Chapter 54 — I Know the True Source of Your Problem

_October 2, 1989, McKinley, Ohio_

{psc} "What's your proposed treatment?" I asked Sophia when we received Crystal's lab results later on Monday morning.

"I'm not sure," Sophia replied. "Other than low calcium, I don't see anything on the lab report."

"What can cause that?" I asked.

"Liver disease, kidney failure, some medications, laxatives, and a number of rare conditions."

"Did you see signs of any of those things?"

"No."

"And you're confident she was telling the truth about other symptoms she's experienced?"

"Yes. I didn't detect any evasion or inconsistencies when I asked the same question in different ways."

"Good. Any other thoughts about her condition?"

"No, but I think you know."

"Think back to biochem — what affects uptake of calcium?"

Sophia thought for a moment, "Vitamin D. If she's deficient, that could cause the problem, but we aren't seeing any other signs of vitamin D deficiency."

"So, what would you do?"

"Get a 'D' level, then call for an endocrinology consult, as she doesn't show signs of IBS or other obvious conditions that would cause malabsorption."

"Nicole, what else would indicate that she might have a low vitamin D level?"

Nicole thought for a second, then smiled, "Her skin is really, really light and she's flaxen-haired. She's wearing long sleeves despite it being warm outside. She also has a hat with her. She's a student as well, so I bet she doesn't spend any time in the sun. If she doesn't drink vitamin D fortified milk or eat the right kind of fish, her levels could be low enough to impair calcium uptake, but not low enough to show other signs."

"Very good. Obviously, there are other possible causes, but we have an initial path to go down before we call for the consult. Let's go see her. Sophia, inquire about sun exposure and diet please."

She acknowledged me and we went back into Exam 3.

"Crystal, I have a few more questions," Sophia said. "Do you get much sun?"

"No. I'd burn to a crisp! A few minutes and I look like a lobster. It's been like that since I was little."

"Do you drink milk?"

"Can't stand the stuff! I stopped drinking it when I was little."

"What about salmon or herring?"

"No. I'm a meat and potatoes girl from Ohio! And nobody in their right mind eats fish from Lake Erie or the Cuyahoga River!"

She had a very good point on that.

"We need to run one more test," Sophia said. "Unfortunately, we'll need to draw more blood."

"What do you think is wrong?" Crystal asked.

Sophia looked to me and I nodded.

"Low vitamin D could explain all your symptoms," Sophia said. "If that's the case, then we'll call an endocrinologist to review your case and advise you on what you should do."

"Can I just take vitamins or supplements?"

"Maybe," I interjected. "The reason we want to have an endocrinologist review the case is that there might be some other underlying problem. I don't think so, but it's possible. Remember, I'm a trauma surgeon, so I have basic diagnostic skills in this area, but an endocrinologist is much better suited to figure out the root cause. Now, if you were injured in an auto accident or having an actual heart attack, I'm your guy!"

"Why did they have you examine me, then?"

"You presented in the Emergency Department, so you'll be evaluated by a trauma specialist. That's because the doctors who work in what you probably call the ER are all trauma specialists. We call other doctors when we need an assist. Believe it or not, your GP is better at this than I am, because it's his job. My main job is to save lives in an emergency, so that's where I've had my specialist training."

"My doctor is in Cleveland, so the nurse at Taft suggested I come here."

"She gave you very good advice," I replied. "Let's get the blood test, then we'll call the specialist."

"Thanks, Doctor!"

"You're welcome. Nicole will draw the blood and we'll come check on you in a bit."

Nicole drew the blood, the three of us left the room, and Nicole put the tube and order in the rack at the Clerk's desk.

"I feel I should have known that," Sophia said.

"You're on your first day of a rotation where you're going to encounter almost anything under the sun," I replied. "You did fine. I had similar feelings when I was in OB. I bet you know far more about that than I do! And that's the point I was making to Crystal. Measure yourself by OB/GYNs and surgeons, not by generalists in Medicine or Emergency Medicine. I know you've done well, because I saw your evaluations and I've seen your procedure book!"

"Hi, Petrovich!" Clarissa exclaimed, walking over to us.

"Morning, Lissa."

"Hi, Sophia; Hi Nicole." Clarissa said.

They both returned the greeting.

"Doctor Gibbs assigned me to walk-ins," she said.

"Me, too! I usually only get called when there is a surgical consult, or multiple transports. Who are your students today?"

"Erik Hubbard and Ernie Snyder; Erik is the Fourth Year."

"I see five charts in the rack! Why are you just standing here?"

Clarissa laughed, rolled her eyes, and went to find her students.

"Do you have to do a Medicine rotation?" Nicole asked.

"No. I'm on the surgical staff. It's Medicine and Pediatrics who are doing ED rotations for now, and that might expand to other services. We could really use a pediatric specialist in the ED. Trauma specialists all have to do paramedic ride-alongs, and paramedics are rotating through the ED."

"I thought pediatrics was your specialty!" Sophia declared. "'Kid Whisperer'!"

"Clarissa would tell you I relate to toddlers because I am one!"

"She might have a point!" Sophia declared mirthfully. "Robby has his moments, too!"

"All men do," Nicole declared. "They're all toddlers, just with more body mass and money!"

"Yeah, yeah," I chuckled. "Go get a chart. This time, you do the H&P with Sophia supervising."

They went to the Clerk's desk, and I went to the lounge to get some water. As was my practice, I sat down with the glass of ice water and my flashcards, with today's topic being infectious diseases. Other doctors came in and out, but didn't stay, and about ten minutes later, Sophia came to the door to let me know they were ready. I put my flashcards away and headed to Exam 2.

"Mr. Wheeler, this is Doctor Mike," Nicole said. "Doctor Mike, John Wheeler, forty-seven. Reports constant chest pain, but no other symptoms, onset was five days ago; BP 140/90; Pulse 100; PO₂ 99%. No history of cardiac problems. No recent illnesses. No medication except Tylenol for discomfort."

"Good morning, Mr. Wheeler," I said. "Do you smoke?"

"No."

"_Crap_," Nicole said, barely audibly.

"It's OK, Nicole," I said. "Just remember next time. Mr. Wheeler, what do you do for a living?"

"I'm an attorney at a title company."

"Can you describe the pain? Is it dull? Shooting? Sharp?"

"Dull, like an ache."

"Does exertion or exercise change the level of pain?"

"Not really, but it does make it hard to breathe."

"OK. Nicole, what's our plan of action?"

"EKG and chest x-ray," she replied. "Nothing indicates a need for blood tests at this point."

"I agree. Proceed."

"Five-lead, right?"

"Yes."

She had Mr. Wheeler remove his polo shirt and connected the EKG leads. A minute later, I saw a perfect sinus rhythm.

"That looks normal to me," she said.

"I concur. Textbook sinus rhythm. Call for a chest series, then take Mr. Wheeler to Radiology. Mr. Wheeler, your heart appears to be in good condition. Your blood pressure and pulse are a bit high, but that could be the result of the pain."

"What do you think is wrong?" he asked.

"At this point, it would be wild speculation. The x-ray will give us a better idea. If it's inconclusive, then we'll discuss our next steps."

"Thanks, Doc."

Sophia and I left the room and Nate signaled that he had labs for us. Sophia retrieved them and looked them over.

"Crystal's D level is 21 ng/ml," she said. "According to the printed reference ranges, that indicates insufficiency, not deficiency."

"And?" I prompted.

"That's consistent with our conclusion. Endocrinology consult?"

"Yes. They'll most likely refer her to a nutritionist, who'll most likely recommend vitamin D supplements, but let's simply tell Crystal what the report says and that we're calling for a consult."

We went to Exam 3 and Sophia explained what we'd found, then placed a call to Endocrinology.

"About ten minutes," Sophia reported when she hung up.

"OK. Stay with Crystal and report to the Resident. I'm going to check on Nicole."

"OK," Sophia agreed.

"Thanks again, Doctor," Crystal said.

"You're welcome."

I left the room and went to the other exam room to confirm that Radiology could take Mr. Wheeler, which they could, and Nicole had already called for an orderly with a wheelchair. I waited with them until the orderly arrived, then sent Nicole with Mr. Wheeler while I returned to Exam 2 just as Matt Keller arrived.

"Hi, Mike, what do we have?"

"My student will present," I said as we went into the room.

"Crystal, this is Doctor Matt Keller from Endocrinology," I said. "Sophia, please present."

She provided an excellent case report, and answered questions from Matt Keller, who reviewed the charts, lab results, and EKG, then examined Crystal. He asked her a number of questions, then asked Sophia and me to step out.

"I don't think you need to bother anyone else," he said. "Vitamin D and calcium supplements and refer her to her GP."

"She's from Cleveland, and that's where her GP is. We'll refer her to the Free Clinic and I'll give Gale Turner a call and fill him in."

"That'll work. She should have repeat labs in ten days to confirm the supplements have increased her D and calcium levels."

"I'll let Gale know."

He left, and Sophia and I had a brief conversation about the correct dosage of each supplement, then went back into the room and Sophia informed Crystal of our findings. I provided her with a brochure from the free clinic, along with written discharge instructions, then had Sophia escort her to Patient Services. I went to the lounge and poured a cup of coffee.

"She wanted to know if you were married," Sophia said with a twinkle in her eye when she returned to the lounge. "She was disappointed."

"I believe I already have my quota of pretty blondes," I chuckled. "Anyway, you did an excellent job with that patient, despite your misgivings."

"I'm sure you know that's the first time I've been given what amounts to full responsibility for a patient."

"And I'm sure you know we throw Fourth Years into the deep end to ensure they can swim! You swam just fine. How did Nicole do during her H&P?"

"A bit tentative, but I didn't need to prompt her. The only thing she missed was the question about smoking. She asked the other questions you did, but I think nerves got in the way of giving a full, accurate report."

"I throw Third Years in the deep end as well," I replied. "You know my thoughts on that."

"Sir William Osler, right?"

"Exactly. You learn by doing. Watch one, do one, teach one. She watched one, now she's done one. She'll do dozens more in the next two months so that next year she can do what you just did."

"You are so different from every other Resident!"

"That's good and bad," I said with a wry smile. "Clarissa likes to say she can't leave me unsupervised for thirty seconds without me finding some way to get into trouble!"

"So like most guys, then!" Sophia teased. "Or toddlers!"

"Well, you're trouble and I got into you!" I replied with a grin.

Sophia laughed, "I'm married now! No more wild Greek girl! And besides, you know my preference in that regard!"

"I do."

"What do you think the x-ray will show?" Sophia asked.

"If I had to guess, most likely a torn pectoral muscle, or a fractured rib. If not those, then a tumor. If the x-rays are inconclusive, then we'll get a CAT scan, but I need an Attending to sign off on that."

"I was surprised you don't have an Attending sign off on all your cases."

"They will, after the fact. Doctor Gibbs signed off on me handling simple cases with obvious treatments without presenting them. She'll review the charts, of course, but in a busy ED, there just isn't enough time to present a vitamin D insufficiency with no underlying cause other than diet and lack of exposure to sun, especially with a consult from an endocrinologist."

"Do any other PGY1s have that privilege?"

"No. Doctor Gibbs did during her PGY1 year, though, as did Ghost."

"Will Clarissa have to present all her cases?"

"At least at the start. Once she shows she can handle basic cases, she'll receive sign-off as well. That's the key for when you start your Residency. Show your Attending that you know your stuff, but also that you know your limits, and they'll allow you to do more things. Fundamentally, everything before Fourth Year is prep work for actually being a doctor, which is what Fourth Year is about. You'll be handed your MD and at that point, you're a Resident, and will be expected to be a Resident."

"Did that idea just blow you away?"

"Clarissa and I talked about it. One day you're a med student, the next day you're the doctor, and expected to BE the doctor. Despite it being the culmination of twenty years of formal education, it's still mind-boggling."

"Mike?" Ellie said from the door to the lounge. "EMS three minutes out with a head-on MVA. Two victims. Doctor Gibbs wants you in the ambulance bay!"

"Be right there! Sophia, game time! This is where we earn our pay."

"I'm still an indentured servant!" Sophia objected.

We left the lounge, put on gowns, gloves, and the newly mandated plastic goggles, and headed to the ambulance bay where Doctor Gibbs, Doctor Foulks, Jamie, Mary, Kellie, and Vickie Cartwright, a Fourth Year, were waiting.

"Bad one," Doctor Gibbs said. "Both patients intubated in the field. One with massive crush injuries; the other a severe head injury; neuro was paged. Mike, you and Nick take the crush injury, as it's certainly going to be surgical. Kellie, you're with them."

"Sophia," I said. "Get a chest tube tray and an ultrasound ready in…"

I looked to Doctor Gibbs.

"Trauma 2," she responded.

"Trauma 2," I confirmed. "Also, ensure there are at least three units of plasma in the fridge. As soon as we get the patient in, type and cross-match."

"Right away, Mi…Doctor!" Sophia exclaimed, heading back into the building.

"Who's running this?" Nick asked.

"You. I'll do the surgical assessment and any surgical procedures at your direction."

"Vickie," Nick said, "monitor, but wait for the assessment before you put on the EKG. Kellie, trauma panel."

The first EMS squad turned into the drive, and I saw the second close behind it. They both pulled up in front of us a few seconds later. Bobby jumped out of the first squad.

"Roughly thirty-one-year-old male; high-speed, head-on MVA; crush injuries to chest and both legs; pulse 120; BP 70/20; no spontaneous breathing; intubated; difficult to bag; PO₂ 88% on Ambu-bag; plasma and IV Ringer's."

"Trauma 2!" Nick declared as they moved the gurney from the squad. "Vickie, vent before monitor."

"He's in cardiogenic shock!" I announced, stating the obvious as we'd been trained to do.

Bobby, Sam, a fireman who was bagging, Doctor Foulks, Kellie, Vickie, and I quickly escorted the patient to Trauma 2, where Sophia was waiting. I noted the ultrasound was powered on, which was good thinking on her part, and also saw the defibrillator was powered on, but not charged. The assembled team moved the patient to the trauma table and the paramedics and firefighter left the room as we sprang into action.

A quick assessment showed signs of bleeding in his chest, which had been crushed, as well as his abdomen.

"He's hypovolemic," I announced. "Sophia, central line kit. We need to be able to get blood into him quickly. Nick, I suspect he's going to lose significant volume when I make the incision for the chest tube, but if I don't try, he's going to de-sat."

"Agreed!" Nick replied. "Do it! Kellie, set up the rapid infuser. Vickie, call the blood bank and get whole blood, stat! Sophia, what is his type?"

"O+," she replied.

Sophia assisted me in inserting the central line as Nick performed a complete trauma workup. The only positive note was that there was no indication of neurological damage.

"Hang the plasma on the rapid infuser," I instructed Kellie. "Start it as soon as I make the incision."

I waited for her to hang the unit, then began the procedure. As I'd feared, a gush of blood came from the incision as soon as I had dissected the subcutaneous tissue muscle.

"No BP! No pulse!" Vickie announced as the monitor blared.

"Severe hypovolemia with at least a 500ccs of blood on the floor," I announced, working quickly to insert the chest tube and connect the Thora-seal. "Hang a second unit, please. And then the whole blood as soon as it arrives.

"BP 60/20," Vickie announced. "Pulse 120. PO₂ 90%."

"Sophia," I said, "call upstairs; we need a thoracic surgeon immediately. Nick, we need him on a table as soon as we get the first unit of whole blood into him. If we wait to try to stabilize him, we'll lose him for sure."

"Agreed! Vickie, get a Foley in, now!"

The whole blood arrived, and we rapidly infused a liter of O+, then Sophia, Vickie, and I transported the patient to surgery.

"Think he'll make it?" Sophia asked after we'd turned the patient over to Doctor Aniston and his team."

"He's lucky to have made it this far," I said. "I'd say a 10% chance, but that's 10% more than if the paramedics weren't as good as they are. Field intubation is huge, because without a clear airway, he would have been DOA with those injuries."

"Why 10%?" Vickie asked.

"Because he's unstable and hypovolemic, with low oxygen sat. Those are all negative indicators for expected outcome. He might code before they even start. But, in the end, he'd die if they don't, so even 10% is an infinitely better chance than he'd have without the surgery. Fundamentally, losing 500ccs means fifty-fifty at best, and I suspect the total blood loss was close to a liter, at which point survival is between ten and twenty percent for crush injuries to the chest. If he lives, his legs are going to need surgical repair. And those shattered bones induce additional risk. What is it?"

"Fat embolism," Vickie replied.

"Treatment?" I asked.

"Supportive only in the vast majority of cases; in rare instances, surgery."

"Correct."

We returned to the ED, and I checked with Doctor Gibbs, but she didn't need a surgical consult, so Sophia and I went to see Mr. Wheeler, who had returned from Radiology. His condition hadn't changed, so it was simply a matter of waiting for the x-rays to be developed, though it wasn't a critical case, so a 'wet read' wasn't indicated.

Sophia, Nicole, and I handled a walk-in with an arm lac, then I looked over the x-rays. They were inconclusive, but I saw what look like a smudge, which meant we'd need to get a CAT scan to determine what it was.

"A smudge?" Nicole asked.

"Sophia?" I prompted.

"The x-ray was to determine if there was a skeletal problem, but there's something else that absorbed some amount of x-rays. The options are another series to focus on that, which is what would have been done in the past, or a CAT scan, which saves time and is able to resolve much finer detail."

"Exactly right," I confirmed. "Let's go see Doctor Gibbs."

Doctor Gibbs was just coming out of the trauma room, and we walked up to her.

"May we present?" I inquired.

"Yes."

"Nicole?"

"John Wheeler, forty-seven. Presented with complaints about constant chest pain, but no other symptoms, onset was five days ago; BP 140/90; Pulse 100; PO₂ 99%. No history of cardiac problems. No recent illnesses. No medication except Tylenol for discomfort. EKG showed textbook sinus rhythm. X-rays were inconclusive. Recommend a CT-scan based on what Doctor Mike called a 'smudge' on the x-ray."

"Do you have the films?" Doctor Gibbs asked.

"Yes."

We went to a light box and Nicole put the four x-rays on the box and turned on the light. I pointed to the 'smudge' and Doctor Gibbs nodded.

"I'll approve the CAT scan. Chart, please."

Nicole handed Doctor Gibbs the chart, and after making notations and signing it, Doctor Gibbs handed back the chart.

"Thank you," Nicole said.

The three of us walked to the exam room, stopping before we went in.

"This is your patient, Nicole," I said. "What are you going to say?"

"That the x-rays were inconclusive and that we need to run more tests. We can't speculate on what the cause of his discomfort is at this point."

"Any thoughts on what it might be?"

"I'm going to guess a tumor."

"That would be the most likely, at this point. Let's go in, then you schedule the CAT scan and manage the case through it."

We went into the room, and Nicole informed Mr. Wheeler of the results of the test, and as I'd expected, he asked what might be wrong.

"At this point, we can't say," Nicole replied. "That's why we want you to have a CAT scan."

"What's that?" Mr. Wheeler inquired.

"CAT stands for Computed Axial Tomography, and the best way to describe it is a very sophisticated x-ray that produces much better images."

"What are my options, Doc?" Mr. Wheeler asked.

"At this point," I said, "it's the CAT scan, or we discharge you against medical advice. Whatever the problem is, the CAT scan will most likely identify it, and we can treat it. Leaving anything untreated risks it becoming for worse."

"Like cancer?"

"I'd prefer not to speculate at this point, but I will say that there are any number of things that it could be that are not cancer. Let's not get ahead of ourselves, though. Nicole will schedule your test and stay with you through it. Once the scan is completed, a Radiologist will review it and let us know what he's found."

"OK."

"Nicole, make the call and then stay with Mr. Wheeler, please."

"Yes, Doctor."

Sophia and I left the room, and I asked her to get a chart so we could see another patient. We saw five more patients before I took my lunch break, though I couldn't take it with Clarissa as we couldn't both leave the ED at the same time. That was a major downside to her trauma rotation, but overall, I felt the rotations were a good idea, though I was happy to be on the surgical service, so I wouldn't have to spend time in Medicine.

When I returned from lunch, there was a message from Radiology, so I returned the call. The Radiologist reported a tumor, which meant an oncology consult, which I let Nicole know after I ended the call.

"How do I talk to him about this?" Nicole asked.

"In trauma, we have two choices — tell them or call for a consult and tell them together. It really depends on your style and your comfort level."

"What's your style?"

"Tell them what I know, then call for a consult. It creates a trust relationship. The downside is that often there are questions I cannot answer. But that's more of a downside for me, then it is for the patient, as least as I see it. Do you want to tell Mr. Wheeler, or would you like me to?"

"I think you should, so I can see how it's done."

"Then let's go. Once we finish, you can turn Mr. Wheeler over to Marv and go home."

"Could I stay until he's either admitted or released? I know my shift ends in a few minutes, but I want to stay."

I considered and nodded, "I'm OK with you following him through until admission or discharge, but if it drags beyond about 2:00pm, I'll want you to go home so you have eight hours off between shifts."

"Thank you," she replied.

Sophia, Nicole, Marv, and I went into Mr. Wheeler's room.

"Hi, Doc," he said. "What did they say?"

"You have a small, 2cm mass between your fifth and sixth ribs on your right side."

"Cancer?!" he asked, sounding shocked.

"That's something the machine, as good as it is, can't tell us. That said, it did show that was the only mass, which is a good sign. I want to call in an oncologist to talk to you."

"What do you think, Doc?"

"My specialty is trauma surgery, so I'm not the best guy to answer that question. It would be like my stepdad, who practices family law, handling property law, or you handling family law."

"An apt analogy. Specialization."

"Yes. I'll call an oncologist to come down and we'll speak to you together."

"OK, Doc," he replied.

I went to the phone and placed the call, and the nurse said that Kurt 'Chemo' Sabey would be down shortly. He arrived about five minutes later.

"Nicole?" I prompted after introducing him.

She repeated the same information she had for Doctor Gibbs and added the results from the CAT scan.

"Good report," Doctor Sabey said to Nicole. "Mr. Wheeler, may I examine you?"

Mr. Wheeler agreed, Chemo examined him, then reviewed the x-rays and the printed images from the CAT scan.

"Our next step," Chemo said, "is a biopsy. I'd like to do it right away, as if, and I mean _if_, the mass is malignant, we want to get it out immediately. If not, then we can schedule it at your convenience in the next week."

"It's coming out either way, right?" Mr. Wheeler asked.

"Yes."

"Then could you take it out and examine it after it's removed?"

"We certainly could," Doctor Sabey replied. "Mike, can we get an OR?"

"Let me call upstairs and see what the afternoon looks like. Mr. Wheeler, should we call someone for you?"

"My wife, please," he replied.

"Nicole, please get the number and place the call. Just say he's being examined, nothing more. It's OK to say he has chest pains, and to say that it is not a heart attack."

"Right away, Doctor Mike!" she exclaimed.

"Sophia, let's draw pre-op labs plus an oncology panel," I said as I picked up the phone.

She handed me the chart, and I wrote the order while I was waiting for the surgical scheduling nurse to provide a time for the surgery. She did, and I hung up.

"3:00pm," I said. "Doctor Edmonds will come in to perform the procedure. Marv, once labs are drawn, arrange for transport, please."

"Will do!" he replied.

"Thanks, Chemo," I said. "We'll take it from here."

Mr. Wheeler laughed, "'Chemo' Sabey? Really?"

"Really," I chuckled. "I had the same reaction when I was told the nickname two years ago. Trust me, you're in good hands with him."

"I'll see you later this afternoon, Mr. Wheeler," Chemo said.

"Thanks, Doc."

"Your wife is on her way here," Nicole said, coming back into the room as Chemo left.

"Nicole, Mr. Wheeler's surgery is scheduled for 3:00pm. Sophia is going to draw pre-op labs and Marv is going to call for transport. When his wife arrives, please either bring her in or take her upstairs, depending on whether he's been moved."

"Yes, Doctor Mike."

"And then go home and get some sleep."

"I will," she replied.

I turned to the patient and said, "Good luck, Mr. Wheeler."

"Thanks, Doc."

I left the room and went to the locker room to empty my bladder, then to the lounge to refill it with tea. Marv and Sophia came in and I asked to see Marv's procedure book. It was typical of a student who was on his third rotation, having done OB/GYN and Psych.

"What are your thoughts on a specialty?" I asked.

"Ask me again in six months," he replied. "I'll have completed trauma, pediatrics, and surgery before I have to fill out my schedule for next year."

"A reasonable approach. Does anything particularly interest you?"

"Nothing jumps out, though I don't think I'm cut out for emergency medicine, at least from what I saw during my Preceptorships."

"I think you'll find something in the other thirty-odd specialties, or hundred or so subspecialties."

"When did you decide on surgery?"

"Trauma surgery," I replied. "I decided on trauma in fourth grade, and that was, and is, my goal. I just chose the new dual-track Residency."

"Ah, OK. From the red scrubs, I thought you were handling consults."

"I am, but I'm permanently assigned to trauma for PGY1 and PGY2. Then I'll spend a year as a general surgery Resident, but also handle consults. After that, I'll alternate between the services and be Board certified in trauma and surgery. There isn't a certification for my specialty yet, as it's too new. Are you from Ohio?"

"Michigan," he replied. "But I want to practice someplace warm!"

I chuckled, "You aren't the first person to say that. Hawaiߴi needs physicians, too!"

"My dream job is a hospital near Waikīkī!"

"Have you been there?"

"A group of friends and I went to Hawai'i for a week after High School graduation. We had an absolute blast, and the climate beats the hell out of Iron Mountain!"

"The UP has some fairly severe winters."

"You know about Iron Mountain?"

"It's an in-joke amongst clergy in the Orthodox Church in the US because that's the considered clerical equivalent of a military officer being sent to Nome. I also know about the UP because it was taken from Wisconsin Territory and given to Michigan as compensation for losing Toledo in the 'Toledo War'. Doctor Saunders is from Sylvania and says Michigan won!"

Marv laughed, "Even with as cold as it is up there in the Winter, I'd have to say you're right."

"Doctor Mike?" Erik, Clarissa's Fourth Year said from the door to the lounge, "Doctor Saunders needs a surgical consult."

"What does she suspect?"

"Appendicitis."

"Sophia, Marv, let's go!"

The consult was basically a formality, because the case was so obvious that a Fourth Year medical student could have diagnosed it, but the rules required a surgeon, so I confirmed Clarissa's work, then placed the call for an emergency procedure.

"With the excision you called in before, we're short surgeons," Nurse Barb, the charge nurse said. "Doctor Roth would like you to scrub in and assist."

"We'll be right up," I replied, then hung up.

"Marv, Sophia, we have a surgery. Marv, call for transport; Sophia, we'll go upstairs and scrub in. Marv, you can scrub in as well, once you bring the patient up. Just stand next to Sophia in the OR."

They both acknowledged my orders and Marv moved to the phone to call for an orderly. Clarissa instructed her Third Year, Ernie, to accompany the patient upstairs with Marv.

"Virgil, we'll see you upstairs," I said to the twenty-one-year-old.

"OK, Doc," he said. "Cut straight!"

"I'll be assisting, but Doctor Roth is the best surgeon in the hospital, so you're in good hands with him!"

Clarissa, Sophia, and I stepped out, leaving the other students with the patient.

"The surgical gods are smiling on you again!" Clarissa declared.

"Or, they're frowning on the patient with the tumor I scheduled for a resection this afternoon."

"Which means that they need you, and you'll actually get to do things no PGY1 _ever_ gets to do."

"If that statement were true, it would be false!" I chuckled. "Sophia, let's go."

We headed upstairs to scrub in and wait for the patient, who had a severely inflamed appendix, which I hoped did not burst before it was removed. Fortunately, that didn't happen, and the procedure was completely routine. I was permitted, as I'd had once before, to close the incision under the careful scrutiny of Doctor Roth.

"I'll go to recovery with the patient," Doctor Roth said. "I can't detain you any longer without creating trouble with Wayne Northrup."

"Thank you for the opportunity."

"Fill out your procedure book and bring it to me. That's two, now, right?"

"Yes."

"Then I'll sign off on you closing for any abdominal procedure where there are no complications of any kind during the surgery."

"Thank you," I replied. "What happened with the MVA?"

"Coded on the table before we even started. We brought him back, then he coded about ten minutes in. Hypovolemic shock, though we didn't get far enough to know what major vessel was damaged. McKnight will tell us. The paramedics and trauma team did a good job of getting him to us alive, but I'd say he was a lost cause at the accident site."

"I expected that outcome. My students inquired, and I suggested he had maybe a 10% chance."

"Optimistic."

I nodded, "I figured, given the head-on collision was over 50mph and those are mostly not survivable."

"Except by drunks, unfortunately. Scrub out and don't forget to bring me your procedure book later this afternoon."

"Thanks, Owen."

"You're welcome."

I scrubbed out, put on fresh red scrubs, and then Sophia, Marv, and I headed back to the ED.

"How often does that happen?" Marv asked.

"Me scrubbing in? About once every two weeks or so. The long-term goal is for me to take the patients up and be the lead surgeon, but that's seven years away. Well, until I'm an Attending. I'll be supervised as the lead surgeon in four or five years."

"Two in the ED, right?" Sophia asked. "Then surgery?"

"Yes."

"It's not normal for an Intern to close, is it?" Marv asked.

"It's not typical," I replied. "The only reason it's happening is because of the new Resident program in trauma surgery. Some of the old rules are changing, and I've made a supreme effort to ensure I've learned the necessary techniques. I know med students bitch about suturing, but I did as much as I possibly could, and that's why I've been permitted to do it in the OR twice. It's as with everything else — show the Attendings and Residents you're competent, capable, informed, and, most importantly, that you understand your limitations, and you'll have plenty of opportunities."

"Doctor Mike will give you every possible chance to succeed," Sophia said. "And the opportunity to do procedures normally reserved for Fourth Years, but only if you demonstrate to him that you're trustworthy."

"On that note," I said, "you did an excellent job this morning, Sophia, especially with that MVA."

"You were right about his chances," she said. "I heard he coded."

"I was optimistic," I replied. "Doctor Roth said he coded the first time before they even started, then about ten minutes in. They hadn't even found the bleeder when he'd lost so much blood there was no hope of bringing him back. Doctor Roth did commend the paramedics and the trauma team for getting the patient there alive. Unfortunately, some we just can't save. Others, like Mr. Wheeler, we catch in time."

"You're sure?" Sophia asked.

"Given we saw no infiltrates or other signs on the CAT scan, even if it's cancerous, we appear to have caught it early. That's the key to a positive five-year prognosis. You'll have to ask Chemo if you want more details, because my knowledge of oncology is extremely limited."

"No nickname for you?" Sophia asked.

I chuckled, "It would be Clarissa who assigned it, and it would not be flattering!"

Sophia laughed, "So true!"

"I take it you two are friends?" Marv asked.

"We actually dated briefly during my Freshman year and his Sophomore year at Taft," Sophia said. "Another girl won his heart, and…sorry Mike."

"It's OK," I replied.

"Have you seen Angie recently?"

"Yes. She's doing as well as can be expected at this point."

"I'm totally missing something," Marv said. "I thought your wife…er, maybe I shouldn't discuss this."

"It's OK," I said,

"I'll tell him the story," Sophia said. "Marv, let's get some coffee."

They went into the lounge and Clarissa waved me over to the clerk's desk.

"How did it go?" she asked.

"About as straightforward as can be; completely textbook from start to finish. I was allowed to close. The appendix was severely inflamed; I mean, angrily red and swollen. I'd say an hour, at most, before it burst. Good catch."

"If only they were all that easy!" Clarissa declared. "Do you have a sec for a private conversation?"

"With you, always. What's up?"

"Consult room, please," she said.

We went there and shut the door.

"I think I know the true source of your problem with Doctor Gibbs," Clarissa said.