Chapter 34 — How Did You Know? _August 7, 1989, McKinley, Ohio_ {psc} After my talk with Krista, I didn't have a good feeling, as it seemed to me that her answer of 'Learn' was said because it was what she knew I wanted to hear. I picked up another chart from the rack, scanned it quickly, then handed it to Krista. This time, I waited until she had taken the patient into the exam room before Al and I entered. "Tiffany Gale, nineteen, complains of abdominal pain," Krista said. I waited, but she didn't give my name, so I said, "Hi, Tiffany. I'm Doctor Mike and this is Al, a medical student. Can you describe the pain?" "A dull ache in my midsection." "How long have you had the pain?" I inquired. "A few days. At first Tylenol worked, but it's not going away and hurts more." "OK. We're a teaching hospital and Krista is a Sub-Intern I'm training. I'd like her to do the primary exam. Is that OK with you?" "Yes," Tiffany replied. "Krista, primary exam and H&P, please," I instructed, handing her the chart. She did a competent job on the exam, though her H&P wasn't nearly thorough enough. As was my practice, I didn't say anything to Krista in the room. "Tiffany," I said, "we're going to discuss Krista's findings. We'll come back and speak to you in a few minutes." "Is there something you're not telling me?" Tiffany asked. "No," I replied. "This is normal with teaching, so that students can learn without being concerned about saying something incorrect in front of patients." Krista, Al, and I stepped out into the corridor. "Two things right off the bat," I said. "First, you didn't introduce me or Al. Second, it's my practice to ask a patient before I touch them." "Nobody else does that!" Krista protested. "Be that as it may, that's what I want done when you're working with me. Remember for next time. Now, how would you like to proceed?" "Blood tests," Krista replied. "What and why?" "CBC and Chem-20 because I couldn't find anything on the physical exam." I shook my head, "Those are standard trauma tests, but your H&P wasn't sufficient to justify them. What are you missing?" "If I knew that, I'd have asked her questions." "OK. We'll go back in, and I'll ask a series of questions to flesh out what you asked." We re-entered the exam room. "Tiffany, I have a few more questions," I said. "Have you experienced any nausea recently?" "A few days, but not constantly," Tiffany replied. "Have you been tired more than usual?" "A bit." "Headaches?" "Yes, but the Tylenol makes them go away." "Are you sexually active?" "No, never." "OK. I'd like to do an ultrasound, if that's OK with you." "What do you think is wrong?" "Given you told Krista you hadn't done anything which might cause a muscular injury, the first differential diagnosis is an ovarian cyst. Has anyone in your family had one?" "Not that I'm aware. How bad is it?" "Usually they're benign and simply uncomfortable. Before I say more, though, I'd like to get a look. OK?" "Yes." "Al, get the portable ultrasound, please." "Right away, Doctor." He left, and I asked Tiffany to lie down and pull up her blouse. When Al returned with the ultrasound machine, I performed an exam and saw exactly what I was looking for. Unfortunately, it was about 7cm in diameter, which meant it was potentially surgical. I pressed a button to print the image, and another one to freeze the image on the screen. I wiped the gel from Tiffany's abdomen and had her sit up. "You have a cyst, as I suspected. It's large enough that I want to call for a doctor from Obstetrics and Gynecology to discuss it with us." "How bad is that?" "Mostly they resolve themselves," I replied. "Have you been diagnosed with one before?" "No." "OK. We need to have a doctor from OB/GYN examine you, given the size of the cyst. Al, call OB for a consult, please." He made the call and about five minutes later, Doctor Roger 'Saint' Moore entered the room. "Moore, OB, What do we have, Mike?" "Hi, Saint," I replied. "7cm ovarian cyst with no remarkable features; over 5cm requires an OB consult. No other appreciable injuries or ailments. No history of previous occurrences." I handed him the image, and he also looked at the screen. "Hi, Tiffany," he said once he'd looked at the images. "I'm Doctor Moore from Obstetrics and Gynecology. You have an ovarian cyst, as I'm sure Doctor Mike has explained. In nearly every case, they are benign and resolve by themselves. Yours is a bit larger than typical, but given you have no history of cysts, I believe the best approach is to have your OB monitor you. Do you have a gynecologist?" "Yes; Doctor Patricia York." "I know Trish," Doctor Moore said. "Make an appointment to see her and she'll advise you. For now, Tylenol or Advil for the discomfort. Doctor Mike will give you written discharge instructions, and Doctor York will receive copies of your charts. Do you have any questions?" "How long does it take to resolve?" "Unfortunately, I can't tell you with any certainty. One way to prevent new cysts is the use of combined oral contraceptives — what are commonly called birth control pills. They won't help with current cysts, but they'll help prevent new ones. You should discuss that with your gynecologist. Any other questions?" "No." Saint made notes on the chart, signed it, and left. I went over the discharge instructions with Tiffany, which were quite simple. Given there was no treatment administered or recommended, I signed the discharge form, gave Tiffany a copy, and reminded her to call her OB. That completed, I directed her to Patient Services and led Krista and Al to the consultation room. "How did you know?" Al asked. "Krista?" I prompted. She shook her head, "I'm not sure how you knew." "It begins with the differential diagnosis. You started OK by asking about any activity which might have caused a muscle strain, but then you didn't follow up with additional questions. What are the differential diagnosis? You should know them from studying for Step 2 of the MLE." "I don't have my diagnostic handbook memorized," she said. "I did study for the exam, obviously." "Do you have your handbook in the pocket of your medical coat?" "No." "You should. I carry mine. There is no harm in looking at it, but step out of the patient room before you do that. The main alternatives are appendicitis, which you did check for when you palpated her abdomen, bowel obstruction, ectopic pregnancy, uterine fibroids, dissecting aortic aneurysm, and a number of postpartum diagnoses. There are other diagnoses which only occur in pregnant women, and you didn't ask that important question. If none of those pan out, you explore further. "So we have a young woman with abdominal pain, nausea, headaches, fatigue, and who has never engaged in sexual intercourse, and who denies any activity which might have caused an injury. At that point, having not found obvious signs of appendicitis, ultrasound is called for, as it can find both ovarian cysts, bowel obstructions, and aneurysms. The most common answer is an ovarian cyst, so that's what I looked for first. "Krista, you had your OB rotation, so that should have been something you thought of, even without looking in your book, because it's such a common diagnosis for young women. I didn't see any ultrasounds in your procedure book, though I know that's not always done with Third Years. That said, this is a common enough ailment you should have known." "I don't think it's right that you're reprimanding me in front of another student," Krista protested. "Have you been to any M&M conferences?" I was reasonably certain of the answer, as I hadn't seen her at any. "No." "Which explains your reaction to a teaching moment. The entire point of an M&M is to learn from errors or omissions, and they are done before your peers. It's not about fault-finding, but about learning from experiences. Yes, it was correction for you, but it was a learning experience for both you and Al. The only way he can learn is to observe, and that includes me pointing out how you can improve your diagnostic skills and your handling of patients. "You said you wanted to learn; this is how you learn. If you want to pass this rotation, you have to show me that you can handle clinical work. What happened in the first two years of medical school has nothing to do with being a doctor, but everything to do with preparing to be a doctor. "I don't care if you aced the MCAT and Step 1 of the MLE; and I don't care if you were first in your class. All that matters now is if you can _be_ a doctor. Besides your other assignment for Thursday, you need to find out who Sir William Osler was, and what he had to say about medical education." She muttered something under her breath, which I didn't quite catch, but I was positive it was derogatory. I decided the best course of action was to let it pass and see how she responded. "Let's go see some patients," I said. Being able to work under pressure being a key trait, but given Krista's history, the paucity of procedures she'd done, and her attitude, I decided to handle the next two patients — an arm lac, and mild concussion. I kept an eye on my students and their responses couldn't have been more different — Al was taking notes while Krista was fuming. That concerned me, and I wondered if I'd been correct in coming down so hard on her. "Mike," Nate called out. "EMS four minutes out with an MI! Use Trauma 3." "Got it. Which nurse?" "Kellie." "Thanks," said, then turned to my students, "Let's go! Gowns and gloves." We put on gowns and gloves and went to the ambulance bay, and a few seconds later, were joined by Kellie. "With a rule-out MI, we do a standard set of things," I said to Krista and Al. "Oxygen, either by mask or canula. We draw a trauma panel, which consists of CBC, Chem-20, ABG, a pregnancy test for any female between ten and sixty, and cardiac enzymes. We also set up a five-lead EKG, and if the patient is being bagged or receiving CPR, we intubate. If the EKG shows arrhythmia, we insert a Foley catheter. "Kellie, blood draws; Krista, EKG and pulse oximeter; Al, either take over bagging or oxygen by canula or mask, whichever the paramedics have used. If he needs a Foley, I'll show you how." Two minutes later, the EMS squad pulled up and Bobby hopped out. "John Cowling; forty-nine; diaphoretic; BP 180/100; tachy at 130; PO₂ 93% on ten liters by mask; resps labored and shallow; reported dizziness and severe chest pain before collapsing; GCS 6." "Trauma 3!" I ordered. We quickly moved the patient to Trauma 3 and transferred him to the trauma table. Everyone performed the tasks I'd assigned, and I performed a primary exam, detecting a murmur. I heard the click of Krista turning on the monitor and looked up. "Inverted T wave, about 8mm, biphasic; QRS complex deflected up and slightly long, but sub 120ms. Al, page Cardiology and tell them we have a suspected incomplete right bundle branch block." Tom made the call and reported the resident would be down right away. "Kellie, Tom will need a 16 French and instruments. Tom, cut away the patient's slacks and underwear, and I'll talk you through inserting the Foley." He did a credible job following my instructions, and we finished just before Doctor Shore came into the room with a Third Year I didn't know. "Shore, Cardiology," he said. "What do you have, Mike?" "Hi, Pat. This is John Cowling; forty-nine; morbidly obese; catheterized with urine in the bag; diaphoretic; BP 180/110; tachy at 120; murmur on auscultation; PO₂ 91% on ten liters; resps labored and shallow; reported dizziness and severe chest pain before collapsing; inverted T waves on the monitor, suggesting an incomplete right bundle branch block." "Angling for my job?" he asked with a smile as he moved to examine the patient. "Confirmed," he said. "Let's get him upstairs." I made notes on the chart and signed it, then handed it to Doctor Shore. "Al," I said, "switch to portable oxygen; Krista, switch to the portable EKG." They completed the tasks, and I instructed Krista to go with Doctor Shore and his student. They quickly left the room, and Al and I followed them out. "Can I ask a question or two?" Al inquired. "Of course. Let's step into the consultation room." We walked into the office and Al shut the door. "Is the problem with Krista going to negatively affect me?" "Only if you allow it to," I said. "You'll get procedures appropriate for a Third Year. Earn my trust, and you'll get more." "How do I do that?" "Follow instructions, learn what I teach you, and have a good attitude. I saw you taking notes during the traumas, which is exactly the right thing to do. I've taught you how to insert a Foley for a male, and you should be able to do the next one without me giving you express instructions. "By all means, ask questions, and I'll watch and guide you if you need it. Females are different, obviously, and I'll teach you to do that when we have the opportunity. Also do the things I suggested earlier — practice suturing, read your cardiology textbook, and study your differential diagnoses. How did you study for the MLE?" "With notes and summaries prepared by our study group." "Review those. What I said earlier is true — those notes have nothing to do with being a doctor, but everything to do with preparing to be a doctor." "That was going to be my second question. What the heck does that mean?" "I'll give you the answer I asked Krista to look up — Sir William Osler was the co-founder of Johns Hopkins Hospital and the creator of the first Residency program. He said, and I'm paraphrasing, that medicine is learned by the bedside and not in the classroom. Your notions about disease shouldn't come from lectures or books, but from examining patients." "Ah! That makes total sense!" "There was an optional textbook for Practice of Medicine that you should read _The Principles and Practice of Medicine_, which he wrote." "Shit," Al swore. "I didn't read any of the extra material." "No time like the present. Do you subscribe to any medical journals?" "No." "At a minimum, you should subscribe to the _Journal of the American Medical Association_, _The New England Journal of Medicine_, or _The Lancet_. When you decide on your specialty, then whichever journal is appropriate. My personal choices are _The Lancet_ and _The Journal of Emergency Medicine_. Any idea what you want to do?" "I'm not sure, but surgery was the most interesting Preceptorship." "That's an extremely competitive Match, which means you need to bust your butt." "Can I come to you for advice?" "My door, such as it is, is always open. Let's see what we have in the way of patients." Krista returned just as Al and I went into Exam 5, where Nurse Carol had brought a young man with a dog bite. "Good morning, Mr. Sayles," I said. "I'm Doctor Mike and with me are my students Krista and Al. We're a teaching hospital, and with your permission, I'd like Al to conduct the preliminary exam." "Why not?" he asked. "Al?" I prompted. "Good morning, Mr. Sayles," Al said. "Could you tell me what happened?" "The neighbor's rat dog is always barking and yipping when I'm in my yard. Today, he came and stole my son's ball, and I tried to get it back. The little fucker bit my hand." "Do you have any other concerns?" "Besides shooting that little rat fuck if he ever comes into my yard again?" "I was thinking more health concerns," Al said with a smile. "Nah, just my hand," Mr. Sayles replied. Al washed his hands, put on gloves, and examined Mr. Sayles' hand. "Mr. Sayles, can you close your fist?" Al asked. The patient did so, but winced in pain, which wasn't surprising. "I believe it simply needs irrigation and a topical antibiotic," Al reported. "Simple punctures and no tearing. NSAID for pain and discomfort." I washed my hands, put on gloves, and verified his exam. "I agree. No tendon involvement. Proceed with irrigation." "Nurse," Al said, "irrigation syringe and a basin, please." Al did a good job washing out the wound, then asked for the topical antibiotic, which he applied. "When was your last tetanus shot?" I asked. "A few years ago," Mr. Sayles replied. "Less than five?" I inquired. "Yeah, it would have been in 1986 when I stepped on a nail at a construction site." "Then we don't need to update it. Let me complete some paperwork, and we'll get you on your way. Just keep the hand clean and dry, and see your physician on Thursday or Friday to check your wound. You can take Tylenol or Advil for pain, whichever works best for you. If you see any redness or discharge that isn't clear, come back right away." "What about work?" "So long as you can keep the wound clean and dry until you see your physician, and the pain isn't too bad, you can work. I can also provide you with the equivalent of a doctor's note if you want to take sick time." "Nah, I want to work; I just want to make sure it's OK." "It is. Give us ten minutes to complete the chart and discharge paperwork, and we'll have you on your way. Carol will bandage your hand for you." "Thanks, Doc." Krista, Al, and I left the room and stood in the corridor. "I should have asked about tetanus," Al said as soon as the door closed. "Just remember next time," I replied. "More importantly, if you think your Resident has forgotten or missed something, ask if you can speak to him or her privately, step out, and state clearly what you're thinking. The only exception is in a serious trauma, where you ask immediately, because that can be the difference between life or death." "Got it." "Write what you did on the chart, please, and fill out the discharge notes for my signature," I said to Al. "After we speak to the patient, make sure you enter it in your procedure book for my signature as well." He updated the chart, I made my own notes, then signed it, and the discharge form. We went back in, Al went over the discharge notes with Mr. Sayles, directed him to Patient Services, and then filed the chart with Nate. Krista looked very unhappy, so after checking my watch, I decided to send Krista for her lunch, as there were no charts in the rack. "Krista, take your meal break now," I said, then turned to Nate and said, "I'll be in the lounge." I went to the lounge and Al followed. "How's your morning going, Mike?" Ghost asked when I sat down on the couch. "Routine," I replied. "No real excitement. You?" "One nasty bike accident first thing, but routine otherwise. The bike accident needed an ex lap and ortho. Fortunately, he was wearing a helmet." "Car?" "Dog." "We just had a dog bite." "Speaking of that," Al said. "Would you sign my procedure book?" He handed it to me and I signed off on his treatment of the patient, then handed it back. "Good job. Was that your first start-to-finish?" "Yes. Thank you." I smiled, "If a Third Year can't irrigate a wound, even on their first trauma rotation, we've all failed miserably. Why don't you take your meal break." "Thanks." He left, leaving just Ghost and me in the lounge. "Making a point with your Sub-Intern?" he asked. "Yes and no. This was so simple that it was the perfect case to give Al a chance to show me he's been paying attention. You know I don't believe in the 'scut only' method, so Krista will have her chances, though I'm fully aware of the concerns expressed by Cardiology." "That's why they give you all the tough ones. Nobody could ever accuse you of not giving someone a chance." "She's already had a pair of lectures and it's only 11:20am on her first day assigned to me." "You had your share of those over the course of your rotations, though none of them were ever about medical procedures, at least as I recall." "No, just some guidance on those. The serious conversations were about my unrepentant idealism and insistence on holistic medicine, which meant spending, and I'm quoting here, 'too much time' with patients. I haven't changed my opinion, even if I've made minor course corrections." "I have noticed you've taken advantage of the red scrubs and don't wear your medical coat except on rare occasions." "Which is the standard for surgical Residents assigned to do consults in the ED. Between you and me, I honestly feel that except in formal situations, we ought to dispense with them." "They do allow a visible distinction between doctors and medical students." "For those who know that it's the long coat for MDs and short coat for students. I bet if we surveyed everyone coming in, less than five percent would have a clue about that. And I know it works both ways — patients see the lab coat an immediately think 'doctor', which probably alleviates some anxiety, but then we immediately mention that a student is a student." "The coat is part of the uniform, if you will, and of all people, I thought you'd be the one to understand that better than anyone except ex-military." "I suspect during catechism that Father Nicholas didn't explain that the cassock and _ryassa_ are simply Byzantine street clothing not all that different from a business suit. They aren't 'uniforms' in the military sense. In fact, so long as they follow the basic pattern, they can be any color and have trim, and vestments vary widely in pattern, though color is dictated by liturgical seasons and feast days. "Only the passage of time and changing styles has made our garments seem more formal than the business suits worn by Protestants. A parallel is the «kosovorotka», which is peasant clothing, but which everyone feels are 'dressy', because of cultural differences between the US and Russia. "I guess my point is, the scrubs are comfortable and far cheaper and easier to clean than my medical coat. These go to the hospital laundry; the medical coats have to go to the dry cleaners. I'll absolutely wear mine, over a shirt and tie, when I speak at the medical school in a few weeks, and that's proper for that venue. Here, especially on long shifts, the ability to change scrub tops three or four times a day is important. I only have two medical coats." "Practical, logical, and likely to create a firestorm if you proposed that change now." "Do you hear me saying anything to anyone about it except you?" I asked. Ghost laughed, "No. You have learned to pick your battles." "Ghost?" Ellie said from the door to the lounge. "Paramedics three minutes out with an MVA." "Be right there," he replied. He got up and left, so I retrieved my _Journal of Emergency Medicine_ from my mailbox where I kept it so that it didn't disappear, and began reading. That lasted about ten minutes before Nate let me know there were a pair of walk-ins. I got up, went out to the clerk's desk and picked up the first chart, then went to Exam 6, where Kellie was waiting with a toddler and his mom. "Hi, Mrs. Patton," I said. "I'm Doctor Mike. Who do we have here?" "My son, Mikey, who stuck a pebble into his ear and I couldn't get it out." "Hi, Mike," I said. "We have the same name. Which ear did you put the rock into?" "This one," he said, tugging on his left earlobe. "I want to take a look, OK?" I asked the suspicious three-year-old. He nodded, so once I washed my hands and put on gloves, I got an otoscope and a fresh speculum and showed it to Mikey. "I'm going to use this to look into your ear," I said. "You won't feel anything except my gloves on your ear." "OK," he agreed. I examined him and saw the pebble lodged in his auditory canal, as well as trauma I suspected was from his mom's failed attempts to remove the stone. Given what I saw, I suspected she'd only succeeded in pushing it further in. I felt I could remove it in the ED, and didn't think I needed an ENT consult. "How did you try to remove it?" I asked Mrs. Patton. "Tweezers," she said. "But I couldn't grasp it." "Kellie, four-prong foreign body forceps, please." She went to the drawer, retrieved a sealed instrument, tore open the package, and handed the sterile instrument to me. "Mikey, I'm going to use this to grab the rock," I said. "You'll feel it, but it shouldn't hurt." I held up the instrument so he could see it, and when he didn't object, I had him lie down. "Mom, if you could hold his head still," I said to Mrs. Patton. She moved to hold his head steady, and I carefully passed the thin ends of forceps past the stone. It took a bit of maneuvering, but eventually I grasped the stone and managed to remove it, depositing it into a basin Kellie was holding. "Bulb syringe and saline, please," I said to Kellie. She brought me the bulb syringe filled with saline, then held the basin below his ear while I irrigated and washed out any dirt or debris that might have remained. Once that was complete, I put a fresh speculum on the otoscope and checked Mikey's ear. "He has some minor scratches," I said. "But nothing that requires medical treatment. I'm going to apply a topical antibiotic and then you can be on your way. If Mikey has any discomfort, children's Advil or Tylenol should help. So long as the pain doesn't last more than a day or two, there's no further treatment necessary. If he complains, or you see any redness, take him to see his pediatrician or bring him back here." "Thanks, Doctor." "Kellie, triple antibiotic on cotton swab stick, please." She brought me the swab, and I carefully applied it to the inside of Mikey's ear. Once that was complete, I filled out the discharge form and made my chart notes. "Mrs. Patton, in the future, I suggest not trying to remove the foreign object yourself. It's too easy to do damage to ear canals or nasal passages." "I thought I could get it," she said. I nodded, "I understand, and I don't think you did any harm, but you could have." "OK." "Mikey, you can sit up," I said. "How do you feel?" "My ear hurts," he said. "Kellie, 5ml liquid ibuprofen, please," I said. "Mikey, we'll give you some medicine that will help you feel better." Kellie prepared the dispensing cup and brought it to Mikey and helped him drink it. "That should do it," I said. "Do you have any questions, Mrs. Patton?" "No. Thank you, Doctor." "You're welcome. Does Mikey have a favorite candy?" She smiled, "Anything he can get his hands on!" Given his age, I decided the best bet was a sucker, so I took a cherry-flavored one from my pouch and handed it to him. "This is for being very brave," I said. "But you need to wait to eat it until your mom says it's OK." "What do you say, Mikey?" Mrs. Patton prompted. "Thank you," he said.. "We're all set, Mrs. Patton. You can see Patient Services across the hall." "Thanks again, Doctor." We all left the room, and I saw Krista coming into the ED. "You need to relieve Paul at the triage desk," I said. She glared at me but headed over to the triage desk. "Uh-oh," Kellie said quietly. I nodded and grabbed the next chart, then went into Exam 2 with Kellie. "Hi, Jodi," I said to the teenage girl with facial contusions and scrapes. "I'm Doctor Mike. What happened?" "I was trying out these new skates called Rollerblades, and I fell." "Rollerblades are those new skates with the wheels all in a line, right?" "Yes." "Is your mom or dad here?" "No. My boyfriend brought me here. My parents both work." She'd signed the consent to treatment form, and given our policy about non-invasive treatment, I could treat her for her injuries without waiting to confirm with her parents or need another doctor to sign off. "Were you wearing a helmet?" I asked. "Yes, and knee pads, elbow pads, and wrist guards, but my face hit the curb." "Does anything else hurt?" "No. The protective gear worked." "I need to do a quick exam, and then we'll get you cleaned up. I do need to ask one question before I provide any treatment — is there any chance you could be pregnant?" "I'm on the Pill," she said. "When was your last period?" "Last week. Why?" "Because we need to take that into account with any treatment. A topic antibiotic won't be a problem, but if I were to need to give you any other medication or decide you need an x-ray, we need to know if you're sexually active. I don't think we'll need an x-ray, but if we do, we'll need to do a pregnancy test just to be safe." "Oh, that would REALLY make my day," she said. "Oral contraceptives are very effective if used as directed," I said. "You're aware they do not prevent sexually transmitted diseases, right?" "Yeah. but I've only ever been with my boyfriend." "OK," I said, making a mental note to give her the pamphlet we had about safe sex. I washed my hands, put on gloves, then did a primary exam, including auscultation and reflexes, along with palpating her abdomen. "I don't find anything wrong except for your scraped face," I said. "We'll use saline to wash the dirt out, then apply some antibiotic ointment. How badly does it hurt?" "It's like a dull throb," she said. "How bad is the bruise?" "Kellie, patient mirror, please," I said. Kellie got the mirror from the drawer and handed it to me. I held it up so Jodi could see the damage, which consisted of a fairly nasty bruise and five small scrapes. "I look like Jim beat me up," she said, shaking her head. "Is that what happened?" Kellie asked. "No," Jodi said. "I really was on my skates. But my dad doesn't like Jim." "I take it you both go to Hayes County High or Saint Augustine?" "Saint Augustine. He'll be a Senior and I'll be a Junior." "OK. Kellie, irrigation syringe and saline," I said. "Jodi, if you'll lie on your back, I'll use sterile saline to wash out the dirt." I cleaned and irrigated the wound, examined it again and decided no x-rays were necessary. After applying the topical antibiotic and having Kellie loosely dress it, I explained how to care for it and suggested seeing her personal physician in a few days for a wound check. I excused myself, left, and returned with the 'safe sex' pamphlet from the Free Clinic. "We hand these out to sexually active teens," I said. "Read it and if you have any questions, stop in the Free Clinic on Main and they'll answer them for you." "I'm not sleeping around," Jodi protested. "And I didn't mean to imply you were, but, as they say, knowledge is power. Kellie will take you to Patient Services." "Thanks, Doctor." "You're welcome." I left the exam room and went to the triage desk to check on Krista, then went to the lounge where Al was waiting. "I wasn't sure if I should come into the exam room." "It's usually OK," I replied. "If it's not, I'll simply ask you to step out." "Krista seems really pissed about me getting that procedure." "My job is to train both of you," I said. "And that means you'll get some procedures, including suturing. As soon as you tell me you've practiced, I'll supervise you doing a few simple ones, then turn you loose on an unsuspecting public! Remember, in twenty-two months, you'll be a doctor, doing exactly what I'm doing." "A weird thought." "It was for me, too." "Mike," Nate said from the door. "Paramedics five minutes out with a chemical burn patient." "Did they say how bad?" "They said 'severe' with respiratory compromise." "Call the Air Ambulance and put them on standby. That'll save us at least five minutes if we need them, which I suspect we will." "Right away!" he agreed. "Al, you averse to a helicopter ride to Columbus?" "Are you kidding? Sign me up!" "Then let's go. Put on a mask, please." I found Kellie and asked Ellie for another nurse, and a minute later, Al, Kellie, Mary, and I were standing in the ambulance bay waiting for EMS, gowned, gloved, and masked. The masks would help a bit, but if it were a toxic chemical, we'd need respirators, which we did not have. They would be part of the equipment added for the new ED wing. For now, we'd have to borrow them from the infectious disease team. "Al, call ID and have them bring down a pair of respirators. We might need them. Tell them we have contamination with an unknown chemical." He went to the phone just inside the doors to make the call, and Loretta came out. "I heard you have a bad one coming in. Want some help?" "Always. I had Nate call for the chopper to be warmed up. I bet we need it. I'll take Al and Kellie. Krista is on triage this afternoon. Al is calling ID for respirators in case we need them." "Good thinking!" Al stepped back out and let me know a med student was bringing down two self-contained respirators. The EMS squad pulled up and Norm jumped out. "Tyler Stephens; twenty-seven; exposed to hydrofluoric acid; severe burns to his arms and face; clothing removed; bathed with saline on site; tachy at 120; BP 90/60; resps labored; PO₂ 92% on nasal canula; 5mg morphine; LOC on site; GCS 6; Saline IV right ankle." With the removal of his clothing and being washed with saline, we wouldn't need the respirators. "Trauma 1!" I ordered, and we began moving. "Al, five-lead and monitor; Mary, two bottles of sterile saline to me, then ABG and Chem-20 from a leg vein; Kellie, calcium gluconate gel and IV calcium gluconate solution. Lor, am I missing anything?" "No!" We rushed Mr. Stephens to the trauma room, moved him to the trauma table, and everyone sprang into action. My first move was to use an entire litre of saline on each eye. I was concerned how they looked, but saving his life had to come first. "Sinus tach!" Doctor Gibbs called out as I began my primary exam. "Intermittent QT prolongation." "The acid is causing hypocalcemia," I said. "I'm concerned that his heart rate is still high which is the opposite response." "Adrenaline," Doctor Gibbs said. "It's stronger." "Yes, of course," I agreed. "Labored breathing. No apparent injuries except superficial partial-thickness burns to both arms, neck, and face. Estimate 30%. Recommend transport to the burn center at OSU." "Agreed," Doctor Gibbs said. "Get suited up, I'll get him ready for transport and meet you on the pad in five minutes." "Kellie, Al, with me!" I requested. They followed me from the room to the lockers. "Al, put on a blue 'trainee' jacket and I think you'll need a medium helmet." Kellie and I put on red 'Flight Surgeon' and 'Flight Nurse' jackets and grabbed our helmets. "Al, just drape the radio leads over your shoulder," I advised. "There are two buttons on them — the white one is for intercom, which is just us; the red one is crew, which includes the pilots. You have to push to talk." "Got it." "Then let's go!" We headed up to the heliport and two minutes later, the chopper landed and the co-pilot jumped out and opened the patient door. A minute later, Doctor Gibbs, Mary, and an orderly wheeled Mr. Stephens out of the elevator. We got him loaded onto the helicopter, I helped Al put on his harness and connect his radio leads as the co-pilot closed the door and climbed into his seat. "Hayes County Air Ambulance departing Moore Memorial Hospital for Ohio State University."