Chapter 28: A Choice of Schedules

July 27, 1989, McKinley, Ohio

"I didn't expect this," I said to Kellie when we finally received the blood test results about 90 minutes later.

"What?"

"Seriously elevated white count. She's going to have to be admitted for further testing."

"Kleist is not going to like that," Kellie observed.

"Tough," I replied. "The patient comes first."

"Obviously."

"I think I'll call for someone from Medicine to come down."

"Reinforcements?"

"There is safety in numbers!"

I went to the phone and dialed Medicine, asked for a consult, and smiled when the nurse said Clarissa would be down right away. She arrived with her student, Pam, about two minutes later, I filled her in and handed her the lab test sheets.

"Nothing appreciated upon exam?" Clarissa asked.

"No," I replied. "As I said, she appears totally healthy. And the tox screen was negative, so she's not taking whatever it is she's slinging. Ready?"

"Yep."

Clarissa, Kellie, and I went into the exam room.

"This is Doctor Clarissa Saunders from Internal Medicine," I said. "I called her because Debbie has an elevated white blood count and will need to be admitted for further testing."

"Oh, come on, Doc!" Detective Kleist protested. "You said she had a clean bill of health!"

"No, I said, 'barring something in the blood work'."

"What's wrong with me?" Debbie asked.

"We don't know yet," Clarissa replied. "I'm going to admit you for further testing."

"Is that absolutely necessary?" Detective Kleist asked.

"It is," Clarissa confirmed, then turned to her med student, "Pam, call up and let them know I'm bringing up a sixteen-year-old with an elevated white count for testing and evaluation."

"Detective," I said, "you'll need to remove the cuffs so we can transfer Miss Jones to a gurney."

"I'd prefer they were kept off," Clarissa said.

"Locked ward, Doc," Detective Kleist said.

"What charges?"

"2nd Class Felony; a hundred tablets of ecstasy. We've been looking for the source at Hayes County High for six months."

"I need to speak to my Attending," Clarissa said.

She went over to the phone and Pam handed it to her. Clarissa had a brief conversation, then hung up.

"According to Doctor Collins, there's a rape suspect in the locked ward, so we can't put Miss Jones in there. And no cuffs are permitted in the normal ward."

"Come on, Doc!" Detective Kleist protested.

"You can take it up with Doctor Baker, the Chief," Clarissa said. "We have limited space for prisoners, but you also can't take her to the lockup."

"Striking out every time!" Debbie said with a smirk.

"Shut up!" Detective Kleist ordered.

"Debbie," Clarissa said, "we need to call your parents. Will you write down their names and their phone numbers, work or home?"

"Nobody home at the house," Detective Kleist said. "We busted her there."

Debbie wrote out her parents' names and their numbers on a pad Clarissa handed her, then, once Detective Kleist had removed the cuffs, we helped Debbie onto a gurney. Clarissa and Pam left with Debbie, accompanied by Detective Kleist, and I went to let Doctor Gibbs know what had happened.

"I bet that went over well," Doctor Gibbs said.

"Fortunately, it's Doctor Baker's problem now!"

"What was she pushing?"

"MDMA. According to Detective Kleist, she had a hundred ecstasy tablets in her possession."

"And pushing to High School kids."

"Yes. I'm sure the cops will be looking for her supplier, and that's probably going to be Federal because it most likely wasn't manufactured here. Granted, I know enough chemistry and biochemistry to synthesize it, and meth is being made by biker gangs in California, but 100 tablets? A lab in Mexico is the source, I suspect."

"I concur," Doctor Gibbs replied. "Why exclude your students?"

"Just a feeling," I replied. "Bob did the primary assessment on the go-kart accident earlier."

"I didn't think you were excluding them systematically, nor did I think you weren't giving them opportunities, just about this instance."

"Mainly because I wanted to limit the number of people in the exam room with a teenage female arrestee."

"A legitimate reason," Doctor Gibbs replied. "That's all."

"Doctor Gibbs?" Ellie said just as I was about to leave. "Altered male, mid-fifties, being brought in by the paramedics. Three minutes out. He was walking naked down Main Street."

"There's something you don't see every day," I said with a smirk.

"Just for that, Loucks, YOU take him!"

"The fun never stops!" I chuckled.

"And no humoring him to walk naked down the corridor!"

"No cheap thrills for you, Lor!" I replied with a grin.

"Trauma 1," Ellie said.

I left the office and went to get Bob and Len, who were in the lounge. The three of us and Kellie went to the ambulance bay.

"Any advice?" I asked Kellie.

"One sailor we transported was a guy from a carrier who ran out on the flight deck naked. It was a bad trip."

"Acid?" I asked.

"Yes."

"Does anyone still drop acid?" Bob asked. "I thought that was a sixties thing."

"Seventies and early eighties, too," Kellie said. "But by the time I got out, we were seeing more huffing and the ubiquitous 'go pills'."

"What were they huffing?" Len asked.

"There are all kinds of chemicals on a carrier, but model airplane cement and whippets were the main ones."

"So, advice?" I inquired.

"I'd go with soft restraints right off the bat. You can always remove them if he's not combative."

"Why assume it's drugs?" Len asked.

"I'd say that's most likely," I replied. "If he were older, dementia would be a choice. Obviously, he could simply be mentally ill, but we need to assume he's on something until we're sure he's not. CBC, Chem-20, and tox screen. Monitor, but no EKG unless we see symptoms that indicate that."

The EMS squad pulled up, and Bobby jumped out.

"Mid-fifties male, no ID, found altered on Main Street," he said. "Pulse 90; BP 140/90; PO₂ 98% on air; no obvious injuries."

"Trauma 1," I said, and we began moving. "Kellie, CBC, Chem-20, EtOH level, glucose panel, and tox screen; Len monitor; Bob, Foley, as I can see he relieved himself on the gurney. Send a urine sample to the lab as well."

"Sir, I'm Doctor Mike," I said to the man. "We're going to take good care of you."

He didn't respond at all, and his stare was vacant, which tended to confirm my thinking that he was on some kind of mind-altering substance, but I couldn't make that conclusion without diagnostically significant evidence.

"Len, soft restraints, please. I'm concerned about what might happen if he comes around."

Ten minutes later, with blood drawn, the Foley in, and an exam completed, I went to Doctor Gibbs to report.

"No obvious injuries that would cause an altered state," I said. "At this point, I recommend observation until the tox screen comes back."

"What else are you considering?"

"A tumor, an aneurism, or a stroke, but I don't see any signs that would indicate those. He's not unconscious, but he's also not responsive to verbal commands, doesn't respond to stimuli, and his pupils are reactive but sluggish. To me, that rules out mental illness. No EtOH on his breath, no acetone smell, and no track marks. He appears well-nourished and has decent hygiene. In my judgment, it's something inhaled or taken orally."

"And if the tox screen comes back negative?"

"Neuro consult."

"Mike?" Nate said from behind me. "Detective Tremaine is here about your patient."

"Ask him to come in, please," I said.

A few seconds later, Detective Tremaine came in.

"Do you have a name?" I asked.

"Kevin Russell. We found his car on Main Street with his clothes and wallet. We also found a powdery substance that we sent to the lab at Taft to identify."

"Cocaine?"

"No. The field tests were negative for coke and heroin. If I had to guess, it's dust."

"Dust?" I asked.

"Angel dust — PCP."

"Phencyclidine," I said. "I've never heard it called just 'dust'. And that would explain it. It can cause hallucinations or psychosis and creates a detachment from reality similar to schizophrenia. I didn't see the usual eyeball movement associated with it, but given it has the effect of desensitization, that could fit."

"Treatment?" Doctor Gibbs asked.

"Supportive and palliative. If he has seizures, lorazepam, and if he becomes psychotic, Haldol. If the Detective is correct, the urine test will show un-metabolized PCP."

"We saw a lot more of that in the 70s and early 80s," Detective Tremaine said. "Most kids are using X these days, and home-manufactured methamphetamine is the up-and-coming drug of choice. You have the X arrestee here, right?"

"Yes," I confirmed.

"Assuming it's PCP," Doctor Gibbs said, "What do you propose after he comes down, Mike?"

"Bring in the social worker for a treatment program. Detective, is he going to be charged?"

"Simple possession and, let's call it misdemeanor disorderly conduct. If he goes into a program, he'll be able to plead it out for probation and a fine for the DO charge."

"Mike?" Ellie said from the door, "Urine test results are in. Lab on line 2."

"Thanks," I said.

Doctor Gibbs picked up the phone and spoke to the lab, nodding as she hung up.

"Positive for phenylcyclohexyl piperidine," Doctor Gibbs said.

"OK," I said. "I'll monitor until he's able to speak to a social worker. Detective, is he under arrest?"

"How long will you keep him?"

"I'll have him admitted to Medicine for overnight observation," I replied. "Then it's up to them. The social worker would see him tomorrow."

"The guy has no rap sheet, so I'll write the citation for disorderly conduct, and if the Taft lab comes back with positive identification on the drug, I'll turn it over to the County Prosecutor, who'll decide if it's worth bringing felony charges or just issuing a citation."

I left the office and went to check on Mr. Russell, and asked Bob to check records to see if Mr. Russell had any previous visits. He left, and I called Clarissa to explain what we had, so she was aware she'd receive a patient, though it would be several hours before I'd be able to send him up.

Bob returned about five minutes later.

"Nothing in the last three years," Bob said. "Archive search?"

"No. We'll see if the police turn up anything. Len, stay here."

Bob and I left the trauma room.

"I thought PCP made people violent," Bob said once we were in the corridor.

"TV would like you to think that," I said, "but that kind of reaction is extremely rare."

"They didn't really cover it in medical school."

"Most of what I know came from researching my friend's condition, and I read several articles on things that had similar symptoms, hoping against hope it was one of them. Sadly, it wasn't, but that's where I learned about PCP or what Detective Tremaine called Angel Dust."

"I was surprised to see you still reviewing your flashcards earlier."

"Why? It's not as if an MD confers eidetic memory! I did cut back to fifty cards in the deck I carry, and twenty-five are always emergency medicine, while the other twenty-five are from the complete set, swapping every day."

"What would it take to be able to make copies of your flashcards and notebooks?"

"I don't have a problem sharing, though it would have to be done here, because I can't risk anything happening to them. I can bring them in sets and you can copy them here. You'll need around 3000 flashcards, total."

"Whoa!"

"I started during First Year and every time I came across something I thought I might need to know, it went onto a card. And there are around a thousand pages of clinical notes divided by rotation."

"Now I know why you were first in your class!"

"It wasn't his good looks or boyish charm, that's for sure!" Doctor Gibbs said, coming up to us.

"Don't you have some medical student to torture or something?" I asked petulantly.

"I'm an Attending! We torture Residents! Torturing medical students is the purview of the Resident!"

"Does Bobby know about this kink of yours?" I asked with a grin.

"I seem to recall a certain Russian girl torturing you!" Doctor Gibbs declared.

"EVERY Russian girl tortured me!" I chuckled.

"Do you have a moment?"

"We're just waiting on Mr. Russell to come around, and Doctor Varma has walk-ins under control."

"My office, please."

I followed her to her office and shut the door.

"What's up?"

"Believe it or not, you aren't in any trouble!"

"First time for everything," I chuckled.

"I know, right?" Doctor Gibbs replied with a smile. "Anyway, Ghost will start working on the September and October Schedule next week when he's back from his honeymoon. We can give you three twenty-four-hour shifts plus an eight-hour shift at the Free Clinic, or three sixteen-hour shifts, two twelve-hour shifts plus an eight-hour shift at the Free Clinic."

I did the quick math in my head.

"Only eighty hours?"

"Northrup is juggling the schedules to try to keep everyone to eighty hours. That means PGY2s and PGY3s will work an extra shift. We'll resolve it completely over the next two years as we're increasing our Resident count by four, increasing by two each of the next two years. That's over and above the ones approved for when the new ED wing opens."

"What would the schedules look like?" I asked.

"If you want the twenty-hour shifts, they'd start at 0600 Monday, Wednesday, and Saturday, and you'd be at the Free Clinic on Friday. If you want the other schedule, all the shifts would start at 0500, Monday through Saturday, except the Clinic day, which would start at 0800. Either way, you'd have Sunday off."

"I'm just thinking out loud," I said, "but with the twenty-four-hour schedule, I'd basically go right from the hospital to church on Sunday morning, and couldn't attend Vespers on Wednesday or Saturday. Either schedule would mean that I'd miss band practice, which I know isn't your consideration. With the twenty-hour schedule, I'd have a messed-up sleep schedule; with the other one, only one day off. Would I be able to choose which day I'm at the Clinic?"

"Yes, because the schedule is changing completely to accommodate the shorter hours."

"Is this across the board? Or just in the ED?"

"Just the ED for now, but over time, the other services will change. The Board and Medical Director are concerned about a repeat of the Libby Zion case, which is why they're starting with the Emergency Department."

"I'd be concerned, too, in their position. I think, all things being equal, I'll take the six-day schedule. And speaking of schedules, I do need to mention that Doctor Warren and Doctor Mertens asked me to speak at the White Coat Ceremony next month and attend the banquet."

"Doctor Warren sent a letter to Doctor Northrup and Doctor Cutter to that effect, requesting we give you time off, which, of course, we will. I expect you'll arrange with Kylie to cover hours for your concerts."

"Yes. And I will miss a Saturday shift, or a good portion of it, when I attend Maryam's wedding. My friend Lara arranged with a family friend to fly us to Chicago in his Twin Beech. We'll fly up on Saturday morning and fly home on Sunday night."

"When is that?"

"October 14th and 15th," I replied. "I'll make sure I find someone to cover the shift."

"I'll let Ghost know your decision."

"Thanks. What about the paramedic training program?"

"That will start in September, as planned. The Fire Department is working out shift schedules to allow for it. Bobby's best guess is one paramedic each morning and one each afternoon, each for four hours for twenty weeks. That lets them stay fully staffed without running into crazy amounts of overtime."

"Now, if we can just arrange for patients needing intubation to arrive at convenient times, that will work."

"That's the big challenge, and we'll see what happens and figure out how to handle ones who have bad luck, so to speak."

"And the ride-alongs?"

"Nurses will start in September, with four nurses each taking one shift a week for eight weeks. We'll do that until they all rotate through. Doctors will have to wait because we're short staffed and will be until we get those additional Residents."

"OK. Anything else?"

"Go heal the sick!"

"I suppose that's better than 'Let's do it to them before they do it to us'!" I chuckled.

"That was the second sergeant on Hill Street Blues, right?"

"Yes. The first one always said 'hey, hey, let's be careful out there'."

"Speaking of TV shows, I take it you're happy Doctor Crusher is back?"

"Hmm," I smirked. "Hot redheaded doctor with a great personality versus a cold-hearted doctor who could give our surgeons lessons in egotism and how to have a successful savior complex?"

"Says the man with an ego the size of the moon and a fully developed savior complex! Those red scrubs fit the man!"

"I won't deny the savior complex, but my ego is not writing checks my skills can't cash."

"OK, 'Maverick' go find someone to save!"

"They come to us, Doc," I replied. "We don't have to go out to the highways and hedges to compel them to come in!"

"Do you have a smart ass answer for everything?"

"Pretty much."

"Get out of here!"

"Getting out, Ma'am!" I chuckled.

I left her office and checked on the patient with Len, who reported no changes. That concerned me a bit, so I called Bob and we hooked up the EKG, which showed normal sinus rhythm.

"What are you looking for?" Kellie asked.

"I don't like the fact that he's in the equivalent of a postictal state this long after ingesting or inhaling the drugs. He has no other symptoms, but something keeps whispering 'hemorrhagic stroke' in my ear. PCP often causes hypertension, and I wonder if that happened around the time he was found. They said he was walking, but there's no way he was walking if he was in this current state."

"CAT scan?" Bob prompted.

I nodded, "I think so. Nothing else makes sense. Let me call for a neuro consult."

I made the call and Doctor Cohen arrived about five minutes later with her student. I went over everything that had been reported, what I'd observed, and the exam results.