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EMERGENCY DEPARTMENT

L.A. UNIVERSITY MEDICAL CENTER

WESTWOOD, LOS ANGELES, CALIFORNIA

THURSDAY, JULY 3, 2014, 7:30
A.M.

T
he next day George arrived at the medical center with a raging hangover. He couldn't remember all the details of the previous evening, but he hoped he hadn't made an ass of himself. Coffee was what he needed. He filled a fresh cup and sat down with Carlos to go over the films taken the previous night. There were a lot, but despite a big thumper of a headache, George was determined to be thorough and accurate.

Halfway through, they came across a film of a wrist that had been definitely misread as being normal. The patient had been released untreated despite there being a fracture of the navicular bone. George pointed it out to Carlos and explained that it was easy for doctors not trained in radiology to miss it. George passed the information on to the head of the ER so that the patient could be tracked down and asked to return to the hospital for a cast.

After finishing going over everything, including CT scans, Carlos left to find out what was “cooking” in the ER, while George sat with his head down on the desk and nursed his hangover. He downed a couple more ibuprofen tablets, happy to have had some quiet time.

Feeling reasonably together, he walked into the ER and approached the central desk, where Debbie as usual was ordering the staff around. Obviously there was no hangover holding her down. He tried to catch her eye, but it was difficult. Lots of things were going on with some major trauma on its way in by ambulance. The sirens already could be heard approaching.

George went around the back of the main desk, where he wasn't more than five or six feet away from Debbie. He stood and waited. And waited. Just when he thought she might be intentionally ignoring him, she glanced over and nodded at him before going back to her work. She
had
been ignoring him. The nod wasn't what he had expected. He didn't know what to expect, but it was more than he got.

Oh, well
, George thought. He tried to attribute the rebuff to her preoccupation running the ER. But nonetheless the snub nagged at him. Had he done or said anything that had upset her? He had certainly been drunk. He could easily imagine how he might have offended her considering the state he was in.

Suddenly, she jumped up and rushed past him.
What the hell?
Then he realized that she was responding to a call from the orderlies down in the major trauma rooms waiting to receive the incoming severely injured patients. He was about to walk off when he looked down at the papers Debbie had spread out on her desk. A familiar item pushed into one of the cubbyholes caught his eye. It was a broken smartphone in an electric-orange case. George could see that the phone's display screen was riddled with cracks. It was Sal's phone! The sight of it felt like a little beacon calling to him from his much-maligned friend. He picked it up and tried to turn it on: nothing. It needed to be charged or it was broken. Most likely it was both.

George glanced around. No one was paying him any attention. He made a sudden decision and pocketed the phone. It would probably end up in the trash anyway. With his prize tucked away in his pocket, he retreated back to the protective environment of the imaging room. He was reaching in his pocket for the phone when Carlos burst in.

“We got a slew of major trauma cases on their way in,” he shouted.

“Okay, ease up,” George said. “It'll sort itself out. There's nothing we can do to be more prepared than we already are. Did you alert the technicians?”

“Yes, and they have both portable machines outside the trauma rooms.”

“Perfect. We're ready to rumble.”

“But there is a pregnant woman who just came in with severe abdominal distress—acute pain with vomiting and diarrhea. Waters told me to organize an ultrasound stat.”

“We'll have to wait until after the major trauma is under control,” George said. “Which ER physician is handling the woman?”

“A newbie. Her name is Kelley.”

George nodded. At least he'd be able to say that he talked to the woman if Clayton asked, but he wasn't sure what he was going to say about Debbie if Clayton asked, as George assumed he would. Friendly last night, Ice Queen today—that is,
if
he was reading her right.

Two minutes later the trauma cases came rolling in: nine victims from a four-car, one-motorcycle wreck on the I-405 Freeway. There was a flurry of activity to deal with them all, including one case of major thoracic trauma requiring tracheal intubation and a chest tube. The portable X-ray machines, all the X-ray rooms, and even the CT room were needed. Despite the commotion there were several occasions when Debbie could have spoken with George, but she didn't. George couldn't figure out if this was intentional or if she was just preoccupied.

Eventually, when the excitement died down, George and Carlos took the opportunity to catch their breath in the suddenly quiet imaging room. For a while it had been like a train station, with ER residents and surgeons being apprised of the radiological findings. Suddenly a shaft of light intruded on their peace.

“What the hell now!” George demanded, the light exacerbating his headache, which had not quite disappeared. He turned to look at the newcomer and saw the silhouette of a tall, slim woman in scrubs.

“I'm sorry. I don't mean to interrupt. When you have a moment, I'd like to discuss a patient with you.”

George saw it was Kelley Babcock. “No! Wait,” he said, rising out of his chair. “I'm sorry. That sounded rude. We just finished a full slate of trauma imaging and . . . well, you know. Anyway, how can we help you?”

•   •   •

W
e have a patient six or seven months pregnant with severe abdominal distress,” Kelley said, leading George and Carlos down the ER hallway. George noticed that she had precise, handwritten notes clipped to the patient's file, which she had downloaded and printed out. She had done her homework. In addition, she herself looked organized and meticulous with her hair in a ponytail. In contrast to all the other ER residents, some of whom seemed to revel in looking as if they had been through a war, with blood-soaked scrubs, Kelley kept hers clean and fresh, changing them whenever the need arose.

She was acting as the patient's emergency room physician, although a more senior resident was supervising. She told George that there had already been a surgical consult, which had ruled out an acute abdomen that would have required emergency surgery. With that off the table, the working diagnosis was viral enteritis.

“The patient is currently being hydrated,” Kelley continued, all business. “Before she's discharged, we think her pregnancy should be evaluated, since she had been lost to follow-up. She hasn't been seen in the OB clinic since her initial visit four months ago.”

George glanced over the file as they walked. Kelley's description of the case and what should be done seemed spot-on. George was impressed.

“An OB consult has been called,” Kelley continued, “but all the OB residents are tied up with deliveries. According to their recommendation, an ultrasound needs to be done in the interim, which is why I stopped by to see you.”

Suddenly George realized he was reading a familiar medical history. He glanced up at the patient's name at the top of the file: Laney Chesney. He recognized it immediately. He had had a past association with the patient and the memory tugged at his heartstrings. She was a juvenile diabetic, just as Kasey had been. But Laney had had a tough life, suffering a traumatic childhood with a drug-addicted single mother. She had run away from home a number of times, ultimately living on the street. George suspected she had supported herself by prostitution and had developed chronic liver disease and a cardiomyopathy.

“I know this patient,” George said, holding up the file and coming to a halt. They were still a good distance from the patient's room. Kelley and Carlos stopped alongside him. Flipping through the chart to the radiological studies, he continued, “As I remember, Laney is a particularly endearing girl with huge, sad eyes. She looks about twelve.”

“I think that is a fair description,” Kelley said. “How do you know her?”

“I did a number of interventional radiology studies to determine the status of her heart,” George said. “I remember the outlook wasn't rosy, to say the least.”

“Your memory serves you well,” Kelley said. “I read over her entire case. Eight months previously she was put on the waiting list for a heart transplant, but because of her liver disease and poorly controlled diabetes, she has a low priority.”

“Jesus,” George said, glancing back at the echocardiology studies. He remembered feeling very sorry for her. “And on top of it all, she gets herself pregnant. Holy shit!”

“Seems that she's made all the wrong choices,” Kelley said, “but it is hard to fault her, considering her social history.”

“I suppose there is no need to ask if she is married or has any kind of social support.”

“Not married,” Kelley responded. “She doesn't even know who the father is. When she was initially seen for her pregnancy she was advised to abort because of her cardiac status, but she categorically refused.”

“Maybe it's the only thing that has given meaning to her life,” George said.

Kelley nodded. “It's a tragedy for sure. I hope we can help her. As I said earlier, she hasn't been in to see anyone on follow-up for almost four months now. It took the severe abdominal complaints to get her in here.”

“That doesn't sound like her. When I was involved, she was always careful about keeping her appointments, particularly because of her diabetes. Do you know why she hasn't been back in?”

“No idea, but maybe the questions about aborting spooked her.”

“Didn't you even ask?” George shot back. Losing a patient like Laney with progressive and demanding medical problems was anathema in an academic care center. The group started walking again.

“No. I haven't asked,” Kelley replied. “Good question, though. I should have.”

George studied Kelley's face. She didn't seem thin-skinned or defensive, which she could have been, considering his tone. She had confidence: another good trait.

They arrived at Laney's room. She had been moved to one of the back rooms as far away from the rest of the ER as possible, since she would have to wait a significant time before being seen by one of the OB residents. The hope was that she could get some much-needed rest. The ultrasound machine, along with a technician, Shirley Adams, was already on hand. An IV was running into Laney's left arm.

“Laney, this is Dr. Wilson and Dr. Sanchez,” Kelley announced. “They will be helping Miss Adams do the ultrasound.”

Laney looked up at her visitors, her face brightening.

“We know—” George started.

“—each other already,” Laney finished.

George managed a smile. Laney was genuinely relieved to see a familiar face. She was a petite girl with Irish-pale, milky-white skin. The huge belly protruding from such a tiny frame made her appear further along in her pregnancy than six or seven months.

“Promise me that you won't let them take my baby,” she said to George straight off. “Promise me!”

“I promise.” George was taken aback by her intensity. It was obvious she was terrified, much more scared than when he had done her echocardiogram. “The ultrasound will not hurt the baby, and it's needed for his or her benefit.” He explained the procedure, making sure that Carlos heard, as this was his first ultrasound. George then asked why she hadn't followed up with her medical appointments.

“Because I have my own doctor now. He sent me here to the emergency room because he couldn't figure out exactly what was causing my stomach problems.”

“What's the doctor's name?”

“I'm not supposed to say.”

“Why is that?” George questioned gently.

“I don't know actually.”

“I think you should tell us so we can get in touch.”

Laney looked from George to Carlos.

“It is important,” George persisted. He could not imagine why she didn't want to say.

Laney cleared her throat. “It's called iDoc. I wasn't supposed to tell anyone, but you are doctors, so I guess it is all right.”

George rocked back. iDoc? The freaking thing was everywhere. “You're a part of the iDoc beta test?” he asked incredulously.

“I am.” She motioned to her shoulder bag on the bedside table. “It's in there. My diabetes is not an issue anymore. And you know how out of whack that was.”

“I remember. But I'm amazed that you have iDoc.”

“I got it through Medicaid,” Laney explained. “I was told that I was lucky; that not many people on Medicaid got it, at least not yet. I like it a lot.”

“What exactly are you two talking about?” Kelley asked. “What is iDoc?”

George gave her a very quick description of the iDoc app.

“That's impressive,” Kelley said. She sounded sincere but made a somewhat skeptical face to George, out of Laney's line of vision. “Listen! I need to run. I have a full plate out there. Laney, you obviously know that you're in good hands,” she said, motioning to George and the others. “I'll be back to check up on you in a bit.” Kelley gave Laney's arm a reassuring pat as she left.

“I'll fill you in later,” George called after her. Then he turned back to Laney. “This won't be hard for you or your baby.” He turned to Shirley and Carlos. “Let's get this done!”

Carlos pulled George aside while the technician got the ultrasound machine up and running next to Laney's bed. “What should I be doing here? I feel like the odd man out.”

“Once Shirley starts the study, I want you to handle the probe yourself so you'll have a better feel for how the study is done. Actually doing it will help your interpretation immensely. Just be patient! I felt the same way you did back when I was starting out.”