Chapter 18 — Dead on My Feet

_July 7, 1989, McKinley, Ohio_

"Doctor Mike?" I heard through the fog of waking from sleep. "Doctor Varma needs you."

I groaned, removed my mask, and saw Nurse Kellie in the dim light. I looked at my watch and saw that I'd only been asleep about fifteen minutes.

"Giant grasshoppers?" I asked, sitting up.

"What?" she asked.

"Nothing. What's going on?"

"Some joker at Taft spiked brownies with Ex-Lax."

"That's a shitty thing to wake me up for," I deadpanned.

Kellie laughed, "You do have a good sense of humor after all!"

"Who said I didn't?" I asked.

"Don't worry about it. There are patients on gurneys who need exams before we give them IVs."

"OK," I said, getting up. "How many altogether?"

"Eleven."

"Awesome," I said sarcastically.

I got up and Kellie handed me a stack of charts, then accompanied me to the first patient, who was on a gurney in the corridor. It took an hour to work through all six patients on gurneys, with each one receiving an IV with Ringer's. None of them had any symptoms other than diarrhea and stomach cramps, so I filled out discharge forms, but didn't sign them, as we wouldn't send them home until they no longer had cramps and had at least one bag of IV fluid.

"Doctor Mike?" Kellie said. "Detective Kleist wants to speak with you. She's in the consultation room."

"Me?"

"You."

"OK. None of the patients are in any danger. Once their IV bags are empty, if they've had no cramps, bring me their chart to sign."

"By your command!" Kellie said with a smirk.

"_Battlestar Galactica_ fan?"

"Season one, not two."

"A wise woman!"

I left and went to the consultation room.

"Detective Kleist? Doctor Mike Loucks."

"Come in, Doc. This will be quick, I suspect."

"What questions can I answer?" I asked.

She smiled and her eyes twinkled, "Are you married?"

"Yes."

"Too bad. About the students — are any of them seriously ill?"

"No. All of them have IVs with Ringer's lactate to ensure they aren't dehydrated."

"Will you give me permission to speak to them?"

"Sure. I take it you want to arrest someone for this?"

"The Dean of Students certainly wants us to."

"Do you know who made the brownies?"

"Nobody in the dorms is talking so far, and everyone who ate one is here."

"They're all fine, so as long as you aren't using enhanced interrogation techniques, they're all yours."

"Maybe they like being tied up!" Detective Kleist said with a smirk.

"Somehow, I don't think the answer to that question is relevant to your investigation," I said with a smile.

"Do you?"

"Same answer."

She nodded, and I left the room, and remembered I was supposed to have called Clarissa at 11:00pm, but had been busy, then slept briefly. I decided it was better not to wake her, and decided to lie down again, but Kellie stopped me to sign a chart for the first patient I'd seen. I did that, and before I could go back to the on-call room, Jay, the midnight to 8:00am clerk, waved me over.

"Paramedics are five minutes out with a toddler found unresponsive in his bed. Trauma 2 is open."

"Where is Mary?"

"She just went into the lounge."

"Thanks."

I let Mary know we had a patient coming in, then asked for a nurse as I'd sent Tom home, thinking it might have been a good idea for me to go home, too. I felt dead on my feet, and I still had over thirteen hours to go on my shift. Kellie was free, so she was assigned to help, asking Nurse Vickie to watch the remaining gurney patients in the corridor.

"Non-responsive toddler at 2:45am?" Kellie asked.

"That's what Jay said," I replied. "I wondered about that, too."

"Is that cop still here?"

"I think so."

"If we see any signs of abuse, just say something about me not seeing toddlers aboard _Nimitz_."

"Why do you two suspect abuse?" Mary asked as we stepped out into the ambulance bay.

"While my experience is limited to my daughter," I said, "by the time she was toddling, she was sleeping through the night, and I sure wasn't awake just before 3:00am on Thursday nights. Sure, it might be that one of the parents works second shift, or whatever, but even then, you check on the kid, and so long as they're breathing, you don't try to rouse them."

"Doctor Mike is exactly right," Kellie said. "During nursing school, we had two cases like that. I'm not saying that's the case, but you know we have to check, and hospital policy is to call a social worker if there are signs of neglect and the police if there are signs of abuse."

"Mary, do you know what to look for?" I asked.

"Besides the obvious, no."

"Old injuries, especially broken bones that weren't properly set and previous, unexplained injuries that resulted in the child being brought to the hospital."

"Couldn't the kid be accident prone?" Mary asked.

"One thing I heard from nurses on military bases," Kellie said, "is that 'accident prone' is often a cover for abuse. Not always, but often."

"We're not jumping the gun here, either," I said as I saw the EMS squad turn into the driveway. "We're just on heightened alert, if you will."

The EMS squad rolled to a stop, and Julie, the lone female paramedic in the county, hopped out of the driver's seat.

"Tommy Mcinnis, twenty-two months, found unresponsive in his crib. BP 130/90; pulse 80; PO₂ 98% on nasal canula; temp 38.3C; no obvious injuries. Parents should be right behind us."

"Trauma 2," I said.

"Mary, I'll want an EKG and monitor; Kellie CBC, Chem-20, ABG, LFT, and glucose panel. And we'll dip a urine."

They both acknowledged my orders, and we quickly moved Tommy to Trauma 2, where Julie simply lifted him onto the treatment table. Kellie switched the oxygen to the hospital feed, and the paramedics left. We quickly set about our tasks and on exam I appreciated a bit of guarding in his abdomen, as well as sluggish pupils. He had a normal Babinski, and other than elevated blood pressure, there were no other signs.

"EKG looks normal," Mary announced. "BP 130/84, pulse 84; PO₂ 99%."

"Kellie, once you draw the blood, have a nursing student take it to the lab and see if Tommy's parents are in the waiting room."

"Yes, Doctor," she responded.

"Mary, what would you do next?" I asked.

"You appreciated guarding, so an ultrasound."

"Differential?"

"For abdominal guarding? It's a long list, even eliminating the ones that are female-only."

"Top three things you'd look for in a two-year-old?"

She thought for a minute.

"Bowel obstruction, appendicitis, and…well, more likely for a girl, but a UTI."

"And based on what we discussed before?"

"Blunt force trauma."

"I'd add one more — incarcerated hernia. Not all that common in kids, but it does happen. Who does the ultrasound?"

"You, right? You're a surgical Intern."

"First lesson about treating kids?"

"They aren't miniature adults. Pediatric consult, right?"

"Make the call, please."

She did, then reported, "Doctor Olson will be down in five minutes. What if you suspected something immediately life threatening?"

"Then I'd do it, but other than the mild hypertension, there's nothing obviously wrong with Tommy except that he's unconscious. Get the ultrasound, so it's ready when Doctor Olson arrives."

"Mike?" Nurse Kellie said. "The parents are here. Do you want to bring them in or come out?"

"Let me come out there, please. You stay with Tommy. Matt Olson from Pedes will be down to do an ultrasound."

"OK. And I hope I wasn't out of line calling you by your given name."

"No, you weren't. I'm OK with informality, though we do want to be careful in front of patient families."

"Yes, of course! His parents are the young couple in jeans and white t-shirts in the waiting room."

"Thanks."

I left the trauma room and went out to the waiting room.

"Mr. and Mrs. Mcinnis? I'm Doctor Mike."

"How is Tommy?" Mrs. Mcinnis asked.

"I've examined him and we're going to run some tests. I have a few questions for you."

"OK."

"When's the last time Tommy ate?"

"A snack before bed, so around 8:30pm. Milk and a cookie."

"How has his appetite been?"

"Good, I think. He eats his meals without fights."

"Have his bowel movements been regular?"

"Yes, I think so," Mrs. Mcinnis said. "I mean, they're like they normally are."

"No diarrhea or constipation?"

"No diarrhea, and he seems regular."

"Is he on any medications?"

"No."

"When was his last pediatric visit?"

"At eighteen months, so about four months ago."

"And he's had all his vaccinations?" I inquired.

"Whatever the doctor recommended, yes."

"Has he been sick recently?"

"He had chickenpox in May," Mrs. Mcinnis said, "but otherwise, no."

That meant Reye Syndrome was possible.

"No vomiting or rashes?" I asked.

"No."

"Did he complain about headaches or have nightmares?"

"No."

Which mostly ruled out Reye Syndrome, assuming they were telling the truth.

"Has he fallen recently?"

"No more than a normal toddler, I think. He scraped his knees about two weeks ago, but no broken bones or anything."

"Has he been irritable or fussy?"

"No more than normal," Mrs. Mcinnis said. "All toddlers get fussy now and then."

"Is your home childproofed?"

"What do you mean?" Mr. Mcinnis asked, speaking for the first time.

"Locks on cabinets, outlet covers, anything that might be dangerous locked away or out of reach? Mainly I'm thinking about cleaning supplies, pesticides, fertilizer, and things like that."

"Nothing is in his reach," Mr. Mcinnis said. "And Sarah is home with him all the time."

"What do you do?" I asked.

"Plumber, but all my stuff is locked in my van."

"Has Tommy been to the hospital at all?"

"Not since I brought him home after he was born," Mrs. Mcinnis said.

"OK. That's all the questions for the moment. I've asked a pediatric specialist to assist, and as soon as we know something, one of us will come speak with you."

"Can we see him?" Mrs. Mcinnis asked.

"He's in a trauma room at the moment and those aren't really designed for visitors," I replied. "One of you could come in for a moment, but that's it."

"Go, Sarah," Mr. Mcinnis said.

"Follow me, please."

I led Mrs. Mcinnis to the trauma room and allowed her to stay until Matt Olson arrived. After he introduced himself, I had Kellie escort Mrs. Mcinnis back to the waiting room.

"What do you have, Mike?" Matt Olson asked.

I went over the results of my exam and my questioning of the parents.

"Let's see what we can figure out," he said.

He repeated the physical exam, confirming what I'd told him, then used the ultrasound to examine Tommy's abdomen.

"What do you see, Mike?" he asked.

I looked closely and saw a moderate dilation of the small bowel that indicated an obstruction along with a possible mass, and said so.

"And the rule?" Matt asked.

"Never let the sun rise or set on a small bowel obstruction," I replied. "Mortality rates increase rapidly every twelve hours for untreated obstructions. But that doesn't explain his lack of consciousness nor his sluggish pupils."

"No, it doesn't, but we need to treat that first. It's a surgical case, so you can certify it. They'll have to wake up Pete Barton, so you should call up."

Pete Barton was the on-call pediatric surgeon. I moved to the phone and dialed the surgical ward.

"Mike Loucks in the ED," I said. "I have an unresponsive pediatric small bowel obstruction, confirmed by Matt Olson. We'll send the patient up shortly."

The nurse asked for Tommy's basic details which I gave her, and let her know the labs had all been ordered. Once everything was confirmed, I hung up.

"He won't start without labs, and we probably have fifteen to twenty minutes before those are back," I said. "I'm concerned about the other symptoms."

"Me, too. The parents claimed he wasn't fussy or crying?"

"Yes."

"I don't believe it. He must have been in pain, and there's a good chance he vomited and had irregular bowel movements. I think we should get a head CAT. Will you sign off?"

"You're thinking 'Shaken Baby Syndrome'?" I asked.

"It does fit the circumstances, because there is no way this little boy was asymptomatic."

"I'll sign off, but we wait for the results before we make any accusations or involve the police."

"Agreed."

"Mary, call for an orderly, and you can take Tommy upstairs. No need for a portable monitor, and he should be fine on room air for transport."

"Right away," she confirmed.

"Shall we update his parents?" I suggested to Matt.

He agreed, and we went to the waiting room as we couldn't use the consultation room because Detective Kleist was still using it.

"Tommy has a bowel obstruction," I said. "He's going to need surgery to relieve it."

"Surgery?" Mrs. Mcinnis asked.

"Yes," Doctor Olson said. "It's a very simple procedure and there are minimal risks compared to doing nothing, which could lead to serious complications or even death."

"And that's why he won't wake up?"

"We don't know the cause of that at the moment," I said. "But we need to fix his small bowel right away, and we'll continue investigate why he won't wake up. The lab tests aren't back yet, and there are some other tests we'll run after surgery."

"I'll take you upstairs," Doctor Olson said. "They'll have consent forms for you to sign, and you can see Tommy before he goes into surgery."

"Thank you, Doctors!" Mrs. Mcinnis gushed.

"Come with me, please," Doctor Olson said.

He led them towards the elevators and I returned to Trauma 2.

"I have $10 that says one of his parents shook him because he was crying," Kellie said. "My money is on the mom."

"Why?" Mary asked.

"Call it a gut feeling," Kellie replied. "Mom's stay-at-home, right Mike?"

"Yes. And I agree with Doctor Olson that he had to have been symptomatic given he has an obstruction and a small mass. Matt's taking the parents upstairs to fill out the consent paperwork."

The phone rang and Mary answered it, then announced the labs were back. She went to get them, and while she was gone, the orderly arrived. Once she returned, I reviewed the labs and saw nothing out of the ordinary except a very slight elevation of Tommy's white blood cell count, though it was only marginally high and might be normal for him.

"I'm going to try to get a nap," I said to Kellie. "I'm dead on my feet."

"Down off the 'I almost died' adrenaline high?"

"I don't have ice water in my veins like some people!"

"Military service will do that to you," she said.

"What was your rank?"

"Lieutenant. If I'd have stayed in, I was up for Lieutenant Commander and would have been assigned as a supervisor at a short billet."

"Why'd you get out?"

"Naval careers aren't conducive to having children," she said. "Not all that different from how it is for women doctors."

"Are you married?"

"Nobody has asked! I'm dating, but haven't found 'Mr. Right' just yet. How long have you been married?"

"Since January."

"And you have a toddler?" she asked with a slight smile.

"Rachel's biological mom died shortly after giving birth to her."

"Oh, my!" she gasped. "I'm so sorry!"

"It's OK. You weren't here two years ago and had no way to know."

"Now I have to ask…"

"Rachel needed a mom, and whatever feelings or emotions I had, that was a priority."

"I can see that," Kellie said. "Single dad in med school would have been tough."

"It was. I had a ton of help from my friends and family. If you don't mind, we can continue this talk later. I'm going to sack out."

We left the trauma room and before I made it to the on-call room, I was approached to sign four more charts for discharge of the Ex-Lax patients. I fell asleep almost as soon as my head hit the pillow.

"Mike?" I heard Kellie call out.

I groaned, removed my eye mask, and sat up, seeing only ten minutes had passed.

"Yeah," I said.

"Drunk driving MVA with three victims. Ghost said to wake you."

"How long?"

"Four minutes."

"I'm going to take a leak," I said. "Meet you in the ambulance bay."

As I got up, she handed me a Styrofoam cup of coffee.

"Thanks. Have Mary meet me in the ambulance bay."

She left, and I drank some of the hot liquid, then went to the locker room to use the urinal, and made it to the ambulance bay just before the first EMS squad rolled to a stop.

"Mike, I'll take patient one, you take patient two, and Naveen will take patient three. Doctor Taylor is available for anyone who needs help."

Kellie, Mary, and I took our patient to Trauma 2, the room we'd just cleared, for treatment. Fortunately, other than a contusion and laceration on his head, he had no injuries. His passenger, who had been on the side of the car the drunk-driver had t-boned, didn't fare nearly as well, and had been sent for emergency surgery by Doctor Casper to repair significant internal injuries. The drunk driver, as happened disgustedly often, was uninjured and was on a banana bag with Deputy Schmidt guarding him.

I contemplated trying to take another nap, and had decided I would, when Jay said there was a call for me.

"Doctor Mike Loucks," I said when I picked up the phone.

"Doctor Clarissa Saunders. You stood me up!"

"You don't want to know, Lissa. Breakfast?"

"Sure. Now?"

"I think I can make a break for it."

"On my way."

We ended the call, I let Jay know I was going to the cafeteria for breakfast. I trudged there, more tired than I'd ever been, and I still had more than twelve hours before the end of my shift.

"You look like death warmed over," Clarissa observed when she saw me.

"I feel like it, too."

"The helicopter?"

"That klaxon caused my adrenal glands to dump several gallons of adrenaline into my system and, when it wore off, I felt more tired than I ever have in my life. I've managed to get about thirty minutes of sleep, total."

"That busy?"

"Besides the eleven Taft students who ate brownies laced with Ex-Lax?"

"No shit?"

"Lots of it, actually! Ringer's for all of them. Also a DUI MVA, possibly abused toddler, motorcycle organ donor, and a police detective who is into bondage."

"I bet that was fun!" Clarissa smirked.

"Not a patient. She was investigating the Ex-Lax incident. Her first question was whether or not I was married."

"Good looking?"

I shrugged, "Doesn't matter, does it?"

"No."

"I think I made a friend, though."

"Student?"

"No. Nurse Kellie Martin. The ex-Navy nurse who was on the helicopter. She started calling me 'Mike'."

"Careful, Petrovich."

"I didn't get that vibe," I replied. "It's more like 'big sister'. How was your night?"

"I probably shouldn't say I managed five consecutive hours of sleep. Are you going to be OK?"

"Do I have a choice? Being tired isn't a legitimate excuse, even if it ought to be."

"Blame the helicopter malfunction."

"It's not nerves or stress, Lissa, it's just being dead on my feet."

"As a result of what happened."

"Let it go, please. I need to make it through this shift."

"It's Mastriano! You think it would show weakness after you criticized her!"

"I don't care what Doctor Mastriano thinks."

"Sure you do! And she's exactly the kind of doctor you do not want to be. And you're proving it. And you might prove it to the detriment of a patient."

"No way, Lissa. I'm tired, but I know my limits."

"What happened with the abused kid?" she asked, changing the subject.

"Surgery for a bowel obstruction. Matt Olson consulted, and he and I signed off on a head CAT after the surgery because the little boy was unconscious."

"Any other symptoms?"

"Sluggish pupils and slightly hypertensive, but everything else was unremarkable."

"Did you check for retinal bleeding with an ophthalmoscope?"

"No. I didn't even think about that. I'm sure Matt will do that after the CAT scan. We were more concerned about the bowel obstruction given the mortality risk."

"True. Be careful, Petrovich. Better to take yourself out of the game than make a mistake."

"I know my limits, Lissa."

"I wonder about that."

We finished eating, and I returned to the ED, where Jay said Doctor Gibbs was looking for me, so I went to the Attendings' office.

"You rang?" I asked.

"You're not THAT tall! Come in, close the door, and sit down."

I did as I was asked and waited for her to speak.

"I can't leave you unsupervised for two minutes!" she said.

"You join a long list of women who have said that to me, most recently Clarissa, about fifteen minutes ago. Helicopter? Mastriano?"

"Mastriano, of course. What was your beef?"

"I have no beef," I said. "You'll need to ask Doctor Mastriano."

"That's quite a change from being an outspoken medical student. Come on, Mike. It's me, Loretta."

"I have an opinion about Doctor Mastriano, but that was formed afterwards. I can work with her. The question is whether or not she can work with me."

"Drop the 'love thy neighbor' schtick and tell me what happened."

"You know it's not a schtick," I countered. "And I don't need to say a word."

"Why is that?"

"A week from today is the M & M. Attendings will, to borrow a term, rip her a new one. I'll get up, repeat what I wrote on the chart, repeat her orders, and it's going to be ugly for her. She made a mistake an Intern shouldn't make, and that's why we have Morbidity and Mortality Conferences."

"Between you and me, as your friend and mentor, what's your take on Doctor Mastriano?"

"Loretta, I'm tired, and I'd prefer to defer this conversation until I'm not."

"You feel up to caring for patients but not up to giving your opinion about another doctor?"

"As strange as it sounds, yes."

"Tell me about the helicopter?"

"It's a good thing Nurse Martin was with us. She was the picture of serenity."

"Why did you send Tom home?"

"His hands were shaking. He should go on the next one, if possible."

"Climb back on the horse?"

"Yes."

"Are _you_ OK?"

"Other than the after-effects of a tanker truck full of adrenaline, yes."

"Any idea what happened? The newspaper didn't have details."

"No. Just that the co-pilot said we had an engine failure, and they set down on a baseball field about six miles north. From the point where the alarm sounded to when we were standing looking at the helicopter was about forty seconds at the most. Probably less due to the effects of adrenaline on time perception."

"Anything interesting happen overnight?"

"Other than the Taft students, fairly typical."

"I asked Ellie to call in a nurse to cover the triage desk so you're not working alone today."

"Mary will be happy about that. I was happy to hear the Hospital Board approved the extra nurses to staff triage."

"Me, too, though you know that money has to come from somewhere."

"All things being equal, I think the tradeoff is probably worth it. Fourth Years need to be doing procedures and assisting in traumas, not sitting at that admit desk. I take it you're happy to be back."

"Absolutely."

There was a knock at the door, and after Doctor Gibbs called out, it opened.

"Doctor Gibbs, there are patients waiting," Nate said. "Is Doctor Mike free?"

"He is. I'll lend a hand, too."

We had a slow but steady stream of patients throughout the morning, with Mary having three opportunities to suture. We were just busy enough that I never had a chance to sit down, though I suspected I might fall asleep if I did relax. I knew I was dragging, but being on walk-ins meant I could mostly operate on autopilot.

I managed to meet Clarissa for lunch, but just as I was finishing my meal, my pager went off, showing five nines, indicating it was an emergency.

"I'll take care of your tray, Petrovich!"

"Thanks, Lissa."

I left the cafeteria and hurried down the long corridor from the cafeteria to the ED, arriving less than a minute after I'd been paged.

"What's up?" I asked Nate.

"Firefighters were battling a warehouse fire, and the roof collapsed. At least six on their way in with various injuries and smoke inhalation."

"Lord have mercy," I said.

"Yeah," Nate agreed. "Level I disaster protocol is in effect. We've paged the on-call Residents and the on-call Attending."

"OK. Thanks. I'll head for the ambulance bay. Where's Mary?"

"Finishing the leg lac in Exam 4."

I went to Exam 4 and opened the door.

"A Level I protocol is in effect," I said. "Are you done?"

"He just needs a dressing and discharge notes."

"I'll sign the chart. Ask Ellie to send a nurse to finish. I need you for trauma."

"Right away, Doctor!"

I headed to the ambulance bay where all the doctors and medical students were assembled, along with several nurses.

"Mike, you're with me on the worst case," Doctor Gibbs said. "I already called for Medicine and Surgery to send people down."

"Do we know what happened?"

"A four-man team was clearing the building and a portion of the roof collapsed. Unknown if the other two being transported are firemen or not."

"Doctor Gibbs?" Ellie called out. "Total transport now eight. At least one of the two additional is critical."

Eight meant every EMS squad in the city or near it had been dispatched, and the two remote stations were, in effect, providing coverage for the entire county.

"Do we have a surgeon and Medicine yet?"

"Doctor Rafiq just arrived. We're waiting on Medicine."

"Send Rafiq out here, please."

"Right away."

She left and Doctor Rafiq joined us, and a minute later, just as the first EMS squad arrived, Clarissa joined us. Doctor Gibbs called out assignments as each of the four firemen had their vitals given, with three of the four in good shape, but the lieutenant of the crew was more severely injured. The critical patient was actually the last to arrive.

"John Doe, mid-forties, rescued from under a fallen beam," the paramedic called out. "Second- and third-degree burns on his extremities; smoke inhalation, including noxious chemicals; multiple internal injuries; BP 80 palp; tachy at 120; PO₂ 88% on ten liters; GCS 7; IV saline TKO."

"Trauma 1!" Doctor Gibbs exclaimed, having reserved that for our patient. "Mike, intubate; Mary, EKG and monitor, then Foley; Jamie, trauma panel and ABG!"

We rushed the patient to the trauma room, and the four of us, plus two paramedics moved him to the treatment table on Doctor Gibbs' count.

"Any idea what chemicals?" Doctor Gibbs asked as I prepared to intubate.

"They work with a lot of solvents, so could be just about anything," Mark Jones, the paramedic replied. "I'll see if I can get you more, but the plant manager wasn't transported."

Which meant he was so obviously deceased that the coroner would deal with it, rather than being brought to us, which wasn't a surprise given the number of victims. I focused on my task, realizing my mind had wandered, and made use of the adrenaline which had been dumped into my system. I got the tube in, connected the vent, set the controls, then auscultated.

"Good bilateral breath sounds," I said. "Crackles high and low."

"Mike second IV, large bore."

I quickly assessed both arms and shook my head, "Current IV is in the only clear location. I can do an ankle or call for a surgeon for a central line. I haven't done one."

"Ankle," Doctor Gibbs ordered.

"Sinus tach," Mary said, looking at the monitor. "BP 80 palp; tachy at 120; PO₂ 91% on vent."

"Lor, no pulse in his right leg," I announced. "Left has a vein."

"Mary, call for a portable x-ray," Doctor Gibbs ordered as she assessed the right leg.

"Foley?" Mary asked.

"I'll risk the mess; call for the x-ray. I think his hip is broken. Call Ortho as soon as you finish with radiology."

She acknowledged Doctor Gibbs' orders, and I got the second IV going, then, because Mary was on the phone, I inserted the Foley.

"Minimal urine," I announced. "Slight pink tinge."

"Train wreck," Doctor Gibbs said. "Rebounding and guarding in the belly, at least one broken rib. Mike, get a nurse to help us and bring in the ultrasound."

I acknowledged her order, moved out of the room, called for a nurse, and grabbed the portable ultrasound. I wheeled it into the trauma room followed by Nurse Alice. Doctor Gibbs barked orders to Jamie, Alice, and Mary, and stepped aside so I could perform the ultrasound.

"You aren't going to like this," I said. "Free fluid in Morrison's _and_ pericardial effusion. I'll aspirate the effusion, but he's going to need an ex-lap, and it's fifty-fifty that or the hip."

"He can live without a leg," Doctor Gibbs said. "He can't live if he bleeds out."

"He's not stable enough for surgery," I said. "Let's see if pericardiocentesis brings his pressure up and his pulse down. Permission to do it blind? He'll code if we wait for a fluoroscope."

"Have you done one blind?"

"Yes."

"Do it! Alice, cardiac needle and catheter with an alligator clip to Doctor Loucks!"

"Doctor Gibbs?" Deputy Joe Miller said from the door. "Your patient is Jack Peters, forty-one."

"Thanks, Joe."

In the thirty seconds that passed while Alice prepared the syringe with the cardiac needle, the catheter, and attached the alligator clip with the lead to the monitor, I reviewed the procedure in my head, thanking God that I had made a point of studying and memorizing the procedure.

"Need any help in here?" Doctor Lindsay asked, coming in the door.

"I'm about to do a blind pericardiocentesis," I said. "I remember how. He's going to need an ex-lap and a hip repair."

"Wonderful. I'll check the others then come back."

She left, and almost immediately, the orthopedic surgical Resident came in.

"Abrams, Ortho; what do we have?"

Doctor Gibbs reviewed the case while I performed the pericardiocentesis.

"Pulse coming down, BP coming up," Mary announced. "110/70; 90; PO₂ 94%."

"Alice, valve and bag, please," I requested.

I connected the valve and bag, which would allow us to drain fluid as it built up.

"Stable enough for transport and surgery," I said. "We're going to need pulmonology as well."

"How bad is the belly?" Kelly Abrams asked.

"How bad is the hip?" I countered.

"He'll lose the leg if we don't reduce the fracture. I think we can do that here and fix whatever else is necessary after his ex-lap."

"What about the risk of femoral compromise?" Doctor Gibbs asked.

"Worth taking," Doctor Abrams said.

"No x-ray?"

"We can't wait."

"Do it!" Doctor Gibbs ordered.

It took five minutes to prepare the patient, then Doctor Abrams performed the complex rotation maneuver to relieve the compression.

"Foot is pinking up, and we have a pulse," Jamie announced.

"Mike? Status?" Doctor Lindsay asked coming into the room.

"He's all yours. Effusion aspirated, and a valved catheter is in place. BP is up and pulse is down. Primary now is his surgical belly; everything else can wait."

"Full rundown?"

I looked to Doctor Gibbs who gave a complete assessment.

"Mike, Mary, bring him up," Doctor Lindsay said. "I'm heading up to scrub."

"Come right back, Mike," Doctor Gibbs commanded. "We're short staffed."

"Will do," I said. "Mary, portable EKG; Alice, we'll need you to bag during transport. Let's go, people!"

Four minutes later, we moved the patient to a gurney, then Mary, Alice, and I quickly moved him out of the trauma room towards the elevators.

"HOLD THE ELEVATOR!" Mary commanded, and as usual, everyone moved out of the way and we rushed into the waiting car. Two minutes later, we turned the Mr. Peters over to the surgical team, and headed back to the ED via the stairs.

"Bummer we can't scrub in," Mary said.

"I agree, but Doctor Gibbs is correct. I suspect that there's a line of people in triage, not to mention families who'll need to be updated."

"Could you explain the procedure for pericardiocentesis?"

"Yes, and I normally would have done that while I was doing it, but as Loretta said, it was a train wreck."

"Think he'll make it?"

"It'll all depend on lung damage," I replied. "His liver didn't seem compromised, which is a good sign. Everything else can be fixed, but scarred lungs are beyond our ability to repair. There are drugs which can help, but at some point, the scarring is too significant."

"Transplant?"

"Possible, but rare, and we'd need a match here in the region in short order. It also depends on what he inhaled. Small particulates, which were indicated by the soot in his nostrils and around his mouth, are the worst if you aren't outright asphyxiated."

"When will you learn to do a central line?"

"Sometime over the next eleven months. If Doctor Lindsay had come in ten minutes earlier, that's what I would have done under her supervision, because it was the better choice."

"So a patient could die because nobody is cleared to do a procedure?"

"It has happened," I said. "And that's one of the reasons for the new specialty."

"I heard there isn't one for next year."

"Every two years, given that's how long the first ED rotation is. Only three have been formally approved, though that will be reevaluated in eighteen months to see if the program continues, is expanded, or canceled."

"Canceled?"

"It's possible, though not likely."

"What would you do?"

"According to the rules, I could transfer to another program that matched mine, which would mean Indiana or University of Chicago right now, but other hospitals are adopting the new specialty. I could also switch to pure surgery, or pure trauma. But I don't think that's going to happen."

"What if I wanted the program?"

"They permitted PGY1s in trauma and PGY2s in surgery to apply, but none of them did. If you're interested, you should speak with Doctor Roth when you do your surgical Sub-I. You'd have to switch to matching in surgery or trauma, not medicine or endocrinology. But speak with Doctor Roth, because he may have other ideas. What made you consider changing?"

"Watching you! I hear from other Fourth Years that PGY1s don't do anything like what you do."

"Part of that is the program, but part of that is how I conducted myself as a Fourth Year. Also, if you're serious about trauma surgery, you should do a second trauma Sub-I as your last rotation. I'll endorse the change and speak to your advisor if necessary, to get your schedule changed."

"But can I work with you?"

"I think Doctor Gibbs will allow that. Just remember there will likely be significant competition for the slot two years from now. That said, if you're here, you can simply apply for the program. If you get it, then it won't be available for the Match."

"What do I need to do besides switch my Sub-I?"

"I don't know if they'll allow it, but a Pathology rotation would be a good choice. That might be tougher to swing, but it'll show you're serious, and you'll be able to cut something every single shift, which is NOT true for any PGY1 or PGY2. What's your class rank?"

"Fourteenth," Mary replied. "But there are less than thirty points between me and fourth."

"That's typical. Sophia Vasilakis is number one, right?"

"Yes. She's a friend of yours, right?"

"She is."

"Mike?" Ellie called out when Mary and I walked into the ED. "Triage has six patients waiting."

"No rest for the weary!" I said as I turned to trudge to the triage desk.