm going to run a continuous strip."

"Approved."

Mary pressed the appropriate buttons on the EKG monitor to start the strip, and then we stepped out.

"Check the rack to see what we have," I said. "We can manage, as we have to wait for Jack's lab tests to come back to rule our infection."

Mary grabbed the next chart, which was a simple hand lac. She examined the wound, and after we discussed her plan, she injected lidocaine. While it was taking effect, we went back to see Jack. Mary turned off the monitor, and we quickly reviewed the strip. There were no anomalies, so we asked Jack to relax until his blood work came back. We went to the other room, Mary sutured the laceration, then we presented to Doctor Wernher, who signed the discharge forms.

By the time the hand lac was streeted, the lab report was back and showed nothing out of range.

"I'm going to ask about alcohol and drug use," Mary said.

"And if he denies any?"

"Then we need a gastro consult," she replied. "I mean, we'll need one anyway, but I have to ask about drugs before I call them."

"Let's go see him."

We went back into the exam room where Jack was waiting.

"Your lab results came back normal," Mary informed Jack. "Our preliminary diagnosis is GERD — Gastroesophageal Reflux Disease. It's a condition where stomach acid moves into your esophagus and is consistent with your symptoms. Before I call for a gastroenterologist to examine you, I need to ask a few more questions, OK?"

"How bad is it?"

Mary looked to me, and I nodded.

"The specialist will discuss it with you," she said, "but generally speaking, it can be treated with diet modification and medication, sometimes over-the-counter. OK to ask a few more questions?"

"Yes."

"Are you taking aspirin on a regular basis?"

"No. Mostly, I take Tylenol if I need something, but I don't even do that that very often."

"Do you eat a lot of high-fat foods?"

"I'm a college student!"

"I'll take that as a 'yes'," Mary said. "Do you drink?"

"Same answer!" he replied with a grin.

"How much and how often?"

"A bottle or two of beer in the evenings, most days. Jack, rum, or vodka at parties, pretty much every weekend."

"The next question is important, both for diagnosis and treatment. Your answer is completely confidential and won't be revealed to anyone except medical staff. Do you use any illicit drugs?"

"X at parties and sometimes Xanax to come down."

The mix of Xanax, X, and alcohol was likely the cause of his GERD.

"By 'at parties', do you mean every week?"

"Pretty much, yeah. Fridays and Saturdays."

"Doctor Mike?" Mary inquired.

"Call for your gastro consult," I replied.

Mary went to the phone and called Medicine, as gastroenterology was a subspecialty of Internal Medicine, with three additional years of Residency following a standard three-year Medicine Residency.

Mary placed the call, and just under ten minutes later, Doctor Larry Milton arrived. Mary provided the exam results and our preliminary diagnosis and Doctor Milton performed his own exam, as was the norm for consults.

"I concur with the preliminary diagnosis," he said. "It's not severe enough to admit it, so I'll write a referral for outpatient treatment. Jack, I'll write out the name of a medical practice and their phone number for you. You need to follow up with them as soon as possible, and you need to stop drinking and using illicit drugs. Both of those exacerbate your condition and will interfere with treatment. Mike, discharge with a recommendation of a low-fat diet and no alcohol consumption."

"Thanks, Larry."

He wrote out a referral slip and handed it to Jack, then left. Mary completed the discharge form, and we excused ourselves to present to Doctor Wernher.

"Whose diagnosis?" he asked.

"Miss Anderson's," I replied.

"How did you come to the diagnosis, Miss Anderson?"

"It's on one of my diagnostic flashcards that Doctor Mike recommended I make, which I study daily."

"How many diagnostic cards do you have?"

"I'd say about a hundred and forty. I started with Doctor Mike's base set of a hundred and added some things that were less common than the hundred most commonly seen diagnoses in the ED."

"Very good work, Miss Anderson," Doctor Wernher said.

He signed the discharge form, and we left his office. Mary retrieved a 'low-fat' diet flyer, and we returned to the exam room to discharge Jack.

"Think he'll follow our instructions?" I asked Mary.

"I'd say there's a good chance he will. He didn't argue with Doctor Milton about the alcohol and drugs, and his body language didn't indicate deception or rejection of the advice. He also listened when I reviewed the discharge notes."

"That was my assessment as well. That said, you never know. But that's on him, not on us. And nicely done, showing me up in front of Doctor Wernher!"

Mary laughed, "That wasn't my intent, and you know it!"

"My ego is easily bruised," I replied.

"I call BS!" Mary exclaimed. "You were _proud_ of me!"

"Busted," I chuckled. "So, the student becomes the master?"

"But isn't that how it always works? You teach me, I find ways to improve on that, I teach the next Resident, and so on."

"That is exactly how it's supposed to be done, Miss Anderson! I do need to warn you what will happen along about August — you will struggle mightily with giving your students a chance to do procedures you want to do. Just as I will with you. It's a constant battle to practice your own skills while teaching someone else."

"I do notice you allow me to do every H&P."

"Only because we don't have a Third Year at the moment. We will each have one once we finish the first ninety days. For the first ninety, we'll each have a Fourth Year surgical Resident."

"I remember, but I meant you aren't doing any at all."

"I got into the habit when I was working in the Free Clinic once a week, because I'd do anywhere from eight to ten exams a day. And now, as a surgeon, I'm not supposed to do primary exams. And neither will you, starting in June. As of June 1st, with two surgeons and two surgical Sub-Interns, we won't catch walk-ins except when things are seriously backed up. We will catch Traumas."

"How are we going to handle those?"

"We'll divide the work. If you have a patient who needs a procedure for which I haven't cleared you, you'll call me. For admits, that's on you."

"It's weird that I go from basically not having any authority to deciding admissions, and Attendings have to listen to me."

"It's always on Residents to assess and admit, especially PGY1s and PGY2s. And you are a surgeon, so, for surgical cases, you do get to tell Attendings on other services what to do. But use that power judiciously. And remember, an ED Attending can always call a surgical Attending to confirm anything we say."

"Have you had that happen?"

"Once or twice someone called Cutter to ask questions, but it was mostly because our program is so different from every other one."

"You're a fantastic teacher, and I wish all my Residents had been like you."

"Thanks. Do you need a break, or shall we take another chart?"

"I see four charts, so let's get a patient."

"There are five charts," I countered.

"No, I'm sure it's four."

"Five," I replied.

She looked quizzically at me, then started laughing.

"I! See! Four! Charts!" she declared.

"Good catch!" I chuckled.

"You are such a geek, Doctor Mike!"

"Thank you! Grab a chart!"

We saw two more patients before lunch, and six after. Just before 5:00pm, Doctor Wernher asked to see me, so I went to his office. He indicated I should close the door and sit, so I did.

"I want to make sure you and I agree on the intention of Doctor Roth's intentions starting June 1st, and then the changes in September."

"As I interpret them, for the first ninety days, my primary task is to teach Mary to perform the procedures on the surgical emergency list — chest tubes, central lines, pericardiocenteses, and crikes. We'll be on the same schedule — weekdays 0500 to 1700 — and we'll each have a Fourth Year surgical Sub-Intern assigned to us. Besides procedures, we're to assess surgical admits and assist with traumas. Miss Anderson will work one additional shift, Saturdays, from 0500 to 1700.

"Starting September 1st, our schedules will change. For 'A' weeks, I'll be in surgery, and Miss Anderson will cover weekdays 0500 to 1700, with another surgical Resident being on call for consults and procedures overnight. She'll also work the same shift hours on Saturdays.

"For 'B' weeks, I'll work in the ED 0500 to 1700 weekdays, and Miss Anderson will work 1700 to 0500, Monday through Saturday. We'll each have two students — a Fourth Year on a surgical rotation and a Third Year on an emergency medicine rotation. Our main job will be surgical assessments, procedures, and traumas.

"That's Doctor Roth's view. To that, I would add that, when possible, Miss Anderson and I will, with our students, catch walk-ins, though mostly when there are significant numbers of patients waiting to be seen. The main limiting factor will be our need to respond to surgical cases or trauma."

Doctor Wernher nodded, "I was hoping your interpretation with regard to catching extra cases was consistent with your desire to stay busy. I think Doctor Roth left you just enough leeway to do that."

"Our duty station, to put it in Navy terms, is the ED, so as I see it, we're extra hands when we're not handling our primary duties. Neither of us is interested in cooling our heels in the lounge, and Miss Anderson won't have any twenty-four-hour shifts the way typical PGY1s do, except when staffing requires it."

"How do you plan to handle the birth of your daughter?"

"I don't! I've already delivered my full quota of babies for my entire career!"

Doctor Wernher laughed, "I'm still at zero and very happy about that. So, besides your usual smart-ass response?"

"Starting in June, my sister-in-law will be at the house whenever I'm not there. She has her driver's license, so she'll bring Kris to the hospital if she goes into labor when I'm not home. When that happens, I'll obviously get someone from Surgery to cover for me, and I'll take a few days off, probably around five. Doctor Roth has said he'll provide coverage for my ED shifts."

"I think we're basically on the same page. I have a question, and I'll understand if you don't want to answer, but why would Doctor Gibbs schedule an Attending and a Resident, both from the ED, to go to a conference together, leaving us seriously short-handed?"